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Teaching Hospital Update - February 1-5, 2010


Email Alert

By Leah Voigt*

February 5, 2010

U.S. Healthcare Spending Reached $2.5 Trillion in 2009, Report Projects

National health spending in 2009 is estimated to have grown 5.7% and reached $2.5 trillion despite a projected decline in the gross domestic product (GDP), an outcome that largely reflects the economic recession, according to a federal report slated for release this week.

In an annual report from the Office of the Actuary at the Centers for Medicare & Medicaid Services, the analysts said the health share of GDP is expected to rise to 17%, an increase of 1.1% and the largest one-year increase since tracking began in 1960. The report, scheduled for publication in Health Affairs, also said public spending growth is expected to exceed private spending during the first four years of the 2009-2019 projection period, with public spending expected to account for more than 50% of all U.S. healthcare spending by 2012.

Overall, from 2009-2019 private spending is expected to grow at a slower average annual rate than public spending, with the public share of spending expected to reach 52% by 2019. In addition, the healthcare sector's share of GDP is expected to reach 19.3% by 2019, according to the report. The projections are done on a current law basis and do not examine the potential 21% cut in Medicare physician payment rates. The report's findings for 2009 also are presented as a projection because data for the calendar year are not complete.

Sarah Barr, U.S. Healthcare Spending Reached $2.5 Trillion in 2009, Report Projects, BNA's Health Care Daily Report, Feb. 4, 2010 (note: registration is required to view this content).

Fractured Evidence: Spine Repair Debate Heats Up

Advocates insist that hundreds of thousands of patients have benefited from vertebroplasty. They say the minimally invasive procedure has freed them from hospital beds and dependence on intravenous narcotics. Spine physicians swear that inserting a large-gauge needle into fractured vertebrae and injecting a cement compound to stabilize the bone hastens healing and helps relieve the often-crippling pain of compression fractures brought on by osteoporosis or metastatic disease.

But two recently published, randomized controlled trials--the gold standard of evidence-based medicine--say otherwise. As far as disability and pain relief were concerned, they found that vertebroplasty for osteoporotic vertebral compression fractures was no better than a sham procedure.

Publication of the results triggered an outraged backlash from radiologists, for whom vertebroplasty is a bread-and-butter operation. The entire specialist community lambasted the studies--statistically and methodologically. But experts in evidence-based medicine argue that when profits are on the line, it is easy to be persuaded that studies are flawed.

So the debate rages, with radiologists citing case after case of success that argue that patients with the worst fractures will have no treatment alternatives if the nation's third-party payors--Medicare and the insurance companies--refuse to pay for the procedure anymore. Both randomized, controlled studies were published last August in the New England Journal of Medicine. They involved a combined total of about 200 patients. Each found that vertebroplasty did not yield significantly better results in terms of disability or short-term pain relief than sham procedures for patients with this type of vertebral fracture.

Critics of the two studies cite a laundry list of complaints: too few patients, failure to meet enrollment, inclusion of patients with milder degrees of pain, and disability than those usually treated.

John Gever et al., Fractured Evidence: Spine Repair Debate Heats Up, MedPage Today (Feb. 4, 2010).

HHS Fields More Than Thirty-Five Reports of Large Data Breaches Since HIPAA Rule Issued Last Year

According to its Office for Civil Rights (OCR), the U.S. Department of Health and Human Services (HHS) has received thirty-five reports of health data breaches that collectively resulted in 712,000 notices to affected individuals since the rule requiring such reporting became effective in September 2009.

Most of the data breaches reported under the new requirement--which was mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act)--involved electronic personal health data that was not encrypted and was contained in lost or stolen portable electronic devices such as laptop computers and thumbdrives. The HITECH Act required that healthcare entities covered by the Health Insurance Portability and Accountability Act (HIPAA) report data breaches involving more than 500 individuals to HHS not less than sixty days after discovering a breach. Smaller breach incidents must be reported at least annually to HHS.

All of the thirty-five reports of large data breach incidents were made via a new HHS web portal through which all data breaches must be reported, including smaller breach incidents that involve breached health data for fewer than 500 individuals.

In addition to the thirty-five large data breach incidents, HHS reports that it has received more than 300 reports of small breaches. Most of those involved paper records that were sent to wrong fax numbers or mailed to wrong addresses.

OCR has indicated that it will investigate the large data breach incidents and will assess the smaller incidents to determine whether investigations are warranted. Encrypting electronic health data exempts healthcare organizations from having to notify affected individuals in the event of a data breach. However, many entities may still consider encryption cost-prohibitive.

Kendra Casey Plank, HHS Fields Thirty-Five Reports of Large Data Breaches Since HIPAA Rule Issued Last Year, BNA's Health Care Daily Report, Feb. 4, 2010 (note: registration is required to view this content).

Difficult Childhood Lingers in the Mind

Researchers have affirmed that adversities faced in childhood have effects on mental health far into the future. Mental illness in adulthood was increasingly likely the more traumas faced in childhood, according to a study reported in the February issue of the Archives of General Psychiatry.

Childhood difficulties potentially explained 32.4% of all the psychiatric disorders examined, they said, based on analyses of the National Comorbidity Survey Replication. Adversities relating to family dysfunction--substance-abusing parents, sexual or physical abuse in the home, neglect, etc.--appeared to have the strongest link to onset and persistence of psychiatric disorders, they reported.

These findings match folk wisdom and decades of research into the negative effects of child maltreatment, said researchers in an accompanying editorial. But the lack of specificity between certain exposures to particular mental health outcomes--such as the death of one's mother leading to depression--was notable, the editorialists said.

The study's authors examined joint associations of twelve retrospectively reported childhood adversities with lifetime incidence of disorders meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria in the National Comorbidity Survey Replication I, a cross-sectional survey of a nationally representative sample of adults in 9,282 American households. Among the respondents, 53.4% reported at least one childhood adversity, most commonly parental divorce (17.5%), family violence (14.0%), family economic problems (10.6%), and parental mental illness (10.3%).

These adversities were all individually and significantly linked to first onset of psychiatric disorders with odds ratios of 1.5 to 1.9 for dysfunctional family factors (physical abuse, sexual abuse, neglect, parental mental illness, parental substance abuse, parental criminality, or family violence) and 1.0 to 1.5 for other factors like life-threatening childhood physical illness, extreme poverty, parental divorce, or loss of or separation from parents. Despite some apparent but not significantly meaningful variation in type of adversity with type of psychiatric disorder, the researchers said that they could rule out that all types were the same for future mental health.

Problems tended to cluster, though. Among people who faced one adversity in childhood, 51.2% to 95.1% faced others as well, depending on the adversity. Risk of mental illness rose with number of issues faced in childhood from an odds ratio of 1.3 for one up to 3.4 for six, and 3.2 for seven or more adversities.

Primary source:
J.G. Green et al., Childhood Adversities and Adult Psychiatric Disorders in the National Comorbidity Survey Replication I: Associations with First Onset of DSM-IV Disorders, 67 ARCH GEN PSYCH 113-23 (2010).

Crystal Phend, Difficult Childhood Lingers in Mind, MedPage Today (Feb. 4, 2010).

President Obama's Budget Increases Funding for Medical Research That Compares Treatment Options

The Obama Administration, in an effort to forge ahead with its sometimes-contentious effort to compare various medical treatments, is proposing a big boost in funding for the agency that oversees the research. Proponents say that the research can provide patients and their doctors with crucial information to help them decide among various drugs or treatments. Critics, on the other hand, say that the research could be used to limit or ration care if the federal government or insurers used the information to deny coverage for a particular test or procedure because it was found to be less effective.

The administration, releasing its 2011 budget request to Congress on Monday, proposed spending $286 million on comparative effectiveness research overseen by the Agency for Healthcare Research and Quality (AHRQ). The agency got $21 million for such research in its current fiscal year budget, and an additional $300 million for such research in the economic stimulus bill.

Efforts to compare drugs or treatments are not new; private insurers and Medicare consider medical evidence at times in a bid to determine whether a new treatment works well for particular types of patients. But the research is often controversial. In December, for example, a recommendation from a government task force dealing with annual mammograms for women under age fifty raised concerns among advocacy groups and lawmakers that it might lead to restrictions on mammograms for some women.

Both the House and Senate healthcare overhaul bills--now stalled in Congress--would also boost funding for comparative effectiveness research. The House legislation would provide $300 million over three years for the research, according to an analysis from Avalere Health, a Washington-based consulting firm. The Senate proposed creating a nonprofit, nongovernmental agency to oversee the research effort, spending $165 million over three years, according to the analysis.

In an interview Monday, AHRQ Director Carolyn Clancy said if Congress approves the president's request, the funding would be used to continue the agency's research in fourteen different areas, including cancer, obesity, and substance abuse.

Mary Agnes Carey & Julie Appleby, Obama's Budget Increases Funding for Medical Research That Compares Treatment Options, Kaiser Health News (Feb. 1, 2010).

HHS Secretary Cannot Guarantee Openness in Talks

HHS Secretary Kathleen Sebelius told Congress on Wednesday that she could not guarantee greater openness in negotiations over legislation to remake the nation's healthcare system. "I am not a principal in the negotiations," Sebelius said in testimony before the Senate Finance Committee. "Nor is my staff."

Sebelius said administration officials provided "technical support" to Congress, but did not control the negotiations. Her comments came about five hours after President Barack Obama affirmed the need for openness in efforts by the administration and Congress to finish work on a healthcare bill intended to expand coverage and rein in costs.

In the rush to pass legislation in December, Senate leaders and White House officials did much of their work behind closed doors, and President Obama said Wednesday that the perception of secrecy may have undermined public trust. "I take some fault for this," President Obama said at a meeting with Senate Democrats. "At the end of the process, when we were fighting through all these filibusters and trying to get it done quickly--so that we could pivot and start talking about other issues that were so important to the American people--some of that transparency got lost. And I think we paid a price for it."

The chairman of the committee, Senator Max Baucus (D-MT) said he was "very confident" that Congress would soon pass a comprehensive healthcare bill, even though the legislation was now stalled. President Obama's budget assumes approval of the legislation. But he and Congressional Democratic leaders have not said how they intend to achieve that goal in the face of continued opposition from Republicans who say the government cannot afford its existing healthcare commitments. Jobs and the economy have replaced healthcare as President Obama's top priority, but Sebelius said passage of the healthcare bill would help create jobs and save them.

Robert Pear, Health Official Can't Guarantee Openness in Talks, N.Y. TIMES (Feb. 3, 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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