|
Medical Privacy Rules Spark Controversy Two weeks after the Bush administration announced that it would go ahead with regulations published by the Clinton administration that aim to protect the privacy of patients, Health and Human Services Secretary Tommy Thompson told Congress April 26 that the administration is "looking at options" for requiring that parents be notified when minors seek medical care. In a statement when the regulations were released April 12, President Bush said, "Legitimate concerns have been raised about the current rule, which I share, such as parents' concern that the rule limits their right to have access to their children's medical records." The President said, " I have asked Secretary Thompson to recommend appropriate modifications to the rule to address these concerns." In a statement of his own the same day, Thompson noted that the Department of Health and Human Services has received more than 24,000 written comments on the patient privacy rules. "To address some of the concerns raised in comments, we will make it clear through guidelines or recommended modifications that parents will have access to information about the health and well-being of their children, including information about mental health, substance abuse, or abortion," the Secretary said. That brought an immediate protest from the American Academy of Pediatrics, which charged that such a change "would go against everything pediatricians have learned over the years about providing quality care to adolescents." "Physicians and young people have identified the issue of confidentiality as a significant barrier to health care. Pediatricians encourage their adolescent patients to involve their parents in health decisions, but adolescents deserve confidentiality like adult patients," said AAP Executive Director Dr. Joe Sanders. Secretary Thompson's statement about a change in the language "must be based on politics, because it certainly isn't based on medical knowledge," Sanders said. "If the administration truly wants to make sure adolescents receive the highest quality care, it should drop this change and implement the rule as currently written." The 386-page medical privacy regulations published November 28 spelled out in detail what health care providers must do to protect the privacy of an individual's medical information, including paper records and oral communications as well as electronic communications. They require that physicians, hospitals, and health care plans get written consent from patients for the release of even routine medical information. They also give patients rights to access their medical records and to know who else has accessed them; and they restrict most disclosure of health information to "the minimum needed for the intended purpose." The regulations specify that "individually identifiable health information of students under the age of 18 created by a nurse in a primary or secondary school that receives federal funds and that is subject to FERPA [the Family Educational Rights and Privacy Act] is an education record but not protected health information.," and therefore the medical privacy regulation does not apply. That doesn't mean students don't have medical privacy rights, but simply that those rights have been guaranteed under a different law, the regs say. Coming at the privacy regulations from another angle, the American Medical Association has urged Secretary Thompson to modify the rules to reduce the administrative burden on physicians, "the one sector of the health care system already ethically bound to safeguard patient privacy." The AMA said Congress needs to "continue to pass legislation to extend privacy requirements to all entities that handle patient information, including employers, marketers, life insurers, and others."
Pledging to move the headquarters of the Department of Health and Human Services to Baltimore from Washington for a week, in order to familiarize himself with the Health Care Financing Administration, the agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP), HHS Secretary Tommy Thompson said he expects to "learn a great deal" by seeing firsthand how HCFA operates. The Bush administration has made strengthening and increasing the efficiency of HCFA a major issue, and the President's 2002 budget proposal includes an increase of $192 million, or 9 percent, in the agency's operating funds, plus $36 million to update an antiquated information technology system. That and other provisions of the President's 2002 budget proposal for health were outlined by Thompson in testimony before the Subcommittee on Health of the House Energy and Commerce Committee April 26. Noting that the National Institutes of Health is "the largest and most distinguished biomedical research organization in the world," the budget aims to double NIH's funding by 2003, starting with an increase of $2.75 billion in 2002, the largest dollar increase ever for NIH. Thompson said NIH will expand its research in four areas "that show the greatest potential for yielding new scientific breakthroughs" - genetic medicine, clinical research, interdisciplinary research, and health disparities. Saying that the President's budget will "strengthen the health care safety net for those most in need," Thompson said the plan calls for expanding the number of federally supported community health centers by 1,200 from the current 3,000 by the year 2006. As a first installment, the budget proposes to increase funding for community health centers by $124 million next year. That increase would be balanced, however, by elimination of the $125 million Community Access Program, which coordinates existing health care resources to improve service to medically underserved populations. The Substance Abuse Block Grant, the primary vehicle for funding state substance abuse efforts, would get an increase of $60 million in 2002, and another $40 million increase would go to "targeted capacity expansion grants that seek to address the treatment gap by supporting strategic and rapid responses to emerging areas of need, including grants to organizations that provide residential treatment to teenagers." President Bush's proposed budget is now being reviewed by various committees
of the House and Senate, and Congress may make changes in the figures cited
by Thompson. The 2002 federal appropriations are supposed to be signed into law
before the new fiscal year begins October 1, but final spending decisions are
often delayed beyond that date. We'll keep you posted.
Addressing Bullying as Part of Violence Prevention A study has found widespread bullying in U.S. schools, and the authors speculate that schools that fail to deal with bullying are missing an opportunity to prevent violence. Recent high-profile school shootings.and many previous episodes have involved issues of bullying and revenge, and it is time to pay attention to bullying as a public health problem, not just "an unpleasant rite of passage through childhood," according to researchers based at the Maternal and Child Health Bureau and the National Institute of Child Health and Human Development. In a survey of a nationally representative sample of U.S. youth in grades 6 through 10 in public, Catholic, and other private schools, the researchers found 29.9 percent of the young people reported moderate or frequent involvement as a bully, or the victim of bullying, or both. The frequency of bullying was higher among sixth through eighth grade students than among ninth and tenth graders, and higher among males than females. Because the focus of the study was to find if there is a relationship between bullying behaviors and overall psychosocial adjustment, students were also asked questions about problem behaviors such as consumption of alcohol and tobacco and truancy; their perceived social and emotional well-being; and parental influences, including parents' attitudes toward drinking. Three items queried the frequency with which students felt lonely, left out, or being alone at school; and three items assessed relationships with classmates-"enjoy being together," "are kind and helpful," and "accept me." The researchers found that both bullies and the bullied "demonstrated poorer psychosocial adjustment than non-involved youth." Those bullied often reported difficulty in making friends and loneliness. The most frequent reason cited for being bullied was that "they didn't fit in," possibly because of a lack of social skills or possibly because other students, fearful of being bullied themselves, avoid the company of a bullying victim. Bullies, on the other hand, were more likely to be involved in other problem behaviors such as drinking and smoking, particularly in middle school. While research on the long-term consequences of bullying is minimal, the studies that have been conducted show negative effects into adulthood, the researchers said. And the prevalence of bullying observed in the study shows the importance of effective intervention; school-based interventions in England and Norway, where bullying has been identified as a serious problem, reduced bullying by 30 percent to 50 percent. In an editorial accompanying the research report, Howard Spivak, MD, and Deborah Prothrow-Stith, MD, note that to date, no studies have examined the relationship between bullying/being bullied and the risk of being involved in more serious violence, such as school shootings, but the reported presence of bullying in Littleton, Colorado, and Pearl, Mississippi, among others, "makes the connection an important concern."
Both bullying and being bullied are "important indicators that something is wrong," they say, and children who evidence either behavior need help. "Bullying is a red flag indicating risk and the need for prevention/intervention." Both the research report and the editorial list extensive bibliographies of research on bullying and examples of school-based interventions. The article, "Bullying Behaviors Among U.S. Youth: Prevalence and Association with Psychosocial Adjustment," by researcher Tanja Nansel and others; and the editorial, "The Need to Address Bullying-An Important Component of Violence Prevention," appeared in the April 26 issue of the Journal of the American Medical Association.
An Immunization Safety Review: Measles-Mumps-Rubella Vaccine and Autism The Institute of Medicine of the National Academy of Sciences said April 24 that "The evidence favors rejection of a causal relationship between MMR vaccine and autistic spectrum disorders." Feeling the need for independent review of a subject that has produced considerable controversy, the Centers for Disease Control and Prevention and the National Institutes of Health engaged the Institute of Medicine to convene a panel of health professionals with wide-ranging expertise in the subject and no connections to vaccine research or manufacturers to examine the possibility of an MMR-autism link. After reviewing all the available evidence, the committee 'can find no biological mechanisms that would explain such a relationship,' the report states. That doesn't settle the matter, the committee observed, because "science is always a work in progress," and there are many problems with diagnosing and determining the onset of autism in children. It would also be hard to study children who have not had MMR vaccinations, since children are almost universally given the long-available measles-mumps-rubella shots in all developed countries. But it is important to explore any hypotheses about a linkage, the report agrees, because the issue "transcends the science alone." MMR vaccination is required by law in all 50 states for entry into school or day care, in part to protect the health of others; and infectious diseases such as measles, mumps, and rubella, if left unchecked, could cause considerable sickness and death. "Public health officials fear a repetition of the pertussis vaccine history of the 1970s, when the combination of low numbers of pertussis cases and public concerns about the vaccine's safety caused immunization rates around the world to plummet, with sobering results. In Japan, for instance, pertussis vaccine coverage dropped from 80 percent to 10 percent in the mid-1970s, resulting in an epidemic involving 13,000 reported cases and 41 deaths. Similar disease outbreaks could easily occur, with devastating effects, were immunization rates to decline as a result of fears regarding MMR vaccine." On the other hand, the panelists conceded, "the responsibility of the government to ensure the safety of the MMR vaccine is high, even if the adverse outcome is rare." "The seriousness of autism-an incurable and serious behavioral disorder-requires rigorous consideration of all possible etiologies. And in any case, the level of public concern about MMR vaccine safety is high and must be meaningfully addressed." "At present," the committee concluded, "no change of MMR immunization procedures is warranted." The committee did not recommend review at this time of the licensure of MMR vaccine or the current schedule for administration of the vaccine, which is given to infants in the first two years of life, with a booster before enrollment in school. What is needed in further research, the report suggests, is to develop common definitions for the poorly understood condition termed "autism," as well as clinical studies to identify risk factors and biological markers of autistic spectrum disorders. A summary of the report and the full text are available online at www.iom.edu.
A Patients' Bill of Rights has been introduced in both the House and Senate and some version of the legislation is expected to pass in this session of Congress. S.6, introduced in the Senate January 22 and a more comprehensive version, S.283/ S.284, introduced February 7, plus House bill H.R. 526, introduced February 8, all seek to provide protection for consumers in managed care, including internal and independent appeals and claims procedures; choice of provider options; access to emergency, specialist, and pediatric care; access to prescription drugs; patient access to information; and prohibition of limitations on medical communications. The second Senate bill, introduced by Senators John McCain (R-AZ) and Edward Kennedy (D-MA) goes into detail about the terms of various forms of insurance coverage, including coverage purchased by individuals or small businesses. All of the bills have been referred to committees and it's not known when they may reach the floor for debate. A bill , H.R. 504, introduced in the House February 7 is called the Community Access to Health Care Act of 2001. It would provide grants to communities and consortia of healthcare providers to "strengthen the effectiveness, efficiency, and coordination of services for the uninsured and underinsured." The idea, according to the bill's sponsors, is to extend health care, including preventive and primary services and mental health and substance abuse services, by building on providers, including clinics, that are already serving the identified populations.The bill has been referred to committee and no action has been taken. H.R. 1111, the Equity in Prescription Insurance and Contraceptive Coverage Act of 2001, introduced in the House March 20, would prohibit group health plans and health insurers who provide coverage for health plans from excluding benefits for prescription contraceptive drugs or devices that have been approved by the Food and Drug Administration. The bill points out that three million pregnancies, or half of all pregnancies in the United States each year, are unintended; and while many private insurers cover prescription drugs, many exclude coverage for contraceptives. The bill also notes that women of reproductive age spend 68 percent more in out-of-pocket health care costs than men do, with contraceptives and reproductive health care costs accounting for much of the difference. H.R. 1111 has been referred to committee and no action has been taken. A bill introduced in the House February 28 would amend the Safe and Drug-Free Schools and Communities Act to add inhalants and the abuse of inhalants to the "drugs" the law is intended to prevent, even though inhalants are not illegal. The bill points out that the number of children using inhalants doubled in the 10 years from 1989 to 1999 and that the vapors react with fatty tissues in the brain, "literally dissolving the tissues." Specifically, the bill defines the term "abuse" with respect to inhalants to mean "the intentional breathing of gas or vapors from the inhalant for the purpose of achieving an altered state of consciousness" and says an "inhalant" may be a legal, commercial available product such as spray paint, glue, gasoline, correction fluid, furniture polish, a felt-tip marker, pressurized whipped cream, an air freshener, butane, or cooking spray. The bill has been referred to committee and no action has been taken. After the Bush administration withdrew a regulation issued in the last month of the Clinton administration requiring employers to take steps to prevent ergonomic injuries in the workplace, a bipartisan group of Senators introduced legislation March 22 calling for reissuance of the ergonomics regulations. The bill, S. 598, would authorize the Occupational Safety and Health Administration to "set forth in clear terms" the actions employers should take to prevent work-related musculoskeletal disorders. The bill has been referred to committee but no action has been taken. A bill, S. 582, introduced in the Senate March 21, would give states the option
to cover certain legal immigrants under Medicaid and the State Children's Health
Insurance Program (SCHIP). The Immigrant Children's Health Improvement Act
would allow states to extend benefits to pregnant women and children who are
lawfully residing in the United States but are currently barred from coverage
by provisions of the welfare reform law. The bill has been referred to committee
but no action has been taken.
The Centers for Disease Control and Prevention announced April 13 that it will make grants of approximately $100,000 each to state health departments in two states to support school-based or school-linked dental sealant programs. In their applications for those funds, state health departments must document unserved dental needs in low-income rural areas or in urban areas where 50 percent or more of children receive reduced-price or free school meals. The applications must also indicate how school-based health services, including school-based health centers, will coordinate and implement oral health education and preventive and treatment services. The April 13 announcement also indicates that two grants in the amount of $100,000 each will be available to state health departments for community water fluoridation. Another $800,000 will go to from three to six states to strengthen oral health programs in general, including collecting data and monitoring school and community intervention and prevention programs. The deadline for state applications is May 15. Application forms are available at www.cdc.gov/od/pgo/forminfo.htm. The grants announcement appeared in the Federal Register April 13 and can be read online at www.access.gpo.gov.
Under an endowment established to prevent dental caries and other oral diseases in children, the American Dental Association's Health Foundation is accepting proposals for competitive grants of up to $5,000 each for dental health education to be conducted at schools, health fairs, or other sites, and for dental health education that is combined with fluoride programs, dental sealant programs, or other prevention programs. Proposals must be postmarked no later than July 31, for projects to be conducted the following year. Applicants will be notified by December 15. Information about the grants is available at www.adahf.org/childgrant.html.
Funding the Wish List When the fiscal year 2001 appropriation for the Department of Health and Human Services emerged from a conference committee in the waning days of the 106th Congress last winter, the money bill was full of earmarks stipulating that parts of the appropriation were to be spent for projects of interest to various congressmen. Those special grants are now being funded by HHS, as it's obliged to do. Here are some of them.
HHS stresses in its grants announcements that all of the wish list projects are already funded and no one else can apply for the designated funds. The grants announcement appeared in the Federal Register (www.access.gpo.gov) April 16 and 23. Thompson Forms Task Force on Patient Safety Health and Human Resources Secretary Tommy Thompson has created a task force of four federal health agencies to collect data on patient safety, in cooperation with states and the private sector. The Centers for Disease Control and Prevention, the Food and Drug Administration, and the Health Care Financing Administration already collect information that helps to monitor health care safety, but no one brings all the information together, Thompson said. State health departments and licensing boards, medical professional organizations, and patient advocacy groups met with the federal agencies in a two-day summit at Reston, Virginia, April 23-24, to plan a user-friendly Internet-based patient safety reporting format.
Early Childhood Typhoid Vaccine Found Effective Scientists at the National Institute of Child Health and Human Development have developed and tested a vaccine that is 92 percent effective in protecting children ages 2 to 5 against typhoid fever. Previously there had been difficulty in creating such a vaccine because the bacterium that causes typhoid inhabits and causes disease only in human beings, making it impossible to test a vaccine on animals as is usually done. Typhoid fever, which is spread by fecal contamination of drinking water or food, or by person-to-person contact, is uncommon in the United States but is a major cause of severe illness in children in under-developed countries, and is sometimes contracted by Americans traveling abroad. Further information is available at www.cdc.gov/ncidod/dbmd/diseaseinfo.
Minnesota Medicaid Services May Be Provided at School Under a change in Minnesota's Medicaid program approved by the Department of Health and Human Services, Medicaid-eligible children with special health needs, including children with physical or developmental disabilities covered by the Individuals with Disabilities Education Act (IDEA), may now receive medical and rehabilitative services at school. HHS Secretary Tommy Thompson urged other states to seek approvals of their Medicaid plans "that will get services to children where they need them-at school." Among the services available to children at school under Minnesota's Early and Periodic Screening, Diagnostic, and Treatment benefit are physical, occupational, and speech therapies and rehabilitative nursing. While targeted to children with Individualized Education Plans under the IDEA, services can be offered to any Medicaid-eligible child with special needs. Minnesota is also allowed to provide personal care services during the school day to Medicaid-eligible children with IEPs or Individualized Family Services Plans; the service may be provided by a provider of the family's choosing and is not restricted to providers employed by the school district. For further information, states are referred to their regional HCFA (Health Care Financing Administration) offices. Administration Urged to Put School Health on National Agenda Wrriting in the April issue of School Board News, published by the National School Boards Association, the chair of the Committee on School Health of the American Academy of Pediatrics urged professionals with expertise and interest in school health to "help this Administration know how to hold educational systems at all levels accountable to a key ingredient for school success: improving the health and safety factors that are now keeping too many children behind." Noting President Bush's pledge to "leave no child behind," Dr. Howard Taras said, "Health reasons cause many children to be left behind, but those factors almost never get addressed with the same urgency, depth, or resolve as purely academic ones. This needs to change." Taras pointed out that while federal dollars account for only 9 percent of school districts' funds, and education makes up only 2 percent of the federal budget, substantial health-related federal funds flow to schools from the Department of Health and Human Services and the Department of Agriculture's Food and Nutrition Service. How Children with Asthma Fare in Managed Care Asthma remains the most common chronic disease in children and a major cause of health care costs nationally, but children with asthma in manag.ed care settings are under-medicated and do not use their bronchodilators regularly, according to an article in the April issue of Archives of Pediatrics and Adolescent Medicine. While most children with asthma have received some pharmacotherapy to combat airway inflammation, the majority of children with frequent need for bronchodilators aren't using enough controller medication to be considered "regular" users of preventive therapy as recommended in national guidelines. The use of bronchodilators falls off in adolescence, possibly in part because students are not permitted to carry their dilators on their persons at school, researchers say. The article, "Use of Anti-Inflammatory Medication in Children with Asthma in Managed Care Settings." By Robert Adams. MBBS, MD, and others, urges clinicians to be aware of "suboptimal asthma management."
|