Health Affairs Web Exclusives

Understanding The Current Population Survey's Insurance Estimates And The Medicaid 'Undercount' [Web Exclusives]

Klerman, J. A., Davern, M., Call, K. T., Lynch, V., Ringel, J. D. — Mon, 02 Nov 2009 17:03:47 PST

The widely cited Census Bureau estimates of the number of uninsured people, based on the Current Population Survey, probably overstate the number of uninsured people. This is because of a Medicaid "undercount": Fewer people report to survey takers that they’re covered by Medicaid than program administrative data show are enrolled. Our study finds that the undercount can be explained by the inability of people to recall their insurance status accurately from the previous year. We suggest that other data sources, such as Census’s American Community Survey, should be studied to determine whether they would provide better estimates of the uninsured.

Job-Based Health Insurance: Costs Climb At A Moderate Pace [Web Exclusives]

Mon, 02 Nov 2009 17:03:47 PST

Each year the Kaiser/HRET Survey of Employer Health Benefits takes a snapshot of the state of employee benefits in the United States, based on interviews with public and private employers. Our findings for 2009 show that families continue to face higher premiums, up about 5 percent from last year, and that cost sharing in the form of deductibles and copayments for office visits is greater as well. Average annual premiums in 2009 were $4,824 for single coverage and $13,375 for family coverage. Enrollment in high-deductible health plans held steady. We offer new insights about health risk assessments and how firms responded to the economic downturn.

How A New 'Public Plan' Could Affect Hospitals' Finances And Private Insurance Premiums [Web Exclusives]

Dobson, A., DaVanzo, J. E., El-Gamil, A. M., Berger, G. — Mon, 02 Nov 2009 17:03:47 PST

Two key health reform bills in the House of Representatives and Senate include the option of a "public plan" as an additional source of health coverage. At least initially, the plan would primarily be structured to cover many of the uninsured and those who now have individual coverage. Because it is possible, and perhaps even likely, that this new public payer would pay less than private payers for the same services, such a plan could negatively affect hospital margins. Hospitals may attempt to recoup losses by shifting costs to private payers. We outline the financial pressures that hospitals and private payers could experience under various assumptions. High uninsured enrollment in a public plan would bolster hospital margins; however, this effect is reversed if the privately insured enter a public plan in large proportions, potentially stressing the hospital industry and increasing private insurance premiums.

Containing Costs And Improving Care For Children In Medicaid And CHIP [Web Exclusives]

Kenney, G. M., Ruhter, J., Selden, T. M. — Mon, 02 Nov 2009 17:03:47 PST

The current health reform debate is greatly concerned with "bending the curve" of cost growth and containing costs, particularly in public programs. Our research demonstrates that spending in Medicaid and the Children’s Health Insurance Program (CHIP) is highly concentrated, particularly among children with chronic health problems. Ten percent of enrollees (two-thirds of whom have a chronic condition) account for 72 percent of the spending; 30 percent of enrolled children receive little or no care. These results highlight the importance of cost containment strategies that reduce avoidable hospitalizations among children with chronic problems and policies that increase preventive care, particularly among African American children.

Portrait Of A Policy And Political Entrepreneur [Web Exclusives]

Blumenthal, D. — Mon, 02 Nov 2009 17:03:47 PST

Senator Edward M. Kennedy: The Master Legislative Craftsman [Web Exclusives]

Nexon, D. — Mon, 02 Nov 2009 17:03:47 PST

Senator Edward M. Kennedy: Making Common Cause With Adversaries While Committed To Health Reform [Web Exclusives]

Marmor, T. R. — Mon, 02 Nov 2009 17:03:47 PST

The Dangerous Shortage Of Domestic Violence Services [Web Exclusives]

Iyengar, R., Sabik, L. — Mon, 02 Nov 2009 17:03:47 PST

Domestic violence is a serious, preventable health problem affecting more than thirty million Americans annually, yet little is known about federally funded service provision. We used the National Census of Domestic Violence Services, an innovative victim-safety focused survey, to count services provided by more than 2,000 programs. During the twenty-four-hour survey period, 48,350 people used these services. The results show substantial unmet demand for services (10 percent of requests) because of resource constraints, particularly in rural, economically disadvantaged, and minority communities. Greater funding of domestic violence programs, particularly housing support, is likely to be a cost-effective public health investment.

Closing The Schools: Lessons From The 1918-19 U.S. Influenza Pandemic [Web Exclusives]

Stern, A. M., Cetron, M. S., Markel, H. — Mon, 02 Nov 2009 17:03:47 PST

When the novel strain of A/H1N1 influenza first appeared in spring 2009, closing schools was initially a common and often challenging strategy implemented in many communities. Arguments for and against closing schools are likely to arise anew if influenza spikes in the fall of 2009. Policymakers and community officials considering this and other nonpharmaceutical responses can learn from the experiences of ninety-one years ago, during the 1918–19 influenza pandemic that killed thousands of Americans. Analysis of the school closure policies of forty-three U.S. cities during that pandemic shows that smooth implementation was associated with clear lines of authority among agencies and with transparent communication between health officials and the public.

Massachusetts Health Reform: Employer Coverage From Employees' Perspective [Web Exclusives]

Long, S. K., Stockley, K. — Mon, 02 Nov 2009 17:03:47 PST

The national health reform debate continues to draw on Massachusetts’ 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This study provides an update on employers’ responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers’ dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms.

Zoning For Health? The Year-Old Ban On New Fast-Food Restaurants In South LA [Web Exclusives]

Sturm, R., Cohen, D. A. — Mon, 02 Nov 2009 17:03:47 PST

A regulation banning new fast-food establishments for one year in Los Angeles, California, was passed unanimously by the city council in July 2008. It was motivated by health concerns and excessive obesity rates in South Los Angeles. However, it might not have had the impact that was intended. This paper reviews the empirical evidence for the regulation and whether it is likely to target the primary levers of obesity. We argue that the premises for the ban were questionable. For example, the density of fast-food chain restaurants per capita is actually higher in other parts of Los Angeles than in South LA. Other changes, such as menu calorie labeling, are likely to have a bigger impact on overweight and obesity.

New York City's Fight Over Calorie Labeling [Web Exclusives]

Farley, T. A., Caffarelli, A., Bassett, M. T., Silver, L., Frieden, T. R. — Mon, 02 Nov 2009 17:03:48 PST

In 2006, New York City’s Health Department amended the city Health Code to require the posting of calorie counts by chain restaurants on menus, menu boards, and item tags. This was one element of the city’s response to rising obesity rates. Drafting the rule involved many decisions that affected its impact and its legal viability. The restaurant industry argued against the rule and twice sued to prevent its implementation. An initial version of the rule was found to be preempted by federal law, but a revised version was implemented in January 2008. The experience shows that state and local health departments can use their existing authority over restaurants to combat obesity and, indirectly, chronic diseases.

Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City [Web Exclusives]

Elbel, B., Kersh, R., Brescoll, V. L., Dixon, L. B. — Mon, 02 Nov 2009 17:03:48 PST

We examined the influence of menu calorie labels on fast food choices in the wake of New York City’s labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.

Adoption And Spread Of New Imaging Technology: A Case Study [Web Exclusives]

Ladapo, J. A., Horwitz, J. R., Weinstein, M. C., Gazelle, G. S., Cutler, D. M. — Mon, 02 Nov 2009 17:03:48 PST

Technology is a major driver of health care costs. Hospitals are rapidly acquiring one new technology in particular: 64-slice computed tomography (CT), which can be used to image coronary arteries in search of blockages. We propose that it is more likely to be adopted by hospitals that treat cardiac patients, function in competitive markets, are reimbursed for the procedure, and have favorable operating margins. We find that early adoption is related to cardiac patient volume but also to operating margins. The paucity of evidence informing this technology’s role in cardiac care suggests that its adoption by cardiac-oriented hospitals is premature. Further, adoption motivated by operating margins reinforces concerns about haphazard technology acquisition.

Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients [Web Exclusives]

Baras, J. D., Baker, L. C. — Mon, 02 Nov 2009 17:03:48 PST

Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients.

Uninsured Adults With Chronic Conditions Or Disabilities: Gaps In Public Insurance Programs [Web Exclusives]

Pizer, S. D., Frakt, A. B., Iezzoni, L. I. — Mon, 02 Nov 2009 17:03:48 PST

Among nonelderly U.S. adults (ages 25–61), uninsurance rates increased from 13.7 percent in 2000 to 16.0 percent in 2005. Despite the existence of public insurance programs, rates remained high for low-income people reporting serious health conditions (25 percent across years) or disabilities (15 percent). Residents of southern states had even higher rates (32 percent with health conditions, 22 percent with disabilities). Those who did not belong to a federally mandated Medicaid eligibility category were about twice as likely as others to be uninsured overall, and uninsurance among this group increased more rapidly over time. These regional and categorical differences reflect gaps in current policy that pose challenges for incremental health reform.

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults [Web Exclusives]

Mon, 02 Nov 2009 17:03:48 PST

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Evidence Of An Emerging Digital Divide Among Hospitals That Care For The Poor [Web Exclusives]

Mon, 02 Nov 2009 17:03:48 PST

Some hospitals that disproportionately care for poor patients are falling behind in adopting electronic health records (EHRs). Data from a national survey indicate early evidence of an emerging digital divide: U.S. hospitals that provide care to large numbers of poor patients also had minimal use of EHRs. These same hospitals lagged others in quality performance as well, but those with EHR systems seemed to have eliminated the quality gap. These findings suggest that adopting EHRs should be a major policy goal of health reform measures targeting hospitals that serve large populations of poor patients.

A Survey Of Primary Care Physicians In Eleven Countries, 2009: Perspectives On Care, Costs, And Experiences [Web Exclusives]

Schoen, C., Osborn, R., Doty, M. M., Squires, D., Peugh, J., Applebaum, S. — Mon, 02 Nov 2009 17:03:48 PST

This 2009 survey of primary care doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States finds wide differences in practice systems, incentives, perceptions of access to care, use of health information technology (IT), and programs to improve quality. Response rates exceeded 40 percent except in four countries: Canada, France, the United Kingdom, and the United States. U.S. and Canadian physicians lag in the adoption of IT. U.S. doctors were the most likely to report that there are insurance restrictions on obtaining medication and treatment for their patients and that their patients often have difficulty with costs. We believe that opportunities exist for cross-national learning in disease management, use of teams, and performance feedback to improve primary care globally.

Health Care Reform Requires Law Reform [Web Exclusives]

Jost, T. S. — Tue, 08 Sep 2009 17:02:05 PDT

Health care financing and delivery reform seems to be under way. Reform will in all likelihood originate with Congress but may also come from the states or even the private sector. Federal law, however, limits states’ options for reform, while state law constrains federal reform, and both state and federal law impede private innovation. Congressional action could facilitate state reform. Alternatively, federal preemption of state law may be necessary for federal reform. If neither Congress nor the states act, action by federal agencies could support private innovation. In any event, law reform is a necessary condition for health reform.

Broadened Use Of Atypical Antipsychotics: Safety, Effectiveness, And Policy Challenges [Web Exclusives]

Crystal, S., Olfson, M., Huang, C., Pincus, H., Gerhard, T. — Tue, 08 Sep 2009 17:02:05 PDT

Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.

Developing A Policy For Second-Generation Antipsychotic Drugs [Web Exclusives]

Rosenheck, R. A., Sernyak, M. J. — Tue, 08 Sep 2009 17:02:05 PDT

Second-generation antipsychotics (SGAs) have replaced older drugs in the treatment of schizophrenia; their costs in the United States have reached $13 billion a year. Recent research, however, shows that their net risk/benefit profiles are no better than some older, cheaper drugs. Stepped therapy, allowing exceptions with prior authorization and giving preference to generic drugs with low risk of both neurologic and metabolic side effects, could increase the cost-effectiveness and safety of antipsychotic drugs. Educational preparation and monitoring of adverse events would foster better acceptance of such procedures among providers, patients, and families. Research to evaluate these interventions would ideally precede their widespread implementation.

Comparative Effectiveness Research For Antipsychotic Medications: How Much Is Enough? [Web Exclusives]

Meltzer, D. O., Basu, A., Meltzer, H. Y. — Tue, 08 Sep 2009 17:02:05 PDT

Second-generation antipsychotics have attracted practitioners’ and policy-makers’ attention, because of concerns over their health effects and costs. Comparative effectiveness data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)—a high-profile National Institutes of Health (NIH)–funded study—have been used to argue for restricting coverage for these costly drugs. But concerns about the design of CATIE and its associated cost-effectiveness analysis and uncertainty about the precision of these findings raise questions about this interpretation. Our work suggests that additional research to increase the precision of comparisons of the effectiveness of antipsychotics would be well worth the cost.

Charitable Expectations Of Nonprofit Hospitals: Lessons From Maryland [Web Exclusives]

Gray, B. H., Schlesinger, M. — Tue, 08 Sep 2009 17:02:05 PDT

Little is known about nonprofit hospitals’ community benefit spending other than for charity care. Better accountability is desirable, but critics have focused too narrowly on charity care. Using data from reporting requirements in Maryland similar to federal rules that take effect in 2010, we describe the broad range of community benefit spending in nonprofit hospitals there, which amounted to 7.4 percent of expenses in 2007. Charity care for hospital services accounted for one-third of this amount (payments to physicians for charity patients are reported separately). Hospitals’ community benefit spending varies with local needs, resources, and resource allocation decisions.

Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates [Web Exclusives]

Finkelstein, E. A., Trogdon, J. G., Cohen, J. W., Dietz, W. — Tue, 08 Sep 2009 17:02:05 PDT

In 1998 the medical costs of obesity were estimated to be as high as $78.5 billion, with roughly half financed by Medicare and Medicaid. This analysis presents updated estimates of the costs of obesity for the United States across payers (Medicare, Medicaid, and private insurers), in separate categories for inpatient, non-inpatient, and prescription drug spending. We found that the increased prevalence of obesity is responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. We estimate that the medical costs of obesity could have risen to $147 billion per year by 2008.

How Medicare Could Get Better Prices On Prescription Drugs [Web Exclusives]

Outterson, K., Kesselheim, A. S. — Tue, 08 Sep 2009 17:02:05 PDT

Congress may reform drug pricing policies under Medicare Part D as part of a larger health reform effort. Currently, the "noninterference" provision prevents the government from negotiating drug prices on behalf of Medicare Part D prescription drug plans. Commonly considered reform proposals borrow ideas from Medicaid, either through returning dual eligibles to Medicaid drug pricing or by imposing mandatory rebates across the Part D population. We examine a menu of other options, including value-based pricing; expansion of generic and therapeutically equivalent substitution; increased formulary diversity; importation; and limited antitrust waivers. These latter options may reduce federal spending without direct government price negotiations.

Games For Health: The Latest Tool In The Medical Care Arsenal [Web Exclusives]

Hawn, C. — Tue, 08 Sep 2009 17:02:06 PDT

At the heart of any promising plan to transform the health care system lie two priorities: broader access to care for patients, and deeper engagement in health care by patients. Although the problem of expanding access to affordable care remains unresolved, new tools for deepening consumers’ engagement in health care are proliferating like viral spores in a virtual pond. Digital games, including virtual realities, computer simulations, and online play, are valuable tools for fostering patient participation in health-related activities. This is why gaming is the latest tool in the arsenal to improve health outcomes: gaming makes health care fun.

Estimates Of Health Care Professional Shortages In Sub-Saharan Africa By 2015 [Web Exclusives]

Scheffler, R. M., Mahoney, C. B., Fulton, B. D., Dal Poz, M. R., Preker, A. S. — Tue, 08 Sep 2009 17:02:06 PDT

This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. We forecast that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totaling approximately 800,000 health professionals. We estimate the additional annual wage bill required to eliminate the shortage at about $2.6 billion (2007 $US)—more than 2.5 times current wage-bill projections for 2015. We illustrate how changes in workforce mix can reduce this cost, and we discuss policy implications of our results.

Job Satisfaction And Morale In The Ugandan Health Workforce [Web Exclusives]

Hagopian, A., Zuyderduin, A., Kyobutungi, N., Yumkella, F. — Tue, 08 Sep 2009 17:02:06 PDT

Ugandan health workers are dissatisfied with their jobs, especially their compensation and working conditions. About one in four would like to leave the country to improve their outlook, including more than half of all physicians. In this paper we report differences by type of health worker, sex, age, sector (public or nonprofit), and location. Policy strategies to strengthen human resources for health in Uganda should focus on salary and benefits (especially health coverage), working conditions and workload, facility infrastructure (including water and electricity), management, and workforce camaraderie.

The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals [Web Exclusives]

McCord, C., Mbaruku, G., Pereira, C., Nzabuhakwa, C., Bergstrom, S. — Tue, 08 Sep 2009 17:02:06 PDT

Five countries in sub-Saharan Africa use nonphysicians to perform major emergency obstetrical surgery. In Tanzania, assistant medical officers provide most of this surgery outside of major cities. Questions about the quality of surgery by nonphysicians have kept most African countries from following this example. We reviewed the records of all patients admitted for complicated deliveries to fourteen district hospitals during four months. Among 1,134 complicated deliveries and 1,072 major obstetrical operations, there were no significant differences between assistant medical officers and medical officers in outcomes, risk indicators, or quality. There were significant differences between mission and government hospitals.

Connecting The Ivory Tower To Main Street: Setting Research Priorities For Real-World Impact [Web Exclusives]

Schur, C. L., Berk, M. L., Silver, L. E., Yegian, J. M., O'Grady, M. J. — Tue, 08 Sep 2009 17:02:06 PDT

Health care decisionmakers face increasing pressure to use health care resources more efficiently, but the information they need to assess policy options often is unavailable or not disseminated in a useful form. Findings from stakeholder meetings and a survey of private-sector health care decisionmakers in California begin to identify high-priority issues, the perceived adequacy of current information, and preferred formats and other desired attributes of research. This is a first step in establishing a systematic approach to linking the information priorities of private-sector decisionmakers with those who fund and conduct research.

The Unhealthy State Of Health Policy Research [Web Exclusives]

Majumdar, S. R., Soumerai, S. B. — Tue, 08 Sep 2009 17:02:06 PDT

Health policies often represent large-scale natural experiments with poorly understood risks and benefits. Unfortunately, researchers often stray from the core principles of study design required to provide valid evidence. The result is that policymakers and the public do not always know what to believe. We illustrate the problem in several fields, including pay-for-performance, cost sharing, and health information technology policies. We suggest a few ways to improve health policy research so that evidence can inform policy more often. The way forward should include more credible data for those making the hard trade-offs between cost and quality of care.

Access, Cost, And Financing: Achieving An Ethical Health Reform [Web Exclusives]

Daniels, N., Saloner, B., Gelpi, A. H. — Tue, 08 Sep 2009 17:02:06 PDT

Three key ethical issues should inform the broader debate about health reform: (1) Why pursue universal coverage? (2) Why is cost containment an ethical issue? (3) What is fairness in financing? After examining these issues, we conclude that the core ethical values underlying each of these goals—including expanding opportunity, sharing burdens equally, and respect for persons—limit the means that can be pursued in health reform. Although national health reform will not accomplish all of the objectives of social justice, true comprehensive reform—even under conditions of political compromise—represents an important step forward.

Putting The Public's Money Where Its Mouth Is [Web Exclusives]

Kessler, D. P., Brady, D. W. — Tue, 08 Sep 2009 17:02:06 PDT

This paper reports the results of a 2009 national survey that quantifies Americans’ willingness to pay to expand health insurance coverage. We asked respondents whether they would support a Medicaid expansion, a subsidy for low-income people, or a subsidy for the chronically ill, if they had to pay more income taxes to cover the program’s costs. Based on respondents’ reported income, we told them approximately how much, in dollar terms, their tax increases would be. Our results reflect a tension in public opinion recognized by previous investigators: a desire for reform but limited willingness to pay for it.

Reforming The Medicaid Disproportionate-Share Hospital Program [Web Exclusives]

McKethan, A., Nguyen, N., Sasse, B. E., Kocot, S. L. — Tue, 08 Sep 2009 17:02:06 PDT

Congress and the Obama administration are considering redirecting federal spending on the Medicaid disproportionate-share hospital (DSH) program to help pay for health reform. In this paper, we propose linking federal Medicaid DSH funding to state-level Medicaid enrollment or uninsured populations, or both. This approach could produce as much as $44 billion in federal savings over time without exposing hospitals to uncertain or across-the-board spending cuts. It could also gradually address state variations in Medicaid DSH funding. We also offer ideas to ensure that DSH spending is more directly connected than it is now to improvements in care for vulnerable populations.

Does Telemonitoring Of Patients--The eICU--Improve Intensive Care? [Web Exclusives]

Berenson, R. A., Grossman, J. M., November, E. A. — Tue, 08 Sep 2009 17:02:06 PDT

Intensive care units are an essential and costly component in most U.S. hospitals. However, little is actually known about what staffing and work-process interventions produce the best balance of quality and costs. We explore the reasons hospitals chose to either adopt or reject an innovative telemedicine approach to supporting delivery of intensive care. Hospital clinical leaders hold strong views but have little objective information on which to judge the worthiness of this innovation. We argue that comparative effectiveness initiatives should emphasize delivery-system and work-process innovations, which are relatively understudied compared to specific drugs, devices, and services.

Expert Review Of Drug Patent Applications: Improving Health In The Developing World [Web Exclusives]

Amin, T., Rajkumar, R., Radhakrishnan, P., Kesselheim, A. S. — Tue, 08 Sep 2009 17:02:06 PDT

Many developing countries have enacted intellectual property laws allowing patents on pharmaceutical products. These countries now must figure out how to provide legitimate protection of innovative discoveries while avoiding drug patents that do not conform to their laws. Using case-study examples, including the antiretroviral tenofovir disoproxil fumarate (TDF, or Viread), we demonstrate the importance of having outside experts participate in the review of drug patents. Vibrant patent review systems require sharing information among developing countries and active consultation with local public health authorities.

A Trade Agreement's Impact On Access To Generic Drugs [Web Exclusives]

Shaffer, E. R., Brenner, J. E. — Tue, 08 Sep 2009 17:02:06 PDT

Millions of people lack access to affordable medicines. The intellectual property rules in the Central America Free Trade Agreement (CAFTA) provide pharmaceutical companies with monopoly protections that allow them to market some drugs without competition by less costly generics. We examined availability of certain drugs in Guatemala and found that CAFTA intellectual property rules reduced access to some generic drugs already on the market and delayed new entry of other generics. Some drugs protected from competition in Guatemala will become open for generic competition in the United States before generic versions will be legally available in Guatemala.

Global Drug Discovery: Europe Is Ahead [Web Exclusives]

Light, D. W. — Tue, 08 Sep 2009 17:02:07 PDT

It is widely believed that the United States has eclipsed Europe in pharmaceutical research productivity. Some leading analysts claim that although fewer drugs have been discovered worldwide over the past decade, most are therapeutically important. Yet a comprehensive data set of all new chemical entities approved between 1982 and 2003 shows that the United States never overtook Europe in research productivity, and that Europe in fact is pulling ahead of U.S. productivity. Other large studies show that most new drugs add few if any clinical benefits over previously discovered drugs. I discuss ways in which Congress, employers, and insurers can increase the value of drugs and revitalize the U.S. pharmaceutical industry.

Using Clinical Information To Project Federal Health Care Spending [Web Exclusives]

Huang, E. S., Basu, A., O'Grady, M. J., Capretta, J. C. — Tue, 08 Sep 2009 17:02:07 PDT

Complications from chronic illnesses often do not emerge for many years. Current federal cost projection methods are constrained by ten-year cost estimates, which capture increases in near-term intervention costs but not changes in long-term costs. Current methods also cannot easily capture the cost implications of changes in disease progression. Type 2 diabetes is a prime example of a chronic illness with long-term health and cost consequences. We present results from an epidemiologically based model that projects federal costs for diabetes under alternative policies, and we discuss the potential changes in the federal budget process needed to capture the full impact of these interventions.