Up in Smoke

In the 1998 settlement agreement, the states are to receive a total of $206 billion compensation from the tobacco industry over a period of years. The states, in turn, pledged to target a significant portion of those funds towards anti-smoking programs…many to be expressly directed at young folks. Objective of course was to combat the unnecessary illness and rising cost-of-healthcare caused by smoking. It is quite obvious that the program is very much off-target.

That assumption is based on the latest report from the Robert Wood Johnson Foundation which monitors how this "tobacco fund" money is being spent; the report is compiled with the assistance of a coalition of public health organizations. This year, after careful analysis, they referred to the list of state anti-smoking programs as the latest example of "A Broken Promise to Our Children".

Each year the states have been receiving huge amounts of settlement money ($21.3 billion for this year alone), based in part on the pledge that a reasonable portion of each year's sum is dedicated to ongoing anti-tobacco-use programs…mainly targeted towards youngsters.

The CDC and its panel of experts spent months charting the minimum portion of this windfall that must be dedicated each year to an ongoing "it-doesn't-make-sense-to-smoke" program in order for these programs to prove effective. It was made quite clear that any less would simply be both ineffective and wasteful.

The agency recommends that, to do this year's job, a total of $1.6 billion must be so targeted. Reports are that states are allocating just $551 million in 2006, about a third of the apparently-necessary funds. It claimed that only Maine, Mississippi, Colorado and Delaware are currently funding prevention programs at the bare minimum levels recommended by the CDC. In fact, the anti-smoking programs of 30 states were found to have spent less than half their recommended annual amounts. The District of Columbia, Michigan, Missouri, South Carolina, New Hampshire and Tennessee spent not a single dollar on any type of anti-smoking program in the year 2005. The overall drop of targeted funds has been steady and consistent since shortly after the program was announced. Instead, most of the dollars originally pledged for programs that would reduce the use of tobacco at all levels -- but especially among our youth -- have mostly been used to pay off "general fund" budget shortages that allow state representatives to boast they are fulfilling their latest "no new taxes" pledges.

States also received smaller amounts of similar-targeted dollars directly from the CDC. California, by far our biggest state, receives $165 million; much of this, too, goes up in smoke, apparently used to fix potholes and repair bridge crossings that should be funded by other means. Meanwhile, the tobacco companies reportedly have increased their own marketing/ advertising expenditures by 84% since the 1998 settlement. Best current estimate is that the industry continues to spend over $15 billion a year marketing its products.

The American Cancer Society insists that anti-tobacco programs work, but only if they are sufficiently funded and ongoing at the required level; which is clearly not the case here. So the once-promised drop in the billions of dollars spent on treating and reducing lung disease and other smoking-related illnesses have become yet another broken promise.

The various anti-smoking advocacy groups are now demanding on-the-ballot budget initiatives that will force state legislatures to spend much more of this industry settlement money on the anti-smoking programs, as was initially pledged. Colorado passed such an initiative in 2004 -- part of tax-increase legislation -- and available smoker prevention-targeted funds rose to $27 million from a previous $4.3 million…$2.5 million above the CDC recommended minimum for the state. Putting them well on the road to becoming one of the very few "good guys" in the still-ongoing tobacco wars.

Kid Coverage Increasing

Just awhile ago, New Jersey's KidKare and similar programs around the country successfully enrolled lots of children and a number of parents in low-cost healthcare programs. It was high-profile for awhile, hasn't been much in print since...and some of the once-available support funds have been slipping into other projects.

But things seem to be turning around again, very much on a state-by-state basis, as small to giant employers continue to cut back their share of employee healthcare costs in an effort to remain competitive. Legislative rule again seems to be…find a way to at least give children some measure of protection and, if there are any extra dollars, cover as many low-income adults at possible.

In the past year, twenty states have made it easier for children to apply and to be taken into a state-supported healthcare program. Best estimate is that over 350,000 children who weren't covered just a year or two ago are now in one of these programs. Illinois seems to be taking the lead by passing legislation that effectively mandates free or low-cost medical care for every child in the state. That added 250,000 to the list of America's "covered kids". At the same time, New Jersey restored medical coverage to 75,000 families that had been temporarily dropped from their rolls due to the state's budgetary problems.

Nationally just 12% of children still lack some form of healthcare coverage. The highest percentage is in Texas, with 20% of the children not covered; the lowest is in Vermont, with only 5% of children uninsured. Michigan, with 90% of its children insured, currently looks like it's doing well, but 200,000 are still uninsured and the dire forecasts for the "Big 3" auto firms make most of their legislators understandably nervous.

Financially-strapped Washington State dropped more than 30,000 children from their state-supported program in the 2003-4 period; now they are trying to turn things around and extend eligibility for families with children. Initially there are to be no costs to these families, but the state made it clear that some form of co-pay is in the plan's near future. At the same time three states -- Pennsylvania, Maryland and Tennessee -- recently admitted it is becoming harder to maintain medical coverage for all the children currently in their programs.

And perhaps strangest of all…California is in the midst of a mammoth governor vs. legislators battle on how to pay to cover its one million kids that lack fallback insurance. The state has so many residents that Californians may be managing to keep a surprisingly-low profile about it by talking in percentages …perhaps since this giant number is less than 3% of its equally-giant overall population.

CDC Seeks New Quarantine Rules

Reacting to the specter of a bird flu pandemic, the feds have proposed an all-new tracking system and the first major changes on incoming-passenger-quarantine rules in over 25 years. These stipulations, which have not received final approval, are designed to much more carefully monitor incoming passengers of airlines and marine shipping interests…to give the feds added rights to delay passenger entry…and to even quarantine suspected carriers through an extended possible- incubation period.

The severe acute respiratory syndrome (SARS) outbreak in 2003 is being used as their guidepost in what to do and how quickly to get the rules in force. Potentially financially devastating as this could be to the carriers, it is well-accepted that the feared worldwide outbreak of SARS was eventually stopped due to a great degree by quarantines imposed by several high-incidence countries.

The CDC plan would mandate that airline and shipping manifests must be kept - electronically, to assure immediate access and tracking -- for 60 days if a passenger is later found to be infected. Quarantines will be possible if the illness breaks out during a flight or voyage. If this last should ever happen, the proposed law would give local and national health officials the authority to offer vaccinations, drugs or other means of prevention; all on a voluntary basis.

Currently such a quarantine law exists for the possible influx of several diseases such as smallpox, yellow fever, cholera, diphtheria, TB, yellow fever and SARS. The proposed new rules also place new and narrower limits on passengers even suspected of having on-board contact with a passenger found to have one of these illnesses.

Airlines especially would be affected by these rulings, since the shortness of their trips requires that preventive action and reporting often must be immediate. The Air Transport Association pledged cooperation but cited the huge expense to an industry already in financial peril.

We're Taking Their Best

In the past five years, the exodus of doctors and nurses from the Philippines has grown to epidemic proportions, creating a shortage of major proportions at home.

Better working conditions and higher pay have convinced these professionals to leave home, but they are apparently leaving the healthcare system of their home islands in trouble. The country's medical society recently categorized it as a major crisis, leaving their healthcare-delivery in near collapse.

Estimate is that about 100,000 well-trained Filipino nurses moved abroad since 1994. The United States and Great Britain are said to offer the best opportunities, wages and working conditions…often plus visas for spouses and children… occasionally even offering subsidized housing.

Doctors are apparently also eager to leave, citing poor working conditions and low pay as the chief reasons. Many doctors don't meet requirements in the west. Which in the past five years has led 3,500 Filipino doctors to retrain as nurses…and then emigrate.

State of the Art IT

HIPAA requires that a ten-digit National Provider Identifier be in place by May, 2007. This in a "pull it all together" effort to codify and replace the various and not-always-consistent current billing numbers of caregivers and government agencies.

The NPI is designed to combine and therefore simplify accurate and speedy electronic communication among healthcare insurers, physicians, hospitals, labs, pharmacies and nursing homes. One ID number for each provider...hopefully creating a provider system that its designers say will match our current and effective patient identification system.

Sun Microsystems, recognized as a specialist in electronic "connectivity", is developing the system and says it is on-target for implementation by the May, 2007.

NY-NJ's First Medical "Smart Cards"

A pilot project designed to offer carry-it-with you portability of medical records will be put into operation by Siemens in a matter of months in two disparate area hospitals: Mt. Sinai and Elmhurst Medical Center. Siemens plans to initially create about 100,000 of the "smart cards", which will include the patient's identity, current health data and medical experiences.

This will be available for both easy access to and ongoing updating by caregivers who are part of the regional smart card system. Making the information always current, portable and protected...without the mammoth amount of time and estimated costs involved in developing the integrated infrastructure required for a "connected" healthcare network. Siemens is currently working on several "smart card" systems with healthcare providers and facilities in Europe.

All personal and private medical information on the smart cards will be encrypted and normally guarded by a PIN number. Backup special entry codes will be available in member-hospital's ERs in cases where the patient is too-sick or too-traumatized to supply it.

Initially several other hospitals -- Englewood Hospital, Cabrini Medical Center, North General, Queens Hospital, St. John's Riverside and Settlement Health will take part in the pilot program. Plan is for a total of at least 45 healthcare facilities in the "metro area" are targeted for linkup. Siemens is proving its belief in the potential of the program by investing $2 million in "seed money" which will used to cover the cost of both the hardware and software that will create the system.

EMR Certification Tests

Updating and adding a few more specifics to a segment of last December's lead story...the government has now awarded a several-million-dollar contract to a group charged with developing pilot programs to both certify electronic medical records and the infrastructure be used to exchange these records among providers. Both projected costs and insights into the possible problems that lie ahead will be examined. The tests, to be conducted by The Certification Commission for Healthcare IT, are scheduled to begin in March. Hands-on work will be performed by three classes of electronic-service companies. "Enterprise vendors" that offer the service basically to hospitals…mid-range vendors that will offer similar services to 10-plus physician practices…and those offering the service to smaller practices.

The CCHIT has selected several such vendors in each of the three categories that make up the program. Each was required to sign a non-disclosure agreement.

CCHIT tests will combine self-reported data as well as input from selected monitor/judges within the organization. Best guess is that these tests will be conducted "virtually" rather than at selected central sites, thus eliminating costly travel expenses for applicants.

Quarterly reports are promised. Goals to have a method of certifying inpatient electronic health records are scheduled to be in place by 2007; a similar certifying process covering the infra-structure stage is scheduled to be completed the following year.

Geriatrician Problems

Chances are increasing that your parents or older siblings have or will soon have a problem finding a doctor who understands the specific problems of senior citizens. The percentage of board certified geriatricians in the United States has fallen 27% since 1998 and now totals less than 7,000. That is in the face of the advancing age of the "baby boom generation"…now moving steadily into the Medicare age bracket.

It is estimated that, if the slow pace continues -- the 7,000 figure represents less than 1% of America's 650,000 practicing physicians -- there will only be about 11,000 geriatricians by 2030; this in the face of a foreseeable need of about 36,000 such specialists. Which means that "generalist" family practitioners will have to try to fill the often-specific needs of many of these people.

Several bills have recently been introduced in Congress to offer incentives to doctors by forgiving at least a portion of their med school loans if they move into geriatrics. All these bills are still "in committee", most likely buried in a pile of other special-target legislation.

Medical Minutia

According to researchers at a major university hospital in Stockholm, male infants born prematurely have a sharply-increased risk of developing high blood pressure during their adult life; the more prematurely born, the greater the risk. The study was based on 330,000 birth records of over 300,000 Swedish men born between 1973 and 1981 and was reported in a recent issue of Circulation.

The research showed that male babies born extremely preterm -- 29 to 32 weeks - were at 45% additional risk; those born a bit later -- 33 to 36 weeks -- had a 24% higher risk factor.

Though the records only covered male births, the researcher estimated that much the same figures would be found in a study of female births.

Think-Small, Remote-Control Surgery

Latest marvel of medicine comes from the University of Nebraska Medical Center, where researchers have developed a team of tiny robots -- about three inches long -- that can potentially enable surgeons to perform minimally-invasive surgery close up or from thousands of miles away.

The miniscule one-time-use machines can be slipped into a small incision and controlled by a team of surgeons. Some units will be equipped with cameras and lights, designed to send back images to the surgeons. Others will contain surgical tools that can make incisions and deliver meds to the target area. The head of the inventive team claims this new technique is also a giant step up from today's "minimally-invasive surgery"; main reason being the robots are easier to maneuver inside the body and require fewer incisions to perform their miracles. A "biopsy robot" is being developed. The units reportedly have performed a number of successful procedures on lab animals; human tests are planned for the spring. Application for FDA approval is planned for sometime this year. And the inventors say the final step will be to greatly reduce the robots' already-miniscule sizes.

The FDA Strikes Back

Apparently tired of taking all the complaints that drugs purchased from Canadian internet pharmacies were as safe and a lot cheaper than those purchased in-the US -- the FDA ran what they referred to as "Operation Bait and Switch" against a number of internet-based pharmacies.

The sting ran at JFK, LA and Miami International Airports in late summer of last year. The results are only starting to surface now and the FDA chieftans are smiling broadly with "I told you so" looks on their faces.

They inspected almost 4,000 incoming prescription drug packages supposedly from Canadian internet pharmacies. Roughly 45% of these prescription drugs were actually shipped from or through established Canadian pharmacies. Roughly 55% were actually shipped in directly from Costa Rica, India, Israel and Vanuatu; shipped in from front companies that the FDA said didn't seem to have the vaguest idea of quality or content of the drugs they offered for internet sales.

Actually only about 15% of the intercepted "Canadian" drugs actually came in from Canada. The balance were originally manufactured in 27 different countries; an undisclosed number contained non-English labels and dosage directions.

They said the four targeted countries were selected because previous analysis had showed each had a history of dealing in exceptionally large quantities of possibly-questionable drugs.

Transcription Tips

When using "however," place a semicolon before and a comma after the word however when it is used as a conjunctive adverb, connecting two complete, closely related thoughts in a single sentence. "He is improved; however, he cannot be released."

Place a comma after however when it serves as a bridge between two sentences. "The patient was released from the hospital. However, his family called to say his condition had worsened."

When however occurs in a sentence and is NOT the first word, it is called an interruptive and requires a comma before and after (unless at the end of the sentence). "He is improved. He cannot, however, be released." "He is improved. He cannot be released, however."

All About Us

"On the Record" is a monthly joint effort of NJPR staffers and a medically-knowledgeable editor. Every article is original, researched and written just for this newsletter.

Purpose of it all is to inform, enlighten and occasionally entertain our readers. And of course to reinforce the image of professionalism, quality and dependability that has been NJPR's hallmark of service for well over thirty years.

Auditing the News

The American Heart Association has issued new CPR guidelines which are radically different from those currently in use. Emphasis is now put on chest compression rather than mouth-to-mouth resuscitation. The recommended rate is now doubled to 30 compressions for every rescue breaths. The same rate applies to both adults and children.

Simply put, the rule now is to push harder and faster on a patient's chest, enabling circulation to build up with each chest compression. Best of all, this method of CPR can be taught in less than half an hour as against the former method which took at least four hours to learn.

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Last updated May 2006