Mary Ellen Schneider

Hurricane Katrina Relief

The federal government is seeking volunteers from a variety health care professions to deploy to the Gulf region. Deployment may last 14 days or longer and may include 12-hour shifts under austere conditions, according to the Health and Human Services department. Volunteers will be unpaid, but will receive travel reimbursement, a per diem, and coverage under the Federal Tort Claims Act for liability coverage and workman's compensation, HHS said in a statement. To volunteer, visit

https://volunteer.ccrf.hhs.gov

Lipitor Indictments

Eleven individuals, a drug repacker, and two wholesale distributors were recently indicted for their roles in the sale of counterfeit Lipitor, according to the Food and Drug Administration and the U.S. Attorney for the Western District of Missouri. The indictment includes charges for conspiracy to sell counterfeit, illegally imported, and misbranded drugs, and conspiracy to sell stolen drugs. The U.S. attorney is alleging a conspiracy that involved manufacturing counterfeit Lipitor (atorvastatin) in Central America, purchasing genuine Lipitor intended for distribution in South America, and illegally importing both products into the United States.

Partnering for Cardiovascular Health

The World Heart Federation and Bayer HealthCare have entered into a 3-year partnership aimed at increasing education on cardiovascular disease to both the public and health care professionals. One aim of the partnership will be to increase awareness among health care providers of the World Heart Federation's Principles for National and Regional Guidelines on Cardiovascular Disease Prevention. “More needs to be done to increase awareness of the significant benefits afforded by behavior change and appropriate medical therapies in achieving CVD prevention,” Sidney Smith, chairman of the federation's scientific advisory board, said in a statement.

Tougher Tobacco Penalties

Six public health organizations including the American Heart Association have filed a court brief in the federal government's lawsuit against the tobacco companies seeking tougher restrictions on tobacco marketing and more money from tobacco companies to fund smoking cessation programs. In July, the groups were made formal parties to the lawsuit and allowed to present arguments in court. The public health groups are seeking $54 billion over 10 years to fund cessation and public education programs compared with the government's request of $14 billion over 10 years. “It is essential that the court adopt a comprehensive remedial approach to prevent and restrain the defendants from continuing to engage in the type of fraud and deception that has been a part, and remains a part, of this industry's standard operating procedure,” the groups wrote in their court brief.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for 96 years, is slated to close as part of the base realignment and closure process. A recommendation by the Department of Defense to be closed was recently approved by members of the Defense Base Realignment and Closure Commission. If President Bush agrees with the recommendations, he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other units will be transferred to Ft. Belvoir, Va. Closures and realignments must begin within 2 years of congressional approval and must be completed within 6 years, according to the base realignment and closure statute.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Hurricane Katrina Relief

The federal government is seeking volunteers from a variety health care professions to deploy to the Gulf region. Deployment may last 14 days or longer and may include 12-hour shifts under austere conditions, according to the Health and Human Services department. Volunteers will be unpaid, but will receive travel reimbursement, a per diem, and coverage under the Federal Tort Claims Act for liability coverage and workman's compensation, HHS said in a statement. To volunteer, visit

https://volunteer.ccrf.hhs.gov

Lipitor Indictments

Eleven individuals, a drug repacker, and two wholesale distributors were recently indicted for their roles in the sale of counterfeit Lipitor, according to the Food and Drug Administration and the U.S. Attorney for the Western District of Missouri. The indictment includes charges for conspiracy to sell counterfeit, illegally imported, and misbranded drugs, and conspiracy to sell stolen drugs. The U.S. attorney is alleging a conspiracy that involved manufacturing counterfeit Lipitor (atorvastatin) in Central America, purchasing genuine Lipitor intended for distribution in South America, and illegally importing both products into the United States.

Partnering for Cardiovascular Health

The World Heart Federation and Bayer HealthCare have entered into a 3-year partnership aimed at increasing education on cardiovascular disease to both the public and health care professionals. One aim of the partnership will be to increase awareness among health care providers of the World Heart Federation's Principles for National and Regional Guidelines on Cardiovascular Disease Prevention. “More needs to be done to increase awareness of the significant benefits afforded by behavior change and appropriate medical therapies in achieving CVD prevention,” Sidney Smith, chairman of the federation's scientific advisory board, said in a statement.

Tougher Tobacco Penalties

Six public health organizations including the American Heart Association have filed a court brief in the federal government's lawsuit against the tobacco companies seeking tougher restrictions on tobacco marketing and more money from tobacco companies to fund smoking cessation programs. In July, the groups were made formal parties to the lawsuit and allowed to present arguments in court. The public health groups are seeking $54 billion over 10 years to fund cessation and public education programs compared with the government's request of $14 billion over 10 years. “It is essential that the court adopt a comprehensive remedial approach to prevent and restrain the defendants from continuing to engage in the type of fraud and deception that has been a part, and remains a part, of this industry's standard operating procedure,” the groups wrote in their court brief.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for 96 years, is slated to close as part of the base realignment and closure process. A recommendation by the Department of Defense to be closed was recently approved by members of the Defense Base Realignment and Closure Commission. If President Bush agrees with the recommendations, he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other units will be transferred to Ft. Belvoir, Va. Closures and realignments must begin within 2 years of congressional approval and must be completed within 6 years, according to the base realignment and closure statute.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Hurricane Katrina Relief

The federal government is seeking volunteers from a variety health care professions to deploy to the Gulf region. Deployment may last 14 days or longer and may include 12-hour shifts under austere conditions, according to the Health and Human Services department. Volunteers will be unpaid, but will receive travel reimbursement, a per diem, and coverage under the Federal Tort Claims Act for liability coverage and workman's compensation, HHS said in a statement. To volunteer, visit

https://volunteer.ccrf.hhs.gov

Lipitor Indictments

Eleven individuals, a drug repacker, and two wholesale distributors were recently indicted for their roles in the sale of counterfeit Lipitor, according to the Food and Drug Administration and the U.S. Attorney for the Western District of Missouri. The indictment includes charges for conspiracy to sell counterfeit, illegally imported, and misbranded drugs, and conspiracy to sell stolen drugs. The U.S. attorney is alleging a conspiracy that involved manufacturing counterfeit Lipitor (atorvastatin) in Central America, purchasing genuine Lipitor intended for distribution in South America, and illegally importing both products into the United States.

Partnering for Cardiovascular Health

The World Heart Federation and Bayer HealthCare have entered into a 3-year partnership aimed at increasing education on cardiovascular disease to both the public and health care professionals. One aim of the partnership will be to increase awareness among health care providers of the World Heart Federation's Principles for National and Regional Guidelines on Cardiovascular Disease Prevention. “More needs to be done to increase awareness of the significant benefits afforded by behavior change and appropriate medical therapies in achieving CVD prevention,” Sidney Smith, chairman of the federation's scientific advisory board, said in a statement.

Tougher Tobacco Penalties

Six public health organizations including the American Heart Association have filed a court brief in the federal government's lawsuit against the tobacco companies seeking tougher restrictions on tobacco marketing and more money from tobacco companies to fund smoking cessation programs. In July, the groups were made formal parties to the lawsuit and allowed to present arguments in court. The public health groups are seeking $54 billion over 10 years to fund cessation and public education programs compared with the government's request of $14 billion over 10 years. “It is essential that the court adopt a comprehensive remedial approach to prevent and restrain the defendants from continuing to engage in the type of fraud and deception that has been a part, and remains a part, of this industry's standard operating procedure,” the groups wrote in their court brief.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for 96 years, is slated to close as part of the base realignment and closure process. A recommendation by the Department of Defense to be closed was recently approved by members of the Defense Base Realignment and Closure Commission. If President Bush agrees with the recommendations, he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other units will be transferred to Ft. Belvoir, Va. Closures and realignments must begin within 2 years of congressional approval and must be completed within 6 years, according to the base realignment and closure statute.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

NASHVILLE, TENN. — States' policy makers are looking for innovative approaches to expand access to health insurance.

“There seems to be renewed interest in trying to build on [employer-sponsored insurance],” Sharon Silow-Carroll, senior vice president of the Economic and Social Research Institute in Teaneck, N.J., said at the annual conference of the National Academy for State Health Policy.

Trends that have combined to spur action in this area include the decline in employer-sponsored insurance, the financial strains on state Medicaid programs, and the rising cost of health care.

States have responded with a number of different approaches:

▸ Limited benefit plans. Some states are allowing the sale of lower-cost, limited benefit plans and other options such as health savings accounts coupled with high-deductible plans.

▸ Premium assistance. Other states are offering premium assistance through Medicaid, State Children's Health Insurance Program (SCHIP), and other public programs. For example, Rhode Island offers subsidies and wrap-around benefits to those eligible for Medicaid and other state health programs. For those individuals who earn 150% of the federal poverty level or less, the state pays the employee's share of the employer-sponsored premium.

▸ Reinsurance. There has also been a lot of interest in reinsurance through indirect subsidies to employers and workers, she said. New York pays 90% of claims between $5,000 and $75,000 for eligible individuals.

▸ State-negotiated health plans. States are also using their purchasing power with or without additional subsidies to provide more affordable health insurance options.

▸ Employer mandates. State policy makers can also try to increase employer-sponsored coverage with mandates that require employers to cover workers or pay a fee to the state to arrange coverage. Such a proposal was recently defeated in California.

Such “pay-or-play” proposals “reemerge every few years in the states,” Ms. Silow-Carroll said. “If a state is very serious about boosting [employer sponsored insurance] in a big way, a pay-or-play type approach really should be on the table as one of the options considered.”

All of these strategies can stand alone but should be part of a comprehensive approach that deals with cost containment, cost issues, and quality issues, and various aspects of different uninsured populations, she said.

Strategies that build on employer-sponsored insurance have advantages for states, Ms. Silow-Carroll said, because they offer a way to expand access to coverage without the state bearing the full cost. For example, the Rhode Island premium assistance program allows the state to cover a family for half the cost under its traditional assistance programs like Medicaid.

But a key limitation, she said, is that under voluntary strategies there has historically been fairly low employer participation—especially among those employers who have never offered coverage in the past.

“To get them to take that step and actually begin to offer coverage, even if it's subsidized coverage, is a hard sell,” Ms. Silow-Carroll said.

NASHVILLE, TENN. — States' policy makers are looking for innovative approaches to expand access to health insurance.

“There seems to be renewed interest in trying to build on [employer-sponsored insurance],” Sharon Silow-Carroll, senior vice president of the Economic and Social Research Institute in Teaneck, N.J., said at the annual conference of the National Academy for State Health Policy.

Trends that have combined to spur action in this area include the decline in employer-sponsored insurance, the financial strains on state Medicaid programs, and the rising cost of health care.

States have responded with a number of different approaches:

▸ Limited benefit plans. Some states are allowing the sale of lower-cost, limited benefit plans and other options such as health savings accounts coupled with high-deductible plans.

▸ Premium assistance. Other states are offering premium assistance through Medicaid, State Children's Health Insurance Program (SCHIP), and other public programs. For example, Rhode Island offers subsidies and wrap-around benefits to those eligible for Medicaid and other state health programs. For those individuals who earn 150% of the federal poverty level or less, the state pays the employee's share of the employer-sponsored premium.

▸ Reinsurance. There has also been a lot of interest in reinsurance through indirect subsidies to employers and workers, she said. New York pays 90% of claims between $5,000 and $75,000 for eligible individuals.

▸ State-negotiated health plans. States are also using their purchasing power with or without additional subsidies to provide more affordable health insurance options.

▸ Employer mandates. State policy makers can also try to increase employer-sponsored coverage with mandates that require employers to cover workers or pay a fee to the state to arrange coverage. Such a proposal was recently defeated in California.

Such “pay-or-play” proposals “reemerge every few years in the states,” Ms. Silow-Carroll said. “If a state is very serious about boosting [employer sponsored insurance] in a big way, a pay-or-play type approach really should be on the table as one of the options considered.”

All of these strategies can stand alone but should be part of a comprehensive approach that deals with cost containment, cost issues, and quality issues, and various aspects of different uninsured populations, she said.

Strategies that build on employer-sponsored insurance have advantages for states, Ms. Silow-Carroll said, because they offer a way to expand access to coverage without the state bearing the full cost. For example, the Rhode Island premium assistance program allows the state to cover a family for half the cost under its traditional assistance programs like Medicaid.

But a key limitation, she said, is that under voluntary strategies there has historically been fairly low employer participation—especially among those employers who have never offered coverage in the past.

“To get them to take that step and actually begin to offer coverage, even if it's subsidized coverage, is a hard sell,” Ms. Silow-Carroll said.

NASHVILLE, TENN. — States' policy makers are looking for innovative approaches to expand access to health insurance.

“There seems to be renewed interest in trying to build on [employer-sponsored insurance],” Sharon Silow-Carroll, senior vice president of the Economic and Social Research Institute in Teaneck, N.J., said at the annual conference of the National Academy for State Health Policy.

Trends that have combined to spur action in this area include the decline in employer-sponsored insurance, the financial strains on state Medicaid programs, and the rising cost of health care.

States have responded with a number of different approaches:

▸ Limited benefit plans. Some states are allowing the sale of lower-cost, limited benefit plans and other options such as health savings accounts coupled with high-deductible plans.

▸ Premium assistance. Other states are offering premium assistance through Medicaid, State Children's Health Insurance Program (SCHIP), and other public programs. For example, Rhode Island offers subsidies and wrap-around benefits to those eligible for Medicaid and other state health programs. For those individuals who earn 150% of the federal poverty level or less, the state pays the employee's share of the employer-sponsored premium.

▸ Reinsurance. There has also been a lot of interest in reinsurance through indirect subsidies to employers and workers, she said. New York pays 90% of claims between $5,000 and $75,000 for eligible individuals.

▸ State-negotiated health plans. States are also using their purchasing power with or without additional subsidies to provide more affordable health insurance options.

▸ Employer mandates. State policy makers can also try to increase employer-sponsored coverage with mandates that require employers to cover workers or pay a fee to the state to arrange coverage. Such a proposal was recently defeated in California.

Such “pay-or-play” proposals “reemerge every few years in the states,” Ms. Silow-Carroll said. “If a state is very serious about boosting [employer sponsored insurance] in a big way, a pay-or-play type approach really should be on the table as one of the options considered.”

All of these strategies can stand alone but should be part of a comprehensive approach that deals with cost containment, cost issues, and quality issues, and various aspects of different uninsured populations, she said.

Strategies that build on employer-sponsored insurance have advantages for states, Ms. Silow-Carroll said, because they offer a way to expand access to coverage without the state bearing the full cost. For example, the Rhode Island premium assistance program allows the state to cover a family for half the cost under its traditional assistance programs like Medicaid.

But a key limitation, she said, is that under voluntary strategies there has historically been fairly low employer participation—especially among those employers who have never offered coverage in the past.

“To get them to take that step and actually begin to offer coverage, even if it's subsidized coverage, is a hard sell,” Ms. Silow-Carroll said.

NASHVILLE — The governor of Massachusetts is proposing to cover the uninsured in his state by creating lower-cost health insurance options and requiring individuals to obtain coverage.

This effort is aimed at providing affordable coverage for the approximately 460,000 or 7% of Massachusetts residents without health insurance, Amy Lischko, assistant commissioner of the Massachusetts Division of Health Care Finance and Policy, said at the annual conference of the National Academy for State Health Policy.

“We really feel like this is the year to get something done, and we're hopeful that parts at least of the governor's proposal will be moved on,” Ms. Lischko said.

This plan is one of a few proposals being considered by the state's legislature. Under the governor's plan, individuals would be required to have a minimum level of insurance or proof of their ability to pay for care on their tax return.

Those who do not comply could see a loss of their personal tax exemption and withholding of a portion or all of their income tax refund for deposit in a state personal health care expenditure account.

Individuals without coverage who use medical services would be required to pay, and there would be more up-front billing by providers. If patients are unable to pay, the provider may request payment from the state personal health care-expenditure account. But policymakers are flexible on the details of how such an individual mandate would be enforced. “This is the hard stuff,” Ms. Lischko said. “There's not going to be insurance police on the streets throwing people in jail that don't have health insurance.”

Coupled with the proposed individual insurance mandate, Gov. Mitt Romney (R) is also proposing to create two new low-cost health insurance options designed to appeal to the 7% of uninsured residents in the state.

But John McDonough, executive director of the advocacy group Health Care for All, commented that there are a lot of unanswered questions about Gov. Romney's plan. For example, there is no guarantee that private insurers step up to offer the new insurance plans envisioned by the governor, Mr. McDonough said in an interview. Also unstated is whether there are sufficient existing funds in the health care safety net to pay for the subsidies required for low-income residents.

Mr. McDonough's group instead favors an approach that would require employers to offer health insurance or pay a fee to the state, as well as expanding Medicaid eligibility and offers subsidies to moderate-income workers.

One program, called Commonwealth Care, will be aimed at about 204,000 uninsured residents who have incomes of more than 300% of the federal poverty level. The other coverage option, called Safety Net Care, is aimed at the 150,000 residents whose salaries are between 100% and 300% of the federal poverty level but who do not qualify for Medicaid.

The Commonwealth Care program tries to ease the burden of rising health care premiums that has hit some individuals and small businesses, Ms. Lischko said. The proposal would allow private insurers to offer new, more affordable health plans.

The proposal would reduce costs for individuals through pre-tax treatment of premiums and make it easier for businesses to offer insurance to their contractors and part-time workers by allowing employers to pay a smaller portion of the health insurance. And Ms. Lischko said that state policymakers expect private insurers to sign on because it creates a new market for younger, healthier people.

The Commonwealth Care plan would include coverage for primary care, hospitalization, mental health, and prescription drugs. But the provider network would be limited and insurers would be able to apply for exemptions from the state's 27 mandated benefits.

“It's not a bare-bones package,” Ms. Lischko said. “But it does have a more defined provider network. We're asking the insurers to really tighten up these networks.” The annual deductible for the plan would be between $250 and $1,000, and copayments would be moderate but somewhat higher than what is seen in the marketplace right now, Ms. Lischko said. And the monthly premium would be less than $200, compared with more than $350 a month in a standard small group.

The Safety Net Care program is designed for individuals who can't afford current insurance products or Commonwealth Care but who don't qualify for Medicaid. Unless subsidized by employers, these individuals would typically be uninsured and receive “free” health care, Ms. Lischko said, at a cost of about $1 billion a year.

This program would feature private insurance with the same benefits as Commonwealth Care, but with lower copays and no deductibles. The monthly premiums would be set according to a sliding scale based on individual income.

For example, a single individual with an income at 300% of federal poverty who earns $28,710 a year would be required to pay a weekly premium of $32.31, and the weekly state subsidy would be $36.92.

Under Gov. Romney's proposal, the Safety Net Care program would be funded with existing resources of about $922 million that are currently used to pay for care for the uninsured.

It's been a balancing act, Ms. Lischko said, in figuring out how to make the plans attractive without incentivizing employers to drop coverage. Some of that can be avoided due to existing tax code provisions for nondiscrimination and existing and new state provisions for nondiscrimination. And competition for workers is also likely to prevent companies from dropping coverage, she said.

NASHVILLE — The governor of Massachusetts is proposing to cover the uninsured in his state by creating lower-cost health insurance options and requiring individuals to obtain coverage.

This effort is aimed at providing affordable coverage for the approximately 460,000 or 7% of Massachusetts residents without health insurance, Amy Lischko, assistant commissioner of the Massachusetts Division of Health Care Finance and Policy, said at the annual conference of the National Academy for State Health Policy.

“We really feel like this is the year to get something done, and we're hopeful that parts at least of the governor's proposal will be moved on,” Ms. Lischko said.

This plan is one of a few proposals being considered by the state's legislature. Under the governor's plan, individuals would be required to have a minimum level of insurance or proof of their ability to pay for care on their tax return.

Those who do not comply could see a loss of their personal tax exemption and withholding of a portion or all of their income tax refund for deposit in a state personal health care expenditure account.

Individuals without coverage who use medical services would be required to pay, and there would be more up-front billing by providers. If patients are unable to pay, the provider may request payment from the state personal health care-expenditure account. But policymakers are flexible on the details of how such an individual mandate would be enforced. “This is the hard stuff,” Ms. Lischko said. “There's not going to be insurance police on the streets throwing people in jail that don't have health insurance.”

Coupled with the proposed individual insurance mandate, Gov. Mitt Romney (R) is also proposing to create two new low-cost health insurance options designed to appeal to the 7% of uninsured residents in the state.

But John McDonough, executive director of the advocacy group Health Care for All, commented that there are a lot of unanswered questions about Gov. Romney's plan. For example, there is no guarantee that private insurers step up to offer the new insurance plans envisioned by the governor, Mr. McDonough said in an interview. Also unstated is whether there are sufficient existing funds in the health care safety net to pay for the subsidies required for low-income residents.

Mr. McDonough's group instead favors an approach that would require employers to offer health insurance or pay a fee to the state, as well as expanding Medicaid eligibility and offers subsidies to moderate-income workers.

One program, called Commonwealth Care, will be aimed at about 204,000 uninsured residents who have incomes of more than 300% of the federal poverty level. The other coverage option, called Safety Net Care, is aimed at the 150,000 residents whose salaries are between 100% and 300% of the federal poverty level but who do not qualify for Medicaid.

The Commonwealth Care program tries to ease the burden of rising health care premiums that has hit some individuals and small businesses, Ms. Lischko said. The proposal would allow private insurers to offer new, more affordable health plans.

The proposal would reduce costs for individuals through pre-tax treatment of premiums and make it easier for businesses to offer insurance to their contractors and part-time workers by allowing employers to pay a smaller portion of the health insurance. And Ms. Lischko said that state policymakers expect private insurers to sign on because it creates a new market for younger, healthier people.

The Commonwealth Care plan would include coverage for primary care, hospitalization, mental health, and prescription drugs. But the provider network would be limited and insurers would be able to apply for exemptions from the state's 27 mandated benefits.

“It's not a bare-bones package,” Ms. Lischko said. “But it does have a more defined provider network. We're asking the insurers to really tighten up these networks.” The annual deductible for the plan would be between $250 and $1,000, and copayments would be moderate but somewhat higher than what is seen in the marketplace right now, Ms. Lischko said. And the monthly premium would be less than $200, compared with more than $350 a month in a standard small group.

The Safety Net Care program is designed for individuals who can't afford current insurance products or Commonwealth Care but who don't qualify for Medicaid. Unless subsidized by employers, these individuals would typically be uninsured and receive “free” health care, Ms. Lischko said, at a cost of about $1 billion a year.

This program would feature private insurance with the same benefits as Commonwealth Care, but with lower copays and no deductibles. The monthly premiums would be set according to a sliding scale based on individual income.

For example, a single individual with an income at 300% of federal poverty who earns $28,710 a year would be required to pay a weekly premium of $32.31, and the weekly state subsidy would be $36.92.

Under Gov. Romney's proposal, the Safety Net Care program would be funded with existing resources of about $922 million that are currently used to pay for care for the uninsured.

It's been a balancing act, Ms. Lischko said, in figuring out how to make the plans attractive without incentivizing employers to drop coverage. Some of that can be avoided due to existing tax code provisions for nondiscrimination and existing and new state provisions for nondiscrimination. And competition for workers is also likely to prevent companies from dropping coverage, she said.

NASHVILLE — The governor of Massachusetts is proposing to cover the uninsured in his state by creating lower-cost health insurance options and requiring individuals to obtain coverage.

This effort is aimed at providing affordable coverage for the approximately 460,000 or 7% of Massachusetts residents without health insurance, Amy Lischko, assistant commissioner of the Massachusetts Division of Health Care Finance and Policy, said at the annual conference of the National Academy for State Health Policy.

“We really feel like this is the year to get something done, and we're hopeful that parts at least of the governor's proposal will be moved on,” Ms. Lischko said.

This plan is one of a few proposals being considered by the state's legislature. Under the governor's plan, individuals would be required to have a minimum level of insurance or proof of their ability to pay for care on their tax return.

Those who do not comply could see a loss of their personal tax exemption and withholding of a portion or all of their income tax refund for deposit in a state personal health care expenditure account.

Individuals without coverage who use medical services would be required to pay, and there would be more up-front billing by providers. If patients are unable to pay, the provider may request payment from the state personal health care-expenditure account. But policymakers are flexible on the details of how such an individual mandate would be enforced. “This is the hard stuff,” Ms. Lischko said. “There's not going to be insurance police on the streets throwing people in jail that don't have health insurance.”

Coupled with the proposed individual insurance mandate, Gov. Mitt Romney (R) is also proposing to create two new low-cost health insurance options designed to appeal to the 7% of uninsured residents in the state.

But John McDonough, executive director of the advocacy group Health Care for All, commented that there are a lot of unanswered questions about Gov. Romney's plan. For example, there is no guarantee that private insurers step up to offer the new insurance plans envisioned by the governor, Mr. McDonough said in an interview. Also unstated is whether there are sufficient existing funds in the health care safety net to pay for the subsidies required for low-income residents.

Mr. McDonough's group instead favors an approach that would require employers to offer health insurance or pay a fee to the state, as well as expanding Medicaid eligibility and offers subsidies to moderate-income workers.

One program, called Commonwealth Care, will be aimed at about 204,000 uninsured residents who have incomes of more than 300% of the federal poverty level. The other coverage option, called Safety Net Care, is aimed at the 150,000 residents whose salaries are between 100% and 300% of the federal poverty level but who do not qualify for Medicaid.

The Commonwealth Care program tries to ease the burden of rising health care premiums that has hit some individuals and small businesses, Ms. Lischko said. The proposal would allow private insurers to offer new, more affordable health plans.

The proposal would reduce costs for individuals through pre-tax treatment of premiums and make it easier for businesses to offer insurance to their contractors and part-time workers by allowing employers to pay a smaller portion of the health insurance. And Ms. Lischko said that state policymakers expect private insurers to sign on because it creates a new market for younger, healthier people.

The Commonwealth Care plan would include coverage for primary care, hospitalization, mental health, and prescription drugs. But the provider network would be limited and insurers would be able to apply for exemptions from the state's 27 mandated benefits.

“It's not a bare-bones package,” Ms. Lischko said. “But it does have a more defined provider network. We're asking the insurers to really tighten up these networks.” The annual deductible for the plan would be between $250 and $1,000, and copayments would be moderate but somewhat higher than what is seen in the marketplace right now, Ms. Lischko said. And the monthly premium would be less than $200, compared with more than $350 a month in a standard small group.

The Safety Net Care program is designed for individuals who can't afford current insurance products or Commonwealth Care but who don't qualify for Medicaid. Unless subsidized by employers, these individuals would typically be uninsured and receive “free” health care, Ms. Lischko said, at a cost of about $1 billion a year.

This program would feature private insurance with the same benefits as Commonwealth Care, but with lower copays and no deductibles. The monthly premiums would be set according to a sliding scale based on individual income.

For example, a single individual with an income at 300% of federal poverty who earns $28,710 a year would be required to pay a weekly premium of $32.31, and the weekly state subsidy would be $36.92.

Under Gov. Romney's proposal, the Safety Net Care program would be funded with existing resources of about $922 million that are currently used to pay for care for the uninsured.

It's been a balancing act, Ms. Lischko said, in figuring out how to make the plans attractive without incentivizing employers to drop coverage. Some of that can be avoided due to existing tax code provisions for nondiscrimination and existing and new state provisions for nondiscrimination. And competition for workers is also likely to prevent companies from dropping coverage, she said.

ATLANTA — A significant burden is placed on the family members of children and adolescents with anxiety disorders, regardless of the age of the child, Catherine Mancini, M.D., said in a poster presentation at the annual meeting of the American Psychiatric Association.

The research shows that the burden affects various areas of family functioning, including the physical and mental health of family members and family closeness, wrote Dr. Mancini and her associates at McMaster University, Hamilton, Ont.

The study included 24 outpatient children (8–17 years old) with an anxiety disorder and 24 family members. The family members—4 fathers and 20 mothers—each completed self-rated questionnaires on the impact of the child's illness on various areas of family functioning.

Among the family members participating in the study, 50% reported some degree of family burden, 50% reported an effect on family health, and 25% reported an impact on family closeness.

A total of 17 of the 24 family members reported that their ill child had become “distressed/anxious/angry when we have not provided assistance.” Family members also reported disruption of routine activities due to the child's illness and care, or “irrational demands.”

Ten of the 24 parents reported that they or another family member had experienced physical change because of the child's illness, including weight loss, back pain, headaches, or sleeping problems.

Dr. Mancini and her associates did not find any significant differences on family burden scales between children aged 9–12 and adolescents aged 13–17.

Although the type of primary diagnosis did not make a significant difference in the family's burden, the researchers did report that primary obsessive-compulsive disorder rated significantly higher on the overall family burden scale than other primary conditions.

Anxiety disorders in male youths also may be associated with higher rates of overall burden and impact on family closeness.

ATLANTA — A significant burden is placed on the family members of children and adolescents with anxiety disorders, regardless of the age of the child, Catherine Mancini, M.D., said in a poster presentation at the annual meeting of the American Psychiatric Association.

The research shows that the burden affects various areas of family functioning, including the physical and mental health of family members and family closeness, wrote Dr. Mancini and her associates at McMaster University, Hamilton, Ont.

The study included 24 outpatient children (8–17 years old) with an anxiety disorder and 24 family members. The family members—4 fathers and 20 mothers—each completed self-rated questionnaires on the impact of the child's illness on various areas of family functioning.

Among the family members participating in the study, 50% reported some degree of family burden, 50% reported an effect on family health, and 25% reported an impact on family closeness.

A total of 17 of the 24 family members reported that their ill child had become “distressed/anxious/angry when we have not provided assistance.” Family members also reported disruption of routine activities due to the child's illness and care, or “irrational demands.”

Ten of the 24 parents reported that they or another family member had experienced physical change because of the child's illness, including weight loss, back pain, headaches, or sleeping problems.

Dr. Mancini and her associates did not find any significant differences on family burden scales between children aged 9–12 and adolescents aged 13–17.

Although the type of primary diagnosis did not make a significant difference in the family's burden, the researchers did report that primary obsessive-compulsive disorder rated significantly higher on the overall family burden scale than other primary conditions.

Anxiety disorders in male youths also may be associated with higher rates of overall burden and impact on family closeness.

ATLANTA — A significant burden is placed on the family members of children and adolescents with anxiety disorders, regardless of the age of the child, Catherine Mancini, M.D., said in a poster presentation at the annual meeting of the American Psychiatric Association.

The research shows that the burden affects various areas of family functioning, including the physical and mental health of family members and family closeness, wrote Dr. Mancini and her associates at McMaster University, Hamilton, Ont.

The study included 24 outpatient children (8–17 years old) with an anxiety disorder and 24 family members. The family members—4 fathers and 20 mothers—each completed self-rated questionnaires on the impact of the child's illness on various areas of family functioning.

Among the family members participating in the study, 50% reported some degree of family burden, 50% reported an effect on family health, and 25% reported an impact on family closeness.

A total of 17 of the 24 family members reported that their ill child had become “distressed/anxious/angry when we have not provided assistance.” Family members also reported disruption of routine activities due to the child's illness and care, or “irrational demands.”

Ten of the 24 parents reported that they or another family member had experienced physical change because of the child's illness, including weight loss, back pain, headaches, or sleeping problems.

Dr. Mancini and her associates did not find any significant differences on family burden scales between children aged 9–12 and adolescents aged 13–17.

Although the type of primary diagnosis did not make a significant difference in the family's burden, the researchers did report that primary obsessive-compulsive disorder rated significantly higher on the overall family burden scale than other primary conditions.

Anxiety disorders in male youths also may be associated with higher rates of overall burden and impact on family closeness.

ATLANTA — Patients who are taking antidepressants for the first time are at greatest risk for discontinuing the therapy, Mark Vanelli, M.D., said in a poster presentation at the annual meeting of the American Psychiatric Association.

The research shows that patients are most likely to stop drug treatment at the time of their first refill, typically 30–45 days after the initiation of therapy, wrote Dr. Vanelli, chief medical officer of Adheris Inc., a Burlington, Mass., company that provides patient adherence intervention programs.

He and his associates analyzed blinded pharmacy records from 1,157 pharmacies across the country to find patients who filled prescriptions for fluoxetine, sertraline (Zoloft), paroxetine (Paxil CR), venlafaxine (Effexor XR), citalopram (Celexa), or escitalopram (Lexapro). A total of 211,565 patients filled prescriptions for the six antidepressants between Oct. 1, 2003, and March 31, 2004.

Patients were divided into two groups: rookies and veterans. Rookies (37% of the sample) were patients with no prior use of any antidepressant in the 180 days prior to the index fill; veterans (63% of the sample) were defined as patients with a history of antidepressant use in the last 180 days.

Researchers followed the patients for 360 days to calculate the number of days to therapy discontinuation. They also analyzed other factors that might contribute to discontinuation, including age, gender, index refills prescribed, copayments, and estimated income.

The median number of days to discontinuation was 67 for the rookies and 184 days for veterans. The likelihood of discontinuing therapy after the initial fill of the prescription was 39.6% for rookies and 19.9% for veterans, Dr. Vanelli reported.

Patients were considered to have discontinued therapy once they were 30 days late for a scheduled refill. Those who switched from one antidepressant to another were considered to have continued with the therapy.

Patient experience was the variable that best predicted medication discontinuation, Dr. Vanelli noted. However, older men with higher incomes and higher index refills prescribed were less likely to discontinue therapy. Higher copays also increased the risk of discontinuing therapy.

The basic trends of drug discontinuation were similar across the six antidepressants included in the study, he said.

However, one of the limitations of the study is that diagnostic information was not available so the intended duration of therapy could not be determined.

The research shows that interventions are needed to help first-time users of antidepressants with medication adherence. Some strategies to improve antidepressant compliance could include following up with rookie patients at the time of the first refill to check on medication response, insight into the illness, and refill status, Dr. Vanelli suggested.

ATLANTA — Patients who are taking antidepressants for the first time are at greatest risk for discontinuing the therapy, Mark Vanelli, M.D., said in a poster presentation at the annual meeting of the American Psychiatric Association.

The research shows that patients are most likely to stop drug treatment at the time of their first refill, typically 30–45 days after the initiation of therapy, wrote Dr. Vanelli, chief medical officer of Adheris Inc., a Burlington, Mass., company that provides patient adherence intervention programs.

He and his associates analyzed blinded pharmacy records from 1,157 pharmacies across the country to find patients who filled prescriptions for fluoxetine, sertraline (Zoloft), paroxetine (Paxil CR), venlafaxine (Effexor XR), citalopram (Celexa), or escitalopram (Lexapro). A total of 211,565 patients filled prescriptions for the six antidepressants between Oct. 1, 2003, and March 31, 2004.

Patients were divided into two groups: rookies and veterans. Rookies (37% of the sample) were patients with no prior use of any antidepressant in the 180 days prior to the index fill; veterans (63% of the sample) were defined as patients with a history of antidepressant use in the last 180 days.

Researchers followed the patients for 360 days to calculate the number of days to therapy discontinuation. They also analyzed other factors that might contribute to discontinuation, including age, gender, index refills prescribed, copayments, and estimated income.

The median number of days to discontinuation was 67 for the rookies and 184 days for veterans. The likelihood of discontinuing therapy after the initial fill of the prescription was 39.6% for rookies and 19.9% for veterans, Dr. Vanelli reported.

Patients were considered to have discontinued therapy once they were 30 days late for a scheduled refill. Those who switched from one antidepressant to another were considered to have continued with the therapy.

Patient experience was the variable that best predicted medication discontinuation, Dr. Vanelli noted. However, older men with higher incomes and higher index refills prescribed were less likely to discontinue therapy. Higher copays also increased the risk of discontinuing therapy.

The basic trends of drug discontinuation were similar across the six antidepressants included in the study, he said.

However, one of the limitations of the study is that diagnostic information was not available so the intended duration of therapy could not be determined.

The research shows that interventions are needed to help first-time users of antidepressants with medication adherence. Some strategies to improve antidepressant compliance could include following up with rookie patients at the time of the first refill to check on medication response, insight into the illness, and refill status, Dr. Vanelli suggested.

ATLANTA — Patients who are taking antidepressants for the first time are at greatest risk for discontinuing the therapy, Mark Vanelli, M.D., said in a poster presentation at the annual meeting of the American Psychiatric Association.

The research shows that patients are most likely to stop drug treatment at the time of their first refill, typically 30–45 days after the initiation of therapy, wrote Dr. Vanelli, chief medical officer of Adheris Inc., a Burlington, Mass., company that provides patient adherence intervention programs.

He and his associates analyzed blinded pharmacy records from 1,157 pharmacies across the country to find patients who filled prescriptions for fluoxetine, sertraline (Zoloft), paroxetine (Paxil CR), venlafaxine (Effexor XR), citalopram (Celexa), or escitalopram (Lexapro). A total of 211,565 patients filled prescriptions for the six antidepressants between Oct. 1, 2003, and March 31, 2004.

Patients were divided into two groups: rookies and veterans. Rookies (37% of the sample) were patients with no prior use of any antidepressant in the 180 days prior to the index fill; veterans (63% of the sample) were defined as patients with a history of antidepressant use in the last 180 days.

Researchers followed the patients for 360 days to calculate the number of days to therapy discontinuation. They also analyzed other factors that might contribute to discontinuation, including age, gender, index refills prescribed, copayments, and estimated income.

The median number of days to discontinuation was 67 for the rookies and 184 days for veterans. The likelihood of discontinuing therapy after the initial fill of the prescription was 39.6% for rookies and 19.9% for veterans, Dr. Vanelli reported.

Patients were considered to have discontinued therapy once they were 30 days late for a scheduled refill. Those who switched from one antidepressant to another were considered to have continued with the therapy.

Patient experience was the variable that best predicted medication discontinuation, Dr. Vanelli noted. However, older men with higher incomes and higher index refills prescribed were less likely to discontinue therapy. Higher copays also increased the risk of discontinuing therapy.

The basic trends of drug discontinuation were similar across the six antidepressants included in the study, he said.

However, one of the limitations of the study is that diagnostic information was not available so the intended duration of therapy could not be determined.

The research shows that interventions are needed to help first-time users of antidepressants with medication adherence. Some strategies to improve antidepressant compliance could include following up with rookie patients at the time of the first refill to check on medication response, insight into the illness, and refill status, Dr. Vanelli suggested.

NASHVILLE, TENN. — Integrating mental health and primary care has the potential to reduce medication mistakes and improve communication among providers, experts said at the annual conference of the National Academy for State Health Policy.

“This is a medical error reduction opportunity as well as a quality and cost opportunity,” said Joseph J. Parks Jr., M.D., a psychiatrist and medical director for the Missouri Department of Mental Health.

The status quo is not working, he said. Individuals with mental illness have increased or early mortality, have high rates of medical comorbidity, and receive inadequate and poorly coordinated health care.

Mental illness also predicts underutilization of medical services. A study of older patients with psychiatric disorders found that individuals with diabetes were less likely to receive more than one medical visit if they also had schizophrenia, bipolar disorder, or posttraumatic stress disorder. Patients with hypertension and any psychiatric disorder were also less likely to have more than one medical visit (Psychiatr. Serv. 2002;53:874–8).

There are several models for integrated mental health and physical care, including embedding primary care in a mental health program, creating a unified primary care/mental health program with common administration and financing, and improving collaboration between mental health and medical providers.

Evidence seems to show that trying to create linkage is difficult, Dr. Parks said. “Collaboration is basically an unnatural act between separate organizations,” he said. Although this model is easier to set up initially, it is harder to make successful over the long run.

Models where primary care is embedded in mental health clinics or primary care and mental health programs are unified are harder to set up initially but easier to operate on a day-to-day basis, he said.

In general, the colocation of services is popular with both patients and providers. On the provider side, it allows physicians and other providers to have a more accurate understanding of one another's incentives, methods, and constraints, Dr. Parks said. Colocation also allows physicians to maintain a single clinical record, which requires less time and creates less potential for errors.

For patients, it breaks down some of the barriers to care, said Susan C. Braun, a nurse practitioner and project director of the Center for Integrated Health Care at the University of Illinois at Chicago.

She runs a program that brings primary care services into an established psychiatric rehabilitation program. That setup allows mentally ill patients to access medical services without going to a large medical center. Instead, they are cared for in a familiar setting, she said.

Providers at Cherokee Health Systems Inc. in Talbott, Tenn., have taken the opposite approach. There, a behavioral health consultant is embedded with the primary care team.

For example, a behaviorist is involved in all well-child visits, said Dennis Freeman, Ph.D., chief executive officer of Cherokee Health Systems. Behaviorists also manage the psychosocial aspects of chronic and acute diseases, address lifestyle and health risk issues, and comanage treatment of mental disorders.

Dr. Freeman said that state regulators and policy makers should reject carved-out payments for mental health services because the majority of these services will continue to be delivered by primary care physicians.

And he encouraged more payers to implement the Health and Behavior Assessment/Intervention CPT codes 96150 through 96155. The codes, issued in 2002, are for use by nonphysicians for services involving the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

Contractual requirements and financial incentives through state Medicaid programs will also help encourage integration of services, Dr. Parks said.

“People will start doing things because it's the right thing to do, but people don't always keep doing things once the excitement dies down,” he said.

NASHVILLE, TENN. — Integrating mental health and primary care has the potential to reduce medication mistakes and improve communication among providers, experts said at the annual conference of the National Academy for State Health Policy.

“This is a medical error reduction opportunity as well as a quality and cost opportunity,” said Joseph J. Parks Jr., M.D., a psychiatrist and medical director for the Missouri Department of Mental Health.

The status quo is not working, he said. Individuals with mental illness have increased or early mortality, have high rates of medical comorbidity, and receive inadequate and poorly coordinated health care.

Mental illness also predicts underutilization of medical services. A study of older patients with psychiatric disorders found that individuals with diabetes were less likely to receive more than one medical visit if they also had schizophrenia, bipolar disorder, or posttraumatic stress disorder. Patients with hypertension and any psychiatric disorder were also less likely to have more than one medical visit (Psychiatr. Serv. 2002;53:874–8).

There are several models for integrated mental health and physical care, including embedding primary care in a mental health program, creating a unified primary care/mental health program with common administration and financing, and improving collaboration between mental health and medical providers.

Evidence seems to show that trying to create linkage is difficult, Dr. Parks said. “Collaboration is basically an unnatural act between separate organizations,” he said. Although this model is easier to set up initially, it is harder to make successful over the long run.

Models where primary care is embedded in mental health clinics or primary care and mental health programs are unified are harder to set up initially but easier to operate on a day-to-day basis, he said.

In general, the colocation of services is popular with both patients and providers. On the provider side, it allows physicians and other providers to have a more accurate understanding of one another's incentives, methods, and constraints, Dr. Parks said. Colocation also allows physicians to maintain a single clinical record, which requires less time and creates less potential for errors.

For patients, it breaks down some of the barriers to care, said Susan C. Braun, a nurse practitioner and project director of the Center for Integrated Health Care at the University of Illinois at Chicago.

She runs a program that brings primary care services into an established psychiatric rehabilitation program. That setup allows mentally ill patients to access medical services without going to a large medical center. Instead, they are cared for in a familiar setting, she said.

Providers at Cherokee Health Systems Inc. in Talbott, Tenn., have taken the opposite approach. There, a behavioral health consultant is embedded with the primary care team.

For example, a behaviorist is involved in all well-child visits, said Dennis Freeman, Ph.D., chief executive officer of Cherokee Health Systems. Behaviorists also manage the psychosocial aspects of chronic and acute diseases, address lifestyle and health risk issues, and comanage treatment of mental disorders.

Dr. Freeman said that state regulators and policy makers should reject carved-out payments for mental health services because the majority of these services will continue to be delivered by primary care physicians.

And he encouraged more payers to implement the Health and Behavior Assessment/Intervention CPT codes 96150 through 96155. The codes, issued in 2002, are for use by nonphysicians for services involving the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

Contractual requirements and financial incentives through state Medicaid programs will also help encourage integration of services, Dr. Parks said.

“People will start doing things because it's the right thing to do, but people don't always keep doing things once the excitement dies down,” he said.

NASHVILLE, TENN. — Integrating mental health and primary care has the potential to reduce medication mistakes and improve communication among providers, experts said at the annual conference of the National Academy for State Health Policy.

“This is a medical error reduction opportunity as well as a quality and cost opportunity,” said Joseph J. Parks Jr., M.D., a psychiatrist and medical director for the Missouri Department of Mental Health.

The status quo is not working, he said. Individuals with mental illness have increased or early mortality, have high rates of medical comorbidity, and receive inadequate and poorly coordinated health care.

Mental illness also predicts underutilization of medical services. A study of older patients with psychiatric disorders found that individuals with diabetes were less likely to receive more than one medical visit if they also had schizophrenia, bipolar disorder, or posttraumatic stress disorder. Patients with hypertension and any psychiatric disorder were also less likely to have more than one medical visit (Psychiatr. Serv. 2002;53:874–8).

There are several models for integrated mental health and physical care, including embedding primary care in a mental health program, creating a unified primary care/mental health program with common administration and financing, and improving collaboration between mental health and medical providers.

Evidence seems to show that trying to create linkage is difficult, Dr. Parks said. “Collaboration is basically an unnatural act between separate organizations,” he said. Although this model is easier to set up initially, it is harder to make successful over the long run.

Models where primary care is embedded in mental health clinics or primary care and mental health programs are unified are harder to set up initially but easier to operate on a day-to-day basis, he said.

In general, the colocation of services is popular with both patients and providers. On the provider side, it allows physicians and other providers to have a more accurate understanding of one another's incentives, methods, and constraints, Dr. Parks said. Colocation also allows physicians to maintain a single clinical record, which requires less time and creates less potential for errors.

For patients, it breaks down some of the barriers to care, said Susan C. Braun, a nurse practitioner and project director of the Center for Integrated Health Care at the University of Illinois at Chicago.

She runs a program that brings primary care services into an established psychiatric rehabilitation program. That setup allows mentally ill patients to access medical services without going to a large medical center. Instead, they are cared for in a familiar setting, she said.

Providers at Cherokee Health Systems Inc. in Talbott, Tenn., have taken the opposite approach. There, a behavioral health consultant is embedded with the primary care team.

For example, a behaviorist is involved in all well-child visits, said Dennis Freeman, Ph.D., chief executive officer of Cherokee Health Systems. Behaviorists also manage the psychosocial aspects of chronic and acute diseases, address lifestyle and health risk issues, and comanage treatment of mental disorders.

Dr. Freeman said that state regulators and policy makers should reject carved-out payments for mental health services because the majority of these services will continue to be delivered by primary care physicians.

And he encouraged more payers to implement the Health and Behavior Assessment/Intervention CPT codes 96150 through 96155. The codes, issued in 2002, are for use by nonphysicians for services involving the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

Contractual requirements and financial incentives through state Medicaid programs will also help encourage integration of services, Dr. Parks said.

“People will start doing things because it's the right thing to do, but people don't always keep doing things once the excitement dies down,” he said.

NASHVILLE, TENN. – Integrating mental health and primary care has the potential to reduce medication mistakes and improve communication among providers, experts said at the annual conference of the National Academy for State Health Policy.

“This is a medical error reduction opportunity as well as a quality and cost opportunity,” said Joseph J. Parks Jr., M.D., a psychiatrist and medical director for the Missouri Department of Mental Health.

The status quo isn't working, he said. Individuals with mental illness have increased or early mortality, have high rates of medical comorbidity, and receive inadequate and poorly coordinated health care.

Mental illness also predicts underutilization of medical services. A study of older patients with psychiatric disorders found that individuals with diabetes were less likely to receive more than one medical visit if they also had schizophrenia, bipolar disorder, or posttraumatic stress disorder. Patients with hypertension and any psychiatric disorder were also less likely to have more than one medical visit (Psychiatr. Serv. 2002;53:874–8).

There are several models for integrated mental health and physical care, including embedding primary care in a mental health program, creating a unified primary care/mental health program with common administration and financing, and improving collaboration between mental health and medical providers.

Evidence seems to show that trying to create linkage is difficult, Dr. Parks said. “Collaboration is basically an unnatural act between separate organizations,” he said. While this model is easier to set up initially, it is harder to make successful over the long run.

Models where primary care is embedded in mental health clinics or primary care and mental health programs are unified are harder to set up initially but easier to operate day to day, he said.

In general, the colocation of services is popular with both patients and providers. On the provider side, it allows physicians and other providers to have a more accurate understanding of one another's incentives, methods, and constraints, Dr. Parks said. Colocation also allows physicians to maintain a single clinical record, which requires less time and creates less potential for errors.

For patients, it breaks down some of the barriers to care, said Susan C. Braun, a nurse practitioner and project director of the Center for Integrated Health Care at the University of Illinois at Chicago.

She runs a program that brings primary care services into an established psychiatric rehabilitation program. That setup allows mentally ill patients to access medical services without going to a large medical center. Instead, they are cared for in a familiar setting, she said.

Providers at Cherokee Health Systems Inc. in Talbott, Tenn., have taken the opposite approach. There, a behavioral health consultant is embedded with the primary care team. For example, a behaviorist is involved in all well-child visits, said Dennis Freeman, Ph.D., chief executive officer of Cherokee Health Systems. Behaviorists also manage the psychosocial aspects of chronic and acute diseases, address lifestyle and health risk issues, and comanage treatment of mental disorders.

Dr. Freeman said that state regulators and policy makers should reject carved out payments for mental health services because the majority of these services will continue to be delivered by primary care physicians. And he encouraged more payers to implement the Health and Behavior Assessment/Intervention CPT codes 96150 through 96155 that were issued in 2002. The codes are for use by nonphysicians for services involving the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

Contractual requirements and financial incentives through state Medicaid programs will also help encourage integration of services, Dr. Parks said.

NASHVILLE, TENN. – Integrating mental health and primary care has the potential to reduce medication mistakes and improve communication among providers, experts said at the annual conference of the National Academy for State Health Policy.

“This is a medical error reduction opportunity as well as a quality and cost opportunity,” said Joseph J. Parks Jr., M.D., a psychiatrist and medical director for the Missouri Department of Mental Health.

The status quo isn't working, he said. Individuals with mental illness have increased or early mortality, have high rates of medical comorbidity, and receive inadequate and poorly coordinated health care.

Mental illness also predicts underutilization of medical services. A study of older patients with psychiatric disorders found that individuals with diabetes were less likely to receive more than one medical visit if they also had schizophrenia, bipolar disorder, or posttraumatic stress disorder. Patients with hypertension and any psychiatric disorder were also less likely to have more than one medical visit (Psychiatr. Serv. 2002;53:874–8).

There are several models for integrated mental health and physical care, including embedding primary care in a mental health program, creating a unified primary care/mental health program with common administration and financing, and improving collaboration between mental health and medical providers.

Evidence seems to show that trying to create linkage is difficult, Dr. Parks said. “Collaboration is basically an unnatural act between separate organizations,” he said. While this model is easier to set up initially, it is harder to make successful over the long run.

Models where primary care is embedded in mental health clinics or primary care and mental health programs are unified are harder to set up initially but easier to operate day to day, he said.

In general, the colocation of services is popular with both patients and providers. On the provider side, it allows physicians and other providers to have a more accurate understanding of one another's incentives, methods, and constraints, Dr. Parks said. Colocation also allows physicians to maintain a single clinical record, which requires less time and creates less potential for errors.

For patients, it breaks down some of the barriers to care, said Susan C. Braun, a nurse practitioner and project director of the Center for Integrated Health Care at the University of Illinois at Chicago.

She runs a program that brings primary care services into an established psychiatric rehabilitation program. That setup allows mentally ill patients to access medical services without going to a large medical center. Instead, they are cared for in a familiar setting, she said.

Providers at Cherokee Health Systems Inc. in Talbott, Tenn., have taken the opposite approach. There, a behavioral health consultant is embedded with the primary care team. For example, a behaviorist is involved in all well-child visits, said Dennis Freeman, Ph.D., chief executive officer of Cherokee Health Systems. Behaviorists also manage the psychosocial aspects of chronic and acute diseases, address lifestyle and health risk issues, and comanage treatment of mental disorders.

Dr. Freeman said that state regulators and policy makers should reject carved out payments for mental health services because the majority of these services will continue to be delivered by primary care physicians. And he encouraged more payers to implement the Health and Behavior Assessment/Intervention CPT codes 96150 through 96155 that were issued in 2002. The codes are for use by nonphysicians for services involving the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

Contractual requirements and financial incentives through state Medicaid programs will also help encourage integration of services, Dr. Parks said.

NASHVILLE, TENN. – Integrating mental health and primary care has the potential to reduce medication mistakes and improve communication among providers, experts said at the annual conference of the National Academy for State Health Policy.

“This is a medical error reduction opportunity as well as a quality and cost opportunity,” said Joseph J. Parks Jr., M.D., a psychiatrist and medical director for the Missouri Department of Mental Health.

The status quo isn't working, he said. Individuals with mental illness have increased or early mortality, have high rates of medical comorbidity, and receive inadequate and poorly coordinated health care.

Mental illness also predicts underutilization of medical services. A study of older patients with psychiatric disorders found that individuals with diabetes were less likely to receive more than one medical visit if they also had schizophrenia, bipolar disorder, or posttraumatic stress disorder. Patients with hypertension and any psychiatric disorder were also less likely to have more than one medical visit (Psychiatr. Serv. 2002;53:874–8).

There are several models for integrated mental health and physical care, including embedding primary care in a mental health program, creating a unified primary care/mental health program with common administration and financing, and improving collaboration between mental health and medical providers.

Evidence seems to show that trying to create linkage is difficult, Dr. Parks said. “Collaboration is basically an unnatural act between separate organizations,” he said. While this model is easier to set up initially, it is harder to make successful over the long run.

Models where primary care is embedded in mental health clinics or primary care and mental health programs are unified are harder to set up initially but easier to operate day to day, he said.

In general, the colocation of services is popular with both patients and providers. On the provider side, it allows physicians and other providers to have a more accurate understanding of one another's incentives, methods, and constraints, Dr. Parks said. Colocation also allows physicians to maintain a single clinical record, which requires less time and creates less potential for errors.

For patients, it breaks down some of the barriers to care, said Susan C. Braun, a nurse practitioner and project director of the Center for Integrated Health Care at the University of Illinois at Chicago.

She runs a program that brings primary care services into an established psychiatric rehabilitation program. That setup allows mentally ill patients to access medical services without going to a large medical center. Instead, they are cared for in a familiar setting, she said.

Providers at Cherokee Health Systems Inc. in Talbott, Tenn., have taken the opposite approach. There, a behavioral health consultant is embedded with the primary care team. For example, a behaviorist is involved in all well-child visits, said Dennis Freeman, Ph.D., chief executive officer of Cherokee Health Systems. Behaviorists also manage the psychosocial aspects of chronic and acute diseases, address lifestyle and health risk issues, and comanage treatment of mental disorders.

Dr. Freeman said that state regulators and policy makers should reject carved out payments for mental health services because the majority of these services will continue to be delivered by primary care physicians. And he encouraged more payers to implement the Health and Behavior Assessment/Intervention CPT codes 96150 through 96155 that were issued in 2002. The codes are for use by nonphysicians for services involving the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

Contractual requirements and financial incentives through state Medicaid programs will also help encourage integration of services, Dr. Parks said.

The Department of Health and Human Services has loosened restrictions on ownership of pharmaceutical and biotech company stocks by National Institutes of Health employees.

A final rule on conflict of interest, announced at a teleconference, continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership. “We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” he said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families must divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case by case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed potential conflicts of interest among NIH scientists. Under the earlier plan, about 6,000 top NIH employees would have been required to sell off all stock holdings in companies affected by NIH decisions. The remainder of NIH employees would have faced the $15,000 limit.

The changes aim to target the requirements at employees making decisions on grants and studies, Dr. Zerhouni said.

The final rule will give NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews, subject to prior approval and review by ethics officials.

The regulation continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees also can practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology, or medical device manufacturers, health care providers or insurers, and NIH grantee institutions. Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. The final regulation will serve as a benchmark for the rest of the research community, Ms. Woolley said.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to address conflicts of interest. Allowing NIH employees to participate in paid outside academic work, which often includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni advocated a broad dialogue about conflict of interest with the entire scientific community. “This is a debate that is way beyond that of NIH,” he said.

For more information on NIH ethics rules visit www.nih.gov/about/ethics_COI.htm

The Department of Health and Human Services has loosened restrictions on ownership of pharmaceutical and biotech company stocks by National Institutes of Health employees.

A final rule on conflict of interest, announced at a teleconference, continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership. “We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” he said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families must divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case by case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed potential conflicts of interest among NIH scientists. Under the earlier plan, about 6,000 top NIH employees would have been required to sell off all stock holdings in companies affected by NIH decisions. The remainder of NIH employees would have faced the $15,000 limit.

The changes aim to target the requirements at employees making decisions on grants and studies, Dr. Zerhouni said.

The final rule will give NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews, subject to prior approval and review by ethics officials.

The regulation continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees also can practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology, or medical device manufacturers, health care providers or insurers, and NIH grantee institutions. Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. The final regulation will serve as a benchmark for the rest of the research community, Ms. Woolley said.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to address conflicts of interest. Allowing NIH employees to participate in paid outside academic work, which often includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni advocated a broad dialogue about conflict of interest with the entire scientific community. “This is a debate that is way beyond that of NIH,” he said.

For more information on NIH ethics rules visit www.nih.gov/about/ethics_COI.htm

The Department of Health and Human Services has loosened restrictions on ownership of pharmaceutical and biotech company stocks by National Institutes of Health employees.

A final rule on conflict of interest, announced at a teleconference, continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership. “We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” he said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families must divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case by case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed potential conflicts of interest among NIH scientists. Under the earlier plan, about 6,000 top NIH employees would have been required to sell off all stock holdings in companies affected by NIH decisions. The remainder of NIH employees would have faced the $15,000 limit.

The changes aim to target the requirements at employees making decisions on grants and studies, Dr. Zerhouni said.

The final rule will give NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews, subject to prior approval and review by ethics officials.

The regulation continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees also can practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology, or medical device manufacturers, health care providers or insurers, and NIH grantee institutions. Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. The final regulation will serve as a benchmark for the rest of the research community, Ms. Woolley said.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to address conflicts of interest. Allowing NIH employees to participate in paid outside academic work, which often includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni advocated a broad dialogue about conflict of interest with the entire scientific community. “This is a debate that is way beyond that of NIH,” he said.

For more information on NIH ethics rules visit www.nih.gov/about/ethics_COI.htm

A jury in Texas last month awarded $253 million to the widow of a man who died after taking Vioxx (rofecoxib). The plaintiff charged that the drug maker Merck & Co. failed to warn physicians about the danger posed by Vioxx, that the drug was improperly designed, and that the company's negligence caused the death of the plaintiff's husband, Robert Ernst. Merck executives plan to appeal the verdict on the grounds that the jury was allowed to hear testimony that was both irrelevant and not based on reliable science, the company said. "While we are disappointed with the verdict, this decision should be put in its appropriate context," Kenneth C. Frazier, Merck's senior vice president and general counsel, said in a statement. "This is the first of many trials. Each case has a different set of facts. Regardless of the outcome in this single case, the fact remains that plaintiffs have a significant legal burden in proving causation." The award included $24 million in actual damages and $229 million in punitive damages. But the punitive damages could be reduced to about $2 million, according to Merck.

A jury in Texas last month awarded $253 million to the widow of a man who died after taking Vioxx (rofecoxib). The plaintiff charged that the drug maker Merck & Co. failed to warn physicians about the danger posed by Vioxx, that the drug was improperly designed, and that the company's negligence caused the death of the plaintiff's husband, Robert Ernst. Merck executives plan to appeal the verdict on the grounds that the jury was allowed to hear testimony that was both irrelevant and not based on reliable science, the company said. "While we are disappointed with the verdict, this decision should be put in its appropriate context," Kenneth C. Frazier, Merck's senior vice president and general counsel, said in a statement. "This is the first of many trials. Each case has a different set of facts. Regardless of the outcome in this single case, the fact remains that plaintiffs have a significant legal burden in proving causation." The award included $24 million in actual damages and $229 million in punitive damages. But the punitive damages could be reduced to about $2 million, according to Merck.

A jury in Texas last month awarded $253 million to the widow of a man who died after taking Vioxx (rofecoxib). The plaintiff charged that the drug maker Merck & Co. failed to warn physicians about the danger posed by Vioxx, that the drug was improperly designed, and that the company's negligence caused the death of the plaintiff's husband, Robert Ernst. Merck executives plan to appeal the verdict on the grounds that the jury was allowed to hear testimony that was both irrelevant and not based on reliable science, the company said. "While we are disappointed with the verdict, this decision should be put in its appropriate context," Kenneth C. Frazier, Merck's senior vice president and general counsel, said in a statement. "This is the first of many trials. Each case has a different set of facts. Regardless of the outcome in this single case, the fact remains that plaintiffs have a significant legal burden in proving causation." The award included $24 million in actual damages and $229 million in punitive damages. But the punitive damages could be reduced to about $2 million, according to Merck.

NASHVILLE, TENN. — The Medicaid program needs to undergo some fundamental changes, including asking patients to share some of the costs, Tennessee Gov. Phil Bredesen said at the annual conference of the National Academy for State Health Policy.

"We have got to get control of the economics of the program," he said.

In Tennessee, Gov. Bredesen has come under fire for his attempts to make cuts and disenroll beneficiaries in the state's financially troubled Medicaid program, known as TennCare.

Just throwing money at the problem nationally won't work, Gov. Bredesen said. For starters, the United States already spends more than any other industrialized nation on health care and still has tens of millions of uninsured citizens. And politically, it's unlikely that an infusion of funds would be available for the program.

Instead, Gov. Bredesen suggested that policy makers need to figure out how to make the existing Medicaid funding go further.

First, he proposed that everyone should pay a little something for everything.

"Unless and until there is some economic tension in the program—unless the users make some of the choices for themselves about how scarce resources are going to be used—the system will continue to be inefficient," he said.

The Medicaid Commission, which is charged with recommending ways to cuts costs in the program, has focused mainly on changes such as negotiating better prices with drug companies and cracking down on asset transfers by Medicaid applicants. However, the commission did tackle beneficiary cost sharing in its recommendation to give states the flexibility to increase copays for some beneficiaries on nonpreferred drugs.

The best way to do that is to let beneficiaries decide what they are willing to pay for and what they aren't, he said. "This is not about being hard-hearted," he asserted.

For example, Tennessee has a number of faith-based clinics that serve the uninsured; at these clinics, everyone pays something for their care. People tend to value things that they pay a little bit for and don't value things that are completely free, Gov. Bredesen said.

Second, government purchasers should pay for the most important things first, he said. Not everything that can be categorized as health care is on an equal footing, he said. For example, providing prenatal care to pregnant women is more important than covering antihistamines, he said.

But in Tennessee, the state spends $280 million annually on two classes of drugs—antihistamines and gastric acid reducers. These two classes of drugs account for 12% of the number of prescriptions written in the TennCare program. "We need to exercise some intelligent discretion here and prioritize what we do," Gov. Bredesen said.

Third, he suggested that the Medicaid program should pay only for what works instead of paying for any new drug that comes on the market. He noted that in 2002, the Food and Drug Administration approved 78 new drugs, of which only 7 contained any new active ingredients that were classified as improvements over existing medications.

"If we limit our oversight to a policy of buy everything but just argue about discounts, we've completely lost control," Gov. Bredesen said.

NASHVILLE, TENN. — The Medicaid program needs to undergo some fundamental changes, including asking patients to share some of the costs, Tennessee Gov. Phil Bredesen said at the annual conference of the National Academy for State Health Policy.

"We have got to get control of the economics of the program," he said.

In Tennessee, Gov. Bredesen has come under fire for his attempts to make cuts and disenroll beneficiaries in the state's financially troubled Medicaid program, known as TennCare.

Just throwing money at the problem nationally won't work, Gov. Bredesen said. For starters, the United States already spends more than any other industrialized nation on health care and still has tens of millions of uninsured citizens. And politically, it's unlikely that an infusion of funds would be available for the program.

Instead, Gov. Bredesen suggested that policy makers need to figure out how to make the existing Medicaid funding go further.

First, he proposed that everyone should pay a little something for everything.

"Unless and until there is some economic tension in the program—unless the users make some of the choices for themselves about how scarce resources are going to be used—the system will continue to be inefficient," he said.

The Medicaid Commission, which is charged with recommending ways to cuts costs in the program, has focused mainly on changes such as negotiating better prices with drug companies and cracking down on asset transfers by Medicaid applicants. However, the commission did tackle beneficiary cost sharing in its recommendation to give states the flexibility to increase copays for some beneficiaries on nonpreferred drugs.

The best way to do that is to let beneficiaries decide what they are willing to pay for and what they aren't, he said. "This is not about being hard-hearted," he asserted.

For example, Tennessee has a number of faith-based clinics that serve the uninsured; at these clinics, everyone pays something for their care. People tend to value things that they pay a little bit for and don't value things that are completely free, Gov. Bredesen said.

Second, government purchasers should pay for the most important things first, he said. Not everything that can be categorized as health care is on an equal footing, he said. For example, providing prenatal care to pregnant women is more important than covering antihistamines, he said.

But in Tennessee, the state spends $280 million annually on two classes of drugs—antihistamines and gastric acid reducers. These two classes of drugs account for 12% of the number of prescriptions written in the TennCare program. "We need to exercise some intelligent discretion here and prioritize what we do," Gov. Bredesen said.

Third, he suggested that the Medicaid program should pay only for what works instead of paying for any new drug that comes on the market. He noted that in 2002, the Food and Drug Administration approved 78 new drugs, of which only 7 contained any new active ingredients that were classified as improvements over existing medications.

"If we limit our oversight to a policy of buy everything but just argue about discounts, we've completely lost control," Gov. Bredesen said.

NASHVILLE, TENN. — The Medicaid program needs to undergo some fundamental changes, including asking patients to share some of the costs, Tennessee Gov. Phil Bredesen said at the annual conference of the National Academy for State Health Policy.

"We have got to get control of the economics of the program," he said.

In Tennessee, Gov. Bredesen has come under fire for his attempts to make cuts and disenroll beneficiaries in the state's financially troubled Medicaid program, known as TennCare.

Just throwing money at the problem nationally won't work, Gov. Bredesen said. For starters, the United States already spends more than any other industrialized nation on health care and still has tens of millions of uninsured citizens. And politically, it's unlikely that an infusion of funds would be available for the program.

Instead, Gov. Bredesen suggested that policy makers need to figure out how to make the existing Medicaid funding go further.

First, he proposed that everyone should pay a little something for everything.

"Unless and until there is some economic tension in the program—unless the users make some of the choices for themselves about how scarce resources are going to be used—the system will continue to be inefficient," he said.

The Medicaid Commission, which is charged with recommending ways to cuts costs in the program, has focused mainly on changes such as negotiating better prices with drug companies and cracking down on asset transfers by Medicaid applicants. However, the commission did tackle beneficiary cost sharing in its recommendation to give states the flexibility to increase copays for some beneficiaries on nonpreferred drugs.

The best way to do that is to let beneficiaries decide what they are willing to pay for and what they aren't, he said. "This is not about being hard-hearted," he asserted.

For example, Tennessee has a number of faith-based clinics that serve the uninsured; at these clinics, everyone pays something for their care. People tend to value things that they pay a little bit for and don't value things that are completely free, Gov. Bredesen said.

Second, government purchasers should pay for the most important things first, he said. Not everything that can be categorized as health care is on an equal footing, he said. For example, providing prenatal care to pregnant women is more important than covering antihistamines, he said.

But in Tennessee, the state spends $280 million annually on two classes of drugs—antihistamines and gastric acid reducers. These two classes of drugs account for 12% of the number of prescriptions written in the TennCare program. "We need to exercise some intelligent discretion here and prioritize what we do," Gov. Bredesen said.

Third, he suggested that the Medicaid program should pay only for what works instead of paying for any new drug that comes on the market. He noted that in 2002, the Food and Drug Administration approved 78 new drugs, of which only 7 contained any new active ingredients that were classified as improvements over existing medications.

"If we limit our oversight to a policy of buy everything but just argue about discounts, we've completely lost control," Gov. Bredesen said.