For years, pharmaceutical companies have been required to grant federal discounts only for drugs dispensed on base, or through Tricare’s mail order option or through Department of Veterans Affairs’ pharmacies. Defense officials tried administratively to get the same discounts for the retail pharmacy network but that effort was blocked in 2006 through a successful industry lawsuit. A short time later, when Tricare officials sought a legislation solution, White House politicos quietly sided with the Pharmaceutical Research and Manufacturers Association in opposing imposition of discounts on prescriptions through retail outlets. Meanwhile, the administration has pressed Congress over the last three years to raise beneficiary co-payments at retail pharmacies to entice greater use of mail order and base pharmacies where federal prices do apply. In passing the 2008 defense bill, the Democratically-led Congress left beneficiary co-payments unchanged, and directed that federal price discounts be expanded to brand name drugs filled in the Tricare retail network. The projected pharmacy savings for fiscal 2009, which total $719 million, exceeds the savings estimate used by Bush administration to argue for higher drug co-payments in the retail network. Only time will tell whether expansion of manufacturer discounts relieves budgetary pressure for raising retail pharmacy co-pays for beneficiaries.

Under the new law, drug companies that refused to extend discounts to Tricare retail outlets risk seeing their drugs removed from the DoD uniform formulary. Drugs left off the formulary for “not honoring federal ceiling price,” said Rear Adm. Thomas McGinnis, chief of Tricare pharmaceutical operations, won’t be dispensed without preauthorization which means a phone call to confirm the specific drug is medically necessary. Then the co-payment will be $22 per prescription rather than $9. “No firm is going to want that for their product,” McGinnis said. A “plain reading” of the new law shows Congress wanted the discounts to be effective at retail outlets 28 JAN 08, the day President Bush signed the bill, McGinnis said. But drug makers have filed a lawsuit in U.S. District Court challenging that contention, and arguing that the discounts don’t apply until DoD publishes a final rule for implementing the law. A proposed rule was published in the Federal Register 25 JUL. Industry comments are due back by 23 SEP. If the court finds that a final rule must be in place before lower prices apply to retail outlets, drug makers will avoid as much as $700 million in refunds to DoD for retail drugs dispensed since 28 JAN. “Because there’s so much money involved here,” McGinnis predicted, “we will see some creative arguments from the industry.”

DoD drug spending more than tripled from fiscal 2000 through 2006, rising to $6.2 billion from $1.6 billion. Most of the increase was in the convenient retail network where annual costs jumped nine-fold, from $455 million to $3.9 billion. McGinnis estimates that the cost of drugs dispensed through retail outlets will reach close to $4.5 billion in the current fiscal year. One reason DoD eased up on its push for federal price discounts in the retail network was the level of savings being realized through voluntary agreements with drug manufacturers for base pharmacies and the mail order program. In establishing a DoD uniform formulary, or approved list of drugs, DoD began studying whole classes of drugs to determine what medicines are both clinically effective and cost effective. Through last October, 322 drugs had been reviewed and 249 were kept on the formulary The rest were bumped, many of them for being too costly with no evidence that they were more effective. McGinnis said during this review process the cost of some drugs fell sharply because manufacturers wanted to ensure that their drugs were on the formulary.

“The industry has been bidding prices below the federal ceiling price, both at the military treatment facility and at the mail order pharmacy,” McGinnis explained. “It will take a while until we see whether they bid some of these retail pharmacy prices below federal ceiling prices.” If that occurs, he said, forcibly extending federal discounts to Tricare retail outlets could lead to savings greater than the current 25%. For now, McGinnis said he will continue to urge beneficiaries to save themselves and the government money by using base pharmacies and mail order to fill their prescriptions. With mail order, beneficiaries get a three-month supply for the same co-pay as a one-month supply through retail. Drugs dispensed on base or through mail order also will continue to cost DoD less. Federal pricing in retail outlets, McGinnis said, merely has narrowed the savings disparity. Using mail order or base pharmacies had saved the government 49% on each prescription. Now it will save about 24%, he said. [Source: Stars and Stripes Tom Philpott article 30Aug 08 ++]

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Lott at the hospital association, which represents UCLA and about 170 other medical facilities, said patients are wrong to think that the charge on their bill reflects the actual cost of treatment. Rather, he said, hospitals use a “cost-plus” system by which charges include both the cost of a service and a portion of general overhead, including treatment of uninsured people who can’t afford the provider’s cost-plus prices. At the same time, insurance companies, along with state and federal authorities representing Medi-Cal and Medicare members, negotiate lower rates in return for delivering thousands of patients to a particular clinic or hospital. The upshot is that providers are overcharging insured patients because they have no other way of meeting total expenses, while insurers are paying significantly less than the billed amount because they know they’re being hit up for unrelated costs. Insurers’ underpayments, in turn, only force providers to increase bills even more. It’s a system that both condones and perpetuates inflation while all but eliminating transparency in the marketplace. It also spells doom for the 45 million Americans lacking health coverage, who have no choice but to pay the full amount of a hospital’s cost-plus charges and thus can be wiped out financially by a major medical problem.

“Healthcare is the one sector where market mechanisms work least,” said Peter Lindert, an economics professor at UC Davis who specializes in public-health issues. “Prices are whatever you can get away with.” As my colleague Jordan Rau reported last week, California state lawmakers managed to pass some bills in the latest session that address healthcare problems but came up well short of their goal of reforming the system to make it friendlier — and more accessible — to patients. Among legislation torpedoed by lobbyists for doctors and hospitals was a bill that would have given the state new powers to collect information on prices charged by healthcare providers. Support for the bill dwindled after lobbyists managed to exempt doctors from the reporting requirement and inserted language recognizing the “tremendous burden” that revealing actual costs would be for providers. Score that a win for the status quo and a setback for anyone who thinks healthcare costs are out of control. “We are rapidly approaching a time where important policy discussions are going to have to be had on this issue,” said Santiago Munoz, associate vice president of clinical services development in the UC president’s office. What’s needed is a massive infusion of political courage to tackle genuine healthcare reform. [Source: Los Angeles Times Consumer Confidential David Lazarus article 7 Sep 08 ++]

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With the praise, the panel also recommended a mixture of more research, greater cooperation among federal agencies, and more education for health care workers and community leaders to further strengthen and share VA’s ability to help veterans and their families. Called the “Blue Ribbon Work Group on Suicide Prevention,” the five-member group was composed of suicide prevention experts from VA, the Department of Defense, the Centers for Disease Control and Prevention, the National Institute of Health, and the Substance Abuse and Mental Health Services Administration. The group was created by Peake and met 11-13 JUN 08. Among the panel’s recommendations to further enhance VA’s outstanding

programs, many of which VA has already begun to implement, are:

* Design a study that will identify suicide risk among veterans of different conflicts, ages, genders, military branches and other factors. VA has committed to work with other federal agencies to design such a study within 30 days.

* Improve VA’s screening for suicide among veterans with depression or post-traumatic stress disorder (PTSD). VA is in the process of designing a new screening protocol, with pilot test undertaken during the fiscal year quarter beginning Oct. 1, 2008.

* Ensure that evidence-based research is used to determine the appropriateness of medications for depression, PTSD and suicidal behavior. VA’s is providing written warnings to patients about side

effects, and the Department’s suicide prevention coordinators are contacting health care providers to advise them of the latest evidence-based research on medications.

* Devise a policy for protecting the confidential records of VA patients who may also be treated by the military’s health care system. VA is already developing a plan to clarify the privacy rights of patients who come to VA while serving in the military.

* Increase research about suicide prevention. VA has announced several funding opportunities this year for research on suicide prevention and is developing priorities for suicide prevention research.

* Develop educational materials about suicide prevention for families and community groups. VA is examining the effectiveness of support groups and educational material for the families of suicidal

veterans, and producing a brochure for the families of veterans with traumatic brain injury about suicide, which will be available within 30days.

* Increase training for VA chaplains about the warning signs of suicide. VA offices responsible for chaplains and mental health professionals are studying ways to implement this recommendation, with a

report due by 1 NOV.

* Develop a gun-safety program for veterans with children in the home, both as a child-safety measure and a suicide prevention effort. A VA directive establishing the program is being developed, with full implementation expected during the fiscal year beginning Oct. 1, 2008.

[Source: VA Media Relations Sep 08 ++]

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Death rates from heart attack, heart failure and pneumonia are widely viewed as yardsticks of a hospital’s overall performance. Last year, the U.S. Centers for Medicare and Medicaid Services (CMS) released a broad comparison of death rates for heart attacks and heart failure, noting how hospitals compared with the national average — better, worse or no different — without releasing the death rates themselves. This year the agency decided to disclose them to consumers. The agency posted its new mortality estimates on a government website www.hospitalcompare.hhs.gov , along with more than two dozen other measures of how well hospitals meet patients’ needs. Among them are statistics on what percentage of a hospital’s patients get appropriate care for a variety of ailments, including childhood asthma, and 10 measures of patient satisfaction with the hospital experience. All three types of measurements give hospitals ways to assess — and improve — their quality of care, but many health officials regard the number of patients who die in the hospital or soon after discharge as the ultimate measure of performance.

Knowing a hospital’s death rates gives consumers more power to influence the quality of their medical care, says Lisa Iezzoni, associate director of the Massachusetts General Hospital Institute for Health Policy. “What the mortality rate does is give you an entree to talk to your doctor and say, ‘Look, is this hospital stay going to kill me?’ ” That’s not an easy question to answer with any certainty. By trying, officials knew they were courting trouble with the hospital industry, Iezzoni says. An earlier effort by Medicare to report on hospital death rates faltered in the early ’90s. The agency wilted under relentless criticism that its so-called death list didn’t give adequate weight to a hospital’s mix of patients, including how sick, poor and old they were. This time, the architects of the new analysis took a different approach. They tallied death rates for common life-threatening conditions, not the hospitals’ overall mortality rates. And they chose a strict statistical formula that allows them to say with 95% confidence that a hospital’s death rates fall within a certain range. But there’s a rub, experts say. Using this method of analysis, only a handful of hospitals stand out as better or worse than the national average. The new formula captures all deaths among 35 million Medicare beneficiaries that occurred within 30 days of the patients’ hospital admission. They also factored in the hospital’s patient mix and how many deaths might be expected in a hospital with that population. Including deaths that occurred within 30 days after admission made it tougher for a hospital to game the system by shipping risky cases somewhere else.

• To compare hospitals near you on heart attack, heart failure and pneumonia refer to www.usatoday.com/news/health/hospitals-graphic.htm

• To view hospitals with highest and lowest death rates www.usatoday.com/news/health/2008-08-20-hospitals-best-worst_N.htm

• To compare hospitals in your ZIP code refer to www.hospitalcompare.hhs.gov/hospital/mortalitytool/index.asp

[Source: USA TODAY Steve Sternberg/ Anthony DeBarros article 20 Aug 08 ++]

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The most common sites for infections in older adults are the urinary tract, the respiratory tract, and the skin. It also is common for seniors to develop an infection prior to an acute deterioration of their chronic medical condition or in combination with other acute medical problems. A typical example is the person with congestive heart failure who develops pneumonia. The symptoms of cough, congestion, and shortness of breath are similar and might occur simultaneously, or the onset of pneumonia might precipitate an acute attack of congestive heart failure. So how do you know if your parent is developing an infection? Look for an acute change in his or her ability to perform day to day activities; subnormal temperature; increased pulse rate; unexplained dehydration; confusion; poor appetite; and fatigue with increased aches and pains. For specific infections you might want to look for the following signs:

• Respiratory infections: Cough, Increased mucus , Abdominal pain, Headache, Chest pain, Generalized weakness, and/or Loss of appetite.

• Urinary infection: New onset of incontinence, Pain with urination, More frequent urination, Flank pain, Weakness, and/or Blood in the urine.

• Skin infection: Redness, Warmth, and/or Pain or tenderness

If you note any of these symptoms, due diligence requires a complete medical evaluation to determine the source of the infection and any other acute medical problems. This is extremely important because of the risk of sepsis (an overwhelming infection that enters the bloodstream, is higher in the elderly). The longer these types of symptoms go untreated, the more likely the bacteria will find its way into the bloodstream. Another concern is the prevalence of antibiotic-resistant infections. The overuse of antibiotics for viral illnesses and the common cold have caused bacteria to mutate and become resistant to antibiotics that once treated most infections. The three super infections that pose a threat are Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C diff), and Vancomycin-resistant enterocolitis (VRE).

• MRSA is diagnosed by obtaining a culture of the body fluid (sputum, urine, blood) where the infection is present. MRSA infections can occur anywhere in the body, and even though treatment with Vancomycin appears successful, a small amount of the bacteria can remain — a phenomenon medical professionals refer to as colonization. The remaining bacteria can cause infections to reoccur at any time.

• C diff and VRE both cause diarrhea and are the result of antibiotics killing the normal, beneficial bacteria that reside in the intestinal tract and allowing infection-producing bacteria to proliferate. C diff can occur after the prolonged use of any antibiotic; VRE is specific to the use of Vancomycin. Treatment includes preventing dehydration associated with diarrhea, a bland diet, and bulking agents to decrease the amount of diarrhea, and administration of Flagyl to treat the condition and allow the normal bacteria to return to appropriate levels.

The good news is that most infections are isolated and can be treated with short-term antibiotics. Basic preventative measures — such as assuring that your parents have a pneumonia vaccination, receive the flu vaccine yearly, avoid others with acute infections, and stay well-hydrated — can decrease the likelihood of serious infections. In addition, keeping the skin well moisturized can prevent skin infections. Dry skin is more likely to crack and tear, providing an opening for bacteria to enter. Urinary tract infections are prevented by good hygiene and adequate fluid intake. For more information about infections in the elderly, super infections, and vaccinations refer to www.health.nih.gov/topics. [Source: MOAA News Exchange Nanette Lavoie-Vaughan article 27 Aug 08 ++]

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• Anchovies and sardines: Despite their reputation as strange pizza toppings, these two are a good source of Omega-3. They also tend to be high in sodium.

• Salmon. This fatty fish is exploding with omega-3 and may be the best bang for your buck in the seafood aisle.

• Bluefin tuna: The seafood equivalent of steak is also packed with Omega-3 and is low in the less desireable Omega-6 fatty acids. Mackerel, herring and rainbow trout are good substitutes for it.

• Crustaceans: If you get tired of fish, switch things up with shrimp, mollusks or Alaskan king crab.

• Oils: Pick up a bottle of flaxseed oil and use it to season your salads. Consider switching to canola oil when you cook—by getting rid of vegetable oils in your diet, you can also lessen the amount of Omega-6 fatty acids in your diet.

• Papaya: To satisfy your sweet tooth, finish up your meal with a slice of papaya, or add it to your breakfast menu.

• Beans. Some legumes are better than others for tipping the omega balance your way. Kidney, pinto, and mungo beans will do you right. Chickpeas are less helpful.

• Spinach. Serve up this leafy green in a salad, or sauté it and add it to pasta.

• Nuts and seeds. Add a nutty flavor to salad, yogurt, or morning mueslix with walnuts or flaxseed. A small handful of either will up your omega-3 intake.

• Winter squash. Keep an eye out for this seasonal vegetable—it makes an interesting side dish that boosts your omega-3 intake.

• Broccoli and cauliflower. These cruciferous veggies are on your side when it comes to omega-3s.

• Papaya. A tropical delight, papaya may be the only fruit in your supermarket with more omega-3 than omega-6.

[Source: Dear Marci/Medicare Rights Center Weekly health tip 18 Aug 08 ++]

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For Vietnam vet James McKasson, who participated in the study, the findings are a reminder that no one exposed to Agent Orange should delay prostate-cancer testing. McKasson, 62, a retired auto mechanic, said he’s doing well after being diagnosed with prostate cancer last year – 40 years after he helped load Agent Orange onto planes in the 1960s. He worked with both liquid and powdered forms of the chemical, and “this stuff would slop around; it would drip on you,” he recalled. “You’d walk through it and get it on your shoes, on your clothes, on your hands. … They didn’t give us any protective clothing at all.” For decades, McKasson didn’t worry much about studies that linked exposure to diseases ranging from diabetes to soft-tissue cancer to birth defects in veterans’ children. “I’m an advocate now,” he said, telling his “stubborn” friends to have regular checks for prostate cancer.

The chemical was used widely during the Vietnam War to defoliate jungle areas where U.S. forces believed enemies were hiding. It also was used around U.S. military facilities at home and abroad as early as the 1950s, according to the Department of Veterans Affairs. About 375,000 men nationwide are on the military’s Agent Orange registry of those exposed, and roughly one-third can be expected to develop prostate cancer, Chaime said. “This has huge implications for men, especially in the VA,” but also for those treated by private insurance, whose primary care doctors and urologists may not have seen the latest data, he added. Of the 13,000 men followed by the study, just under half had been exposed to Agent Orange. Among the 6,214 exposed, 239 were diagnosed with prostate cancer over eight years, compared with 124 of 6,930 unexposed veterans. [Source: The Sacramento Bee Carrie Peyton Dahlberg article 5 Aug 08 ++]

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This will help determine whether more than 60,051 veterans who were approved for back benefits got the right amounts. The head of the Pentagon’s Defense Finance and Accounting Service (DFAS) said at a hearing that he thinks the error rate in granting benefits was less than 1%. And an executive of a DFAS contractor, Lockheed Martin, said past problems were caused by automation and data flaws that are now resolved. But DFAS director Zack Gaddy also disclosed at the House hearing that a high-level management team was sent to Cleveland two weeks ago to review DFAS operations. That would coincide with work by Kucinich’s staff on the domestic policy subcommittee of the House Oversight and Government Reform Committee, looking into denial of veterans’ benefits.

The controversy stems from a decision by Congress in 2003 and 2004 to allow veterans to collect their military disability pay as well as their veterans pensions. Previously, the amount of their disability pay was deducted from their pensions on retirement. The change created thousands of claims for retroactive payments — and to what Kucinich says may have been the improper denial of checks for more than 28,283 veterans, as well as errant payments to many others. Gaddy put the number of denials somewhat lower, at 25,448. Kucinich’s subcommittee staff reviewed thousands of pages of records and e-mail and determined that DFAS and Lockheed Martin only brought the backlog of 133,057 cases to date last month. After growing frustrated by numerous delays, DFAS lent its own federal workers to help Lockheed Martin with its Cleveland benefits call center, which freed up more of the contractor’s employees to clear the veterans backlog. That raises questions, Kucinich said, about whether taxpayers were billed for Lockheed Martin’s call center work even though federal workers were the ones performing it. The Pentagon audit will attempt to answer the question.

In helping its contractor, DFAS also reduced its oversight, Kucinich said, failing to double-check or audit Lockheed Martin decisions on benefits as frequently as it should have. The problem now, Kucinich said, is that no one knows whether the decisions on granting retroactive pay and benefits were proper. Even the ranking Republican on the subcommittee, Darrell Issa of California, agreed that a 100% review of all denials should be done, “so that if one case falls through the cracks, another doesn’t.” Joseph Cipriano, president of Lockheed Martin Business Process Solutions, blamed the problems on poor or incompatible data. A database from the Department of Veterans Affairs was inadequate for the new task, he said. Additional factors such as changes in veteran’s disability status and deaths complicated efforts, and a lot of information had to be input manually before it could be processed. Kucinich cited the case of a retired Army sergeant major, Harold Lewis, who appealed after his denial and ultimately got $15,000 in retroactive pay. This suggested the system was error-prone, Kucinich said. But Cipriano said Lewis case was one of the earliest ones handled. After realizing there was a problem, Lockheed Martin updated the data and fixed the problem, Cipriano said. [Source: [Source: Cleveland Sun Times Stephen Koff article 16 Jul 08 ++]

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