HHS Urged to Clarify ‘Payer of Last Resort’ in School Medicaid Reimbursement
An Advisory Committee on Regulatory Reform appointed by Health and Human Services Secretary Tommy Thompson issued its final report November 21.
Among hundreds of recommendations for simplifying and clarifying existing regulations, the advisory panel noted that an "old" version of Medicaid and School Health: A Technical Guide for States still references Medicaid as payer of last resort for health-related services provided by schools. The panel pointed out, however, that a May 2000 "transmittal" from HHS "indicates the opposite."
The advisory committee urged HHS to "immediately clarify the policy related to payment for these services" and to "finalize and publish" a revision of the Technical Guide.
The recommendation, number 16 in a list of 256 final recommendations made by the advisory group, also urges the Department of Health and Human Services to "Publish regulations in a timely fashion" and notes that "States are left in limbo or held responsible for unclear policies."
The full text of the final report of the HHS Advisory Committee on Regulatory Reform, including an appendix listing the committee’s final recommendations, can be read at http://www.regreform.hhs.gov.
Editor’s Note: A spokesman for the Centers for Medicare and Medicaid
Services told Health and Health Care in Schools December 2 that a draft
of a revised version of Medicaid and School Health: A Technical Guide
for States is currently being circulated to "stakeholders" for comment.
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Annual Summary of Vital Statistics Shows Continued Decline in Teen Pregnancies
In its annual report on vital statistics drawn from birth certificates, fetal death reports, and death certificates, the American Academy of Pediatrics said in December that the birth rate for teen mothers dropped 5 percent from 2000 to 2001, to 45.9 births per 1,000 females aged 15 to 19 years, a record low. The teen birth rate has fallen 26 percent since 1991; declines were more rapid (35 percent) for younger teens aged 15 to 17 years than for older teens aged 18 to 19 years (20 percent). The proportion of all births to unmarried women of all ages remains about the same, at one-third.
The use of timely prenatal care increased slightly from 2000 to 2001, to 83.4 percent. For the first year in almost a decade, the preterm birth rate declined (to 11.6 percent); however, the low-birthweight rate was unchanged at 7.6 percent.
In 2001, the provisional infant mortality rate in the United States was 6.9 per 1,000 live births, the same as in 2000. The report points out that racial differences in infant mortality remain a major public health concern, with the rate for infants of black mothers 2.5 times those for infants of non-Hispanic white or Hispanic mothers. In 2000, 66 percent of all infant deaths occurred among the 7.6 percent of infants who were born at low birthweight. Among all states, Maine and Massachusetts had the lowest infant mortality rates. The United States continues to rank poorly in international comparisons of infant mortality.
The provisional death rate in 2001 was 8.7 deaths per 1,000 population, the same as the 2000 final rate. In 2000, unintentional injuries and homicide remained the leading and second-leading causes of death for children 1 to 19 years of age, though the death rate from homicide decreased by 10 percent from 1999 to 2000. Among unintentional injuries to children, two-thirds were motor vehicle-related; among homicides, two-thirds were firearm-related.
In a discussion of its data, the AAP noted that in 1997, the most recent year for which abortion statistics are available, an estimated 55 percent of teen pregnancies ended in live birth, 29 percent in induced abortion, and 15 percent in fetal loss. From 1990 to 1997, teen birth rates fell 13 percent while abortion rates fell much more, by nearly a third.
During the late 1990s, the declines in teenage birth rates were driven by reductions in first birth rates, which account for nearly four in five teen births. "Repeat births account for only 21 percent of all teen births, but are of particular concern as a teenager with two or more children is at greater risk for a host of difficulties," the report points out.
"Annual Summary of Vital Statistics—2001" was published in the December
2002 issue of the journal Pediatrics. Reprints are available from the
National Center for Health Statistics at mmacdorman@cdc.gov.
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Study Looks at Effect of Abstinence-Only Education on HIV/AIDS Prevention
"Before the abstinence-only program, I could say, ‘If you’re not having sex, that’s great. If you are, you need to be careful and use condoms.’ Boy, that went out the window."
That quotation from a teacher introduces a case study of federally funded abstinence-only education programs in one state—Texas—by the international advocacy group Human Rights Watch, which tried to determine whether withholding information about condoms, contraception, and other protective practices violates the rights of young persons to full information about their health.
As defined in Section 510(b) of the Welfare Reform Act, "abstinence education" means an educational or motivational program that "has as its exclusive purpose, teaching the social, psychological, and health gains to be realized from abstaining from sexual activity." What abstinence-only funding recipients cannot say, according to administrators of the federal program in the Department of Health and Human Services, is "if you decide to become sexually active, then here are methods" to prevent pregnancy or sexually transmitted diseases; and they may not provide instruction in the use of condoms or contraception.
Human Rights Watch points out that since 1997, the U.S. Congress has allocated more than $350 million—$100 million in fiscal year 2002 alone—to support abstinence-only education. The money goes to states, which must contribute three dollars to every four dollars of federal funds. The states, in turn, distribute the money in a range of different ways--in some states the department of health has primary authority over the program, in others the governor’s office has that authority, and in some cases the authority is shared. States can fund a wide variety of activities, including media campaigns, school-based programs, and community-based projects. In Texas, the governor’s office and the state health department share authority for the Texas Abstinence Education Program, which funds 32 "abstinence contractors."
For the Texas study, Human Rights Watch visited four programs in the state: the McLennan County Collaborative Abstinence Project (McCAP); the Scott & White Sex Education Program; the Medical Institute for Sexual Health; and Laredo’s "Mi Futuro/My Future" sex education program. All received federal funding, and all provided abstinence-only education materials and training to school districts.
In all of the programs, teachers and students who were interviewed confirmed that there was no discussion of how to protect against sexually transmitted infections, though Scott & White encourages teachers to use an activity in which cut-up pieces of rubber gloves, plastic bags, and condoms, are used to demonstrate that condoms "are one of the thinnest plastics and can easily break."
All of the Texas programs included a "virginity pledge" as part of the abstinence-only school curriculum, including a possible pledge of "secondary" or "renewed" virginity for those who have previously had sex. Health educators told Human Rights Watch that such pledges were often interpreted by students as protecting them from both past and future infection.
Concluding that abstinence-only programs are "drying up" other sources of information for young persons about the risks of HIV/AIDS, Human Rights Watch points to many national and international commitments to providing all individuals with full information about health, and to conflicts between government programs in the United States devoted to HIV/AIDS prevention and the exclusion of such information from abstinence-only programs.
The full text of the report, "Ignorance Only: HIV/AIDS, Human Rights,
and Federally Funded Abstinence-Only Programs in the United States:
Texas: A Case Study," is available on the Human Rights Watch website
at http://hrw.org/reports/2002/usa0902/
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Survey Finds Children Who Most Need Dental Care Least Likely to See a Dentist
Caries is the most prevalent non-self-limiting disease of childhood, and the fact that dental problems grow steadily worse if they are not treated makes access to dental care by children an important public health issue. But in the current health care system, researchers found, the children with the most dental problems are the least likely to go to a dentist for prevention or treatment.
Writing in the November 2002 issue of the American Journal of Public Health, Clemencia Vargas and Cynthia Ronzo confirm that children from low socio-economic backgrounds and those belonging to a racial/ethnic minority were less likely than their more advantaged peers to have had a dental visit in the year preceding the survey and were more likely to be "episodic" rather than "regular" users of dental care.
Factors inhibiting use of dental care in their sample of 39,944 persons included inability to pay, geographic difficulty in reaching providers, lack of dentists who are willing to treat Medicaid or SCHIP patients, and negative cultural attitudes toward dental health care, the researchers report. Their conclusions: "Despite their presence, dental needs do not drive dental care use among children, and children’s dental care utilization is inadequate."
The researchers conceded that an important limitation of their study was the lack of data on dental insurance coverage in the National Health and Nutrition Examination Survey (NHANES) from which they drew their statistics. "However," they said, "most children covered by Medicaid do not get dental care."
Noting the need for more dental providers who are willing to treat young children and children from low-SES families, the researchers suggested that barriers at the provider level can be reduced by guaranteeing adequate payments through Medicaid and the State Children’s Health Insurance Program, training more pediatric dentists, and providing incentives for dental care providers to practice in underserved areas.
Reprints of the research report, "Relationship Between Children’s Dental Needs and Dental Care Utilization: United States, 1988-1994," published in the November 2002 issue of the American Journal of Public Health, are available from cmv001@dental.umaryland.edu.
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WORTH NOTING
SAMHSA Reports Increase in Driving Under Influence of Drugs
The Substance Abuse and Mental Health Services Administration (SAMHSA) reported November 19 that eight million persons aged 12 or older reported driving under the influence of illegal drugs during the past year--a 3.6 percent increase from 2000. The report is based on data from the National Household Survey on Drug Abuse. "Drugged driving is under-reported because it is under-recognized," SAMHSA
Administrator Charles Curie said. "Young people, as well as parents, need to know that driving under the influence of any illegal drug is just as dangerous as driving under the influence of alcohol."
Additional information, data and tables, as well as copies of the full
report are on-line at: www.DrugAbuseStatistics.samhsa.gov.
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CDC Advises Schools on Strategies for Managing Asthma
In a report released in November, the Centers for Disease Control and Prevention identified six strategies for schools and districts to consider when addressing asthma within a coordinated school health program. The strategies are:
The full text of the report, "Strategies for Addressing Asthma Within
a Coordinated School Health Program," is available at www.cdc.gov/healthyyouth/healthtopics/asthma.
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Comprehensive Report on Vaccines Available on Web
A new report on vaccines by the National Institute of Allergy and Infectious
Diseases (NIAID) describes achievements in the field of vaccinology
in the past two decades and offers expert perspectives on vaccine research-related
topics such as regulations, safety evaluations, economic considerations,
and vaccine risk communication. The "Jordan Report 20th Anniversary"
can be read at website www.niaid.nih.gov/dmid/vaccines/jordan20.
The report is named for infectious disease researcher Dr. William Jordan,
who directed its preparation from 1976 to 1987 and who launched NIAID’s
Program for Accelerated Development of Vaccines.
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ASHA Announces New Publication
The American School Health Association has announced a new publication,
Health in Action, to be published four times a year, with each 20- to
24-page issue to cover a single topic, such as the chronic health conditions
diabetes and depression, HIV infection, and violence prevention. Each
issue will include current knowledge on the topic, lesson plans, and
lists of resources. To view a sample mini-edition on diabetes or to
become a subscriber, visit the Health in Action website at www.ashaweb.org/healthinaction.html.
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UN Finds Women Now Account for Half of HIV Cases
For the first time in the 20-year history of the AIDS epidemic, just
as many women as men worldwide are infected with HIV, the United Nations
reported in November. In a report released in London, the UN said the
virus continues to invade new regions of the globe and is spreading
most rapidly in Eastern Europe and across Central Asia into China, where
it was almost nonexistent a few years ago. There were 5 million new
infections in 2002, bringing to 42 million the number of people currently
living with HIV, the UN reported.
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New Searchable Website Consolidates HIV/AIDS Information
Aimed at health care providers, researchers, people living with HIV/AIDS,
and the general public, a new comprehensive website offering information
on treatments and clinical trials went online December 2. AIDSinfo will
include guidelines on treating HIV/AIDS in children and adults, treating
opportunistic infections and other co-infections, and preventing mother-to-child
transmission of HIV. The site, jointly sponsored by several agencies
in the federal Department of Health and Human Services, can be accessed
at http://aidsinfo.nih.gov.
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The following information appeared during the month of November in the News Alerts section of this website.
NIH Offers Education Loan Repayment for Research
Health professionals may apply before November 30 for extramural loan repayment programs sponsored by the National Institutes of Health for clinical, pediatric, and contraception and infertility research. Grantees will receive up to $35,000 of the principal and interest on their education loans in return for at least 50 percent of time and not less than 20 hours a week of research. Deadlines will be announced later for two other loan repayment programs, for research into health disparities or clinical research by persons from disadvantaged backgrounds. Information and application forms are available at www.lrp.nih.gov.
Soros Advocacy Fellowships Available to Physicians
The Program on Medicine as a Profession of the Open Society Institute has set an application deadline of January 14, 2003, for the Soros Advocacy Fellowship for Physicians. Participating physicians will work for a 12-24-months with U.S.-based advocacy organizations to design and implement projects that address such issues as racism, violence, environmental hazards, and education. Funding is not available for direct service or research. Applicants must apply with the commitment of an advocacy organization that is prepared to house, mentor, and support them throughout the fellowship period. For further information, go to www.soros.org/medicine.
Large Study Finds No Link Between Autism and MMR Vaccination
A study of all children born in Denmark from January 1991 through December 1998 found no connection between measles, mumps, and rubella (MMR) vaccination and autism. The data showed the risk of autism was similar in vaccinated and unvaccinated children, researchers say in an article published in the November 7, 2002, issue of The New England Journal of Medicine.
The MMR vaccine used in Denmark during the study period was identical to that used in the United States. The Danish national vaccination program recommends that children be vaccinated at 15 months and provides the vaccination free of charge. All diagnoses of autism were based on the International Classification of Diseases, 10th Revision (ICD-10), which is similar to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) with regard to autism. In Denmark, children are referred to specialists in child psychiatry by general practitioners, schools, and psychologists if autism is suspected.
The researchers said their study "provides three strong arguments against a causal relation between MMWR vaccination and autism. First, the risk of autism was similar in vaccinated and unvaccinated children, in both age-adjusted and fully adjusted analyses. Second, there was no temporal clustering of cases of autism at any time after immunization. Third, neither autistic disorder nor other autistic-spectrum disorders were associated with MMR vaccination. Furthermore, the results were derived from a nationwide cohort study with nearly complete follow-up data."
Commission Reports Mental Health System ‘In Disarray’
A commission on mental health appointed by President Bush in February has issued an interim report that describes the U.S. mental health system as being "in disarray" and not oriented to recovery. In a section on the mental health of children, the report cites the Dallas, Texas, school-based mental health program as an example of successful intervention. The full text of the commission report is available for reading or downloading at www.mentalhealthcommission.gov/reports/reports.htm.
President’s Commission on Mental Health Holds Public Meetings
The New Freedom Commission on Mental Health appointed by President Bush in April is holding its first public hearings December 4, 5, and 6, in Arlington, Virginia, a suburb of Washington, D.C. The commission is mandated to conduct a comprehensive study of the United States mental health services delivery system and to make recommendations on improving the delivery of public and private mental health services for adults and children. At the December meetings, the commission is scheduled to receive reports from several of its subcommittees, including Suicide Prevention, Criminal Justice, Co-Occurring Disorders, and Evidence-Based Practices, as well panel presentations on related topics.
The following are the dates and times of the open meetings:
December 4 – 3:30 p.m. to 6:00 p.m.
December 5 – 8:30 a.m. to 10:00 a.m. and 3:15 p.m. to 5:15 p.m.
December 6 – 8:30 a.m. to 12:30 p.m.
Additional information is available at www.mentalhealthcommisision.gov
Funds to Be Available for Reentry Services for Juveniles
The Substance Abuse and Mental Health Services Administration announced
November 19 that if sufficient funds are appropriated by Congress for
fiscal year 2003, SAMHSA will make $6 million available for a grant
program to provide substance abuse treatment and reentry services to
sentenced juveniles and young offenders returning to the community from
the juvenile justice system. Deadline for applications is January 17,
2003. For further information, potential applicants should read the
Federal Register announcement at http://a257.g.akamaitech.net/7/257/2422/14mar20010800/
edocket.access.gpo.gov/2002/02-29960.htm.
Nurse Centers to Research Health Disparities
The National Institute of Nursing Research (NINR) is creating eight new centers to address health disparities research. Each center involves a partnership between the schools of nursing of two or three universities that have or are developing research programs in health disparities and have a significant number of minority nursing students. A total of $15 million over five years will be committed for the program, which is jointly supported by the NINR and the National Center on Minority Health and Health Disparities (NCMHD), both part of the National Institutes of Health. Goal of the program, said NCMHD Director Dr. John Ruffin, is to identify "scientifically based interventions that work against health disparities throughout our entire society". For the sites of the centers and further information, see website www.nih.gov/ninr.
FDA Approves New Rapid Test for HIV Antibody
The Food and Drug Administration has approved the OraQuick Rapid HIV-1 Antibody Test for use by trained personnel as a point-of-care test to aid in diagnosis of infection with human immunodeficiency virus type 1 (HIV-1). The test can detect antibodies to HIV in fingerstick whole blood specimens and provide results in approximately 20 minutes. That should substantially increase the number of persons who receive their test results and improve the delivery of treatment and counseling services, the Centers for Disease Control and prevention said in a notice to readers of the November 22 Morbidity and Mortality Weekly Report. Sites wanting to perform this new HIV-1 rapid test that are not already certified to perform moderate-complexity laboratory tests under CLIA (Clinical Laboratory Improvement Amendments of 1988) must enroll in the CLIA program, which is administered by the Centers for Medicare and Medicaid Services. Information, applications, and state agency contact information are available at www.cms.hhs.gov/clia.
Trial Shows Vaccine May Prevent HPV Infection
A vaccine tested in a clinical trial was 100 percent successful in preventing infection with human papillomavirus type 16 (HPV-16) in sexually active young women. HPV-16 is one of five HPVs that are responsible for most cervical cancer. In the clinical trial, 2,392 females 16 to 23 years of age were randomly assigned to receive three doses of either a placebo or the HPV-16 vaccine. They were then followed for 17 months. The incidence of persistent HPV-16 infection was 3.8 per 100 woman-years at risk for the placebo recipients and 0 per woman years at risk for the vaccine group. Merck Research Laboratories, which developed the vaccine, is currently working to develop one that will protect against several more types of HPV. The vaccine will not be available for several years, but when it is, researchers indicated maximum benefit would be achieved by vacccinating young girls before they become sexually active. The research report, "A Controlled Trial of a Human Papillomavirus Type 16 Vaccine," appeared in the November 21, 2002, issue of the New England Journal of Medicine. Reprints are available from kouts@u.washington.edu.
Clinical Trial Tests Herpes Vaccine for Women
A clinical trial to test whether an experimental vaccine will prevent genital herpes in women began enrolling volunteers last week. Some 7,550 women who are free of two common types of herpes simplex viruses—HSV-1 and HSV-2—will participate in the trial at 16 sites in the United States. The trial, a partnership between the National Institute of Allergy and Infectious Diseases and the vaccine’s manufacturer, GlaxoSmithKline Biologicals, follows earlier and smaller tests in which the vaccine appeared to prevent herpes infection in women but not in men. Volunteers in the new trial will be vaccinated at one and six months and then followed for 20 months. Between 50 percent and 80 percent of Americans are infected with HSV-1, typically in childhood, and about one in five persons over the age of 12 is infected with HSV-2. Once in the body, HSV migrates to nerve cells and remains there permanently, with possible recurrence of symptoms such as blisters and ulcers. The virus has been identified as a risk factor for the spread of HIV-AIDS in adults.
SAMHSA Announces Availability of Youth Violence Prevention Grants
Approximately $4 million in 2003 funds is expected to be available for 24 grants to public and private organizations for community collaborations to prevent youth violence and promote youth development, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced November 26. The grants will range between $150,000 and $200,00 per year for two years. Funding depends on Congress’ enactment of SAMHSA’s appropriation when the new session convenes in January. Deadline for submitting applications is January 22, 2002. For further information, see the Federal Register for November 26, 2002.
Managing Life-Threatening Allergies in Schools
The Massachusetts Department of Education has posted a comprehensive guide to handling food allergies in school. The 84-page guide is the result of a collaboration between the Massachusetts Department of Education, the New England chapter of the Asthma and Allergy Foundation of America, the Massachusetts School Nurse Association, the Massachusetts Food Service Association, the Massachusetts Committee of School Physicians, and parents of children with food allergies. Information and advice was provided by the Massachusetts Department of Public Health. The guidelines can be accessed at www.doe.mass.edu/cnp/2002/news/allergy.pdf.
Funds Available to State Health Departments for Diabetes Prevention, Control
Health departments of the states and territories can apply to the Centers for Disease Control and Prevention for grants to link community diabetes programs that support social and environmental policies to promote wellness in people with diabetes. The money—approximately $23 million in fiscal year 2003--cannot be used for direct patient care, screening, individual health services, or treatment of diabetes. States are required to match federal funds at $1.00 of state money for every $4.00 or $5.00 of federal contribution. States are referred for further information and application forms to the CDC website, www.cdc.gov.
FDA Approves Non-Stimulant ADHD Drug
The Food and Drug Administration has approved the first new drug in
three decades for treatment of the symptoms of attention deficit hyperactivity
disorder (ADHD). Strattera (atomoxetine), marketed by Eli Lilly and
Company, is not defined as a stimulant under federal drug laws, and
appears to have no potential for abuse. It will be a prescription drug,
but will not be classified as a controlled substance. The drug is not
approved for use by children younger than six. Strattera is expected
to be for sale at pharmacies in January, Lilly said. The new medicine,
which will be taken just once a day, operates by increasing the level
of norepinephiene, a chemical in the brain that transports signals between
nerve cells.