Monday, March 9, 2009

News Clipping Archives

 

Monday / Reigonal

March is month to boost produce in diet (Baltimore Sun)

Re-Entry says it can see new veterans, while others getting care at VA clinic Tess Hill (Cumberland Times-News)

Money Stimulates Debate in States Over Plan's Goals (Washington Post)

Arthritis starting to affect younger people (Baltimore Sun)

Health Care Comes Home (GOVERNING: Connecting America’s Leaders)

Girl's Cries For Help 'Fell on Deaf Ears' (Washington Post)

Chicken waste air emissions remain unregulated (Salisbury Daily Times)

National / International

Stem-cell stocks jump on expected Obama policy (Daily Record)

Nurses Win Settlement Over Wages (Wall Street Journal)

Opinion

Creative Disruption (GOVERNING: Connecting America’s Leaders)

 

Maryland / Regional

 

March is month to boost produce in diet

Locally grown fruits and vegetables can be both economical, healthful

 

By Meredith Cohn

Baltimore Sun

Monday, March 9, 2009

 

Eat your fruits and vegetables. It's not hard, and they'll help you stay fit. That's the message from state officials, who have launched a month-long educational campaign to support March's National Nutrition Month. Buying local produce will also provide the freshest and most affordable foods, say the officials from the departments of Agriculture and Health and Mental Hygiene.

 

The officials say 80 percent of heart disease, stroke and diabetes can be prevented by eating well, along with exercising and not smoking. A quarter of Maryland adults are obese and the rate of obese kids has more than doubled in the past two decades. Yet, nationally only 10 percent eat the recommended five or more daily servings of fruits and vegetables. In Maryland about a quarter of adults eat the right amounts. Fresh, frozen and canned all count.

 

Health Secretary John M. Colmers says people can easily up the amounts by adding, for example, a piece of fruit to breakfast, snacking on raw vegetables in the afternoon and eating fruit for dessert. The American Dietetic Association, which launched National Nutrition Month, says that, in addition to fruit, consumers should emphasize whole grains, low-fat dairy products, lean meats, fish, beans and eggs. And they should cut down on saturated fats, cholesterol, salt and sugar.

 

Agriculture Secretary Roger L. Richardson says the state produces many types of healthy foods and many are available year-round. To find locally grown products and recipes, go to marylandsbest.net. For healthy recipes, tips on label reading and nutritional guidelines, go to fruitsandveggiesmorematters.org.

 

Copyright © 2009, The Baltimore Sun.

 

Re-Entry says it can see new veterans, while others getting care at VA clinic Tess Hill

Cumberland Times-News

Monday, March 9, 2009

CUMBERLAND — Having worked on a fee-basis arrangement with Re-Entry Associates for a number of years, the Martinsburg Veterans Affairs Medical Center began looking to move to a contractual arrangement with the center. However, as the move began, questions arose about the licensure of some of the staff at Re-Entry.

“We found the licenses at Re-Entry Associates were not to the standard of care we provide within the Veterans Health Administration,” said Ann Brown, director of the Martinsburg VAMC. “All of the mental health providers have to have appropriate licensure to work within the state they practice.”

Co-owner of Re-Entry Associates Irene Melotti said there was a change in the VA handbook in 1991 that required all social workers to be licensed and require a certain level of education.

“Things have changed over time. Back in 1982 when Peggy Melotti (co-owner of Re-Entry Associates) started, there was no such thing as a licensed social worker,” Melotti said. “And anybody who had done business with the VA since 1991 and had never been interrupted fell under a grandfather clause.”

Dan Reeser, social work executive for the Martinsburg VAMC, expanded on this change.
“There was a change in 1991, and there was some grandfathering allowed,” Reeser said. “But you had to already have a certain level of education from an accredited university, you needed to have a master’s degree in social work to move to a higher level of licensing for clinical work.”

He said if the staff did not have that licensing, then they were not able to be grandfathered into the clause.

“Bottom line, some of the providers do not have the minimum qualifications to even be considered, so the grandfathering doesn’t apply because the minimum isn’t met,” Brown said.

Irene Melotti has withdrawn her occupancy permit for a new facility to be built on Williams Road.

“I have contacted the mayor and city and am withdrawing my governmental-use occupancy permit for Williams Road,” Melotti said. “Due to the fact that attorney Jeff Getty insisted that we are a medical ambulatory use, I will re-file for a permit under that.”

Melotti said Re-Entry is still under a five-year contract with the U.S. Department of Veterans Affairs Vet Center program that allows them to see new veterans.

“That contract is a five-year contract. We’re in the first year with a four-year renewal,” she said. “This allows us to see new veterans to try to stabilize them.”

Melotti said though veterans may have to transition to a new clinic, she plans to support the veterans as much as the law allows.

Now, the 150-plus veterans seen by Re-Entry Associates will move to the Cumberland Community-Based Outpatient Clinic at 200 Glenn St., about one mile from Re-Entry Associates.

“We have already made contact with all of the folks transitioning, and the vast majority have already been in to the Cumberland center for their first appointment and about 30 others have an appointment in the very near future,” Brown said.

Outpatient clinics are also located in Petersburg and Franklin, W.Va. “So by transitioning them, we have provided care closer to their home.”

Brown said the Cumberland clinic has a full-time psychologist who was already seeing a number of veterans also being seen at Re-Entry. Some extra staff had been sent to Cumberland on an interim basis, but a newly hired licensed social worker will be stationed at the Cumberland clinic around March 30.

“That was our plan, to double the size of our mental health staff out there to address the incoming 150 or so veterans,” she said. “Now we have a stable group of providers for those veterans.”

By bringing the veterans from Re-Entry to the clinic, said Brown, the Martinsburg VAMC is just providing a more comprehensive health care for veterans.

“The Martinsburg VA and all of its 60 CBOCs value our veterans and want to provide comprehensive health care for all of them,” Brown said. “We saw this as a way to expand our services to the Re-Entry veterans for a comprehensive health care. It was a quality-of-care issue that we have solved and provided qualified, licensed mental health care providers.”

 

Copyright © 1999-2008 cnhi, inc.

 

Money Stimulates Debate in States Over Plan's Goals

 

By Alec MacGillis

Washington Post

Monday, March 9, 2009; A01

 

As tens of billions of dollars in stimulus funds begin to flow across the country, states and federal agencies are gripped by disputes over whether the money is being used in ways that violate the letter or spirit of the legislation, battles that raise new questions about precisely what the intent of the legislation was and that threaten to delay the infusion of funds into the staggering economy.

 

Kansas may save some of the state funds that will be freed up by stimulus money it is getting -- even though putting money in the bank would not stimulate the economy. Texas is spending nearly a tenth of its transportation funding on a long-delayed highway loop around Houston, despite criticism that the project goes against President Obama's call to move away from oil dependence. West Virginia wants to expand access to Medicaid but is still waiting for an answer about whether that goal is being encouraged under the law.

 

In many ways, the questions swirling at the state level are a continuation of unresolved debates in Washington over the purpose of the $787 billion package -- whether it was meant solely to boost the economy or also to lay the groundwork for longer-term reforms and transformation.

 

"There's definitely a lot of confusion in state capitals about what the Recovery Act means," said Chris Whatley of the Council of State Governments, who is traveling the country dispensing advice to state officials. "They're making budget decisions now, and there's still this base level of uncertainty. . . . There's an inherent tension in the differing goals in the bill."

 

In many states, the debate revolves around what to do with the state money that has been freed up by an $87 billion stimulus provision to increase for two years the share of Medicaid costs covered by the federal government.

 

Patient advocates and medical providers say the provision was clearly intended to expand Medicaid spending, both to stimulate the economy and to help people in need. States, they say, should expand the services that are covered, increase provider payments, broaden eligibility rules or keep the freed-up state money on hold in anticipation of higher Medicaid demand.

 

In Virginia, the state hospital association urged the state to set aside much of the $600 million made available by the increased federal share to cover an anticipated surge in Medicaid costs in the next few years, which will be a particular challenge once the stimulus funds dry up. But the governor and legislature have agreed instead to use the freed-up money to balance the current overall budget to prevent layoffs in other areas -- a course most other states are also pursuing.

 

Katie Webb, senior vice president of the hospital association, said the state's decision was unsurprising but shortsighted, while legislators counter they had no choice but to cover the current gaps. "It doesn't prepare us for what's going to happen," Webb said. "I guess I thought the intent of Medicaid stimulus was to use the money for Medicaid."

 

This debate has perhaps been most stark in Kansas, where Republican leaders in the legislature want to use some of the state money freed up by the increased federal Medicaid share not just to cover other spending but also to comply with a state requirement that its budget contain a small end-of-year cushion. It is unclear whether this is allowed under the stimulus rules, which forbids states to use the money to fill "rainy day" funds.

 

But Jay Emler, chairman of the Kansas Senate's Ways and Means Committee, said he was all for socking the money away. He said that after he lost his corporate job 10 years ago, he was careful to save any additional money he got in the years afterward, and that the state should respond the same way.

 

"When [the stimulus] runs out, we're going to be in a world of hurt . . . so I'd rather see this go into a fund that we would not be able to access except for emergencies," he said. "While this is a 'stimulus' package, that's not how I run my personal life. I don't know a whole lot of people who go out and spend if they realize that in two years they're not going to have money."

 

This approach dismays advocacy groups in Kansas. The state, they say, would do much more to stimulate the economy -- and improve its fiscal prospects -- if it spent the freed-up state money on shortening the waiting list for people with developmental disabilities, raising pay for direct-care workers or lowering the income threshold for Medicaid.

 

"We think [the Republican plan] violates the letter and the spirit of the law," said Rocky Nichols, a former Kansas state legislator who runs a disability rights organization. "This is a Medicaid stimulus provision, not a 'bail out the state deficit' provision. . . . If they hoard it, it's not going to do a thing."

 

In Kentucky, which plans to use most of the freed-up state money to balance its budget, Terry Brooks, head of a children's health advocacy group, said he recognized the budgetary demands but hoped there could be at least some way of innovating with the money, such as increasing outreach to families that qualify for the children's health insurance program. "Is this simply switch-and-bait money for us to maintain the status quo, or can we use it to really be a catalyst?" he said.

 

There is also confusion in the handful of states that are considering broadening Medicaid eligibility. To keep states from trimming people from their Medicaid rolls, the legislation decrees that states maintain the same eligibility rules they had last summer if they want the increased federal money.

 

But West Virginia and South Dakota, which want to take advantage of the stimulus to expand Medicaid eligibility, are struggling to determine whether that rule is both a floor and a ceiling -- that is, whether states that make their rules more generous will receive the higher federal match for the newly enrolled residents. The states hope that is the case, because the federal government encourages broader Medicaid coverage. But they have yet to get a clear answer from Washington, where the relevant departments are still waiting for most of their top appointees to be put in place.

 

In several states, the biggest fights over the bill's intent have involved transportation. In Seattle, Mayor Greg Nickles is upset that most of the state's new transportation funds are being disbursed to small road projects outside Seattle and that the city will not get the $50 million it expected to redevelop a road in a rejuvenated part of downtown. Massachusetts may use some of the highway money it is getting for public transit -- the law's fine print allows for that, a provision most states are disregarding.

 

In Texas, "smart growth" advocates are outraged that the state Transportation Department has decided to spend $181 million to build a 14-mile stretch of the "Grand Parkway," a proposed 180-mile loop beyond Houston's outer suburbs. The advocates say it is hard to accept that a highway long sought by developers is at last getting its decisive boost from the stimulus legislation passed by an administration that says it wants to move the country past sprawling development patterns.

 

The state should put the money toward a proposed toll road and light-rail line in the highly congested U.S. 290 corridor running into Houston, the advocates say.

 

Texas "is using stimulus money that one would assume would be for something transformative to instead build the biggest boondoggle of all time," said David Crossley of the group Houston Tomorrow. Developers "had given up on this project, and suddenly it's possible because of a president coming up with money to transform transportation," he said. "It's pretty ironic."

 

But the Grand Parkway's supporters say they are the ones true to the legislation's intent -- of stimulating the economy quickly with projects that are "shovel-ready."

 

"Because of the time constraints placed on stimulus spending, we had to select from projects we had already been working on," said Chris Lippincott, a spokesman for the Transportation Department. "We will use these funds to solve transportation problems, but it is clear to us that the main goal is to put shovels in the dirt and money in people's pockets quickly."

 

Debates over the law's intent are also taking place within federal agencies. Interior Secretary Ken Salazar instructed his division chiefs last month to focus their spending on renewable-energy projects. This took some of them aback, because the law lays out clearly what the money is to be spent on -- things such as reclaiming abandoned mines, maintaining trails and upgrading volcano-monitoring equipment.

 

Interior spokeswoman Kendra Barkoff said Salazar's instructions were not in conflict with the law. Some of the work laid out in the law, such as new buildings, could be done with energy goals in mind, she said. And the Senate report for the stimulus granted the Bureau of Land Management leeway to spend some of its money on new staff to speed up the permitting process for wind and solar projects on federal lands. "There's some flexibility," she said.

 

To some economists, the debates over the exact intent of the law are beside the point. Most important, they say, is to spend the money, even if it is for a different purpose than what the law decrees. That is a hard mind-set for ever-prudent state budget officers to adopt, said Scott Pattison, director of the National Association of State Budget Officers.

 

"As finance people, we try to be very thoughtful and considered about how it's spent," he said. "Whereas an economist will say, 'Listen, I understand where you're coming from -- but from an economic mind-set, it just has to get out there.' "

 

Copyright 2009 Washington Post.

 

Arthritis starting to affect younger people

Expert advice

 

By Liz Atwood

Baltimore Sun

Monday, March 9, 2009

 

Arthritis affects almost 80 percent of Americans. And those affected are getting younger, according to Dr. Barry Waldman of OrthoMaryland and director of the Center for Joint Preservation and Replacement at the Rubin Institute for Advanced Orthopedics at Sinai Hospital. "We don't really know why, but we're seeing an epidemic of patients with wearing out of joints in their 40s and even late 30s." But the good news, Waldman says, is that diet and exercise are the best ways to treat the disease.

 

What is arthritis?

The word means inflammation of the joint. This inflammation causes the cartilage in the joint to wear out. As it wears out, it causes four problems: pain, redness, swelling and deformity.

 

Are all those symptoms usually present?

No. They don't have to be. And there are all kinds of arthritis. The one we're most familiar with is osteoarthritis, the premature wearing out of the joints. There are other kinds caused by a number of diseases called inflammatory arthritis.

 

Who is most susceptible to osteoarthritis?

Past traum41a and family history can play a role. But the vast majority of people just get it, and we don't know why.

 

How is it diagnosed?

Generally by X-ray.

 

What do you see on the X-ray?

A narrowing of the joints where the cartilage has worn away.

 

What are the most common symptoms people experience?

Pain and swelling. The pain tends to be worse when they are sedentary. When they're active, the joint hurts less.

 

Why?

We don't know, but cartilage tends to be healthier when it's moving.

 

When should someone seek treatment?

When the symptoms are interfering with things they want to do, whether it is walking or exercising.

 

Are there other conditions people could have that would give the same symptoms?

It could be an injury, but generally there are not a lot of disorders you can confuse with arthritis.

 

Does delaying treatment make the condition worse?

We encourage people to see a doctor because there are some kinds of arthritis that can be slowed down with medication.

 

Some people say weather makes their arthritis worse. Does research support that?

There have been a lot of studies done on arthritis and weather, and it seems that weather doesn't make a difference in arthritis pain. As far as we know, it's an old wives' tale.

 

What are the treatment options for those with osteoarthritis?

We always try things that aren't surgery first. The best early treatment is exercise. Getting the muscles stronger around the joint will help. The next thing we try is acetaminophen, otherwise known as Tylenol. Then we move on to anti-inflammatory medicines like Motrin or Alleve. If that doesn't work, there are medicines we can inject into the knee or shoulders. We can try anti-inflammatories like cortisone. We have one injectable medicine made of cartilage that can act as a cushioning agent.

 

Do over-the-counter remedies like glucosamine help?

There was recently a large study that [the National Institutes of Health] did that found that glucosamine and chondroitin didn't help improve arthritis; it was very ineffective. The American Academy of Orthopedic Surgeons now recommends against taking it.

 

What about arthroscopic surgery?

One of the complications of arthritis is that a big piece of cartilage can come loose inside the joint. Arthroscopic surgery can be very helpful in that case, but for most people, just washing out the joint with surgery won't help.

 

Copyright © 2009, The Baltimore Sun.

 

Health Care Comes Home

 

March 2009 issue

 

By John Buntin

GOVERNING: Connecting America’s Leaders

Monday, March 9, 2009

 

North Carolina has built a coordinated medical system for the poor that includes old-style house calls. And it’s making a big difference.

 

Dr. Jugta Kahai had a problem. One of her patients, a 9-month-old boy with asthma, kept showing up in the emergency room. He was struggling for breath. His mother was distraught. And Dr. Kahai was puzzled. During office visits, she had talked at length with the mother about the importance of keeping the home clean and free of environmental factors that might trigger an attack. The mother seemed to understand the doctor's suggestions. And yet the child was still arriving in the emergency room in extreme distress.

 

Fortunately, the baby's physician had access to a resource most doctors only dream of — a local case manager, funded by the state, who could assist her in caring for patients with chronic illnesses. What the case manager found when she went to see the baby and his mother was surprising. The family's mobile home was in a rough part of town but it was spotless — too spotless. The mother proudly explained that she cleaned the house every three days using half a gallon of bleach. And that, it turns out, was the problem. The overuse of a high-powered cleanser was triggering asthma attacks.

 

The bleach-cleaning stopped. Soon after, so did the emergency room visits. And North Carolina's Medicaid program was spared tens of thousands of dollars in unnecessary expenses.

 

It wasn't a random good catch. Over the course of the past decade, North Carolina's Community Care program has quietly made major strides toward achieving one of the most-discussed goals in health reform — a patient-centered form of care that replaces episodic treatment based on individual illnesses with a long-term coordinated approach. It's what health experts sometimes refer to as "the medical home."

 

Some of that coordination is more complicated than a call to a case manager to make a home visit. Sometimes, the case manager becomes a regular and long-term team member in caring for a patient who has several chronic illnesses, as well as other serious problems.

 

One recent morning, for instance, Elissa Hanson, a case manager in the Wilmington area, went out to pay one of her Medicaid patients a visit. Linda, who is 52 and diabetic, had reported a dangerously low blood-sugar reading earlier that morning. Hanson wanted to find out what was amiss and prevent further complications.

 

When she got to Linda's house, Hanson chit-chatted with her patient for a while and then got down to business: What had happened to cause the dangerously low reading? Linda said she had hurt her arm and was unable to eat. After making sure that Linda had gotten medical care for the arm — she'd gone to a nearby walk-in clinic — Hanson turned to a routine she usually goes through on visits with Linda: a review of all the medications she currently is taking — glipizide and insulin for diabetes, as well as pills for hypertension, heart disease and high cholesterol. Hanson walked her through each one, explaining why and how often Linda should be taking each. For Linda, this is essential. She can't read.

 

There's another complication. Linda is an alcoholic. "But I never preach to her not to drink," Hanson says. "I talk about what you need to do to manage your diabetes when you're drinking alcohol. Her promise to me is that she'll eat something when she drinks."

 

The deal between case manager and patient is working. Linda is no longer showing up routinely in the emergency room in diabetic shock — and that is good for her health and for the Medicaid program's bottom line.

 

In 2006, health spending in the United States was twice the amount per capita of the average developed country. Health care now accounts for more than 16 percent of the country's gross domestic product, but the nation's 750,000 physicians, 5,000 hospitals, and 16,000 nursing homes remain bits and pieces of a fragmented system. Steven Schoenbaum, executive director of the Commonwealth Fund's Commission on High Performance Health Care, sees the lack of coordination among providers and facilities as adding up to a non-system. And that's a problem because studies show that the more care is organized, the better the outcomes are of that care.

 

By virtually any measure, U.S. outcomes are bad. To cite just one: According to the Organization of Economic Development, the United States ranks dead last among developed nations in avoiding preventable deaths.

 

Policy makers have reacted to the organizational issue in several ways. One of the most common responses for Medicaid programs has been to steer recipients into managed-care plans run by insurance companies that are paid a per capita fee to provide care for beneficiaries. They coordinate care in the sense that a primary care physician acts as a gatekeeper to specialty care. But managed care often doesn't work well in rural areas where doctors are scarce. Nor do managed-care plans typically include doctors in small practices — urban or rural. But small, one- or two-doctor practices account for 45 percent of the nation's primary-care physicians. They often lack the resources to make investments in forms of health information technology that would make it easier to share patient information. And they don't have the time to coordinate care for patients with complex chronic conditions such as asthma, hypertension, diabetes and heart disease.

 

Yet it is precisely this small subset of patients who most need coordinated care. Research indicates that patients with multiple chronic illnesses — some of which are preventable, all of which are treatable — account for as much as 75 percent of total health care spending. Within Medicaid, the numbers are formidable: 5 percent of all beneficiaries account for up to 50 percent of total Medicaid spending. More than 80 percent of these high-cost beneficiaries have three or more chronic conditions, and up to 60 percent have five or more. Yet, the Center for Health Care Strategies reports, "the majority of these patients receive fragmented and uncoordinated care often leading to unnecessary and costly hospitalizations and institutionalizations."

 

The medical home is seen as one solution to the problem of fragmented care. The private sector has begun to make some progress: The Geisinger Health System in Pennsylvania is currently the most notable model. It ties doctors, hospitals, labs, case managers and other health providers and institutions into one seamless system in which the primary-care physicians can coordinate all inpatient and outpatient medical care.

 

North Carolina's Community Care is not as ambitious. But it has patiently grafted a means for coordinating care for its Medicaid patients onto a traditional fee-for-service medical system. In doing so, it has created a model of care with many of the attributes of a medical home.

 

Primary-care physicians and case managers, guided by claims data and chart audits, work together to improve care and coordinate treatment across 1,200 medical practices serving more than 884,000 Medicaid recipients — nearly 10 percent of the state's population. This systematic approach to coordinated care has contributed to dramatic reductions in childhood asthma and better diabetes control. It also has saved the state serious money — more than $150 million a year for the past two years.

 

This isn't traditional case management, where a nurse or outside vendor calls and visits patients, independent of their physician, in an effort to get them to take their medications or be compliant. Instead, it's something new — an integrated, team-based approach. Not surprisingly, policy makers from other states — and in the U.S. Congress — are now taking a close look at the program.

 

"This has national significance," says Emory University's Kenneth Thorpe, a close adviser to some of the congressional Democrats who are crafting health legislation. "It has a good shot at being part of health reform."

 

North Carolina has built its coordinated care/medical home system gradually and from the ground-up. Community Care started as a small-scale pilot project in rural Wilson County in 1988. Medicaid agreed to pay participating physicians in two medical practices a reasonable reimbursement rate, plus a small case management fee ($2.50 per patient per month), if the physicians would agree to coordinate care for their patients. The program proved popular and cost-effective, leading the state to secure a waiver from the federal government to expand the program to other counties.

 

When lawmakers decided to roll out the program statewide in 2005, they made a critical decision. They would not run the program from the state capital in Raleigh. Instead, they set up 14 networks around the state. Each network has an executive director, who oversees a team of case managers, as well as a medical director, invariably a well-regarded local doctor, who works with local physicians. The state sets broad treatment priorities (childhood asthma, diabetes) and provides support. Consultants help develop treatment strategies and a sophisticated electronic database gives case managers access to their clients' medical histories. The state also draws on claims data to provide feedback to participating physicians and to help local networks conduct chart audits to identify areas of improvement.

 

In general, the state touch is light. Local networks have great leeway in setting specific goals and figuring out how to meet them. The program is emphatically personal. Instead of interacting with state bureaucrats in Raleigh, local physicians work with case managers (often registered nurses) who spend a day or two in their offices every week. Instead of discussing their current practices with some distant M.D. employed by a bottom-line oriented insurance company, doctors talk about best practices with a local medical director who is a colleague and, most likely, a friend from the neighborhood.

 

"The local structure is a key element," says Laura Gerald, a physician who serves as an asthma consultant to the state. "Problems are local. Solutions are local. You need people who know the resources and who know the players to figure this out, locally. So that's critical."

 

But it is the teamwork and inside support that marks the program. "I can call anytime, and they'll send over caseworkers," says Nanili Baijnath, the medical director of the New Hanover Community Health Center in Wilmington. One case manager has arranged a group office visit for several patients with diabetes, which uses the doctor's time more efficiently and offers patients a chance to be part of a support group. Others have helped the clinic staff connect patients with mental health resources. Or the medical director helps find specialist referrals. The services keep everyone connected. "I feel I'm part of a far bigger community," Baijnath says.

 

Since its statewide rollout four years ago, Community Care has made impressive strides in improving the lives of Medicaid patients, particularly those with asthma and diabetes. It's also saved the state significant money. Given those results, the legislature last year directed the program to save an additional $29 million by focusing even more of its efforts on managing patients with multiple chronic illnesses.

 

"We had been working on it from a disease-management standpoint — asthma, obesity, other kinds of things like that," says Tara Larson, acting director of North Carolina's Medicaid program. "But when you start to look at people with multiple conditions — the aged, blind and disabled — you start to see how things are interrelated." The focus on multiple chronic illnesses, she says, is "a natural step forward."

 

It's also quite a big challenge. For while the potential savings are obviously large, so are the costs and difficulties of addressing these patients' needs, which are rarely limited to medical ones. For case managers such as Elissa Hanson, coordination and cost control are proving to be Community Care's toughest assignments to date.

 

The same day that Hanson stopped by to check on Linda, case managers in the same network — Access III of Lower Cape Fear, which serves 50,000 Medicaid patients who live in and around the city of Wilmington — assembled to talk over their most challenging cases. Case manager Beverly Newton started with one of her patients, a 40-year-old woman with diabetes.

 

"She can tell you all the medicines — what she should take," says Newton. "She can tell you what you should eat. She's the perfect patient." But only in theory. Newton notes that the patient has been admitted to the hospital three times for diabetic ketoacidosis — a build-up of acid in the blood stream that can lead to a coma or death. In between, she has been treated at a local hospital emergency room multiple times for having blood sugar that was either too high or too low. Although she knows them by heart, the patient has been unable to stay on her meds or follow nutritional guidelines. She also shows several signs of cognitive deficiency, perhaps connected to a past history of traumatic brain injury.

 

But Newton wasn't giving up. She'd called the home health agency responsible for the patient's care and arranged for a diabetes counselor to pay her a visit. She and the client's primary care physician had finally persuaded her to agree to see a psychologist. They also had identified another problem — her responsibilities as a parent.

 

"She has two kids, one who's two and one nine years old," Newton reports, "and when you go there, the little girl is just all over the place." The kids' father appeared to be the landlord of the trailer park where the mother lives — but he is married to someone else. Most of the parenting fell to the client, who was obviously overwhelmed. So Newton and the diabetes counselor signed her up for a parenting class. "The next step," Newton says, "will be getting the two-year-old in day care somewhere."

 

The next client the team discusses also reflects the range of social and financial problems the medical teams confront. This client had been hospitalized four times during the course of the year for problems stemming from his many ailments. He has diabetes, hepatitis, a peptic ulcer, coronary heart disease, chronic pancreatitis, chronic anemia and is clinically depressed. Working with his primary-care physician, a case manager had straightened out the 18 medications he is taking. And now he has a new problem. Each prescription for his 18 medications has a $3 co-payment. The patient had been supported by a Social Security disability check. However, he'd been informed that because he owed the state of Florida $33,000, his SSI check would be sent to authorities in Florida until the debt was repaid. As a result, his income has dropped to zero.

 

Executive director Lydia Newman shakes her head. "He'll end up in a rest home" — at a cost to the state of roughly $3,000 per month — because he doesn't have money for the co-pays," she says, with some anger. But the case managers are not throwing in the towel. One has a contact at a drug store chain who could arrange free medication for a few months. Another is ready to take the client to the local Social Security office to see what can be done.

 

Reflecting on Community Care's future, Newman expresses amazement at the program's growth and the state's support. The number of case managers has grown from 10 to 18 in three years, and the case management fees to physicians can be as high as $5 per patient — twice what they were. Even that fee does not approach the true cost that intensive management of chronically ill patients entails. "You can't manage someone who's really sick in 15 minutes," says Torlen Wade, of the North Carolina Foundation for Advanced Health Programs. "You can hardly even do an evaluation of the medicine they're on."

 

There are other significant challenges. Up to 60 percent of patients with chronic illnesses also suffer from depression. Yet case managers have few mental health resources to draw on.

 

That said, North Carolina knows that it has created something that is becoming a model for what a state can do to cure some of the ills of the health care system. "We are focused on key priorities," Newman says. "That's how we've thrived.

 

© 2009, Congressional Quarterly Inc., GOVERNING, City & State and GOVERNING.com are registered trademarks.

 

Girl's Cries For Help 'Fell on Deaf Ears'

Pr. William Officials Were Told of Abuse

 

By Jonathan Mummolo

Washington Post

Monday, March 9, 2009; A01

 

Prince William County police, social services and school officials received numerous reports from people who saw firsthand that 13-year-old Alexis "Lexie" Agyepong-Glover was being abused and neglected by her adoptive mother in the two years before the woman allegedly killed her.

 

But Lexie was not removed from the home.

 

Lexie's school bus driver said she made several reports, the first when she saw marks on Lexie's wrists and forearms that looked as if she'd been tied up. She also told authorities that Lexie had a large welt on her head and tried to board the bus in her underwear. Another bus driver and her attendant told police that they saw Lexie's mother driving off with her in the trunk of her car.

 

In the weeks before Lexie was found dead Jan. 9 in an icy creek, neighbors said they reported finding Lexie hungry, wandering the streets wearing only a barbecue grill cover, physically injured and, above all, terrified of her mother, Alfreedia Gregg-Glover.

 

"We thought by making a police report, the police would get her out" of the home, said Marlene Williams, the school bus driver who, along with her attendant, Brenda Taylor, told police and Lexie's principal that they saw Lexie's mother drive off with her in the trunk.

 

"We don't know how much that little girl suffered," Taylor said. "Her cries fell on deaf ears."

 

Prince William police Maj. Ray Colgan said police would have taken action if they had found Lexie to be in danger. He said that when police were called about the trunk incident and the injuries seen by the neighbor, Social Services was notified and the incidents were investigated. He said the pending criminal case and privacy laws prevented him from giving too many details.

 

"As far as I know, I think we've done everything properly we could have done," Colgan said. "We will continue to review it, and if we need to make some changes, we will."

 

Jack Ledden, director of Prince William's Department of Social Services, and a school system spokesman declined to comment, citing confidentiality rules and the ongoing investigation. Gregg-Glover's court appointed attorney, John V. Notarianni, did not return calls for comment.

 

The Prince William Board of County Supervisors announced Friday that it has requested that the Virginia Department of Social Services review the county's response. The review will include all child welfare programs, including child protective services, prevention and treatment, foster care and adoption. Such a review is required by state law, but the board requested that the state accelerate the process. It is expected to take three months.

 

Gregg-Glover, 44, was indicted last week on charges of murdering her daughter and lying to police. She told police Jan. 7 that Lexie had run away, which sparked a massive search. Police say they later learned that she had dumped Lexie in the shallow creek in the Woodbridge area, still alive. Lexie was found dead two days later from drowning and exposure to the cold. Gregg-Glover was also charged with child abuse, the county's chief prosecutor said.

 

Prince William Commonwealth's Attorney Paul B. Ebert said the medical examiner's report "showed there were recent injuries and old injuries" to Lexie's body. "The recent injuries, coupled with the cause of death, certainly indicated it was a horrible death," he said.

 

When Gregg-Glover appealed to the media for help in finding her daughter, she said Lexie was mentally disabled, suffered from autism and other ailments, and acted much younger than her age. But several of Lexie's former counselors have disputed that characterization, saying Lexie was a smart, affectionate girl who had reactive attachment disorder, a condition that makes it hard to form emotional bonds and is sometimes found among abused and adopted children.

 

Those who sought help for Lexie in the years and weeks before her death are angry that no one helped the girl, who tried to tell people what was happening to her when she was out of earshot of her mother.

 

One afternoon in September 2007, Williams and Taylor were dropping off students at the Robert Day Child Care Center in Manassas when they noticed a frightened girl being marched out of the building by a stern woman. They took their eyes off the pair for a few moments, then saw the woman drive off alone.

 

"I think she put her in the trunk," Taylor recalled telling Williams. But, uncertain, they said nothing.

 

Two weeks later, they pulled into the day-care center and saw the same white Toyota parked outside with the trunk cracked open. Minutes later, they saw Lexie emerge from the building with Gregg-Glover behind her, fists clenched. She and Lexie walked to the back of the car, where the mother looked around and then opened the trunk, Williams and Taylor said.

 

"Lexie walks right over, climbs in that trunk," Taylor said. "She did not hesitate, like she had been doing it every day."

 

Horrified, the pair watched the car drive off and called their dispatcher. They went to a Prince William police station later that evening and gave written statements of what they had seen. They drew a diagram of the position of the cars in the lot, gave the tag number of Gregg-Glover's car and later told Lexie's principal, they said.

 

Police told them that they went to Gregg-Glover's house to investigate and that she denied the incident. Lexie did not speak up for herself, they said.

 

"Are you going to get her out of the home?" Williams said she asked police.

 

They told her that they had to "get their ducks in a row," she said, and when she left a message days later to follow up, police didn't call her back.

 

It was not the first time authorities were alerted.

 

In March 2007, Lexie's regular school bus driver, Nancy Frederick, said Lexie was getting off the bus when Frederick noticed marks on her wrists and forearms that appeared as if she had been tied up. Lexie told Frederick's attendant, Lissette Romero, that her mother had taken her on a trip to North Carolina and had bound her hands during the ride and made her lie on the floor the whole way, Romero said.

 

The following spring, Frederick said, Lexie boarded her bus with a large welt on her head.

 

Lexie told her, "I hit myself." Frederick asked her why, and she replied, "If I don't, my mom is going to hit me," Frederick recalled.

 

Lexie told Romero that her mother would order her to hit herself and that she would videotape it, Romero said.

 

Frederick and Romero said they notified Lexie's school, PACE West, about the welt on her head, and Frederick told officials at Prince William's Department of Social Services about the welt and the marks on her wrists. Officials told her that they would look into it.

 

"It didn't do any good," Frederick said.

 

In October, Lexie came to the bus on two occasions in her underwear, Frederick said. The first time, Frederick and Romero gave her a coat and blanket and called their dispatcher. Police went to the house but returned her to her mother after Lexie remained quiet.

 

"I said, 'Can't you do anything?' " Frederick said. "They said, 'Ma'am, we can't charge her with anything.' "

 

The next school day, Lexie came to the bus in the same condition, this time with Gregg-Glover close behind, videotaping the incident and ranting that she could not tolerate the girl any longer before taking the girl back inside, Frederick said.

 

"She said, 'I don't know what I'm going to do. She's ruining my life, and I want her out,' " Frederick said.

 

Shortly after that, Lexie was pulled out of PACE West, and Frederick never saw her again.

 

Troubling reports persisted into the weeks before her death, when Lexie ran away at least three times in December, only to be returned to Gregg-Glover, according to neighbors and officials. On March 11, because of her habit of running off, she was fitted with a locator bracelet, used to track endangered people, by sheriff's deputies, officials said.

 

On Dec. 2, about five weeks before her death, Lexie showed up outside neighbor Wes Byers's house early in the morning, as temperatures hovered near freezing. She told Byers and his wife that she had run away after her mother opened a quarter-size gash on her head with a stick, and she was wearing a tarp used to cover a grill, Byers said. She pleaded with him not to be sent home.

 

After clothing and feeding Lexie, who was famished, Byers called authorities. Police came to his house and took Lexie to a hospital, and Byers followed. Gregg-Glover arrived there, as did a county social worker. Lexie's mother told police that her daughter had a habit of hitting herself and she had the video to prove it, Byers said he was told by police. Lexie left with Gregg-Glover that day, he said.

 

In late December, sheriff's deputies tracking Lexie with the bracelet found her inside the house of her next-door neighbor, Jonah Seaman. Seaman said deputies found Lexie in red pajamas, hiding behind a Christmas tree in his living room, devouring a bowl of cereal she had taken from his kitchen.

 

"She looked terrified," Seaman said. "She looked really scared."

 

After reporting her missing one last time, Gregg-Glover positioned the tracking bracelet near a Manassas library to make police think Lexie had run off the day she disappeared in January, police said.

 

Two days later, a man out for an afternoon walk discovered Lexie's body.

 

Staff writer Josh White and staff researcher Meg Smith contributed to this report.

 

Copyright 2009 Washington Post.

 

Chicken waste air emissions remain unregulated

 

By Alex Ruoff

Salisbury Daily Times

Monday, March 9, 2009

 

DAGSBORO -- When discussion on waste produced by poultry farms begins, it almost always centers around nutrient-rich runoff into area water sources, an issue the state combats regularly.

 

But air emissions resulting from ammonia produced by chicken waste remains unregulated.

 

"There are no air quality regulations anywhere," Dagsboro poultry grower Traye Matthes said. "There are no EPA guidelines, and there just isn't any way to get rid of it."

 

Ammonia is a byproduct of animal waste, which according to a 2006 Oxford University study, can cause respiratory and eye irritation in as little as 20 parts per billion. This can be especially dangerous for people who already suffer from respiratory issues, for example the elderly or children, whose systems are not yet fully developed.

 

Matthes has been raising chickens since 1992. He said the state regulates manure spreading to curb unwanted runoff into waterways, but doesn't do anything to reduce air emissions.

 

"Proper ventilation is good because it's about bird comfort, but we in the industry have ways of reducing ammonia," he said.

 

Companies such as Perdue Farms and Allen Farms produce types of poultry litter and bedding materials that work to absorb manure byproducts such as ammonia, and work to spray area chicken houses with ammonia sulfate, Matthes said, to reduce the amount of ammonia released.

 

"A lot of people don't realize how much this industry works to reduce our emissions," Roxana poultry raiser Mack McCary said.

 

McCary has been raising chickens for more than 40 years and said emissions from the coops is almost self-regulating because less ammonia means happier, healthier chickens.

 

Reducing moisture and maintaining temperatures in the chicken houses directly reduces ammonia output, McCary said.

 

"If the ammonia levels go anywhere above 25 parts per million, it becomes detrimental to the birds," he said.

 

But, Matthes said the state and the industry are going to have to face the topic of air emissions in the next five years or so because the issue isn't going away.

 

"This is Delmarva; we've been here and we're here to stay," he said. "We've been working in this area for a long time and we've been looking at our effect on the area for a long time."

 

The industry

It would be difficult to argue that the poultry industry isn't one of the biggest in Delmarva.

 

According to the Delmarva Poultry Industry -- a trade association for area poultry industries -- last year alone the four largest companies, along with about 1,800 growers, produced 571,263,000 broiler chickens, roasters and Cornish hens.

 

That accounts for 3.472 billion pounds of bird, making the First State the eighth-biggest producer in the nation.

 

Such production makes it incumbent upon growers like McCary and associations and DPI to work to reduce the industry's byproducts of ammonia and nutrient runoff. DPI Executive Director Bill Satterfield said his agency has initiated a number of programs to aid in this effort.

 

"Ammonia is a natural byproduct of living chickens, and the primary concern of farming families and communities is to provide a positive atmosphere for those chickens, which means reducing ammonia is a top priority," he said.

 

So DPI began the Vegetative Environmental Buffers program two years ago to reduce ammonia's effect on poultry producing areas. The program works to plant trees around farms and plants that absorb the ammonia emissions in the air and the ground.

 

"It's good for the neighbors and it's good for the emissions," Satterfield said. "We're the only trade that hires a full-time tree planting guy."

 

Utilizing U.S. Department of Agriculture grants, the program has been working to naturally cut back ammonia levels entering the surrounding environment, but it's only a first step.

 

The state's role

The Delaware Department of Natural Resources and Environmental Control has recently created a new Web site to assist poultry operations with meeting new reporting requirements concerning chemical emissions from animal waste.

 

The site is in response to an EPA reporting rule requiring any farm defined as a large Concentrated Animal Feeding Operation to craft Nutrient Management Plans for manure storage, among other things.

 

"Our whole effort here was to help local farmers comply with federal requirements; it has nothing to do with controlling emissions," DNREC's Environment Program Manager Ellen Malenfant said. "These are reporting requirements from the federal government because the EPA has been known to levy penalties for anyone who does not report, and we wouldn't want that."

 

Malenfant said there are two types of air emissions that must be reported to the EPA -- one-time and continual releases.

 

One-time releases relate to spills, and continual releases refer to larger poultry operations whose manure emits these chemicals repeatedly.

 

Why start reporting now?

Delaware Department of Agriculture Program Administrator Bill Rohrer said DNREC, along with Delaware Nutrient Management, is working to minimize the impact of these regulations to area operations through efforts to assist farmers with the new reporting process.

 

Still, the added pressure by the EPA raises questions related to emission impact, he said.

 

"What we're mostly concerned with is water quality and preventing the over application of manure and the proper disposal of waste," Rohrer said. "Farmers are now being held to a higher level of regulation."

 

DNREC's Air and Waste Management Air Quality and Monitoring division handles the monitoring of emissions for Delaware through the issuance of permits.

 

"This is not an attempt by anyone to regulate these (operations)," Director of DNREC's Air and Waste Management division Jim Werner said. "It's part of a broader environmental management system."

 

Copyright 2009 Salisbury Daily Times.

 

National / International

 

Stem-cell stocks jump on expected Obama policy

 

Associated Press

Daily Record

Monday, March 9, 2009

 

Shares of stem-cell therapy developers continued gaining ground Monday after President Obama said he would overturn restrictions on federal funding for embryonic stem cell research.

 

The reversal has been widely anticipated since the election, as Obama had pledged on the campaign trail to overturn the ban. The policy's main effect was on choking off funding to government agencies and academic research centers, as most stem cell companies relied on venture capital and other forms of funding to conduct research.

 

Still, lifting the ban is symbolically positive for many companies, including Menlo Park, Calif.-based Geron Corp., which has been working on embryonic stem-cell therapies for about a decade.

 

Geron shares jumped 81 cents, or 20.1 percent, to $4.68 in midday trading. The stock has traded between $1.95 and $8.50 over the last 52 weeks. Geron is the first company to receive federal approval to begin human studies of an embryonic stem cell therapy.

 

Embryonic stem cells are early-stage cells capable of becoming any of the more than 220 cell types in the human body. Their use in research and eventual treatments has been controversial because they are collected by cloning embryos in a laboratory, but the embryo is destroyed in the process.

 

Other types of stem cells, such as adult stem cells, can be gathered from a person's skin, for example, and are less controversial, though many scientists have said that embryonic stem cells have a greater potential for medical therapies.

 

Elsewhere, Rockville, Md.-based Neuralstem is seeking FDA approval for human studies using adult stem cells. The stock rose 20 cents, or 23.3 percent, to $1.06 per share.

 

Columbia, Md.-based Osiris Therapeutics Inc., which focuses on adult stem cell-based therapies, gained 30 cents to reach $18.31. San Diego-based Cytori Therapeutics Inc. gained 47 cents, or 20.4 percent, to reach $2.78. The company is developing studying adult stem cells but also operates a tissue bank for the preservation of stem and regenerative cells.

 

Shares of Palo Alto, Calif.-based StemCells Inc., which also focuses on adult stem cells, surged 66 cents, or 47.8 percent, to $2.04.

 

Copyright 2009 Daily Record.

 

Nurses Win Settlement Over Wages

 

By Kris Maher

Wall Street Journal

Monday, March 9, 2009

 

A health-care network in upstate New York agreed to settle a class-action lawsuit alleging that managers conspired to keep registered nurses' wages artificially low, in a move that could affect other defendants in the case and four related suits across the country.

 

Northeast Health of Troy, N.Y., agreed to pay $1.25 million in a settlement that is scheduled to be filed Monday in U.S. District Court in the Northern District of New York. The company didn't admit any wrongdoing and called the allegations in the lawsuit "completely false and offensive." About 2,500 nurses are represented in the class, and the settlement is subject to court approval.

 

"We never conspired with any other hospital to suppress nurse wages, nor did we ever violate the antitrust laws in any manner," the health-care network said in a statement. The network, which has more than 5,000 employees, said it agreed to the settlement in order "to stop spending our scarce resources on this litigation." A spokeswoman declined to comment further.

 

The suit, brought by two Albany, N.Y., nurses, is one of five related suits filed in 2006, in which nurses alleged that hospitals agreed to enter into a conspiracy to keep nurse wages low and did so by sharing compensation information such as wage surveys.

 

Heidi Hartmann, president and labor economist at the Institute for Women's Policy Research, said the settlement was significant and could have a spillover effect on the related cases. One company's settling could set a precedent for the other defendants, she said.

 

Copyright 2008 Dow Jones & Company, Inc. All Rights Reserved.

 

Opinion

 

Creative Disruption

Will innovation bring efficiencies to health care — or blow it up?

 

March 2009 issue

 

By Penelope Lemov

GOVERNING: Connecting America’s Leaders Letter to the Editor

Monday, March 9, 2009

 

The current buzzword among MBA grads is "disruptive innovation." It may sound like a term to use when all hell is breaking loose. But what it refers to is any breakthrough — such as Henry Ford's assembly line or eBay's retail network — that makes goods or services simpler to deliver and more affordable to buy. The same approach can work for the health care system, according to Jason Hwang, a physician and the co-author of The Innovator's Prescription. In fact, two disruptive innovations already are shaking up health care.

 

The first is retail clinics. Those are the plain little outposts in the back of stores such as CVS or Wal-Mart, where patients can walk in and be seen for a sore throat, infected fingernail or other minor ailments. The clinics are convenient and affordable. And they're disruptive because they replace doctors — the most expensive health providers in our system — with nurse practioners who rely on technology and data to point them to standard methods of treating patients. "The clinic depends on process," Hwang says. "It takes intuition out of the equation."

 

As they secure a toehold in the health care system, retail health clinics are moving into phase two. Large corporations are offering on-site clinics for employees, and the public sector is following suit. A few weeks ago, Arizona's Maricopa County became the nation's largest jurisdiction to set up a workplace clinic where employees can get a prescription filled or an immunization shot. The clinic could save the county $575,000 per year in health costs.

 

Retail clinics are disruptive in mostly positive ways. Primary care physicians already are overworked. And too many patients use the emergency room for minor illnesses that could be treated elsewhere. While retail clinics might divert some customers away from some doctors, they are a benefit for the overall health care system.

 

The second disruptive innovation is less clear-cut. It's the rise of specialty hospitals — niche institutions that focus on treating just one disease or providing one type of surgery. Unlike retail clinics, they don't take the expert out of the picture here — this is more like brain surgery, after all. The hospitals deliver efficiencies by targeting their resources. They don't have to invest in providing a full range of services, the way most other hospitals do.

 

That's a problem. Specialty hospitals tend to cherry-pick high-paying, well-insured patients from general hospitals that depend on those patients to offset costs for the low-paying services they provide. In other words, this disruption undermines essential pieces of health care infrastructure. Some states have moved to protect full-service hospitals by making it harder for the specialists to go into business.

 

Hwang sees that as a mistake. General hospitals, he notes, are burdened by an antiquated business model that relies on profitable patients to subsidize the cost of unprofitable patients and services. Injecting specialty hospitals into the mix may create winners and losers, but it could force the whole system to adapt. "Hospitals should be paid what they deserve to be paid for a service rendered," he says. "The payment system has to change."

 

No one would argue with that. We should pay providers a fair price for each service. But we don't. And if specialty hospitals are allowed to do to the health industry what disruptive innovations have done to other indusries, the pain may be too much for the health system to bear. We aren't talking about a better way to produce a car or sell vintage cameras to each other. We're talking about the future of hospitals that provide a full range of care and make it available to everyone. If disruptive innovation cherry-picks the profitable patients, who'll pay for the rest?

 

© 2009, Congressional Quarterly Inc., GOVERNING, City & State and GOVERNING.com are registered trademarks.

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