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States Lack Data on Children’s Use of SCHIP, Medicaid Services States focus more on setting requirements for providers and networks under Medicaid and SCHIP (State Children’s Health Insurance Program) than on monitoring compliance with those requirements or analyzing beneficiaries’ use of services, according to a report released in February by the U.S. General Accounting Office (GAO). The GAO noted that overall, the 16 states surveyed for the report imposed more access-related requirements on participating providers and more actively monitored children’s use of services in their Medicaid managed care programs than in their Medicaid fee-for-service programs or SCHIP. Medicaid managed care: State requirements for managed care plans ranged from very broad provisions that health plans must have "adequate" physician networks for serving their enrolled members to very specific standards, such as the number and geographic proximity of physicians and maximum time frames within which a new beneficiary receives a first appointment. States less often verified data that plans submitted to show compliance with these requirements or independently monitored physicians’ availability. In one instance of verification, a state found that a third of a health plan’s physician network was not accepting new Medicaid patients, thus limiting access for new beneficiaries. The value of plan-submitted data that states used to monitor children’s use of services was often compromised by continuing problems with their completeness and reliability. Furthermore, information derived from beneficiary satisfaction surveys was not necessarily representative of all Medicaid managed care beneficiaries. Medicaid fee-for-service: Most states did not set goals for or analyze the availability of participating primary care physicians, even though a majority of Medicaid-eligible children in half the states reviewed are still served in fee-for-service (FFS) programs. In most FFS programs, beneficiaries may seek care from any providers participating in the Medicaid program and may change providers at any time if they are dissatisfied. However, when FFS payment rates are lower than those paid by other purchasers—which was the case in most states reviewed—providers can be discouraged from participating in Medicaid and thus restrict beneficiaries’ access. States did little to monitor the use of services by Medicaid-eligible children in FFS programs despite having a ready source of data in their claims payment systems. SCHIP: Nine of the 16 states used the same providers, administrative systems, and monitoring approaches for their SCHIP programs as they did for Medicaid. The remaining seven states, whose SCHIP programs were distinct from Medicaid and used managed care almost exclusively, set few requirements for or monitored providers’ availability to SCHIP-eligible children. States with distinct SCHIP programs also reported fewer efforts to monitor children’s use of services than in their Medicaid programs. The 16 states surveyed by the GAO were Arkansas, California, Colorado, Florida, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Nevada, New York, Ohio, Pennsylvania, Tennessee, Texas, and Washington. The GAO report, "Medicaid and SCHIP: States Use Varying Approaches to Monitor Children’s Access to Care," released February 14, 2003, is available in PDF at website www.gao.gov. Consent for Emergency Medical Services for Children and Adolescents The American Academy of Pediatrics has issued a new policy statement concerning pediatric patients who seek treatment in hospital emergency rooms unaccompanied by a legal guardian. (A minor is considered "unaccompanied" if he or she arrives for treatment either alone or with a teacher, older sibling, child care provider, divorced noncustodial parent, grandparent, foster parent, or state social services worker, among others, who are not legal guardians.) Under U.S. common law, parental consent generally is required for the medical treatment of minor children, the statement notes, but states have enacted a number of statutes that allow for the treatment of minors without parental consent in situations that often arise in emergency departments. In addition, federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA), mandates a medical screening examination for every patient seeking treatment in a hospital that participates in programs that receive federal funding. EMTALA preempts conflicting or inconsistent state laws, essentially rendering the problem of obtaining consent for the emergency treatment of minors a non-issue for participating hospitals. "Current medical ethics recommendations also appear to support the ED treatment of unaccompanied minors," the position statement notes. But although emergency care of an unaccompanied minor may need to proceed without parental consent, "the physician should seek consensus from the patient or family as soon as possible," and if a conflict develops, may have to evaluate the young patient’s emotional and intellectual maturity and understanding of the medical condition, to determine if the patient may accept or refuse treatment. Sometimes, a physician may need to involve the court or a social services agency to proceed with treatment against patient or parental will. There is also the problem of reimbursement for services to an unaccompanied minor. Though care must be provided without consideration of ability to pay, there are issues of patient confidentiality—sometimes, for example, the first notification a parent has that treatment has been given is the receipt of a bill from the hospital. The policy statement makes the following recommendations:
The AAP policy statement, "Consent for Emergency Medical Services for Children and Adolescents," appeared in the March 2003 issue of the journal Pediatrics. The Other Inflammatory Disease—Skin Ailments in Children Guidelines for asthma care first issued in 1991 have had "a tremendous positive impact" on many aspects of asthma treatment, including heightened awareness that asthma is a disease of chronic inflammation. It may now be time to develop similar guidance for another childhood ailment with many of the same attributes as asthma—atopic dermatitis—say physicians on a panel representing dermatology, allergy, asthma, immunology, and pediatrics. It’s well known that the prevalence of asthma is rising, in the United States and other developed and developing countries, the panel noted, but less attention has been given to similar increases in atopic dermatitis (inflamed conditions of the skin such as eczema) that are also allergic. It’s believed, in fact, that such skin ailments are a risk factor for childhood asthma. The panel conceded that the causes of the current pandemic of allergic diseases "remain unknown." Their report notes some possibilities—increased exposure to allergens and indoor and outdoor air pollution; profound changes in lifestyle such as diet, body weight, and antibiotic use; the theory that vaccinating children against many childhood diseases may delay maturity of the immune system, making it more vulnerable to allergen sensitization; and finally, the role of genetics—some children simply react more severely than others to the same stimuli. Calling both allergic skin ailments and asthma "exaggerated inflammatory response to environmental triggers," the physician panel urged updating of U.S. guidelines for the management of atopic dermatitis similar to the guidelines now in place for asthma treatment. The panel noted especially the importance of early intervention with anti-inflammatory agents. Current asthma management guidelines include four components that could be incorporated into dermatitis treatment recommendations, the panel pointed out. They are:
The article, "Atopic Dermatitis and Asthma: Parallels in the Evolution of Treatment," appeared in the March 2003 issue of the journal Pediatrics. Reprints are available from leichenfield@ucsd.edu. Dietary Supplement Under Scrutiny The federal Food and Drug Administration (FDA) is considering whether to ban a dietary supplement generally sold as "ephedra," which is alleged to have been implicated in the heatstroke death of a major league baseball pitcher during spring training. The athlete’s death, in combination with a report by the RAND Corp. that ephedra has killed some users, prompted the FDA to announce February 28 that it will seek public comment on whether the substance should be banned. The FDA is also asking for comment on a proposal to require that labels on bottles of the supplement must bear a warning that the pills can cause heart attacks and stroke, or even kill. Ephedra is an over-the-counter ephedrine alkaloid marketed to promote weight loss and increase energy. The substance stimulates the central nervous system, speeds metabolism, and increases the rate at which a person burns calories. It also drives up blood pressure and heart rate. Because it is a "dietary supplement" or "herbal supplement," ephedra has never been required to prove its safety or efficacy to the FDA; a law passed by Congress in 1994--the Dietary Supplement Health and Education Act—exempts supplements from FDA regulation. Supplement manufacturers are not required to report adverse events, as prescription drug manufacturers are, and the Food and Drug Administration can move against a dietary supplement only if there is strong evidence of harm. In the case of ephedra, there have been warnings about safety for some time. The American Medical Association has urged that ephedra supplements be banned because they may contribute to heart attacks and stroke, and athletes in the National Football League, the International Olympics, and the National Collegiate Athletic Association are forbidden to take the substances. A study published online by the Annals of Internal Medicine, noted that ephedra accounted for 64 percent of all adverse reactions to supplements that were reported to poison control centers in 2001, even though ephedra-containing products represent less than 1 percent of the supplement market. In addition to freeing supplements such as ephedra from regulation, Congress a year ago made it legal for both supplements and prescription drugs to advertise without FDA permission. This has led to a proliferation of supplement ads on the Internet, leading the New England Journal of Medicine to point out in its February 27 issue that "Anyone with a public e-mail account is likely to receive hundreds, if not thousands, of messages a year in which unproven claims are made about dietary supplements or other products and the medical wonders they can achieve. Many of these claims seem too good to be true, and nearly all are." Anticipating a possible ban, a leading ephedra manufacturer, Metabolife, issued a statement deploring "irresponsible marketing practices" that lead athletes to use the substance inappropriately. Metabolife also called for less stringent government regulations, such as banning sale of ephedra to minors. Legislation that would prohibit sales of dietary supplements containing ephedrine alkaloids to individuals under the age of 18 was introduced in Congress February 12 by Representative Susan Davis (R-CA). Science-based information on herbs and other supplements is available on a website maintained by the Integrative Medicine Service at Sloan-Kettering Cancer Center in New York. The free website, www.mskcc.org/aboutherbs, explains conditions the agents are used to treat, adverse effects, potential drug interactions, and other details about the properties of 135 herbal and botanical agents. WORTH NOTING CDC Reports on Smallpox Immunizations The Centers for Disease Control and Prevention (CDC) reported February 27 that as of that date, smallpox vaccine had been administered to 7,354 civilian health care and public health workers in 40 jurisdictions. The CDC and state health departments are conducting surveillance for vaccine-associated "adverse events," and so far no life-threatening complications have been reported. In the February 21 issue of Morbidity and Mortality Weekly Report (MMWR), the CDC noted that seven nonserious adverse events occurred as the result of vaccinations between January 24 and February 18, 2003. In a telebriefing February 27, the CDC noted two further incidents, both in the state of Florida. In one, rated as moderate-to-severe, a woman developed a generalized rash after vaccination and was successfully treated with antihistamines. The other incident involved a man who suffered a heart attack while playing tennis, which the CDC said "is not known to be causally associated with smallpox vaccinations." The CDC said its surveillance is ongoing and any adverse reactions to the smallpox vaccine now being used will be reported. In a related development, legislation introduced in the House of Representatives February 13 would provide compensation and "assured access to care" for individuals injured by the smallpox vaccine. The bill, H.R. 865, "Smallpox Vaccine Compensation and Safety Act of 2003," would require states to explain possible side effects to persons receiving the vaccine and individuals who reside with them. The bill, introduced by Rep. Henry Waxman (D-CA), has been referred to a House committee. Thompson Suggests Changes in Medicaid In testimony to Congress February 27, U.S. Secretary of Health and Human Services Tommy Thompson said states are confronting "serious challenges" in running their Medicaid programs and 38 states have already reduced services or eligibility. While states are required to continue Medicaid for "mandatory populations," they are free to eliminate coverage of "optional populations" and to drop optional coverage, Thompson pointed out. He said the Bush administration is considering giving states the option of replacing their Medicaid programs with "partnership allotments" in which the federal portion of SCHIP (State Children’s Health Insurance Program) and Medicaid funding would be combined into two allotments, one for long-term care and one for acute care, with states given flexibility to tailor health benefits. HHS Expected to Set Procedures for Enforcing Privacy Regs The Office for Civil Rights (OCR) in the U.S. Department of Health and Human Services, which is responsible for enforcing privacy regulations under the Health Insurance Portability and Accountability Act (HIPAA), has not yet published the enforcement procedures it will use. But HIPAA consultants told a privacy conference in Washington February 26 that OCR will probably reflect congressional intent in the law, meaning that inadvertent failures to comply with HIPAA would result in steps to correct the problem, rather than monetary penalties. The HIPAA law allows imposition of a penalty of not more than $100 for each privacy violation, with the total amount that could be imposed on one person for all violations of an identical requirement in a calendar year not to exceed $25,000, but it’s anticipated that OCR would impose such monetary penalties only in cases of egregious or repeated violations of the privacy rules. Research Notes SBHCs Reduce Asthma Hospitalizations Schoolchildren with asthma who are enrolled in schools with school-based health centers had fewer hospitalizations and missed fewer days of school than their peers in schools without SBHCs, according to a survey by Mayris Webber and colleagues reported in the February 2003 issue of Archives of Pediatrics and Adolescent Medicine. Data about asthma symptoms and medication use, activity limitations, hospitalizations, and absenteeism were obtained from parents of kindergarteners through fifth graders attending six schools in the Bronx, New York; four of the schools had SBHCs and two did not. In an accompanying editorial, Julia Lear, director of the Center for Health and Health Care in Schools, pointed out that while research such as that reported in the Archives "suggests better clinical outcomes for children through school-based interventions," there has been little federal funding for research on these centers and few federal dollars spent on their expansion. She cited a recent decision by the U.S. Department of Health and Human Services to limit Healthy Schools, Healthy Communities grants to institutions that meet governance requirements applicable to all community health centers, a move that is expected to make some 75 percent of institutions that currently sponsor school-based health centers ineligible for federal funds. The research report by Webber and colleagues, "Burden of Asthma in Inner-City Elementary Schoolchildren: Do School-Based Health Centers Make a Difference? and the editorial, "School-Based Health Centers: A Long Road to Travel," appeared in the February issue of Archives of Pediatrics and Adolescent Medicine. Reprints of the research report are available from mwebber@montefiore.org. Reprints of the editorial are available from jgl@gwu.edu.
February News Alerts The following information appeared during the month of February 2003 in the News Alerts section of this website. President Proposes Health Funding for 2004 The following are some health-related provisions of President Bush's proposed federal budget for fiscal year 2004, released February 3. Health Resources and Services Administration
Centers for Disease Control and Prevention
National Institutes of Health
Substance Abuse and Mental Health Services Administration
Agency for Healthcare Research and Quality
Centers for Medicare and Medicaid Services
The President's budget is the first step in the budget and appropriations process that will decide federal funding for health and other programs in fiscal year 2004. The budget proposals will now be reviewed in congressional hearings before Congress begins work on appropriations. Final funding may or may not reflect the President's budget proposals. Note: Congress has not yet completed final appropriations for the current 2003 fiscal year for the Department of Health and Human Services and other federal departments and agencies. Therefore, the increases in health funding proposed in the 2004 budget are explained as changes from the 2003 budget proposal. Actual increases may differ, depending on what Congress finally appropriates this year. President Asks Funds for HIPAA Enforcement As part of his proposed budget for fiscal year 2004, President Bush is asking Congress to appropriate $34 million to cover operations of the Office for Civil Rights (OC) in the U.S. Department of Health and Human Services, with a part of that money intended to support "the investigative, legal, and related administrative expenses associated with implementing compliance with and enforcement of the HIPAA privacy rule." Noting that HIPAA (the Health Insurance Portability and Accountability Act) privacy rule goes into effect April 14, 2003, the budget document notes that "OCR is developing policy guidance, public education, and technical assistance materials for health care providers, health plans, and clearinghouses that maintain individuals’ health information." I n addition to its HIPAA responsibilities, the HHS Office for Civil Rights is responsible for enforcing civil rights statutes that prohibit discrimination on the basis of race, national origin, disability, age, and, in limited instances, sex and religion, in federally assisted health care and social services programs. The OCR website for HIPAA guidance and information is www.hhs.gov/ocr/hipaa. Educational Scholarships The George Washington University School of Education and Human Development announces scholarships in its Educational Leadership in Early Childhood Special Education. This post-master’s Education Specialist Degree Program is a two-year, part-time program of study. Scholarships are awarded on a competitive basis with scholarships available for 90 percent of tuition cost. Course work includes special education, school counseling, teacher education, technology and public health. The program is currently enrolling students for the 2003 summer session. For more information contact Nancy Conner at 202-994-3724 or nconner@gwu.edu. EPA Seeks Data on Environmental Influences on Child Health The U.S. Environmental Protection Agency announced January 14 that it is looking for state-of-the-art technology to help in data collection for a long-term study of environmental influences on children’s health and development. Information on the study, the National Children Study, is available at www.NationalChildrensStudy.gov. Study Finds Children Get Little Moderate to Vigorous Activity in School PE An observational study of 814 third-graders in 684 elementary schools in 10 states conducted by the National Institute of Child Health and Human Development (NICHD) found children in school physical education classes engaged in moderate to vigorous activity an average of 25 minutes per week, far short of national recommendations. The third-graders had an average of 2.1 PE lessons per week, of 33 minutes each; only 5.9 percent had PE every day. During their PE sessions, children accrued 4.8 minutes of very active and 11.9 minutes of moderate to vigorous activity, with boys spending proportionately more time than girls in such exercise. Current recommendations are for preadolescent children to accumulate at least one hour per day of physical activity, with one opportunity to do that being school PE classes. The study, "Frequency and Intensity of Activity of Third-Grade Children in Physical Education," was published in the February 2003 issue of the journal Archives of Pediatrics and Adolescent Medicine. Reprints are available from NICHD at friedmas@exchange.nih.gov. Study Finds Low Birthweight, Prematurity Often Overcome by Age 8 A study that followed low birthweight premature children from six hours after birth to eight years of age found that most of the children improved significantly on both verbal comprehension and intelligence tests between their third and eighth birthdays, often reaching normal range. "These results are the first indication that the brain may recover from injury over time in these children," said researcher Dr. Laura Ment of the Yale University School of Medicine. About 1.4 percent—more than 50,000—of babies born in the United States each year have very low birthweight, defined as weighing less than 1500 grams (about 3 pounds, 5 ounces) at birth. Because of medical advances, including use of a surfactant to treat respiratory distress syndrome, 85 percent of low birthweight infants now survive. The study, reported in the February 12, 2003, issue of the Journal of the American Medical Association, plans to continue testing the group of children through high school to see how they mature. HHS Publishes Rules for Electronic Health Transactions On February 20, the U.S. Department of Health and Human Services (HHS) dropped the other shoe, publishing final regulations for the electronic security section of the Health Insurance Portability and Accountability Act (HIPAA). The standards require health insurers, health care clearinghouses, and health care providers to implement administrative, physical, and technical safeguards to protect individually identifiable health information that is transmitted electronically. The rules detail many technical aspects of electronic health communications, including safeguarding access to computerized records and the use of certain transaction codes and data sets. The security regulations become effective April 21, 2003, but most covered entities will have a full two years—until April 21, 2005--to comply. HHS noted that the security regulations will work in concert with HIPAA privacy standards that were published earlier and are scheduled to go into effect April 14 this year. The privacy rules require health insurers, health care clearinghouses, and health care providers to keep confidential all individually identifiable health information--written, oral, and electronic. The text of the new security standards is available in the Federal Register for February 20, 2003. EPA Reports on Environmental Contaminants that Affect Children In a report released February 24, the U.S. Environmental Protection Agency (EPA) cited progress in reducing some environmental hazards that particularly affect children, noting that there is a continued decline in the number of children with elevated blood lead levels, a reduction in children’s exposure to secondhand tobacco smoke, and decreases in exposure to air pollution and contaminants in drinking water. But EPA Administrator Christine Whitman says much remains to be done, including reducing emissions of diesel pollutants from trucks and buses, adopting stringent restrictions on the use of organophosphate pesticides, making sure playground equipment is no longer made with wood treated with arsenic-containing preservatives, and reducing emissions of sulfur dioxide and nitrogen oxides and mercury from electric utilities. The report describes the way levels of contaminants in children’s bodies are measured and the "body burdens" and illnesses caused by environmental hazards. The report, "America’s Children and the Environment" can be downloaded (PDF required) at www.epa.gov/envirohealth/children. HHS Seeks Safer Smallpox Vaccine As efforts by the U.S. Department of Health and Human Services to vaccinate health care workers against smallpox faltered, largely because of concerns about possible adverse effects from the vaccination, HHS Secretary Tommy Thompson February 25 announced the award of two contracts to develop safer smallpox vaccines. Two companies, one in Denmark and one in Cambridge, Massachusetts, must produce several thousand doses of their prototype vaccines within six months, along with data indicating its effectiveness in their models. The companies will then conduct tests of the vaccine’s safety in healthy human adults, after which they must develop plans for large-scale manufacture of the candidate vaccines and show they could deliver up to 30 million doses to the federal government. Calling the possibility of intentional release of the smallpox virus in the United States "remote but extremely grave," Thompson said, "We need a vaccine that can safely be administered to all Americans, including individuals with weakened immune systems, children, and pregnant women."
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