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P u b l i c a t i o n s & R e p o r t s special challenge, given the limited capacity of Food Marketing to Children and Youth: younger children to process these messages Threat or Opportunity?, a 6 December 2005 report from the Institute of Medicine (IOM), The report can be read free on the Web at http://www declares that if the food industry does not vol- untarily shift its child-oriented television ad-vertising toward healthier foods, then Con- Comparative Effectiveness of Manage- estimated $10 billion-plus is now spent each ment Strategies for Gastroesophageal Re- year for all types of marketing of food and bev- flux Disease (GERD), a 14 December 2005 re- erages to children, and the report, authored by port from the Agency for Healthcare Research and Quality (AHRQ), finds that drugs can be Michael McGinnis, says that most of this is as effective as surgery in managing one of the spent to promote unhealthy products.
The IOM panel found “strong evidence” that TV advertising influences the food and enters the esophagus, causing heartburn and beverage “preferences,” “purchase requests,” potential damage to the esophagus. It is con- and “short-term consumption” of children servatively estimated to affect 3–7 percent of ages 2–11. There was moderate evidence that adults, resulting in $10 billion in direct health advertising influences the “usual dietary in- care costs annually. In Section 1013 of the take” of children ages 2–5 and weak evidence for this association among children ages 6–11.
and Modernization Act (MMA) of 2003, Con- The panel also found strong evidence that ex- gress directed AHRQ to begin reporting on the posure to TV advertising is associated with comparative effectiveness of different ways of adiposity, or body fatness, in children ages 2–11 treating various conditions. MMA authorized and teens ages 12–18, although “current evi- $50 million a year for this research, but Con- dence is not sufficient to arrive at any finding gress actually appropriated only $15 million in about a causal relationship from television ad- vertising to adiposity” (emphasis added).
The report calls for an array of strategies to studies prepared for AHRQ by the Tufts–New England Medical Center Evidence-Based Prac- youth, including an educational campaign fi- tice Center, is AHRQ’s first Section 1013 report nanced jointly by government and the food, and the first of ten analyses that it will release beverage, and restaurant industries. The panel examining treatments for diseases prevalent in the Medicare population. Subsequent reports Health and Human Services (HHS) designate will examine conditions common to enrollees an agency to report to Congress within two in Medicaid and the State Children’s Health years on progress made and further actions needed. The report calls for more research into According to the AHRQ report, for the ma- various emerging forms of child-oriented food jority of patients with chronic uncomplicated GERD, a class of drugs known as proton pump placement, character licensing, the Internet, inhibitors (PPIs)—which includes such well- “advergames,” and “viral marketing.” The IOM panel warns: “Commercial and non-commer- can be as effective as surgery in relieving symp- cial content are becoming more indistinguish- toms and improving quality of life. There is no able, sophisticated, and blended, presenting a difference in effectiveness among the various H E A L T H A F F A I R S ~ Vo l u m e 2 5 , N u m b e r 2 DOI 10.1377/hlthaff.25.2.557 2006 Pr, Inc. PPIs. Another class of drugs known as H re- ceptor antagonists—examples include Pepcid Physician Acceptance of New Medicare and Tagamet—are less effective, but they also Patients Stabilizes in 2004–05, a 9 January cal procedure called fundoplication, which in- “Medicare access to physicians remains high volves tying the top of the stomach around the and has stabilized in recent years, after declin- end of the esophagus to prevent the regurgita- ing between 1996–97 and 2000–01.” Nearly 73 tion of acid, to avoid having to take medica- percent of physicians accepted all new Medi- tions indefinitely. However, studies indicate care patients in 2004–05, up from the 71.1 per- that 10–65 percent of patients who undergo cent of physicians who did so in 2000–01, the this procedure have to return to taking medi- report says. The slight increase, which was not cation. New endoscopic surgical procedures statistically significant, occurred despite a are also available for GERD patients but had small net decrease in Medicare payment rates not yet generated enough evidence for the between 2002 and 2005. These rates declined 5.4 percent in 2002. Congress then prevented further declines by legislating annual increases Carolyn Clancy emphasized that her agency’s of about 1.5 percent in 2003, 2004, and 2005, research is meant to lay out options for con- “effectively offsetting over time most of the sumers, physicians, and others and is not in- pointed out that Congress barred Medicare doubtedly factors into individual physician’s from basing coverage decisions on AHRQ’s re- decisions to accept new Medicare patients, it’s less clear that changes in Medicare physician Free copies are available at http://effectivehealth payment are a key factor driving changes in the overall proportion of physicians accepting Medicare patients,” write HSC president PaulGinsburg and colleagues Peter Cunningham and Andrea Staiti. “For example, while physi- The 2005 National Healthcare Dispari- cian payment rates rose sharply between 1997 ties Report, released 9 January 2006 by and 2001, the percentage of physicians accept- AHRQ, reveals that Hispanics lag behind non- ing all new Medicare patients declined be- Hispanic whites on measures of health care tween 1996–97 and 2000–01.” The report sug- quality and access, and they are falling further gests that physicians’ acceptance of Medicare behind. Hispanics scored below non-Hispanic patients is likely influenced by the same “over- whites on twenty of thirty-eight quality mea- all health care system dynamics” that affect sures and seven of eight access measures. His- physicians’ acceptance of privately insured pa- panics scored higher on only six quality mea- tients. Acceptance rates for the privately in- sures and no access measures. Moreover, 59 sured have “followed the same general trend as percent of disparities faced by Hispanics were acceptance of Medicare patients, decreasing widening. In contrast, in 58 percent of the between 1996–97 and 2000–01, and then in- cases where blacks trailed whites on quality or creasing significantly after 2001,” the research- access measures, the gap was narrowing. Nev- ertheless, blacks still scored below whites on twenty of forty-six quality measures and four these trends? “Growing physician capacity of eight access measures, while doing better on constraints between 1997 and 2000–01 have five quality measures and no access measures.
eased somewhat,” the report says. “Sharp in- Free copies are available at creases in the number of physician office visits during the late 1990s have abated in recent years, increasing by about 1.5 percent annually groups, physician P4P will have a particularly between 2001 and 2003, compared with aver- difficult time if each health plan tries to create age increases of about 4 percent between 1996 its own separate measures and payment incen- and 2001.” Among patients age sixty-five and tives, HSC predicts. Apart from the adminis- older, the difference was even starker: “The trative hassles for physicians, “the numbers of number of physician office visits was un- patients with a particular condition enrolled changed between 2001 and 2003, after having in a particular health plan seeing a particular increased about 5 percent annually between physician” would be so small that quality mea- surement would be “practically meaningless,” Free copies are available at and payments per physician would be “too small to gain physician acceptance and influ-ence practice patterns.” On the other hand, the report notes, government action could greatly Can Money Buy Quality? Physician Re- accelerate P4P adoption. In early 2005 the sponse to Pay for Performance, a 14 Decem- Centers for Medicare and Medicaid Services ber 2005 HSC report , says that paying physi- (CMS) launched a P4P demonstration project cians based on performance is generating “lots involving ten physician groups. Should con- of buzz” but “little action.” During its 2005 gressional efforts to integrate P4P into Medi- round of site visits, HSC found that physician care physician payments succeed, “private P4P has “become a significant topic of discus- plans and Medicaid programs could well de- sion among health plans and physician lead- cide to adopt Medicare’s measures, which in ers” in all twelve of the nationally representa- turn would reduce the problem of lack of stan- tive communities it visits every two years. But the organization observed “significant P4P Although not mentioned in the HSC report, programs for physicians” in only two mar- the recommendations set forth in Performance Measurement: Accelerating Improvement, a 1 Decem- such programs were “either minimal or nonex- ber 2005 IOM report, also address the issue of standardization for physicians and other pro- Jessica May, Robert Berenson, and Jennifer Congress establish a new board within HHS to designate, and when necessary develop, Boston are early P4P adopters “in part because standardized performance measures. “A well- many physicians in these sites are organized functioning national system that can meet the into large medical groups, integrated systems, or independent practice associations. P4P is porting is unlikely to emerge from current vol- more difficult to implement in small physician untary, consensus-based efforts, which are of- practices that lack the resources and infra- structure to manage care systematically and connection to explicit, over-arching national track performance data.” Indeed, physician goals,” explains the report, authored by an P4P “has not yet touched the majority of the IOM panel led by Steven Schroeder of the Uni- nation’s medical practices, which have fewer versity of California, San Francisco.
than five physicians,” says the HSC report. In Free copies of the HSC report are available at http:// at least one area, preventive services for Medi- The IOM report can be care beneficiaries, quality in smaller physician read free on the Web at groups is inferior to that in their larger coun- terparts, and the report warns that the dispar-ity in P4P adoption could widen this qualitygap.
H E A L T H A F F A I R S ~ Vo l u m e 2 5 , N u m b e r 2


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