Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
In his weekly address on Saturday, President Obama said that the Department of Veterans Affairs will begin today to make it easier for veterans with post-traumatic stress disorder (PTSD) to receive the treatment and benefits that they need.
“Just as we have a solemn responsibility to train and equip our troops before we send them into harm’s way, we have a solemn responsibility to provide our veterans and wounded warriors with the care and benefits they’ve earned when they come home,” Obama said.
“We also know that for many of today’s troops and their families, the war doesn’t end when they come home,” Obama said. “Too many suffer from the signature injuries of today’s wars: post traumatic stress disorder and traumatic brain injury. And, too few receive the screening and treatment they need.”
For many years, veterans with PTSD “have been stymied in receiving benefits” by requirements that they produce evidence proving a specific event caused the PTSD. Streamlining this process “is designed to help both the veterans of the Afghanistan and Iraq Wars, along with generations [of older veterans], who have served and sacrificed for the country,” he said.
Under the new regulations, veterans will no longer have to just document specific events that caused their PTSD. Instead, they will be required to show a diagnosis of PTSD that was related to service overall.
“I don’t think our troops on the battlefield should have to take notes to keep for a claims application. And, I’ve met enough veterans to know that you don’t have to engage in a firefight to endure the trauma of war,” Obama said.
Some disagreement has arisen, though, among veterans groups about requiring veterans only to use VA facilities and providers for PTSD diagnosis and treatment—and not private practitioners.
Barry Searle, director of The American Legion’s veterans affairs and rehabilitation division, said, “This requirement seems to be a step backward in an otherwise commendable move by the VA.”
“Private healthcare providers should be given the opportunity to work with veterans and diagnose those who suffer from PTSD,” he said. If the VA has concerns about the consistency of PTSD assessment standards, “it should create a certification process for private practitioners that would satisfy its requirements,” he added.
The Centers for Medicare and Medicaid Services (CMS) has expanded the amount of information available on its Hospital Compare website to include 11 new outpatient measures, along with updated information related to 30 day mortality and readmissions rates for patients related to heart failure, heart attack, and pneumonia.
As of March, data from more than 4,600 acute care, critical access, and children's hospitals could be found on the site; 80% are acute care hospitals that can receive financial incentives through Medicare's inpatient prospective payment system.
The site currently receives over one million page views per month "making it one of our more popular resources for consumers," said Marilyn Tavenner, CMS acting administrator, at a telebriefing.
The new information being released on Hospital Compare is not a surprise to the nation's hospitals, said Barry Straub, CMS's chief medical officer. This data had already been shared with the hospitals several months ago, including patient satisfaction data. "Many hospitals have already begun to improve their efforts based on these measures," he said.
The big change is that Hospital Compare has expanded beyond the inpatient setting to look at the coordination of care in the outpatient setting. These 11 measures capture elements of care for patients in the outpatient departments, emergency departments, and observation services: They include:
Five specifying immediate treatments for outpatients with heart attack symptoms or chest pains (such as administration of clot-busting drugs within 30 minutes).
Two specifying antibiotic use and actions to prevent infection of surgical wounds on the day of surgery.
Four specifying use of radiology and imaging, including computed tomography scans, mammographies, and magnetic resonance imaging (MRI).
The category on imaging is specifically designed to "shine a spotlight on the problem of unnecessary exposure to contrast materials or radiation," Straub said. It includes: data on the rates of outpatient MRIs for low back pain, outpatient retests after a screening mammogram, as well as two ratios that look at the use of double CT scans.
On the imaging measures, though, "there is more for us to learn," said American Hospital Association President and CEO Rich Umbdenstock, at the briefing. "These are frequency measures, and we want to be sure we learn from them what the right number of follow-up images might be. It is still an evolving science."
The Hospital Compare site also has updated its information on 30-day readmission rates and mortality rates. The new risk-adjusted data, gathered from July 1, 2006 to June 30, 2009, now shows tracking over a three-year period of time as opposed to the earlier one-year period (2005-2006), Straub said.
Using the latest data, the national 30-day mortality rate related to heart attacks showed a downward trend—falling in this year's report by nearly half a percentage point to 16.2%. Mortality rates related to heart failure and pneumonia, however, were essentially unchanged at 11.2% and 11.6% respectively.
National 30-day readmission rates, though, still remained high, Straub said. No significant change was found in the readmission rates for heart attack (19.9%), heart failure (24.7%), and pneumonia (18.3%) patients compared to data in 2005. "There's much opportunity for improvement here," he said.
Mortality rates did differ among geographic areas, Straub added. For heart attacks and heart failure, higher mortality hospitals were concentrated in the South; lower mortality hospitals were found predominantly in the Northwest and Northeast. Pneumonia mortality showed less geographic variation.
Thirty-day readmission rates also varied geographically. For all three conditions, hospitals with higher readmission rates were located in East, and hospitals with lower rates were located in the West.
"This gives us information on how we might target our quality improvement efforts, our public reporting efforts, and our value-based purchasing and financial incentive methods to try and address those areas with the most need," Straub said.
With the appointment this week of Institute for Healthcare Improvement President and CEO Don Berwick, MD, as administrator of the Centers for Medicare and Medicaid Services, the Cambridge, MA-nonprofit has named its executive vice president and chief operating officer, Maureen Bisognano, as its new head.
Since joining IHI in 1995, Bisognano has been a frequent speaker at major conferences on quality improvement, and had travelled globally to work with healthcare leaders. Before joining IHI, she was senior vice president of The Juran Institute, where she consulted with senior management on the implementation of total quality management in healthcare settings. Before that, she served as CEO of the Massachusetts Respiratory Hospital in Braintree, MA, where she participated in the National Demonstration Project, the precursor to IHI.
Bisognano began her career in healthcare in 1973 as a staff nurse at Quincy City Hospital. While at the hospital, she served as director of nursing, director of patient services, and chief operating officer.
Currently, she is an instructor of medicine at Harvard Medical School and a research associate in the Division of Social Medicine and Health Inequalities at the Brigham and Women's Hospital. She is also an elected member of the Institute of Medicine of the National Academy of Sciences.
"Maureen Bisognano is the ideal successor to Don Berwick, who has led IHI with such extraordinary insight, vision, and drive since its founding in 1991," said IHI Board Chairman A. Blanton Godfrey, in a statement. "Maureen has been Don's chief partner in IHI's management and evolution since she joined IHI in 1995. She is a prominent authority on improving healthcare systems and is well known and widely respected throughout the global healthcare improvement community."
"Though we have made many strides in improving safety, effectiveness, and efficiency in health care, there is much work left to be done," Bisognano said in a statement. "Together, we will carry IHI's work forward, maintaining the qualities associated with Don — a commitment to excellence, a constant focus on innovation based on research and listening to patients and people on the front line, a firm belief in collaboration, and the joy of making change a reality."
Yesterday, President Obama used a recess appointment to install Institute for Healthcare Improvement President and CEO Donald Berwick, MD, as head of the Centers for Medicare and Medicaid Services. While recess appointments by presidents are not uncommon, they can be controversial—especially after healthcare reform has been debated publicly for the past year.
Berwick received hundreds of endorsements from medical, trade, labor, and consumer organizations. But he also has come under the scrutiny of numerous senators who had anticipated engaging him in discussion of over the finer details of healthcare reform.
In introducing him yesterday, Obama said it was “unfortunate that at a time when our nation is facing enormous challenges,” many in Congress have decided to delay critical nominations for political purposes. The recess appointment will allow Berwick to “get to work on behalf of the American people right away,” Obama added.
“Given the importance of health reform to millions of Americans, tapping a respected leader for CMS is of the utmost importance,” said American Hospital Association President and CEO Rich Umbdenstock said in a statement. “Don has dedicated his career to engaging hospitals, doctors, nurses and other healthcare providers to improve patient care. ... His knowledge of the healthcare system makes him the right choice.”
“Dr. Berwick will provide leadership and inspire the talented and dedicated people at CMS as it embarks on the implementation of the recently enacted healthcare law,” said Chip Kahn, president and CEO of the Federation of American Hospitals. “Dr. Berwick is a proven leader in improving the quality and safety of healthcare in this country. The FAH looks forward to working with Dr. Berwick to fulfill the promise of healthcare reform.”
J. Fred Ralston, Jr., MD, president of the American College of Physicians, said in his statement that his group joined more than 700 stakeholders on the front lines of healthcare delivery—including business, consumers, insurers, and clinicians—to support Berwick’s nomination. “He is well respected in the healthcare community and [is] known for his desire to bring constructive change to healthcare delivery.”
“As a research professional, a clinician, and a policy analyst, he brings an extensive background that’s crucial to ensuring that healthcare policy improves patient care and the practice of medicine,” said AAFP President Lori Heim, MD, of Vass, NC, in a statement. “His leadership has helped ensure that best practices in medical care and groundbreaking medical research are brought to the physicians' offices, and his support for strengthening primary care in the Medicare and Medicaid systems will help set the path for building up the foundation of all high quality healthcare.”
In the Senate, where confirmation hearings would have been held, Sen. Max Baucus (D MT), chair of the Senate Finance Committee, criticized the White House for not going through the standard nomination process. “Senate confirmation of presidential appointees is an essential process prescribed by the constitution that serves as a check on executive power and protects ... all Americans by ensuring that crucial questions are asked of the nominee—and answered,” Baucus said.
However, Baucus added, “I look forward to working with CMS as they implement health reform to deliver the better healthcare outcomes and lower costs for patients we fought to pass in the landmark health reform law.”
Sen. Chuck Grassley (R-IA), the Senate Finance Committee’s ranking minority member, said the Obama administration “has taken advantage of the fact that there’s no check on its power, with one party control of Congress and the White House,” he said. “The nomination hasn’t been held up by Republicans in Congress and to say otherwise is misleading. As ranking member of the committee of jurisdiction, I requested that a hearing take place two weeks ago, before this recess.”
“The American people deserve better than this type of arrogance of power,” said Sen. Orrin Hatch (R-UT). Without so much as even a hearing, President Obama chose to circumvent the Senate and the American people by recess appointing his controversial nominee, Donald Berwick....No Senator—Democrat or Republican—was given the chance to ask Dr. Berwick about his strong support of Britain’s single payer National Health Service or his belief that government delivers higher quality care than the private sector.”
Sen. Tom Harkin (D IA), chairman of the Health, Education, Labor and Pensions (HELP) Committee, said, “In light of Republican arguments for strengthening Medicare and reducing waste, fraud, and abuse in the system, their opposition to Dr. Berwick’s nomination is unfathomable.”
Sen. John Kerry (D-MA), from Berwick’s home state, said: “Republican lockstep stalling of Don’s nomination was a case study in cynicism and one awful example of how not to govern. Republicans screamed that these federal programs were in trouble, then tried to deny the Administration the capable guy the President had chosen to oversee them. The President did the right thing making this a recess appointment.”
The federal government's decade-long quest to limit drug manufacturers' abilities to keep generic medicines off the market for a specified time—through deals called "pay-to-delay"—took a new turn last week when the House approved an amendment to the War Funding Bill (HR 4899) intended to curb such practices.
Restrictions on "pay-to-delay" were included in the initial House healthcare reform approved last year and in President Obama's healthcare reform proposal this year, where it was portrayed as a cost-saving measure. It was excluded, however, in the final Senate bill—and the subsequent healthcare reform law—passed in March.
But attention since then has been refocused on pay-to-delay in the courts. This spring, the U.S. Second Circuit Court of Appeals in New York upheld the legality of Bayer AG to pay a potential generic competitor, Barr Pharmaceuticals, to delay the introduction of Cipro, a popular antibiotic.
In an unusual move, the court—saying that its hands were tied on the issue by a previous ruling on the drug Tamoxifen— "invited" the plaintiffs in the case (including retail pharmacies CVS and Rite Aid) to petition for a rehearing by the full appeals court.
Following the court case, Federal Trade Commission (FTC) Chairman Jon Leibowitz said, "This is further evidence that courts are rethinking their approach to pay-for-delay settlements."
According to Leibowitz, FTC economists have estimated that deals between brand name and generic drug companies were costing consumers about $3.5 billion a year by delaying consumers' access to lower-cost generic drugs. "Congress has taken a critical step towards ending a practice that is dramatically increasing the cost of prescription drugs," he said after the House action.
The legislation now goes to the Senate where a similar amendment- -introduced by Senators Herb Kohl (D-WI), Charles Grassley (R- IA), and Susan Collins (R-ME)—has been included in the pending Tax Extenders Act (HR 4213).
As expected, the legislation is encountering industry opposition- -including from the group representing the generic pharmaceutical manufacturers. The amendment "will delay consumer access to affordable medicines by severely restricting drug patent litigation settlements," said the Generic Pharmaceutical Association (GPhA) in a statement.
In addition, "more than a decade of evidence shows that patent settlements actually help bring lower-cost generic drugs to market much sooner than patent expiration dates—saving millions of dollars for consumers and the health care system," the group said.
Also, Teva Pharmaceutical Industries last week announce that it launched a generic version of Wyeth's antidepressant Effexor XR, which has had annual sales of approximately $2.75 billion in the United States. Through the current patent settlement agreement with Wyeth, the company was able launch this product seven years earlier, said William Marth, president and CEO of Teva North America, in a statement.
The Congressional Budget Office, weighing in on the issue earlier this year with a bill (S. 369) introduced by Sen. Kohl, said that limiting agreements between brand name and generic drug manufacturers could save the federal government $2.4 billion between 2010 and 2014. The savings would primarily come from government payers such as Medicare or Medicaid paying less for medications.
With Congress away from Washington, DC, this week for the July 4th break, the White House indicated Tuesday that it will use a recess appointment to put nominee Donald Berwick, MD, in as head of the Centers for Medicare and Medicaid Services.
The action is expected to bypass the political storm clouds that have been gathering in anticipation of the Senate confirmation hearings for Berwick, a pediatrician, Harvard University professor, and head of the nonprofit Institute for Healthcare Improvement in Cambridge, MA.
Berwick has received broad support nationwide from a variety of consumer, health, and trade groups such as AARP and the American Medical Association. However, numerous GOP members had been indicating in recent weeks that they would stall Berwick’s nomination and address problems they saw with new healthcare reform law passed in March.
With the agency “facing new responsibilities to protect seniors’ care” under the new healthcare reform law, it was felt “there’s no time to waste with Washington game playing,” says Dan Pfeiffer, the White House’s communications director in a White House blog Tuesday night.
Berwick’s “firsthand knowledge of the healthcare system” makes him “the right administrator to tackle the law’s requirements,” particularly as CMS works to “improve nursing home care, reduce unnecessary hospital readmissions, and expand coverage to millions of Americans who need it most,” Pfeiffer says.
The new healthcare reform act also attaches a Jan. 1, 2011, deadline to many of these priorities, “making steady, experienced leadership all the more critical,” Pfeiffer says. CMS has been without a permanent administrator since 2006.
However, in recent weeks, a number of GOP senators have pointed to Berwick’s comments pertaining to what they consider rationing healthcare and to his support of the socialized British healthcare system.
As if “shoving a trillion dollar government takeover of healthcare down the throat of a disapproving American public wasn’t enough,” the Obama Administration intends to “arrogantly circumvent the American people yet again by recess appointing one of the most prominent advocates of rationed healthcare to implement their national plan,” said Senate Minority Leader Mitch McConnell (R-KY) in a statement on Tuesday.
“Dr. Berwick is a self-professed supporter of rationing healthcare, and he won’t even have to explain his views to the American people in a congressional hearing,” said Sen. John Barrasso (R-WY).
While recess appointments often stir up controversy, they are not that unusual. They were used by President Clinton 139 times and by President George W. Bush 171 times.
At least 30% more people were encouraged to get screenings for colon cancer following automated phone reminders, according to a Kaiser Permanente Center for Health Research study funded by the National Cancer Institute.
The study -- the first to examine whether automated calls can increase screenings for colon cancer -- involved nearly 6,000 Kaiser Permanente members in Oregon and Washington who were overdue for screenings. .
Half of the group received automated calls stressing the importance of screening and offering them free at home test kits. If they failed to respond to that first call, a follow-up call -- accompanied by a second call, if necessary -- would be placed during six-week intervals. Results of the study appear in the July issue of Medical Care.
Within six months, 22.5% of individuals who received reminder calls ordered and completed a stool card test, compared with only 16% of those who did not receive reminder calls, according to David Mosen, PhD, MPH, an investigator at the Kaiser Permanente Center for Health Research in Portland, OR. "We think this is pretty significant given that this is a pretty challenging group to get in [for a screening]. They were overdue," he says.
"We were very encouraged by the results. Colon cancer is one of those cancers that are preventable if the screening is done regularly, so I think it's a very worthwhile thing to do," Mosen says.
Several screening methods for colon cancer, the second leading cause of cancer death in the United States, are available, including: a colonoscopy, a sigmoidoscopy, and the fecal occult blood test (a non invasive test to detect blood in the stool). FOBT--the test used in this study -- has often been recommended as a first step for screening, and requires people to place stool samples on cards that are mailed to a lab.
While the stool test is easy to take, many often see it as unpleasant, according to Adrianne Feldstein, MD, the study?s principal author and a researcher at the Center for Health Research. "This study shows that simple, automated calls motivate more people to take the test," says Feldstein.
In the study, people ages 51 to 80 received calls because they had not had a colonoscopy in the last 10 years, a flexible sigmoidoscopy or barium enema in the last five years, an FOBT test in the past 12 months, or a clinician referral for FOBT or barium enema within the last three months.
The automated calls, recorded in English and Spanish, are about one minute long and cost less than $1 a call on average, according to Mosen.
After reviewing the results of the study, conducted in 2008, Kaiser Permanente in Oregon and Washington decided to use the automated phone calls to remind all its members who are overdue for colon cancer screening.
Medicare beneficiaries in nine areas of the country who use certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) could see average price reductions of about 32% off the current cost of those items come Jan. 1, 2011. The savings will be realized through the first round of a new competitive bidding program to determine the price Medicare pays for the equipment.
The program, which replaces Medicare's existing fee schedule amounts with market based prices, is expected to save more than $17 billion over 10 years. It will ensure "continued access for beneficiaries to high quality products" from accredited suppliers that "meet stringent quality and financial standards---which help to reduce fraud," according to Jonathan Blum, Centers for Medicare and Medicaid Services' deputy administrator and director of the Center for Medicare.
The first round of the program is scheduled to begin on Jan. 1, for beneficiaries in Charlotte, Cincinnati, Cleveland, Dallas, Kansas City, Miami, Orlando, Pittsburgh, and Riverside, CA. Suppliers that wished to participate in the program submitted bids last year. CMS plans to announce the contract suppliers in September once all contracts have been finalized.
As part of the first round of the competitive bidding program, price reductions are expected among frequently used items such as an oxygen concentrator, a semi electric hospital bed, and a typical monthly supply of 100 diabetic test strips and 100 lancets.
To take advantage of the savings, Medicare beneficiaries living in the nine communities who use certain medical equipment and supplies may have to choose a new Medicare contract supplier if they wish to have Medicare help with payment. Medicare said it will work with local partners and healthcare providers to inform beneficiaries about the changes.
Suppliers that are not contract suppliers may continue to provide certain rented medical equipment, oxygen, and oxygen equipment for those beneficiaries who are clients at the time the program begins -- if they elect to continue furnishing the items as "grandfathered" suppliers.
Two trade groups, though, have expressed opposition to the DMEPOS requirements. The American Association for Homecare, in Arlington, VA, said seniors and people with disabilities who rely on home medical equipment and services "will pay a steep price under Medicare's controversial and mislabeled competitive bidding program for durable medical equipment."
The bid prices on DMEPOS "will translate into unsustainable reimbursement rates for homecare providers," says Tyler Wilson, the association's president. "Over time, it will make it harder for seniors and people with disabilities to get the home medical equipment and services they require to live independently."
If CMS officials proceed with the DMEPOS bidding program, "we urge caution against any action that would undermine or reverse the benefits of coordinated care," says Joseph Harmison, PD, president of the National Community Pharmacists Association.
He added that the inclusion of small pharmacies in the bidding program or reimbursing them at the newly announced mail order rates "eventually would result in the virtual elimination of independents from the program."
This is because "independents don't operate with the purchasing power of large chains or mail order competitors and thus can't always match those prices," Harmison says.
In the healthcare reform debate, hospital pay-for-performance has received plenty of discussion—how it could impact health outcomes, how it could promote efficiency, how it could change care coordination. But a nagging question remains: could use of pay for performance end up taking funding away from hospitals across the country providing care in poor, underserved areas?
Beginning in 2013, the first step of pay-for-performance implementation starts—when hospitals will have some revenues withheld by Medicare and then returned if they meet specific clinical targets.
However, pay-for-performance assumes that hospitals will all have the same economic and human resources that they need to perform or to improve their performance, says Jan Blustein, MD, PhD, a New York University professor of health policy and medicine, and two of her colleagues in a new Public Library of Science (PLoS) journal study.
In a way, there are similarities between implementing pay-for-performance in hospitals and implementing the “No Child Left Behind“ initiative several years ago for education, Blustein says in an interview. “I think it’s very challenging,” she says. “One of the problems is we know very little about what helps and what works.”
In education, schools are told to do better—“but there is no science there. We really don’t know what works in the school,” she says. While there is some evidence that teachers matter, “there’s not a lot of evidence to support that.”
“And the same thing is true in healthcare. We know a lot about what works to improve a patient’s health, but we really don’t know about what works to improve organizational performance.” Some may use consultants heavily, or others may work with groups of hospitals. “Perhaps that’s a good thing to do. But I think that we really don’t know.”
But, if the resources aren’t there for the hospital to make improvements, would those hospitals end up losing money in the long run based on performance? In other words, they ask, could the government be rewarding well-funded hospitals at the expense of poorer hospitals that provide critical services to support the need of the underserved?
To test this assumption, Blustein’s team looked at the link between local economic and human resources and hospital performance for two common heart conditions—acute myocardial infarction and heart failure—for 2,705 hospitals between 2004 and 2007. They calculated hospitals’ scores using the same methodology proposed for Medicare’s new pay for performance reimbursement plan.
They also examined regional variation for five factors: poverty, unemployment, provider shortage, non high school graduates in the work force, and college graduates in the work force.
They found that although overall performance scores for heart attack and heart failure improved during the study, quality at hospitals in disadvantaged regions still continued to “lag significantly behind” more advantaged hospitals.
Hospitals in those counties, for instance, with widespread poverty throughout the population had lower average performance scores for treating heart failure and heart attack than those in affluent counties. Hospitals in areas that had a lower percentage of college graduates in the workforce also had lower average performance scores.
Noting that nearly 33% of the hospitals studied were in disadvantaged counties, the researchers said that a pay for performance model may “exacerbate inequalities” across regions by rewarding hospitals located in regions that are rich in economic and human resources—and punishing facilities that are in disadvantaged locations.
They determined that in the long run, even though these facilities in underserved areas could demonstrate improvements over the four yeas, they still would end up receiving reduced reimbursement under a pay for performance system for failing to reach the levels of more affluent hospitals.
Although the Centers for Medicare and Medicaid Services said that it will be scrutinizing the distribution of funds to determine whether hospitals are being disadvantaged, the study’s authors stress that the agency must take a more “proactive approach” now to consider changes.
As an alternative, Blustein and her colleagues suggest, that hospitals receive credit for their levels of improvement achieved—regardless of their starting point. That could help hospitals in economically disadvantaged areas, where many of the hospitals starting at a lower-performing baseline exist.
Also, changing the model so that improvement is assessed over a longer time frame “could help make the program more equitable” as well, they said.
“Holding providers accountable is not an unreasonable approach to quality improvement,” the researchers conclude, but it should be done “in a way that attends to the profound inequalities in local circumstances that shape life in the 21st century.”
Contradictory federal policies on how to dispose of unused prescription medications—plus the lack of disposal options—appear to be creating confusion among patients and providers, according to those testifying Wednesday at a hearing of the Senate Special Committee on Aging on drug waste and disposal.
"Odds are that many of us have half empty bottles of medicine lying around our houses. Some of us may have thought we were doing the right thing by flushing them down the toilet, or throwing them away with our trash. But these disposal methods can have a damaging effect on our environment," said the Committee Chairman Herb Kohl (D-WI), who is calling for a new federal guideline on prescription drug disposal.
Under current policies, the Food and Drug Administration (FDA) and the Office of National Drug Control Policy (ONDCP) now post disposal guidelines that conflict with information posted by the Environmental Protection Agency (EPA) and the Fish and Wildlife Service.
"Disposing of unused or expired medications in a fashion that is simple, legal, and environmentally responsible is a challenge," said R. Gil Kerlikowske, director of the White House?s Office of National Drug Policy Control.
Currently, his office advises controlled substance users to dispose of drugs in one of three ways: flushing them (in the case of limited dangerous drugs); throwing them in the trash with proper precautions; or participating in prescription take-back events. His group calls for flushing "exceptionally dangerous drugs" because misuse of these prescription drugs "creates a high risk" of immediate harm: "Their potential danger outweighs the potential environmental impact," he added.
The EPA and Fish and Wildlife Service, though, have opposed the flushing of prescription medications—citing studies, such as those from the U.S. Geological Survey that have found many bodies of water throughout the states contaminated by personal care products, including prescription drugs.
More take-back programs are being used across the country for the disposal and destruction of prescription drugs, but all require a waiver from the Drug Enforcement Agency if it involves controlled substances. Programs have ranged from permanent sites that accept the prescriptions to one day events. But, new ideas have been developed such as the mail/ship back program now used in Maine.
An operational test agreement was formed between the U.S. Postal Service and the Maine Drug Enforcement Agency to ship unused medications in mailer envelope distributed at 150 pharmacy and health and human service agencies throughout the state, said Stevan Gressitt, MD, the founding director of the Maine Institute for Safe Medicine.
The program, implemented in 2007, handles both controlled and noncontrolled medications. All drugs undergo high heat incineration upon receipt, Gressitt said at the hearing.
One strategy that needs more focus is "to make sure drugs aren't wasted in the first place," Kohl said. This means finding ways for physicians not to over-prescribed medications. For instance, he cited another program in Maine that aims to reduce waste by limiting initial prescriptions for a list of drugs that are known to provoke adverse drug reactions in some people.
Once the patient and physician decide to continue the medication, more is prescribed. "Not surprisingly, waste also reduces costs," Kohl said. The program save Maine's Medicaid program nearly $250,000 just this year, he said.