Whitney Palmer

Healthcare. Politics. Family.

Medicare Passes, Budget Left Unfinished As Congress Wraps Up 2003

Published in the January 2004 AAMC Reporter

In early December, President Bush signed the sweeping Medicare legislation Congress passed after a six-year struggle to revamp the program. The $400 billion law, narrowly approved by Congress in November, includes a discount prescription drug card and voluntary prescription drug benefit, better Medicare fee-for-service benefits and provisions to help teaching hospitals and academic physicians.

The AAMC sent a letter of support to the House and Senate leadership on Nov. 19. In the letter, AAMC President Jordan J. Cohen, M.D., expresses the AAMC’s appreciation and highlights a number of provisions that will benefit academic medicine.

In the letter, he states, “We are pleased that the agreement includes support for teaching hospitals by ameliorating current reductions to the Medicare Indirect Medical Education (IME) adjustment and states’ Medicaid Disproportionate Share Hospitals (DSH) allotments.” Dr. Cohen goes on to acknowledge the agreement’s “inclusion of temporary relief from cuts to Medicare physician payments, as well.”

Steve Lipstein, president and CEO of BJC Healthcare in St. Louis, and chair of the AAMC’s Medicare Special Action Committee, views the measure with pause, calling it “an upside with a cautionary flag.”

“Congress took many steps forward that will be good for hospitals and doctors,” he says. “But the problem is that [the bill’s provisions] will cost an additional $100 billion over the next 10 years, and it comes when the federal government still has a very large deficit. If this [Medicare] program is deficit financed, you have to wonder if it can be sustained in the long term.”

The law, known as “The Medicare Prescription Drug, Improvement and Modernization Act of 2003,” increases Indirect Medical Education (IME) payments from 5.5 percent to 6 percent from April 1 to Sept. 30, 2004, 5.8 percent in FY 2005, 5.55 percent in FY 2006, and 5.35 percent in FY 2007 before rebounding to 5.5 percent in FY 2008. The hospital inpatient update will remain at full market basket for FY 2004, and hospitals that are part of CMS’s quality initiative in FY 2005-2007 will receive full market basket updates. Those not participating will be reduced by 0.4 percent.

State Medicaid DSH allotments are 116 percent of FY 2003 levels for FY 2004 — the levels will hold until the year they fall below levels scheduled by the Balanced Budget Act. Increases will then be controlled by inflation. “Low DSH” states will see increases of 16 percent over the next five fiscal years.

It also maintains the “carve out” of Medicare Direct Graduate Medical Education (DGME) and IME payments associated with Medicare Advantage plans (Medicare Advantage is the new name for Medicare+Choice).

There are also provisions for physicians. The physician payment conversion factor is set at least at 1.5 percent for 2004 and 2005, using a 10-year rolling average when calculating the gross domestic product.

In addition, the law includes a number of provisions affecting financing for residency programs. It reapportions the amount of hospital resident limits that are “unused” to teaching hospitals that need to increase resident limits. More specifically, if a hospital’s resident count fell below the resident limit on or before Sept. 30, 2002, the limit wil drop by 75 percent of the difference. Hospitals wishing to increase their limits can apply to receive up to 25 additional positions.  The increases will be granted in this order: rural hospitals, hospitals in small urban areas, and hospitals where the resident training program is the only one in the state.

In addition to passing the Medicare legislation, Congress attempted to complete work on the seven outstanding FY 2004 appropriations bills before adjourning in 2003. The House voted Dec. 8 to approve a $328.1 billion conference agreement on the omnibus spending legislation that included all seven bills. However, Senate action on this legislation will not take place before Jan. 20. The agreement includes a $1 billion (3.7 percent) increase for the National Institutes of Health. But the real increase is reduced to $835 million (3.1 percent increase) by the 0.59 percent across-the-board cut applied to every account in the bill, including all non-defense FY 2004  appropriations bills already enacted, designed to cover part of the cost of the package’s other priority programs.

The NIH budget will drop further because the conference agreement authorizes the HHS secretary to impose a 2.2 percent “tap” on Public Health Service budgets to fund evaluation research programs, such as the Agency for Healthcare Research and Quality (AHRQ). The agreement also calls for the transfer of $150 million from the NIH to the global HIV/AIDS fund.

The conference agreement provides $294.2 million for Title VII health professions education programs — a 4.6 percent cut. For Title VIII nursing education programs, the bill includes $141.9 million, an increase of 25.9 percent. The AHRQ receives $303.7 million, the same amount as in FY 2003.

Under the omnibus agreement, VA medical care gets a $2.8 billion (11.9 percent) hike from FY 2003 and VA medical research receives an $8.2 million (21 percent) increase.


March 25, 2010 Posted by | Healthcare, Politics | , , , , , | Leave a comment

Medical Schools Seek Security of Student Background Checks

Published in the October 2004 AAMC Reporter

Law enforcement and federal government jobs are not the only professions requiring criminal background checks anymore. Mindful of terrorist threats and increased patient safety concerns in America’s hospitals, many medical schools now conduct background checks on incoming students.

For years many institutions performed checks on all faculty and staff, but because medical students have frequent contact with patients some schools are extending the policy. Several schools conduct checks, and one institution views them as a proactive measure that could benefit students in the future. According to 2003 AMCAS data, of the 201 applicants who reported felony convictions, 199 were not admitted while two were accepted. There were 34,786 total applicants in 2003-2004.

A recent murder-suicide case involving a University of Arkansas medical student who had a criminal history brought the use of background checks back to the forefront. The University of Arkansas does not conduct background checks currently but is considering changing the policy in the wake of this incident.

Ohio State University initiated its own comprehensive background check policy and inaugurated it this year with first-year students. Current students will be retroactively checked, beginning with fourth-year students because they are closer to working in clinical settings.

“We’re doing it to protect the institution and to assess the students so if something does come up, we can work with them to see if they can still become a licensable professional,” said Judith Westman, M.D., Ohio State University’s associate dean of student affairs and medical education administration.

Only applicants who have been interviewed and recommended for acceptance are subject to background checks. Students receive a letter of their admittance pending a background check. Initially, students will pay for the checks, and if they choose to matriculate, the school will reimburse them. Background checks, depending upon whether the student is from Ohio or out of state, cost between $17 and $40.

Checks and Balances

When designing the background check policy, Ohio State officials were careful to separate it from any admission decisions, Dr. Westman said, citing the need to protect students’ civil rights. The school did not want to be accused of conducting a “witch hunt” for students with a criminal background or for denying entry based on past events.

Ohio State divides reported criminal incidents into two categories: minor offenses and those that disqualify a student from accessing clinical sites. For example, if a student had a conviction related to mental health problems, the school would help the student accumulate the documentation detailing successful treatment needed to appeal to the state medical board. But if the check unearthed a sexual assault or child abuse, the student could not be placed in a clinical rotation, Dr. Westman said.

“If someone has been arrested and convicted of voyeurism, how can I put them in a gynecology exam room?” she said. “This is a patient safety issue, and they can’t be placed in a clinical setting. Therefore, they can’t be allowed to continue in the program.”

Almost one half of U.S. states already require criminal background checks or are considering legislation that would require them for doctors applying for licensure, and the AAMC is working with member institutions to develop guidelines on the use of background checks. Several schools indicated they are weighing the benefits and burdens of background checks.

Full Disclosure

Duke University School of Medicine’s policy is similar to Ohio State’s. School officials evaluate both misdemeanors and felonies. Although the school has never found anything unsavory in a student’s past that was not disclosed, there is a policy in place should that happen, said Richard Wallace, Duke’s assistant director of admissions.

If a student lies about a conviction, Wallace said the vice dean of the medical school, dean of students, an advisory panel of four other deans and the school’s legal counsel evaluate the nature of the crime and determine whether the student can matriculate.

“We make it very clear to these students that we’re not trying to keep them from enrolling in school,” Wallace said. “We’re just trying to make sure there are no skeletons in their closet that will come back to haunt them or to haunt Duke.”

The checks also benefit the students when they reach clinical rotations because hospitals affiliated with Duke require everyone who interacts with patients to undergo a background check.

Oregon Health Sciences University also began criminal background checks on first-year students this year because the students will need a background check before entering a clinical setting. However, the school decided that current students will not be checked.

“Our institution felt it made sense to ask questions of students to ensure we have people here who have the background that should allow them to be here,” said Robert Vieira, Ed.D., Oregon’s vice provost for academic and student affairs.

The campus public safety office pays for the background checks from its departmental budget. The cost of adding students to the 12,000 employee background checks being conducted annually is minimal, Dr. Vieira said. If the check unearths an incident, the public safety office along with an administration official and the medical school dean determine whether the student can remain enrolled.

Check Required

Other schools require background checks simply because state law mandates them. Students at the University of Minnesota Medical School submit to background checks at the beginning of each school year. During orientation, students fill out the forms that allow the state to determine whether they are fit to work in clinical sites.

Rather than benefiting the institution, Minnesota officials look at running criminal background checks as a method of protecting the public health in general.

“This is an issue of the public needing to feel the people taking care of them are secure,” said Helene Horowitz, Ph.D., Minnesota’s associate dean for student affairs. “Having the checks in place at the governmental level ensures the public adequate precautions have been taken for those one-in-a-million situations where patients are hurt.”

According to James Thompson, M.D., president and CEO of the Federation of State Medical Boards (FSMB), conducting background checks when students enter medical school would protect the public. One of the Federation’s primary goals is to prevent those with criminal pasts from entering the medical profession.

“The cost to society is great when medical schools educate individuals who will never be allowed to practice medicine because of prior criminal history,” he said. “Having background checks prevents these people from becoming part of the profession.”

Identifying students with criminal records before they enter medical school could prevent situations where potentially violent individuals could be given access to hospitals and lethal doses of medication, Dr. Thompson said. Relying on self-disclosure forms is inadequate because too many applicants lie when questioned. For example, a recent Florida state background check of all healthcare workers discovered that 44 percent of individuals guilty of felonies did not reveal the infraction.

But waiting for background checks can be time-consuming, according to officials at the North Carolina Medical Board. North Carolina runs checks through the FBI and results often take as long as eight weeks, and fingerprints are sometimes lost.

March 25, 2010 Posted by | Healthcare | , , , , | 2 Comments

NIH Tightens Policy on Outside Income

Published in the March 2005 AAMC Reporter

Under the new regulations announced in February by NIH Director Elias Zerhouni, M.D., all NIH employees, including its 5,000 scientists, must abandon any paid or unpaid work with pharmaceutical, biotechnology or healthcare companies, with certain exceptions. They are also prohibited from speaking, teaching or writing for academic institutions that are or recently were NIH applicants, grantees, contractors or CRADA partners.

The regulations are in response to congressional pressure to rein in  unapproved outside activities that some NIH employees engaged in, unbeknownst to agency administrators. In addition, they are an attempt to restore the agency’s integrity as an institution of scientific objectivity. The Department of Health and Human Services will review the limitations to determine whether they are sufficient.

“We wanted to break with the past and start with a clean slate,” Zerhouni said. “There’s nothing more important to the

Elias Zerhouni, M.D., former director of the National Institutes of Health. Courtesy: National Institutes of Health.

NIH than putting the public first and clearing the way to provide health advice with no taint or appearance of conflict of interest.”

Scientists will also be affected in terms of personal financial holdings. Any employee with financial interests such as stock in a biotechnology, pharmaceutical or medical company is subject to a cap of $15,000 on such holdings. The limitations also apply to their immediate family members. Certain high-level officials are prohibited from holding any such interests. The agency also prohibits senior employees from receiving gifts equal to or greater than $200 in value if the award is given because of their official position or from a prohibited source.

Many of the researchers initially cited for failure to report outside income were later absolved, according to recent media reports. These reports suggest that in many cases researchers were mistakenly accused, because of discrepancies in methods of reporting to Congress to names of scientists who received permission to perform outside work and the dates of that work.

The AAMC endorsed the new NIH policy regulating the outside activities of its employees because trust in NIH’s integrity was threatened, as well as Congressional support for the NIH and beyond.

However, the AAMC also expressed support for the NIH’s plan to assess the impact of these new rules, especially on recruitment and retention, within one year. Given the sweeping changes being made and the possibility of unintended consequences, modifications may be necessary.

Tighter restrictions will help the NIH regain its stature in the eyes of federal lawmakers and could help the agency  move past the revelations of employee misconduct, according to David Blumenthal, M.D., professor of medicine and healthcare policy at Harvard University Medical School.

“The regulations will get the heat off the NIH from Congress and other groups,” Blumenthal said. “It will enable Zerhouni to go to the Hill and speak with other groups and not work under the cloud of suspicion associated with previous practices.”

Over the past 14 months, media reports unearthed details about some NIH scientists who were reportedly abusing the former policy by accepting sizable monetary sums for their efforts. The overwhelming majority of NIH employees, however, followed the rules. But all employees are still subject to the changes, and many of the more stringent measures sound too draconian for some academics.

“These regulations are too strict,” said James Siedow, Ph.D., vice provost for research and biology professor at Duke University. “With all the furor and revelations over the past year and a half, the NIH has been put in a box, and the pendulum has been forced too far in one direction.”

Siedow served on a blue ribbon panel last summer that was charged with drafting preliminary conflict of interest regulations for the agency.

Science flourishes best when its practitioners have free, face-to-face contact, and scientists and researchers who are not allowed to interact with their peers regularly tend to become insular, Siedow said. The agency might struggle to attract and keep the nation’s top scientists because they will not be subject to restrictions elsewhere.

Zerhouni acknowledged that the agency may encounter problems in recruiting and retaining quality scientists, but he said rehabilitating the NIH’s reputation on the national stage was his primary concern.

According to Philip Pizzo, M.D., dean of the Stanford University School of Medicine who also served on the blue ribbon panel, banning too many outside activities on employees who have done nothing wrong or who have no control over NIH granting decisions could further deteriorate employee satisfaction.

“Such a ban is likely to create even further demoralization among the NIH community, especially those individuals who are in the large majority, who appear to have followed the rules and to have not engaged in prohibited activities,” Pizzo said.

Pizzo hopes the ban will be lifted, especially for scientists with no granting authority, once NIH administrators have a clear picture of employee activities.

Other activities are still permitted under some circumstances. Scientists can teach college courses as part of an established curriculum, and they can also teach or write for a continuing professional education program. If a pharmaceutical or other prohibited company funds the program, the money must be an unrestricted educational grant.

In addition, NIH employees are free to write articles, chapters or textbooks that will be peer-reviewed. such direct ties between academic medicine and the agency are important to support and foster, Pizzo said.

“Interactions between academia and NIH scientists are both desirable and mutually beneficial, and I hope that the current restrictions do not further limit those interactions or collaborations,” he said. “That would not serve the nation’s science mission.”

March 25, 2010 Posted by | Healthcare, Politics | , , , , | Leave a comment


%d bloggers like this: