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House Republican Plan Would Increase Medicare Payments to Providers (New York Times)
The Eyes and Ears of the Hospital (New York Times Letters to the Editor)
Bush threatens to veto anti-terror bill (Baltimore Sun)
Explosive devices found in man's home (Baltimore Sun)
Hospital expansion breaks ground today (Baltimore Sun)
Tamar's Children (Baltimore Sun Editorial)
Experts: Tuberculosis threat is growing (USA Today)
Study: Press needs to take note on medical reporting (USA Today)
New D.C. Law Lets Retarded Defendants Be Committed (Washington Post)
Health Care Firm Has Eye On Loudoun (Washington Post)
D.C. Postpones Paramedics' Use of Morphine (Washington Post)
Citing Shortfalls, Governors Seek Medicaid Relief (Washington Post)
Error in an EPA Clean-Air Study (Wall Street Journal)

House Republican Plan Would Increase Medicare Payments to Providers

By Robert Pear
New York Times
Wednesday, June 5, 2002

WASHINGTON, June 4 - Under intense pressure from health care lobbyists, House
Republicans say they have decided to increase Medicare payments to doctors, hospitals and
health maintenance organizations, reducing the amount of money available to provide prescription drug benefits to the elderly.

Lobbyists for the health care industry have endorsed the Republican package, which is tentatively
scheduled for a vote on the House floor this month. But advocates for the elderly have reserved
judgment, saying some older people will not sign up for the drug plan unless the benefits are more generous.

As Congress sets out to overhaul the federal health insurance program for the elderly, it is trying to meet two needs.

Millions of older people are desperately seeking drug benefits. At the same time, Congress must increase payments to providers, lawmakers say, or more hospitals will close, more doctors will refuse to take new Medicare patients and more H.M.O.'s will pull out of Medicare.

Members of Congress from both parties and both chambers say new drug benefits and increased
payments to providers must come from the same limited pot of money. But the Democratic-controlled Senate is willing to spend more than the Republican-controlled House.

The Senate could go along with the House in raising Medicare payments to doctors and hospitals, but it is likely to insist on more generous drug benefits.

In February, President Bush said any increase in Medicare payments to some health care providers must be offset by cuts for others. In March, the administration suggested that Congress trim payments to hospitals. Both suggestions proved politically unacceptable in an election year.

Hospitals mobilized a lobbying campaign after House Republican leaders proposed cutting $17 billion from projected Medicare payments to hospitals over the next 10 years. A quiet rebellion by rank-and-file House members, including many from New York, forced House Republican leaders to reverse themselves.

Representative Bill Thomas, the California Republican who is chairman of the Ways and Means
Committee, said Republican leaders had reached an agreement with the American Hospital Association and the Federation of American Hospitals that would increase hospital payments by $9 billion over the next decade - a net shift of $26 billion.

In a bulletin sent to its 5,000 members, the hospital association described this as "a considerable
turnaround."

Eric Weissenstein, an analyst at Charles Schwab's Washington Research Group, said the changes were evidence of "the lobbying clout that hospitals were able to bring to bear in an election year."

The Senate will be at least as generous and might provide even more money to rural hospitals, Mr. Weissenstein said, noting that Senate leaders and senior members of the Finance Committee came from rural states.

But David M. Certner, the director of federal affairs at AARP, said the changes meant that there would be "less money for drug benefits in a pot that was already insufficient."

House Republicans have set aside $350 billion for drug benefits and other changes in Medicare over the next 10 years. Money used to increase payments to providers may, in some cases, improve care for Medicare patients, but will not be available for drug coverage.

Doctors, like hospitals, hailed the prospect of higher reimbursement. Medicare payments to doctors were cut 5.4 percent this year, and with no change in current law, federal officials said, they will be reduced by 5.7 percent in each of the next two years and by 2.8 percent in 2005.

The American Medical Association led a lobbying campaign to reverse the cuts. House Republicans said their legislation would increase payments to doctors by $20 billion over five years, including increases of 2.5 percent next year, 2.3 percent in 2004 and 2.4 percent in 2005.

Likewise, House Republicans said they had decided to increase Medicare payments to H.M.O.'s by roughly $3.5 billion over the next decade. In recent years, many private health plans have pulled out of Medicare, calling payments inadequate.

House Republicans also plan structural changes in Medicare that would enable beneficiaries to buy coverage from an array of competing private health plans. If an H.M.O. held down costs, beneficiaries would receive three-fourths of the savings, and the government would keep the remainder.

Senator Max Baucus, the Montana Democrat who is chairman of the Finance Committee, said he had heard no clamor for such changes.

"The interest in prescription drug benefits is increasing," Mr. Baucus said in an interview, "but the interest in structural reform of Medicare is falling off. It doesn't save money. There's no consensus. And in states like Montana, there's no Medicare managed care anyway."

House Republicans said they had finished work on the centerpiece of their Medicare bill - providing drug benefits.

Under the drug plan, they said, a beneficiary would have to pay premiums estimated at $34 a month, a $250 deductible, 20 percent of drug costs from $251 to $1,000 a year, and 50 percent of drug costs from $1,001 to $2,000.

Beneficiaries would then be responsible for any additional drug costs until they had spent $4,500 of their own money. Medicare would cover costs beyond that.

Republicans say Medicare could use its purchasing power to negotiate drug discounts averaging 30 percent.

Under that assumption, Republicans said, a person with $1,000 in annual drug costs would spend $748 in premiums, deductible and co-payments, and would save $252. A person with $2,000 of drug costs would have to pay $1,008 and would save $992.

Likewise, the Republicans said, a person with $5,000 in drug costs would spend $2,808 and would save $2,192, while a person with $10,000 of drug costs would pay $4,908 and would save $5,092. A patient with drug costs of $20,000 a year would pay the same amount, $4,908, but would save $15,092, the Republicans said.

Copyright 2002 The New York Times Company

The Eyes and Ears of the Hospital

New York Times Letters to the Editor
Wednesday, June 5, 2002

To the Editor:

Re "Shortage of Nurses Hurts Patient Care, Study Finds" (news article, May 30):

The lesson from these findings is that hospital quality of care is more a function of registered nurses and their training and support than of equipment and technology.

Some of our finest hospitals have chosen to bite the bullet of managed care by investing in better nursing, thereby realizing their missions by offering superior care. Depreciation of the professional practice environment for hospital nurses and the unmet need for more of them are due to the same managed-care-driven market forces.

The 1996 Institute of Medicine report that recommended that hospitals expand the use of registered nurses with advanced training also said Congress should mandate 24-hour registered-nurse coverage in nursing homes by 2000. This hasn't happened, but it should be done to protect nursing home residents, who are even more dependent on their professional caregivers.

JOHN STEEN
Ewing, N.J., May 30, 2002

The writer is a consultant to the American Health Planning Assn.

To the Editor:

I agree with Dr. Jack Needleman that registered nurses are "the eyes and ears of the hospital," but as a registered nurse and a doctoral student in family health care nursing, I would like to extend the metaphor ("Shortage of Nurses Hurts Patient Care, Study Finds," news article, May 30).

We as nurses are positioned to gain entree to our patients' worlds, to see through their eyes and to perceive their fears and concerns.

With the ability of nurses to navigate two divergent worlds, the "world of the patient" and the "world of medicine," we are not only the "eyes and ears of the hospital" but also the "voice," in which we are responsible for advocating the needs of our patients and their families.

It is our responsibility as nurses to share with the public the less visible yet exciting and sacred work that we do.

FRANCES M. STRZEMPKO
San Francisco, June 1, 2002

To the Editor:

In "Shortage of Nurses Hurts Patient Care, Study Finds" (news article, May 30), a spokeswoman for the American Hospital Association suggests that hospitals have known this "for some time."

If this is the case, why haven't hospitals tried to improve patient care?

The answer may be that hospitals, as well as the entire health care delivery system, have little incentive to improve quality of care (outside of professional norms).

Perhaps if managed care plans had incentives to pay hospitals based on quality as well as on price, this might also change the incentives of the hospitals.

WARREN GREENBERG
Washington, May 30, 2002

The writer is professor of health economics at George Washington University.

To the Editor:

Re "Shortage of Nurses Hurts Patient Care, Study Finds" (news article, May 30):

While the American Hospital Association condemns establishing staffing ratios as "simplistic," nurse-patient ratios may be one of the only concrete protection measures the public can look to.

If the many nurses working outside of hospitals, or even health care, know that an institution adheres to a minimum standard of care, they may choose to return to the bedside, alleviating this system-induced shortage.

JUDY SHERIDAN-GONZALEZ
Bronx, June 3, 2002

The writer heads the delegate assembly of the New York State Nurses Association.

To the Editor:

Re "Shortage of Nurses Hurts Patient Care, Study Finds" (news article, May 30):

As a registered nurse, I am concerned about the growing nursing shortage. But Congressional action this year may help address this crisis.

The House and the Senate have passed different versions of the Nurse Reinvestment Act, a bill I sponsored to bring more nurses into the work force. The House leadership has promised that we will finish work on this bill in the next month.

There is also an effort to substantially increase financing for nurse education programs this year, which will help nursing schools and health care facilities train more nurses.

LOIS CAPPS
U.S. Representative, 22nd Dist., Calif.
Washington, May 30, 2002

Copyright 2002 The New York Times Company

Bush threatens to veto anti-terror bill
Senate's version stands at $4.3 billion more than what president requested

Associated Press
Baltimore Sun
Wednesday, June 5, 2002

WASHINGTON - The Bush administration threatened yesterday to veto the Senate's $31.4 billion anti-terrorism bill, setting up an election-year duel over a package that the White House says has grown too costly.

The bill's mostly Democratic defenders pressed ahead anyway and fired back at Republicans who promised to offer amendments that cut the bill's price tag.

"It's easy to sit around and carp and complain and criticize," said Senate Appropriations Committee Chairman Robert C. Byrd, a West Virginia Democrat who is the bill's chief architect. "But there are some around here who feel they have to do some things to help this country."

Even as the two sides got ready for what looked like a lengthy battle, the Senate voted 91-4 to drop a ban on new emergency loans for airlines until Oct. 1. The loans are part of a bailout program enacted just after the Sept. 11 attacks.

The vote was a boon to ailing US Airways, which says it needs a $1 billion loan this summer. By erasing the $393 million the loan restrictions were supposed to save, the overall bill's cost grew to $31.4 billion.

President Bush asked Congress in March for $27.1 billion in anti-terror spending for the rest of the federal fiscal year, which ends Sept. 30. Like the Senate measure, his plan is dominated by funds for defense, intelligence, aviation safety, local law enforcement, and to help New York rebuild from the attacks. Most Senate add-ons are for domestic security programs.

In a statement delivered to senators, the White House budget office said senior advisers would urge Bush to veto the measure as written by the Democrat-dominated Senate.

"The Senate bill includes scores of unneeded items that total billions of dollars - all classified as an 'emergency,'" the statement said. "The bill adds unrequested funds for numerous programs and projects throughout nearly all of the federal agencies."

Projects that the administration found objectionable include $100 million to secure Russian nuclear weapons and $315 million for construction by the Centers for Disease Control and Prevention - which the White House said could not possibly be spent this year.

The statement also said only half of the $40 billion that Congress and Bush provided for anti-terror programs in the fall has been spent - reducing the need for more spending. And it said the administration will oppose amendments that boost the bill's price tag.
Such amendments, totaling billions of dollars, have been written by senators of both parties.

The GOP-led House approved a $29 billion version of the measure last month. White House officials have called it acceptable because it includes a conditional $1.8 billion extra for the Pentagon that the administration says it would not expect to spend.

After delivering the statement to Republican senators, White House budget director Mitchell E. Daniels Jr. said the Senate should pass a measure "at a level which really we believe meets the nation's needs, but is really all the nation can afford."

Sen. Ted Stevens of Alaska, top Republican on the appropriations panel and co-author of the bill, called the veto threat "just a tactic."

"We'll work this out" by the time a compromise House-Senate bill is finished, he said.

Despite pleas by Byrd, Stevens and others to hasten work on the bill, Republican Sens. Phil Gramm of Texas and John McCain of Arizona said they plan several amendments that would trim the spending.

Copyright � 2002, The Baltimore Sun

Explosive devices found in man's home

Baltimore Sun
Wednesday, June 5, 2002

A 30-year-old Sykesville man was charged yesterday with possession of destructive devices, after authorities said they found evidence that he was making pipe bombs and offering them for sale.

Peter Schindelbeck of the 7400 block of Village Road was arrested after an investigation by the state fire marshal's office and Sykesville Police Department.

A search of his apartment at 9 a.m. yesterday turned up five explosive devices with evidence of explosive manufacturing, said W. Faron Taylor, a spokesman for the fire marshal.

The devices ranged from 2 1/4 inches to 4 inches in length and were an inch in diameter.

Taylor said that while relatively small, the devices had the potential not only for serious injury, but "they could also kill someone."

Authorities were investigating the extent of Schindelbeck's alleged manufacturing and distribution.

Schindelbeck was taken into custody without incident at the state's Springfield Hospital Center, where he works as a rehabilitation specialist with a private company.

He was being held last night on $20,000 bail.

Copyright � 2002, The Baltimore Sun

Hospital expansion breaks ground today
Emergency department to relocate; four-story tower part of first phase

By Athima Chansanchai
Baltimore Sun Staff
Wednesday, June 5, 2002

Carroll County General Hospital will break ground today on the first phase of an $80 million expansion - the largest in its 40-year history - that includes an enlarged emergency department and a four-story tower.

The additions and improvements, approved by the Maryland Health Care Commission in January, will help the Westminster hospital meet the medical needs of a fast-growing county, hospital officials said.

As part of the groundbreaking, the 172-bed hospital will launch Fulfilling the Promise, a campaign to raise $8 million in private funds for the project. The hospital has received $5.6 million in pledges over the next three to five years and has collected about $2 million.

"So far, we've hit the ground running," said Ellen Finnerty Myers, vice president of development, who joined the hospital last year to lead fund-raising efforts. "People see that the expansion is really needed. This hospital was founded by going door to door to the community and raising $750,000."

Overall, the two-year project will expand the hospital by 41 percent to 378,000 square feet. The hospital is paying for the project with bonds, cash reserves and fund raising, officials said.

As part of the first phase, the emergency department will be relocated and expanded, nearly doubling its size to 21,250 square feet, officials said.

A four-story tower will be built atop the hospital's south wing for patient care. That will double the number of private medical and surgical rooms to 81.

The last part of the first phase calls for the renovation of the front entrance off Center Street. The first phase should be complete in about a year, said Teresa Fletcher, director of marketing and public relations.

"We're trying to get good service to the community and looking forward to having facilities that will support the staff's efforts to care for the patients properly," said Leslie Simmons, vice president of patient care services.

"This expansion will go a long [way] toward making the emergency department the right size to handle the increased volume that we've seen. The patient tower - with its private rooms - will make sure there is a not a lot of wait for beds," she added, noting that 25 percent of the hospital's beds are in private rooms.
The expansion will reconfigure rooms to raise that percentage to 85 percent.

The second phase calls for renovations to the emergency department, expanding outpatient services to include new programs such as pulmonary rehabilitation, wound care and diabetes.

Financial contributors include:

A group of 250 hospital volunteers who joined together to pledge $1 million, which will be paid over five years.

Members of the Tevis family, owners of Tevis Oil and Modern Comfort Systems, who have donated $250,000.

BB&T, which has given $150,000, and Westminster Union Bank, $160,000.

650 hospital employees, who have money taken from their paychecks to meet a $450,000 goal.

The groundbreaking ceremony will be held at 4 p.m. in the front lobby by invitation only.

Copyright � 2002, The Baltimore Sun

Tamar's Children

Baltimore Sun Editorial
Wednesday, June 5, 2002

JAQWAN DYE would be nuzzling her infant daughter right now, feeding her and changing her diaper, watching her drift off to sleep. She would probably be studying to earn a high school diploma, attending parenting sessions with other new moms and bonding with her baby in the weeks before her release from the Baltimore City Detention Center.

That's how the 20-year-old inmate, serving time for a drug charge, would be spending her days now if Maryland prison officials hadn't delayed the launch of an innovative program for pregnant women serving short sentences. Twice now, the opening of Tamar's Children has been canceled, first in March, then in May. Each time public safety officials came up with another reason. Money. Medical staffing. Liability.

It's not as though prison bureaucrats hadn't been briefed on the project, for which organizers have raised nearly $3.5 million in federal and local grants. Monthly meetings with project leaders, prison reps, the University of Maryland Medical System and mental health professionals have been ongoing for a year.

The reasons for the holdup are sounding more and more like excuses for state officials, however well intentioned, who didn't do their homework. The issues of staffing, funding and liability are legitimate ones, but now is not the time to raise them, long after project coordinator Joan Gillece got a thumbs-up from Stuart O. Simms, secretary of public safety and correctional services. Is it
bad faith, poor planning or promises that can't be kept? It may be all three.

And in the muddle and confusion, a unique opportunity for women inmates and their newborn children may be lost. The clock is ticking on those federal grants. What a loss it would be.

Named for Tamar, a biblical figure who was raped and shunned, the project would give eligible pregnant women a new start for themselves and their unborn children. Various studies have identified inadequate bonding between mother and baby and poor parenting skills as risk factors for trouble later in a child's life. The Tamar's Children project is expected to give children a strong emotional footing and reduce the recidivism rate among women prisoners.

Now pregnant inmates surrender their infants to a relative or foster family after delivery. While they may see their babies on visiting days, mothers are not permitted to hold them for security reasons. Jaqwan Dye cradles a photo of her baby girl instead.

The project would offer prenatal care, trauma counseling and a variety of treatment services, even housing aid, to about 30 women a year held in a facility more conducive to developing that essential bond between mother and child. Pregnant inmates would arrive there in their final trimester and stay as long as six months after delivery. They would deliver their babies at the University of Maryland Medical Center, as they do now, but follow-up care would be provided for mother and child at the center.

The beauty of the Tamar's Children project is that it uses outside grants to pay for new services while relying on the state prison's medical contract to cover the inmate's health care costs. It sounds like a win-win partnership, especially in these tight budget times. The project has a host of supporters, from women judges to state health workers to students at the Key School in Annapolis.

Project coordinators say they won't give up. They have already received a commitment for $200,000 to $300,000 in federal funds to meet the state's latest request, a round-the-clock nurse at the site. But prison officials are still searching for a place to house the project.

The children of the Tamar project deserve a chance; they should not be shunned.

Copyright � 2002, The Baltimore Sun

Experts: Tuberculosis threat is growing

USA Today
Wednesday, June 5, 2002

WASHINGTON (AP) - Tuberculosis is the No. 1 killer of women of childbearing age worldwide, and the epidemic is growing with the spread of bacteria that is resistant to drugs that have worked in the past.

Experts attending the 4th World Congress on Tuberculosis said Monday that latent TB is a difficult disease to diagnose. In poor countries, women with the disease often aren't diagnosed until severe symptoms appear, they said.

"Many women are diagnosed only after they have become too ill" to care for their families, said Carol Nacy, head of the Sequella Foundation, a private group that is organizing tests for new TB drugs and vaccines.

By the time the disease is diagnosed, a patient may have infected 10 to 15 others, Nacy said. Even when women are diagnosed and receive drugs to treat their TB, mothers will often give the medicine to their children instead of taking it themselves.

"That's one reason TB is the number one killer of women of childbearing age," Nacy said Monday at a news conference of the World Congress.

Historically, tuberculosis is one of most deadly diseases known. About a third of the human population, roughly two billion people, are infected with TB bacteria, often in a latent form difficult to diagnose. But even in that form, the disease can be spread as droplets from sneezing or coughing.

About 10% of those with a latent infection, some 200 million people, will develop an active disease. About two million people worldwide die of TB annually, and some estimate that more than 90 million people could succumb to the disease over the next 30 years.

TB is a significant public health problem in developing nations, with China and India accounting for about a third of all cases worldwide. There were fewer than 16,000 cases of active TB in the United States last year, and about half of those cases involved recent immigrants.

A combination of drugs, including isoniazid and rifampin, has been shown to cure TB, but the treatment requires the medications be taken every day for 6 to 9 months, a regimen that is often difficult for patients to follow.

Failure to take the full course of drugs encourages the development of drug-resistant strains of TB which can then be passed from patient to patient. Drug-resistant TB represent about 14% of the cases in Estonia and more than 10% of those in one province of China. Worldwide, experts estimate that about 4% of TB cases involve a bacterium resistant to at least one of the treatment drugs.

Even when the bacterium becomes resistant to some drugs, it still can be controlled, but at a high cost.

A report by the National Institute of Allergy and Infectious Diseases, one of the National Institutes of Health, says an outbreak a decade ago in New York City of drug resistant TB cost almost a $1 billion to control. The Centers for Disease Control and Prevention said drug resistant cases of TB have dropped in the U.S. from 2.7% of all cases in 1993 to about 1.2%.

The World Health Organization, a United Nations agency, the NIH, the Centers for Disease Control, foundations such as Sequella, and health agencies in many countries are working to control a rising epidemic of TB through development of new drugs and vaccines, aggressively pushing programs of treatment, and finding new ways to diagnose the disease quickly while it is in its latent form.

New cases of TB have declined in countries including India and China, using a program called Directly Observed Treatment Short-course, or DOTS. This involves an aggressive effort to diagnose the disease and then for health care workers to confirm that patients take their medications. DOTS is now being used in 148 countries, said Dr. Jong-Wook Lee, head of the WHO tuberculosis program.

The WHO goal is to identify 70% of new TB cases, and to cure 85% of those cases, Lee said.

"Even in huge countries with a heavy burden of TB it is possible ... to achieve very high levels of cure," Lee said in a statement.

� Copyright 2002 USA TODAY, a division of Gannett Co. Inc.

Study: Press needs to take note on medical reporting

By Rita Rubin
USA Today
Wednesday, June 5, 2002

The next time you read or hear about the latest medical breakthrough, you might want to take it with a grain of salt and a healthy dose of skepticism, suggest two studies out today in the Journal of the American Medical Association.

In one study, physicians Steven Woloshin and Lisa Schwartz of the Veterans Affairs Medical Center in White River Junction, Vt., and Dartmouth Medical School assessed newspaper coverage of research presented at scientific meetings. In the other study, Woloshin and Schwartz examined press releases issued by seven top medical journals.

The pair analyzed news coverage of five high-profile scientific meetings in 1998. They found that a quarter of the research covered by the press never ended up getting published in peer-reviewed medical journals.

"Our hypothesis was that any medical research of sufficient importance for the general media would also appear in the medical literature," Woloshin and Schwartz write.

Yet the research that received front-page coverage was no more likely to be published in a medical journal after presentation at a meeting than studies that received less prominent coverage.

Why the disconnect between press coverage and medical journal publication? Organizations that sponsor medical meetings are too aggressive in courting the press, Woloshin and Schwartz say. They should use higher standards in determining which studies merit press releases, the authors say. And, in writing those press releases, "the idea that it's preliminary needs to be communicated," Woloshin says.

For their part, news organizations should consider raising their threshold for reporting on research presented at scientific meetings, the authors write.

Woloshin and Schwartz also take medical journals to task for hyping research findings in press releases. A number of top journals, including JAMA, routinely send out press releases about studies they're publishing. Research suggests that these press releases do increase the chance that journal articles will get press coverage.

But the press releases often omit important information, such as the limitations of research or whether a drug company paid for it, Woloshin and Schwartz say. "I think we're arguing for more complete press releases," Schwartz says. (JAMA did issue press releases on the Woloshin and Schwartz articles, but the pair say they did not get to see them in advance.)

Of the seven journals studied, Circulation, published weekly by the Dallas-based American Heart Association (AHA), generated the fewest and the longest press releases, according to the authors.

Carole Bullock, senior communications manager at the AHA, says Circulation was one of the first journals to begin routinely issuing press releases. Each week, editor James Willerson sends his picks for press releases to the AHA's science and media relations staffs, which then meets to choose the top ones. "Almost always we're in agreement," Bullock says.

For the AHA's annual scientific sessions, Bullock says, she reads all 4,000 abstracts selected for presentation. She whittles them down to 400, and then the AHA's science media relations staffs spend a day rating their newsworthiness.

Bullock acknowledges that her job isn't easy. "It's very difficult to communicate science. Our job is to translate it into a way people will really understand."

� Copyright 2002 USA TODAY, a division of Gannett Co. Inc.

New D.C. Law Lets Retarded Defendants Be Committed

Washington Post
Wednesday, June 5, 2002; Page B01

Defendants found incompetent to stand trial because of mental retardation may be committed through civil procedure under a law approved by the D.C. Council yesterday.

Passed 11 to 2, the law, which gives the discretion for that action to D.C. Superior Court judges, turns the treatment and placement of those defendants over to the Mental Retardation and Developmental Disabilities Administration of the D.C. Department of Human Services. The alternative to such placement could be the release of a defendant who is found to be mentally retarded and unable to stand trial.

Council members Sandy Allen (D-Ward 8), chairman of the Committee on Human Services, which oversees the mental retardation administration and the Department of Health, and Jim Graham (D-Ward 1) cast the dissenting votes. Allen said she opposed it because she thought the bill made an unclear distinction between the mentally ill and the mentally retarded.

The bill, which incorporates suggestions from the D.C. Public Defender Service, allows judges to remove mentally retarded defendants accused of violent crimes from the streets by allowing their commitment to "the least restrictive setting," such as a special group home. The annual cost could be $480,000.

D.C. Council member Harold Brazil (D-At Large) pushed a similar bill in July 1999 after a highly publicized case of a man who admitted to sexually assaulting a 12-year-old boy. The U.S. attorney's office had requested such legislation in 1997, but both efforts were rejected.

In February, Brazil introduced a different version in response to the case of George F. Gray, a 19-year-old mentally retarded man who admitted sexually assaulting a 5-year-old boy in Southeast Washington last summer.

Council members gave it a lukewarm reception.

In April, with language recommended by the Public Defender Service, whose lawyers represented Gray, Brazil revised the legislation to emphasize that the commitment procedure be geared more toward the needs of the mentally retarded person and to include the "least restrictive setting" language.

Gray, charged with first-degree sexual assault, is confined to St. Elizabeths Hospital. He could have been released because D.C. law has allowed for commitment of mentally ill criminal defendants, but not for mentally retarded defendants.

Officials with the Public Defender Service said they have not asked for Gray's release and sought an appropriate institution for him at the request of his mother.
St. Elizabeths officials said their hospital was not appropriate, and Public Defender Service officials recommended placing Gray in a secure group home where he would be monitored round-the-clock.

Gray, ordered held while doctors determine whether he is a sexual psychopath, has a June 28 status hearing before Judge Shellie F. Bowers. He could be committed through civil procedure under the new law.

Before a judge can commit a defendant to the custody of the mental retardation administration, the Office of Corporation Counsel must petition the court for the action. The person then may request a jury trial, and the corporation counsel's office must prove that the defendant is mentally retarded and likely to injure others.

Patricia A. Riley, special counsel to the U.S. attorney's office, said the office has "been concerned about the public safety issues around these kinds of cases, and this legislation makes it possible to address them."

Laura E. Hankins, chief legislative counsel for the Public Defender Service, said the legislation addressed the needs of the mentally retarded.

"I think it reflects the effort of the Public Defender Service, the U.S. attorney's office and the Williams administration to come up with a bill that doesn't just address public safety but also the . . . needs of the mentally retarded citizens," Hankins said.

Brazil said that he would have liked to avoid the "least restrictive setting" language but that he was happy the measure finally passed.

"You can't have people that rape and murder people and there's no action taken to prevent that from happening again," Brazil said.

� 2002 The Washington Post Company

Health Care Firm Has Eye On Loudoun
Hospital in Arlington Would Be Relocated

Washington Post
Wednesday, June 5, 2002; Page B01

The nation's largest hospital chain wants to create a health care campus in the region's fastest-growing jurisdiction, Loudoun County, by relocating a general hospital from Arlington and a psychiatric hospital from Falls Church, state officials said yesterday.

Nashville-based HCA Inc. said the plan is contingent on Northern Virginia Community Hospital of Arlington accepting its purchase bid.

HCA said it wants to develop a facility of 180 to 260 beds at an unspecified location in Loudoun by transferring some or all of the 164 licensed beds at the financially strapped Arlington hospital and the 100 licensed beds at HCA-owned Dominion Hospital, according to state officials, who must approve such a move.

Details will be included in the application for state permits, which must be filed by July 1. After taking recommendations from Northern Virginia regional health planners, the state would make a final decision by February.

With a population of more than 169,000, Loudoun is the region's fastest-growing jurisdiction and one of its most affluent. The one county hospital is often crowded, and Loudoun officials say there is not only a need for more beds but beds in other parts of the county.

"We're big in communities that are rapidly growing," said HCA spokesman Jeff Prescott. "That's a major strategy for us, and certainly that would describe Loudoun County."

But some health specialists said yesterday that the transfer of hospital beds to a wealthy outer suburb would hurt closer-in areas with their overburdened emergency rooms and crowded wards.

Arlington County Health Director Susan Allan said Northern Virginia Community's emergency room serves a vital purpose.

"This is a very problematic time for us to have a hospital relocating or losing beds within the inner jurisdictions of Northern Virginia," said Allan, adding that after the terror attacks of Sept. 11, there is added concern that enough beds exist to absorb a surge in emergency patients.

"There wasn't enough capacity to begin with," she said. "This is going to raise some public questions about whether we should be doing something to stop it."

Negotiations for HCA's purchase of Northern Virginia Community Hospital continued yesterday without an agreement. The owner of the hospital, Kindred HealthCare of Louisville, declined to comment.
The hospital has informed some of its 450 staff physicians that a deal is in the works that could lead to a dramatic reduction in beds. Some also have been told that HCA might leave only outpatient surgery facilities at the campus on south Carlin Springs Road.

HCA pursued a similar plan in 1998, when it proposed to relocate its Pentagon City Hospital in Arlington to a site near the Franconia-Springfield Metro station.

After regional health planners criticized the proposal as unnecessary, HCA and its local partner, Virginia Hospital Center-Arlington, closed down Pentagon City Hospital. The partnership broke up as well.

The same health planners will review HCA's Loudoun proposal, and some officials already are expressing concerns.

About 300 new hospital beds have been approved for hospitals in Loudoun and western Fairfax counties, all of which serve Loudoun residents, said Dean Montgomery, staff director of the Health Systems Agency of Northern Virginia. The agency evaluates applications for changes in health services in Fairfax, Loudoun, Prince William and Arlington counties and Alexandria.

Loudoun Hospital Center President Rodney Huebbers was critical of the HCA plan, saying the county cannot support a second hospital despite its dramatic growth. Last month, Loudoun Hospital Center applied for permission to increase its bed count from 133 to about 200, he said. Huebbers said in a statement that he is prepared to oppose HCA's proposed campus because it could undermine the hospital center's expansion plan.

Loudoun politicians who have long pushed for more medical facilities in the county welcomed the plan.

"I give them credit for figuring out a way to work the system," said Supervisor James G. Burton (I-Mercer). "There's no question Loudoun County is to the point where it has the need for two hospitals."

Burton said HCA's plans would greatly benefit Loudoun residents, some of whom live 30 miles from a hospital.

Montgomery said he knows of no evidence that Arlington has too many hospital beds.

"If [Northern Virginia Community Hospital is] doing poorly in a booming market, it suggests that perhaps they aren't doing what they should be doing," Montgomery said. "Every hospital around them is doing well. I don't think geography is the explanation."

� 2002 The Washington Post Company

D.C. Postpones Paramedics' Use of Morphine
Council to Wait Until Fire Department Finishes Training

Washington Post
Wednesday, June 5, 2002; Page B03

The D.C. Council has delayed by a year a plan to allow fire department paramedics to administer morphine, Valium and other controlled substances to patients. The plan was put on hold after a union leader warned that medics using the drugs might not get proper training or supervision.

The council's decision on the rider to the city's new anti-terrorism law postpones an attempt to bring the District into line with other jurisdictions that allow paramedics to administer controlled substances to relieve pain, stop seizures and calm heart attack patients.

Kathy Patterson (D-Ward 3) said she and other council members wanted to wait until the fire department could show that it had properly trained workers to use the drugs.

Fernando Daniels III, the fire department's medical director, said he would probably resubmit the proposal before the year is up.

The department had asked the council to change a District law that allows only nurses and medical interns, under the supervision of a doctor, to give controlled substances to patients. Under the proposal, paramedics could administer the drugs if they called a hospital and received permission from a doctor.

Morphine and other controlled substances have been carried on ambulances elsewhere for decades, according to Robert Bass, Maryland's emergency medical services director. But District paramedics have not been able to use them. The fire department would like its paramedics to be able to administer morphine, Valium and Versed, a drug that is similar to Valium but acts faster,
Daniels said.

In some cases, D.C. paramedics use other drugs, such as nitroglycerin for heart attack patients. But the paramedics say they carry nothing that works as well as Valium to stop a seizure. In many cases, they say, they must rush patients to a hospital because they lack the drugs to treat them.

"D.C.'s been getting along without it," Bass said. "But that doesn't mean the patients that need it are getting the optimal care."

In December, the fire department finished an updated protocol for emergency care that included the proposed rules on controlled substances. The rest of the protocol has been approved by the D.C. Department of Health and will go into effect as soon as medics are trained, Daniels said.

The rules on controlled substances were held up because they required the council to change the law.
Kenneth L. Lyons, head of the emergency medical workers union, this year criticized the bill in a letter to Patterson and at a council hearing. He said that despite promising to teach paramedics the proper use of the drugs, the fire department trains and supervises them poorly.

Even a small error in dosage or injection could harm a patient because the drugs are powerful, Lyons said.

"I think the paramedics will administer the medicines as they're trained, and that's my point," Lyons said. "That could be dangerous."

He also questioned whether the drugs would be properly stored, saying that the department needed to have double-locked boxes to prevent theft.

Lyons is also pushing for requiring the presence of two paramedics when the drugs are administered. Most of the department's paramedics work two to an ambulance, but some work alone as ride-along paramedics on fire engines. The paramedic engine company program has been championed by outgoing Fire Chief Ronnie Few, but Lyons's union has opposed it.

Daniels said he is willing to work with Lyons on the issue.

� 2002 The Washington Post Company

Citing Shortfalls, Governors Seek Medicaid Relief

Washington Post
Wednesday, June 5, 2002; Page A03

Alarmed by a continuing decline in states' revenue, leading governors yesterday again asked Congress for short-term relief from rapidly rising Medicaid costs. They conceded the odds are against their getting any help.

Michigan Gov. John Engler (R), chairman of the National Governors Association, told reporters, "I think we've got a shot at this," but added that the best he had been able to get from leaders of the House and Senate is a "wait-and-see" answer.

Kentucky Gov. Paul Patton (D), the group's vice chairman, sounded a bit more hopeful because "members of Congress see what's going on," as cutbacks in state budgets threaten education and other programs.

The governors released an updated report -- the latest in a year-long series of such warnings -- on what Engler called "the continued deterioration in the fiscal health of the states."

Key findings from a May survey:

o Individual income tax collections in the first three months of the year dropped 14 percent from the same period in 2001, a loss of $14.5 billion.

o In April, a key month for tax returns, collections were down 21 percent, a loss of $8.5 billion.

o Payments of estimated taxes in the first quarter -- often an early indicator of receipts for the year ahead -- were running 27 percent behind those in 2001.

Worsening the fiscal situation, refunds processed by the states in the same period were 14 percent higher than last year, a $3.5 billion hit to their budgets.

The revenue shortfall, according to Raymond C. Scheppach, the NGA's executive director, reflected a sharp falloff in capital gains, stock options, dividends, interest and rents, largely attributable to the slump in the economy. Refunds grew because wages and salaries were below what taxpayers had expected.

The report said that corporate income taxes have slumped for five straight quarters. By contrast, sales taxes -- a major source of state revenue -- have held up better, rising 3.2 percent in calendar 2001.

Engler and Patton said that with most states required to balance their budgets each year, spending has been trimmed from earlier estimates and one-time transfers have been made from "rainy day" fund reserves, from tobacco litigation settlement money and similar sources.
"You can't do that year after year," Patton said, "and our main worry is how we get through the next two years. Even if the economy comes back, state revenues usually lag a year to 18 months."

The governors asked Congress last autumn to provide $4.5 billion in immediate fiscal relief, as part of either the economic stimulus bill or the recovery money approved after the Sept. 11 terrorist attacks. The measure would have increased by 1 percent the Medicaid payments to each state over the next 18 months.

The provision was included in separate bills passed by the House and Senate but was dropped in final negotiations aimed at keeping the package within the spending bounds set by President Bush.

With Medicaid expenses rising 13 percent -- far faster than overall state spending -- the governors again are seeking that relief. They support a bill sponsored by Sens. Susan Collins (R-Maine) and Ben Nelson (D-Neb.). No similar legislation has been introduced in the House and prospects do not appear bright in either chamber.

� 2002 The Washington Post Company

Error in an EPA Clean-Air Study
May Have Inflated Soot's Effects

By John J. Fialka
Staff Reporter of the Wall Street Journal
Wednesday, June 5, 2002

WASHINGTON -- A major study used by the Environmental Protection Agency to set Clean Air Act standards for industries and cities contains a software error that may have overstated the health dangers of small particles of soot and other pollutants.

A nonprofit research company, the Health Effects Institute of Boston, warned the agency last week that the two-year-old study of the air in the nation's 90 largest cities may have an error rate of as much as 23%. While the error resulted in both higher and lower predictions, a repeat study shows that the health risks of pollution are "more often smaller" than reported, according to the institute.

The flawed study, called the National Morbidity, Mortality and Air Pollution Study, was completed by researchers at Johns Hopkins University in 2000. It became part of the scientific basis for the EPA's air-pollution regulations governing industries, such as utilities and diesel-engine makers, as well as cities.

Joe Martyak, an EPA spokesman, said that "we're in the process of analyzing this right now" and that the matter will be reviewed by outside scientists on EPA's Clean Air Scientific Advisory Committee next month.

He said the agency's concern that small particles of soot pose major health problems is supported by other studies. A study published in the Journal of the American Medical Association in March showed that the levels of soot and other tiny particles found in large and midsize U.S. cities increase the risk of premature death from lung cancer and heart disease.

"There still remains a very strong link," Mr. Martyak added, saying the EPA believes it is too early to compute the effect the software error may have had. "We were glad to have this brought to our attention."

Scott Segal, a lawyer who represents the Electric Reliability Coordinating Council, a group of utilities, said the agency has used the Hopkins study for predictions of premature death from pollution. "This is going to be a long hot summer for epidemiologists," he said, predicting that the error means the EPA may have to take more time to set a new eight-hour pollution standard for large cities.

Bill Buff, a spokesman for the Diesel Technology Forum, which represents makers of engines, fuel refiners and antipollution manufacturers, said the error may not affect pending regulations on diesel engines, which are becoming cleaner.

"Still, it seems important to us. Maybe the fact is the sky isn't falling," he added.