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Teaching Hospital Update - January 25-29, 2010


Email Alert

January 29, 2010

By Leah Voigt*

President Obama Addresses Healthcare Reform in State of the Union Speech

President Barack Obama drew sustained laughter from Congress, especially Democrats, on Wednesday evening when he declared in his State of the Union speech that "by now it should be fairly obvious that I didn't take on health care because it was good politics."

But after spending 2009 emphasizing that a healthcare overhaul was his top domestic priority, President Obama gave it much less prominence in his address. He did not mention it until more than half an hour in--a sign of how imperiled the bill has become. In the last week, Democrats have vigorously debated among themselves how to salvage the legislation. Speaker Nancy Pelosi suggested Wednesday that the Senate would have to take the next step and make substantial changes in its bill before the House would act again.

Senate aides said the changes recommended by Ms. Pelosi could add
$300 billion to the cost of the legislation, which already carries a ten-year price tag of nearly $1 trillion. House Democrats disputed the $300 billion figure.

Even if Democrats can resolve their internal disputes, they must contend with opposition from Republicans, who have been emboldened by their victory in a special Senate election last week in Massachusetts. "If anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors and stop insurance company abuses, let me know," President Obama said. "Let me know." Hearing that invitation, the House Republican leader, Representative John A. Boehner of Ohio, raised his left hand high.

President Obama's speech did nothing to resolve differences between the House and the Senate or to clarify the way forward. Just twenty weeks ago President Obama stood in the same place and made an urgent plea to a joint session of Congress. "The time for bickering is over, the time for games has passed," he said on September 9. "Now is the time to deliver on health care," he said then. But on Wednesday healthcare was wedged into a catalog of presidential priorities, which included jobs, the economy, education, bank regulation, energy independence, deficit reduction, and the war in Afghanistan.

Robert Pear and David Herszenhorn, Health Care Gives Way, N.Y. TIMES (Jan. 28, 2010).

Switch to Low-Fat Milk in Schools Shows Benefit

When New York City public schools made the switch from whole milk to skim or low-fat milk, students cut their annual fat and total calorie consumption, department researchers found. According to a report issued in the January 29 issue of CDC's Morbidity & Mortality Weekly Report, milk-drinking students consumed 5,960 fewer calories and 619 fewer grams of fat per year after they made the switch. At 3,500 calories per pound, the reduction would be the equivalent of 1.7 pounds of body weight over the course of a year.

"The switch to lower-fat milk likely has improved the overall nutritional environment of NYC public school children," researchers wrote. On the other hand, they found most of the low-fat milk consumed was chocolate milk, which has a substantially higher sugar content than unflavored milk.

In 2005, the New York City Department of Education began reviewing its food policies and determined that replacing whole milk with fat-free or low-fat milk could decrease students' fat and calorie intake. At subsequent board meetings, milk industry advocates suggested that without whole milk or chocolate- or strawberry-flavored milk, student milk consumption would decline, thus decreasing calcium and vitamin intake. Nonetheless, the Department of Education began phasing out whole milk in 2005, and limited flavored milk to fat-free chocolate milk.

The researchers did not have data on student consumption of milk, so they analyzed system-wide school milk purchases. They found that per-student school milk purchases dropped 8% between 2004 and 2006, but then gradually began to increase. By 2009, purchases had risen 1.3% from five years prior: from 112 per student in 2004 to 114 in 2009. Fat-free milk accounted for 42% of all purchases in 2009, compared with less than 7% in 2004.

In 2004, students purchased more than eighteen billion calories and 520 million grams of fat in the form of milk. That fell to less than
fourteen billion calories and 98 million grams of fat in 2009, representing a 25% and 81% decrease, respectively. Over that five-year time period, the researchers calculated that if calorie and fat savings were distributed among all students--including those who don't drink milk--they would consume 3,484 fewer calories and 382 fewer grams of fat each year.

The authors noted that the study was limited because there were no data to evaluate the magnitude of the correlation between milk purchasing and milk consumption. Also, no data were collected on students' diets, so the researchers could not assess the policy's larger effects on diet.

Primary Source:
Effects of Switching From Whole to Low-Fat/Fat-Free Milk in Public Schools--New York City, 2004-2009, 59 MMWR 70-73 (2010).

Kristina Fiore, Switch to Low-Fat Milk in Schools Shows Benefit, MedPage Today (Jan. 28, 2010).

Innovative Alaska Health Plan Outperforms Many Others in Lower Forty-Eight

The buzzwords of healthcare reform can sound abstract and confusing. Yet ideas like patient-centered medical homes, integrated care teams, and chronic disease management are already a reality in what some might consider an unlikely setting for a healthcare innovator--Southcentral Foundation--a nonprofit healthcare provider owned by, led by, and serving Alaska Natives.

About a decade ago, Southcentral's patients made it clear they were unhappy with the care they received. That led to a sweeping patient-driven overhaul of how care is delivered--and defined. Southcentral views physical, mental, social, and spiritual wellness as being interconnected. Primary care teams work closely with mental or behavioral healthcare services, and they incorporate traditional native healers when appropriate. Patients--called customers at Southcentral--can get same-day appointments if needed, or can communicate with their healthcare teams by email, phone, or fax.

By performance and quality measures, including the Healthcare Effectiveness Data and Information Set or HEDIS, Southcentral is outperforming many better-known health plans elsewhere in Alaska and in the rest of the U.S. The organization serves 50,000 people in the Anchorage area and about 140,000 throughout the state. Only half the patients are insured through Medicare, Medicaid, and private plans; the foundation also receives Indian Health Service funds.

Joanne Kenen, Innovative Alaska Health Plan Outperforms Many Others in Lower 48, Kaiser Health News (Jan. 26, 2010).

Court Backs Some Tobacco Ad Bans, Nixes Others

A recent federal court decision moved public health advocates several big strides forward and a couple of steps back in their effort to defeat a free speech challenge to new Food and Drug Administration (FDA) restrictions on tobacco advertising.

In a January 5, 2010, ruling, the U.S. District Court for the Western District of Kentucky upheld most of the provisions in the federal Family Smoking Prevention and Tobacco Control Act that it said validated the government's interest in protecting consumers from misleading tobacco claims. The law, enacted in June 2009, gave FDA authority to regulate tobacco for the first time. Among the restrictions upheld by the court were a requirement for larger warning labels and a ban on the sale of modified-risk, or "light," products without prior FDA approval.

But the court took issue with the constitutionality of what it said were two overly broad provisions--one prohibiting the use of color and graphics on advertisements and the other, banning statements implying that FDA regulation of tobacco products makes them less harmful. Two of the nation's largest cigarette makers--R.J. Reynolds Tobacco Co. and Lorillard Tobacco Co.--joined by other manufacturers and retailers, sued the FDA in August 2009. They alleged the various advertising restrictions violated their First Amendment rights to market their products to adults. The companies are not contesting the FDA's regulatory authority nor its restrictions on advertising to children.

FDA and tobacco companies both claimed partial victories and said they were reviewing the opinion. Lorillard and R.J. Reynolds specifically praised the court's decision upholding use of color and graphics in advertising. Nonetheless, both sides are expected to appeal to the 6th U.S. Circuit Court of Appeals, with public health advocates urging the FDA to continue the fight.

Amy Lynn Sorrel, Court Backs Some Tobacco Ad Bans, Nixes Others, Am. Med. News (Jan. 25, 2010).

A Few Extra Pounds May Benefit Older People

A little excess weight after age seventy could do the body some good, according to results of a study involving 9,000 older patients. Overweight participants in the cohort study had the lowest ten-year mortality. Normal-weight and obese participants ages seventy to seventy-five had a similar and slightly higher risk of death, researchers at the Western Australian Center for Health and Aging in Perth found.

The findings add to evidence suggesting that being overweight in older age is not such a bad thing and might even be beneficial. "These results lend further credence to claims that the body mass index [BMI] thresholds for overweight and obese are overly restrictive for older people," the researchers concluded in an article in the Journal of the American Geriatrics Society. The authors also found that a sedentary lifestyle doubled the mortality risk for older women but did not affect survival of older men.

The World Health Organization (WHO) has established four BMI thresholds to characterize body weight, with a BMI of ≥30 kg/m2 considered obese. The authors noted that the thresholds were derived primarily from studies of younger and middle-age adults. Whether the cut points for overweight and obese are appropriate for older individuals has remained unclear.

Two previous systematic reviews and a meta-analysis showed no increased mortality risk associated with a BMI in the overweight range for older people. However, methodologic differences complicated the comparison of different studies, the researchers wrote. So they sought to address some of the uncertainty by analyzing data from two large Australian cohort studies involving more than 9,000 individuals ages seventy to seventy-five (4,677 men; 4,563 women). The principal objectives were to determine the BMI threshold associated with the lowest mortality in older people and to determine whether the relationship between BMI and mortality differed between men and women. Data for the analysis came from self-reported measures of height and weight, which the authors used to calculate BMI for the study participants. Participants also provided demographic, lifestyle, and health information.

Using the WHO criteria for BMI, the authors found that 1.3% of men and 3.1% of women were underweight; 43.5% of men and 50.3% of women were normal weight; 44.3% of men and 33.5% of women were overweight; and 11% of men and 13.1% of women were obese. During ten years of follow-up, overweight study participants had a 13% lower risk of death compared with normal-weight participants. Obese participants had a mortality risk similar to that of normal-weight participants.

Primary Source:
L. Flicker et al., Body Mass Index and Survival in Men and Women Aged 70 to 75, J AM. GERIATRIC SOC. (2010), DOI: 10.1111/j.1532-5415.2009.02677.x.

Charles Bankhead, A Few Extra Pounds May Benefit Older People, MedPage Today (Jan. 28, 2010)

AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers Weekly and appropriate AHLA Practice Groups.

*We would like to thank Leah Voigt, Esquire (Squire Sanders & Dempsey LLP, Washington, DC), for providing this week's update.

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