U.S. Attorney General Eric Holder issued formal guidelines for federal law enforcement agencies across the nation, advising them to focus resources on "serious drug traffickers" and away from patients and their caregivers who are using marijuana in compliance with laws in 14 states authorizing the drug's use for medical purposes.
"It will not be a priority to use federal resources to prosecute patients with serious illnesses or their caregivers who are complying with state laws on medical marijuana, but we will not tolerate drug traffickers who hide behind claims of compliance with state law to mask activities that are clearly illegal," Holder said in a media release announcing the guidelines. "This balanced policy formalizes a sensible approach that the department has been following since January: effectively focus our resources on serious drug traffickers while taking into account state and local laws."
The memorandum stresses that the guidelines are "intended solely as a guide to the exercise of investigative and prosecutorial discretion" by federal prosecutors, and not a back-door effort to "legalize" marijuana, which the federal government still classifies as a dangerous drug. The guidelines also do not provide a legal defense to a violation of the federal Controlled Substance Act.
A criminal marijuana operation that would prompt a federal investigation would have characteristics that include: the use of firearms; violence; sales to minors; money laundering; amounts of marijuana inconsistent with purported compliance with state or local law; marketing or excessive financial gains similarly inconsistent with state or local law; illegal possession or sale of other controlled substances; and ties to criminal enterprises, the guidelines state.
The guidelines also state that prosecutors should not be deterred from pursuing a criminal case if it appears that state laws are being used as a pretext for running a criminal drug enterprise. For that matter, the memorandum says federal prosecutors reserve the right to prosecute people who are otherwise in "clear and unambiguous compliance" with state medical marijuana laws if the "investigation or prosecution otherwise serves important federal interests."
Allen St. Pierre, executive director of the National Organization for the Reform of Marijuana Laws, says Holder's memorandum will help legitimize medical marijuana initiatives in states like Maine, which is holding a public referendum on medical marijuana next month.
"It allows for greater movement on this topic as a local and state issue," St. Pierre says. "When we lobby state representatives, they often in my view will oddly defer back to the federal government."
St. Pierre says Holder's comments also reflect a drastic shift in the federal government's views on medical marijuana.
"Ten years ago, they were saying there is no such thing as medical marijuana. It is Cheech & Chong medicine. It is a big hoax. It is the camel's nose under the tent," St. Pierre says. "They've backed off drastically from that rhetoric and have at least acknowledge that with 75 million Americans living in states with medical marijuana, with numerous other states coming on board every election cycle."
At our recent event, HealthLeaders Media '09: The Hospital of the Future Now, the former CEO of Harvard Pilgrim Charlie Baker sat down to talk about the growing importance for healthcare providers to develop multidisciplinary systems of care. Baker, who is now running as a Republican candidate for Governor of Massachusetts, also discussed how three aspects of the national health reform debate are similar to the Bay State's ongoing universal coverage efforts.
On the Senate side, the closed-door healthcare reform negotiations by representatives from two committees—Finance and Health, Education, Labor, and Pensions (HELP)—remained for the most part uneventful on Monday.
However, Finance Chairman Max Baucus (D-MT), in a reporter teleconference call, said earlier in the day that the public insurance option—which was not included in the Finance bill—"was alive" and they are "still looking at it," he said. "We're trying to see what makes the most sense."
His comments came after several White House aides said over the weekend on Sunday television news shows that while President Obama supports the public insurance option, it wouldn't necessarily have to be in place to receive his signature.
While the president complained that the insurance industry was making a "last ditch effort to stop reform" last week, new areas of support emerged this week when numerous groups—including labor groups, such as the Service Employees International Union and AFSCME, community groups, such as Families USA, and Democratic-backed groups, such as Organizing for America—said they were hoping to generate nearly 100,000 calls to Congress on Tuesday.
In what is being called a "Time to Deliver," President Obama plans a live simulcast to supporters today, encouraging them to call members of Congress and show support health insurance reform.
Overall, Congress has only about eight working weeks left to complete its work in 2009. The goal appears now to have a bill on the Senate floor after Nov. 2, with debate expected through Thanksgiving.
In the House, Majority Leader Steny Hoyer (D MD) said last week that any votes would likely occur on the House floor after Nov. 2. Reconciliation between House and Senate bills, if approved, probably would occur no earlier than December.
Charts released by California state health planners Monday show enormous frequency variation in four surgical procedures in each of 58 counties, a finding sure to raise questions about regional appropriateness of care throughout the state.
The charts were released for each of three years, 2005, 2006, and 2007, by the Office of Statewide Health Planning and Development (OSHPD), the agency that collects and researches discharge data for nearly every hospital in the state. The statistical collection is said to be the largest state quality database in the country.
Among the 13 counties with the state's largest populations—more than 800,000—for example, the charts received some wide and unexplained differences. Hospitals in Kern County performed the most percutaneous coronary intervention or stent procedures in 2007, 512 per 100,000 admissions, which was 46% more than the state average and nearly double the number performed in Contra Costa County. San Diego County was second with 437.1 stents per 100,000 admissions.
Fresno County performed the most coronary artery bypass graft procedures in 2007, 186.6 per 100,000 admissions—50% more than the state average and 254% more than San Francisco.
Kern County also performed more hysterectomies than the 13 other large counties, 544.2 procedures per 100,000 admissions, while Ventura County performed the most laminectomy or spinal fusion procedures, 336.2 per 100,000 admissions. State averages for those procedures in 2007 were 321.3 and 201.1 respectively. Among the most populated counties, San Francisco County performed the fewest hysterectomies and the fewest laminectomies, 149.4 and 126 per 100,000 admissions.
The state charts are an effort to publish information about regional utilization similar to reports produced by the Dartmouth Atlas, which looks at regional variations in medical practice and healthcare utilization and cost, especially in the last months of life.
But while the data is risk-adjusted for age and sex, it is not corrected for severity of disease or co-morbidities, defects that make the data hard to interpret, acknowledges Joe Parker, director of OSHPD's Healthcare Outcomes Center. "There's a lot of unexplained variation and the numbers change quite a bit," Parker says.
He adds even though these are "fairly crude numbers" it may indicate that there are doctors practicing medicine in ways "that are very divergent . . . raising interesting and useful questions that policymakers, or county public health officials or anyone else might like to ask."
For example, it is unclear from the data whether counties where practitioners perform the lowest numbers of these four procedures, such as Alameda, Los Angeles or San Francisco, put up barriers to access, or whether their residents are just healthier and need such procedures less frequently. Or, perhaps, in those counties, standards of practice or less aggressive doctors and hospital policies hold back physicians from performing the procedures on patients for whom any benefit is less probable.
Likewise it is unclear whether providers in Kern, Fresno, and Riverside counties, which are above the state average in all four procedures, are overutilizing care, or whether their patients are just a lot sicker. Or, perhaps, those counties may have fewer barriers to care for the poor.
"This might be a starting point for researchers who want to delve into this deeper," says Debby Rogers, RN, vice president for the California Hospital Association. But she adds that it isn't very useful to hospitals because it is not hospital specific.
Parker indicates one of the surgical categories examined, laminectomy or spinal fusion, does offer a clue about regional variation in practices. "For laminectomy or spinal fusion, the evidence is not as robust that people get a whole lot of benefit." He adds he would be "more suspicious" if he saw a lot of those procedures.
The same goes for hysterectomies. Research suggests that hysterectomies, one of the most common and controversial surgical procedures in the country, is often unnecessarily performed to correct endometriosis, which can usually be corrected through easier methods, Parker suggests.
Brian Paciotti, an OSHPD research scientist who specializes in utilization statistics, emphasizes that his agency is not pointing fingers at any hospital system or provider group for anomalies in care. But he says for those counties where there are large differences, "it's up to the people, and the stakeholders, in these counties to drill down and take a look at why."
The state also released three other county-by-county charts listing:
Pediatric quality indicators, including rates of short-term diabetes complications, asthma, gastroenteritis, perforated appendix and urinary tract infections
Prevention indicators, including rates of uncontrolled diabetes, bacterial pneumonia, congestive heart failure, hypertension, and diabetic lower extremity amputations
Patient safety indicators, indicating avoidable hospital events, such as postoperative hematoma or hemorrhage, postoperative wound problems, infections related to care, and pneumothorax related to care.
The 2007 charts can be compared with 2006 or 2005 to see if any of practice patterns may be shifting.
The Dartmouth Atlas has become an Exhibit A of evidence that the system of providing healthcare in the U.S. is chaotic. It shows enormous variation in regional practice, Medicare spending, and utilization of healthcare resources in the last six months of life for 12 chronic illnesses, without any improvement in quality.
But a new relatively low budget study by researchers at six teaching hospitals in California may have unveiled the Dartmouth study's Achilles' heel. These academic physicians found lower mortality among patients hospitalized at facilities that used more resources—such as days in the hospital and procedures—than those that used fewer resources.
"Our study puts a significant dink in the Dartmouth Atlas armor," says Ted Ganiats, MD, one of the paper's authors and interim chair of the Department of Family Medicine at the University of California Medical Center in San Diego. "The insight the Dartmouth atlas provides may not be accurate."
The study, "Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients with Heart Failure," was published last week in the journal, Circulation.
Instead of looking just at care for Medicare beneficiaries in their last six months of life, called the "Looking Back" approach as the Dartmouth researchers have done, the California study also looked at all 3,999 elderly individuals hospitalized between January 1, 2001 and June 30, 2005 for heart failure, the "Looking Forward" Approach.
They also looked at a subset of those 3,999 patients—the 1,639 individuals who died—and compared the care they received during the previous six months.
Ganiats says in addition to the expense of days in the hospital, spending may have involved more aggressive cardiac catheterization and more attempts to determine optimal medication doses or increased echocardiography. It may have also included more coronary artery bypass graft procedures or left ventricular assist devices.
"By only including individuals who have died in the analysis, researchers cannot identify differences on health outcomes such as survival," the researchers wrote.
Unlike the Dartmouth study, the California researchers were able to perform more accurate risk adjustments to account for 21 co-morbidities, dual Medicaid eligibility, and admission year to account for changes in clinical practice, according to the researchers.
Michael Ong, MD, assistant professor of medicine in residence at UCLA and the paper's principal investigator, said that the analysis "does not help us determine what types of resource use or strategies might have resulted in these findings." But another project, also funded by the California Healthcare Foundation, is trying to identify activities that can improve these outcomes, he said.
In addition to UCLA and UCSD, the four other hospitals involved in the study included Cedars-Sinai Medical Center, Los Angeles; the University of California, San Francisco; the University of California, Irvine; and the University of California, Davis.
Which hospitals had higher mortality rates and which ones spent more versus less was not disclosed, although the hospital variations were labeled as hospital A, B, C, D, E, and F.
The basic Medicare premium will shoot up next year by 15%, to $110.50 a month, federal officials announced. The increase means that monthly premiums would top $100 for the first time, and about 27% of Medicare beneficiaries will have to pay higher premiums or have the additional amounts paid on their behalf. The other 73% will be shielded from the increase because, under federal law, their Medicare premiums cannot go up more than the increase in their Social Security benefits.
A new Washington Post-ABC News poll shows that support for a government-run healthcare plan to compete with private insurers has majority support from the public. Independents and senior citizens, two groups crucial to the debate, have warmed to the idea of a public option, and are particularly supportive if it would be administered by the states and limited to those without access to affordable private coverage.
A union is threatening a one-day strike involving 16,000 registered nurses at 39 hospitals in California and Nevada, saying hospitals aren't providing enough protections against swine flu for its members. The union said one of its members died in August after contracting swine flu and that dozens of others have been sickened by the disease. It wants to use the contract negotiations to establish safety procedures around the United States.
In an effort to reconcile a nearly $250-billion difference between the House and Senate approaches to overhauling healthcare, Senate Majority Leader Harry Reid (D-NV) is pushing a bill to halt scheduled reductions in Medicare payments to physicians. The measure would end the cuts and set Medicare payment rates at current levels. Doing so would allow Democrats to maintain the American Medical Association's support for an overhaul without having to absorb the cost of higher doctor payments in the final healthcare bill, the Los Angeles Times reports.
Mergers-and-acquisitions activity among U.S. healthcare companies is on pace for one of its strongest years, the Wall Street Journal reports. In addition, while overall deal activity in the U.S. has tumbled, the value of healthcare deals this year is up from 2007 and 2008. Two factors are driving the deals: continued easy access to financing and efforts by healthcare companies to find new revenue, the Journal reports.
