The Vera Institute of Justice released its report today on the participation of HIV positive NYC foster children in HIV drug trials from the last 1980s until 2005. The city's Administration for Children's services commissioned the report in 2005 when allegations arose concerning the participation of certain children in the study. These allegations included: that race was a factor in the selection of participants, that children were at times inappropriately removed from their homes and placed in foster care to facilitate their participation in the study, and that the trials themselves adversely affected the children's health.
First, the study found that no child died as a result of his or her participation in a study. Sadly, 80 of the 532 children enrolled in HIV trials over this period of time did die, but investigators could find no connection between these deaths and any clinical trial. The study also noted that while there were instances of side effects in the children, these side effects were consistent with the literature published about the drug at the time. The study also fond several instances in which physicians took note of these toxicities and made appropriate adjustments. Second, the study finds no evidence that children were removed from their homes to due parental refusal to allow children to participate in drug trials. The study notes that 3/4 of children enrolled in foster care were enrolled before they were one year old, and more than 1/2 were enrolled directly in the hospital from birth. Third, the study finds that the while the trials did predominantly involve black and Hispanic children, their representation in the trials was reflective of the demographics of the HIV epidemic at the time.
On the other hand, there were some findings of concern. A number of them centered around informed consent: in seven cases, consent was given by someone who had no legal right to do so, consent forms were often written in medical jargon, and consent was at times accepted in the form of handwritten notes or over the phone. Sixty four children were enrolled in trials that were never reviewed bu the city's own Medical Advisory Panel (MAP), which had been developed specifically for that purpose. Twenty one children were enrolled in trials that had been reviewed by MAP and were not recommended, although 13 of these had been enrolled prior to entering foster care.
The report concludes with a few concerns and recommendations, mostly centered around the need for clearer and more comprehensive policy around the participation of foster children in clinical trials.
Further coverage of the study can be found at the NYT website.
Finally, on a personal note, one of the study's seven authors is my roommate, Reena Gadhia, who used to work at Vera and is now an RN at the Allen Pavilion of Columbia Presbyterian. Reena worked on this project a lot while at Vera, and has since gone to DC to present her research at a conference. Congrats Reena!
Wednesday, January 28, 2009
Kaiser studies Medicaid/SCHIP eligibility
The Kaiser Foundation has released its eighth annual 50 state survey on Medicaid/SCHIP eligibility. Nationwide, the principal findings of the study were optimistic. It reports that “the commitment to children remains strong” and that many states have broadened Medicaid access in the past year despite economic challenges. The authors noted, however, that it is still more difficult for parents to get Medicaid than children.
The study broadly affirmed that New York has some of the most liberal Medicaid requirements in the country. New York’s Medicaid/SCHIP income eligibility requirements were consistently at or above the national median. Some things that set New York apart:
- New York both working and jobless parents could qualify for Medicaid even if their income was more than 100% of the federal poverty level (FPL). Nationally, the median cutoff is 68% of FPL for a working parent and 41% of FPL for a jobless parent. (In some states, even working parents must make less than 50% of FPL to qualify for Medicaid, which leads one to wonder how some state legislators interpret the word “poverty”.)
- New York provides Medicaid to pregnant women at 200% of FPL; the national median is 185%.
- New York provides children with SCHIP (In NY, Child Health Plus) up to 400% FPL. When New York passed legislation raising eligibility from 250% to 400%, the Center for Medicaid and Medicare Services (CMS) rejected the plan, and children who fall between 250% and 400% are now paid for with state funds.
- New York is one of 23 states in which a an adult working at the state minimum wage qualifies for Medicaid.
The study also discussed ways in which New York’s generous policies are expanding:
- New York has adopted the option to allow children leaving foster care upon reaching age 18 to keep their Medicaid coverage.
- In February 2008, New York introduced a “presumptive eligibility law” for SCHIP.
The study broadly affirmed that New York has some of the most liberal Medicaid requirements in the country. New York’s Medicaid/SCHIP income eligibility requirements were consistently at or above the national median. Some things that set New York apart:
- New York both working and jobless parents could qualify for Medicaid even if their income was more than 100% of the federal poverty level (FPL). Nationally, the median cutoff is 68% of FPL for a working parent and 41% of FPL for a jobless parent. (In some states, even working parents must make less than 50% of FPL to qualify for Medicaid, which leads one to wonder how some state legislators interpret the word “poverty”.)
- New York provides Medicaid to pregnant women at 200% of FPL; the national median is 185%.
- New York provides children with SCHIP (In NY, Child Health Plus) up to 400% FPL. When New York passed legislation raising eligibility from 250% to 400%, the Center for Medicaid and Medicare Services (CMS) rejected the plan, and children who fall between 250% and 400% are now paid for with state funds.
- New York is one of 23 states in which a an adult working at the state minimum wage qualifies for Medicaid.
The study also discussed ways in which New York’s generous policies are expanding:
- New York has adopted the option to allow children leaving foster care upon reaching age 18 to keep their Medicaid coverage.
- In February 2008, New York introduced a “presumptive eligibility law” for SCHIP.
Tuesday, January 27, 2009
must read for primary care providers
Terrific blog post on Wonk Room from Friday. Covers the evolution of the health portion of the stimulus bill, including how it will incentivize the development of IT in primary care. There's a great point at the end about how IT is in some ways uniquely relevant to PCPs (primary care providers) who "own their infrastructure" in way most specialists don't.
Thursday, January 22, 2009
new insurance proposal
Governor Paterson is working on a plan to extend the period of time employed adults ae permitted to claim their children as dependents for health insurance, the New York Times reports. Currently, New Yorkers can claim their children up to age 19, unless the child is a full time student, in which case they can claim up to age 22. The new plan would extend that age to 29. The plan is modeled on an NJ law that offered the same option to parents, provided the children are under 31, reside in the state or are enrolled in college, and have no dependents of their own.
Analysts note that the effects of the Jersey law have been "incremental", pointing out that 55% of the nations workers work for companies that self-insure, and are therefore subject only to federal regulations. However, since 800,000 people, or 31% of uninsured New Yorkers, fall into the demographic targeted by this plan, legislators are paying attention. Austin Shafran, a spokeman for new Senate majority leader Malcolm A. Smith, is quoted in the Times as saying: “The plan seems like a very legitimate step in the right direction toward improving access to health care. We’re really taking a look at it.”
Analysts note that the effects of the Jersey law have been "incremental", pointing out that 55% of the nations workers work for companies that self-insure, and are therefore subject only to federal regulations. However, since 800,000 people, or 31% of uninsured New Yorkers, fall into the demographic targeted by this plan, legislators are paying attention. Austin Shafran, a spokeman for new Senate majority leader Malcolm A. Smith, is quoted in the Times as saying: “The plan seems like a very legitimate step in the right direction toward improving access to health care. We’re really taking a look at it.”
Sunday, January 18, 2009
safety net as stimulus?
The Kaiser Foundation put out this analysis over a week ago, but it’s still worth posting. It addresses an aspect of the health care safety net that I haven’t heard discussed much in the context of the recent recession: how the spending of these programs can actually bolster the economy. The analysis is a review of 29 studies of 23 states, as well as one national study conducted by Families USA.
The study’s main finding is “Medicaid spending generates economic activity, including jobs, income and state tax revenues, at the state level.” The study finds it does so in two ways: the trickle-down (or “multiplier”) effect, and the Federal Medical Assistant Percentage (FMAP). According to the study, the trickle-down effect varies according to the size of the health care sector in a given state, the extent to which the state relies on Medicaid, and the FMAP for that state, but it is always there. The FMAP is a federal match program in which the federal government provides at least one dollar of federal money for every one dollar of state money spent on Medicaid. It’s determined using a formula that compares the state’s average income to the national average income. The FMAP for Mississippi, the poorest state, is 76%; that is, 76% of the dollars spend on Medicaid in that state come from the federal government. New York’s FMAP is the minimum, 50%.
The authors make the point that the FMAP means Medicaid pulls at least as much money into the state as the state is spending, and, at times, significantly more. For example, if Mississippi were to cut $1 of Medicaid out of its budget, it would lose $4.17 of healthcare spending in that state. Since that $4.17 will no longer be circulating in the state, the state’s economy has lost more by limiting spending than it gained by saving. For every dollar New York cut, it would lose two in spending. This is an important point as legislators look for ways to trim budgets.
Although none of the state-specific studies analyzed are devoted to New York, the national study, conducted by healthcare watchdog group Families USA, does have New York-specific information. Published in April ‘08, the study uses the Regional Input-Output System (RIMS II) to quantify the trickle-down effect of Medicaid cuts proposed by President Bush last year. The study estimated that $1.5 billion in lost federal funding would result in $1.1 billion in lost wages, $3.1 billion in lost business activity, and 25,500 lost jobs for the state.
The study’s main finding is “Medicaid spending generates economic activity, including jobs, income and state tax revenues, at the state level.” The study finds it does so in two ways: the trickle-down (or “multiplier”) effect, and the Federal Medical Assistant Percentage (FMAP). According to the study, the trickle-down effect varies according to the size of the health care sector in a given state, the extent to which the state relies on Medicaid, and the FMAP for that state, but it is always there. The FMAP is a federal match program in which the federal government provides at least one dollar of federal money for every one dollar of state money spent on Medicaid. It’s determined using a formula that compares the state’s average income to the national average income. The FMAP for Mississippi, the poorest state, is 76%; that is, 76% of the dollars spend on Medicaid in that state come from the federal government. New York’s FMAP is the minimum, 50%.
The authors make the point that the FMAP means Medicaid pulls at least as much money into the state as the state is spending, and, at times, significantly more. For example, if Mississippi were to cut $1 of Medicaid out of its budget, it would lose $4.17 of healthcare spending in that state. Since that $4.17 will no longer be circulating in the state, the state’s economy has lost more by limiting spending than it gained by saving. For every dollar New York cut, it would lose two in spending. This is an important point as legislators look for ways to trim budgets.
Although none of the state-specific studies analyzed are devoted to New York, the national study, conducted by healthcare watchdog group Families USA, does have New York-specific information. Published in April ‘08, the study uses the Regional Input-Output System (RIMS II) to quantify the trickle-down effect of Medicaid cuts proposed by President Bush last year. The study estimated that $1.5 billion in lost federal funding would result in $1.1 billion in lost wages, $3.1 billion in lost business activity, and 25,500 lost jobs for the state.
Friday, January 16, 2009
state of the city
Mayor Bloomberg gave his the Sate of the City address this afternoon at Brooklyn College. Understandably, the focus of his speech was on efforts to ameliorate the effects of the suffering economy on the city, and he announced a plan to create 400,000 jobs by 2015.
The Mayor also discussed public safety, certainly a component of public health, at some length. He outlined a three part plan to improve the safety of gun sales in the city (requiring a background check on employees of gun dealers, adding a mental health component to the background check of customers, and using "micro-stamp technology" on all guns sold in New York). He also proposed some measures designed to beef up the city's security: computer technology that could detect suspicious movements from camera footage, integrating the Police and Fire dispatch centers, and training more officers to respond to "simultaneous, multiple attacks."
The only explicit mention of health-related social services was the Mayor's expressed desire to crack down more on Medicaid fraud. However, he also did mentioned a plan to support growth in the medical sector in an effort to diversify the city's economy. Finally, the Mayor proposed opening a Family Justice Center in the Bronx, and develop a database that enables the NYPD to increase its home interventions.
Family Justice Centers are run by the Mayor's Office to Combat Domestic Violence; the offer integrative services (attorney consults, financial advice/aid) for the victims of domestic violence.
The Mayor also discussed public safety, certainly a component of public health, at some length. He outlined a three part plan to improve the safety of gun sales in the city (requiring a background check on employees of gun dealers, adding a mental health component to the background check of customers, and using "micro-stamp technology" on all guns sold in New York). He also proposed some measures designed to beef up the city's security: computer technology that could detect suspicious movements from camera footage, integrating the Police and Fire dispatch centers, and training more officers to respond to "simultaneous, multiple attacks."
The only explicit mention of health-related social services was the Mayor's expressed desire to crack down more on Medicaid fraud. However, he also did mentioned a plan to support growth in the medical sector in an effort to diversify the city's economy. Finally, the Mayor proposed opening a Family Justice Center in the Bronx, and develop a database that enables the NYPD to increase its home interventions.
Family Justice Centers are run by the Mayor's Office to Combat Domestic Violence; the offer integrative services (attorney consults, financial advice/aid) for the victims of domestic violence.
SCHIP passes Senate Finance Committee
The Senate Finance Committee passed a bill to reauthorize and expand the SCHIP (State Children's Health Insurance Program) yesterday. The new bill could add as many as four million children to the program's roster, and adds 31.5 billion dollars to the program over the next four and a half years, the AP/Boston Globe reports
In New York, SCHIP is called "Child Health Plus". To receive SCHIP benefits in the state of New York, a child's care provider can make up to 200% of the federal poverty level (FPL) ($34,340/year) if the child is less than one year old, 133% of the FPL ($22,836/year) if the child is between one and six, and 100% ($17,710/year)of the FPL if the child is between six and 18. In FY2007, New York spent $324 million of federal money on SCHIP. It also contributed about $174.5 million of state money.
SCHIP is a relatively young program (begun in 1997) funded by the federal government but administered by states to ensure health insurance for children; it was mostly designed for the children of families who have modest incomes but are not eligible for Medicaid. In the fall of 2007, President Bush vetoed two bills sent to him by Congress designed to reauthorize and expand SCHIP. In their place, in December 2007, the President authorized an extension of the plan that would maintain the program without expanding it through the end of March 2009.
In New York, SCHIP is called "Child Health Plus". To receive SCHIP benefits in the state of New York, a child's care provider can make up to 200% of the federal poverty level (FPL) ($34,340/year) if the child is less than one year old, 133% of the FPL ($22,836/year) if the child is between one and six, and 100% ($17,710/year)of the FPL if the child is between six and 18. In FY2007, New York spent $324 million of federal money on SCHIP. It also contributed about $174.5 million of state money.
SCHIP is a relatively young program (begun in 1997) funded by the federal government but administered by states to ensure health insurance for children; it was mostly designed for the children of families who have modest incomes but are not eligible for Medicaid. In the fall of 2007, President Bush vetoed two bills sent to him by Congress designed to reauthorize and expand SCHIP. In their place, in December 2007, the President authorized an extension of the plan that would maintain the program without expanding it through the end of March 2009.
Monday, January 12, 2009
mobile HIV testing
NYT today covered moible HIV testing units in Westchester county, which has the highest rate of HIV in the state outside of NYC. The testing uses a specimen obtained from a gum swab and takes about twenty minutes. The vans also offers counseling for anyone who needs it. This type of rapid response testing is the same offered in several EDs throughout NYC.
Sunday, January 11, 2009
Great new graphic
This is a terrific tool to play with if you're interested in health disparities in NYC. It actually covers the entire state, but it's particularly useful for the city.
https://apps.nyhealth.gov/statistics/prevention/quality_indicators/start.map
You plug in a zip code, and they give the demographics of that area (size and population) as well the "hospital admission rate". This is the rate at which people in the area are admitted to hospitals for "preventable conditions": asthma, diabetes, hypertension, congestive heart failure, etc. The idea is that anywhere the hospital admission rate is more than 100%, the admission rates for that area are higher than those statewide. Obviously, there is an intuitive link between higher than average hospital admissions and poor primary/preventative care.
The numbers initially include all the conditions analyzed, but you can disambiguate the data using the drop down menu by the upper right hand corner of the map. I played around with it focusing on diabetes and asthma, and used my zip code in Washington Heights (10033) and a SoHo zip (10013) to get some pretty interesting statistics. Apparently there are health disparities in NYC; who knew?
Interestingly, the Kasier Foundation noted that the highest hospital admissions rates come from rural areas. Their summary, as well as link to an article in the Syracuse Post-Standard:
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=56277
https://apps.nyhealth.gov/statistics/prevention/quality_indicators/start.map
You plug in a zip code, and they give the demographics of that area (size and population) as well the "hospital admission rate". This is the rate at which people in the area are admitted to hospitals for "preventable conditions": asthma, diabetes, hypertension, congestive heart failure, etc. The idea is that anywhere the hospital admission rate is more than 100%, the admission rates for that area are higher than those statewide. Obviously, there is an intuitive link between higher than average hospital admissions and poor primary/preventative care.
The numbers initially include all the conditions analyzed, but you can disambiguate the data using the drop down menu by the upper right hand corner of the map. I played around with it focusing on diabetes and asthma, and used my zip code in Washington Heights (10033) and a SoHo zip (10013) to get some pretty interesting statistics. Apparently there are health disparities in NYC; who knew?
Interestingly, the Kasier Foundation noted that the highest hospital admissions rates come from rural areas. Their summary, as well as link to an article in the Syracuse Post-Standard:
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=56277
Thursday, January 8, 2009
Hello
My first post will be just a quick introduction. I am a registered nurse pursuing a Master's degree in Nursing. My BS in Nursing was my second undergraduate degree; it was a one year accelerated program designed for students who wanted to be nurses but who already had four year degrees in other fields. My BA was in the social sciences, and one of the only two science classes I took in college was nicknamed "Sex" by the student body. (The course guide opted for the more discreet title "The Evolution of Human Nature", but it obviously fooled no one.) So transitioning into classes that actually had right and wrong answers was not easy. However, I was lucky enough to take care of my prereqs quickly, and to begin my nursing degree almost exactly a year after finishing undergad.
I was also lucky enough to get into my first choice nursing school: Columbia University. Its medical campus is centered around Columbia-Presbyterian Hospital, in the Washington Heights area of New York. A year after starting my degree at Columbia, I finished the bachelor's portion of the program and became a registered nurse. Like most people in my class, I moved on immediately to my Master's in Nursing, which, combined with passing the state's nursing boards, will qualify me to practice as a Nurse Practitioner in New York. I will complete my degree in December 2009.
In addition to nursing , I'm interested in public health, particularly in New York and particularly as it pertains to HIV. I intend for this blog to discuss all three subjects, although the ratio is to be determined. To that end, an interesting study recently came out from the New York Department of Health exploring a link between binge drinking and HIV among MSM. You can download the full study at the end of the press release.
I was also lucky enough to get into my first choice nursing school: Columbia University. Its medical campus is centered around Columbia-Presbyterian Hospital, in the Washington Heights area of New York. A year after starting my degree at Columbia, I finished the bachelor's portion of the program and became a registered nurse. Like most people in my class, I moved on immediately to my Master's in Nursing, which, combined with passing the state's nursing boards, will qualify me to practice as a Nurse Practitioner in New York. I will complete my degree in December 2009.
In addition to nursing , I'm interested in public health, particularly in New York and particularly as it pertains to HIV. I intend for this blog to discuss all three subjects, although the ratio is to be determined. To that end, an interesting study recently came out from the New York Department of Health exploring a link between binge drinking and HIV among MSM. You can download the full study at the end of the press release.
Subscribe to:
Posts (Atom)