About two-thirds (66.8%) of primary care physicians (PCPs) in the United States have difficulty obtaining outpatient mental health services for their patients-a rate more than twice as high as rates for other services-according to study findings published online April 9 in Health Affairs. The study was conducted by Peter J. Cunningham, PhD, senior fellow at the Center for Studying Health System Change (HSC), Washington, DC, and funded by the Commonwealth Fund.

A proposal for a pilot project to save money for a health plan was developed collaboratively with a clinic manager and the medical director of a local clinic. The goal was to encourage and support physicians in changing the proton pump inhibitor (PPI) medication prescribed for patients from a brand-name PPI to omeprazole, a more cost-effective generic option. The health plan identified members who had filled a prescription for a brand-name PPI and asked their physicians to consider switching the patients’ therapy to omeprazole. If the physician agreed to the change, the clinic would then send a letter to the patient, in which the physician recommended the change along with a new prescription for omeprazole. Following successful implementation in the initial pilot clinic, the program was extended to 4 more clinics. After achieving significant cost savings at all 5 clinics, the health plan is now expanding the program to more clinics as well as considering launching similar programs targeting other medication classes. (Drug Benefit Trends. 2009;21:158-163)

Health insurers, pharmaceutical manufacturers, and other major players in the US health care industry have promised that they will help stem the rate at which costs are rising by looking for ways to slice outlays by $2 trillion during the next decade. At a May 11 meeting with industry leaders, President Obama called the pledge “a watershed event.”

Health plans are increasingly shifting costs to plan members to share the burden of rising health care costs. A survey of the published literature and conference presentations was conducted to examine the contributors and burden of out-of-pocket costs (OPCs) for persons with diagnosed cancer. This review indicates that the OPCs for cancer patients covered by health plans are increasing and becoming a financial burden that may be exacerbated by a concomitant loss of income. Furthermore, caregivers also acquire certain costs in the care of patients, such as loss of income or prospects for career advancement. The trend toward cost shifting may also have a negative impact on patient care. Further study of this issue is warranted and should include a complete analysis of all patient costs to gauge the full impact on the quality of medical care. Health plans need to evaluate whether pursuing cost-shifting strategies is in the best interests of both patients and health plans over the long term. (Drug Benefit Trends. 2009;21:145-153)

US adults with lower levels of education have worse health on average, while those with more education are likely to be in better health (Cover Figure). Nearly half (45.2%) of US adults aged 25 to 74 years described themselves as being in less than very good health, with level of health directly correlated with education level attained, according to findings of Reaching America’s Health Potential Among Adults: A State-by-State Look at Adult Health, a survey released in May by the Robert Wood Johnson Foundation Commission to Build a Healthier America. The relationship between lower levels of education and poorer health was consistent for all ethnic and racial groups (Figure).

An increase in the rate of celiac disease (CD) diagnosis resulted in a significant reduction in direct medical costs and utilization of health care services, according to a team of researchers led by Peter H. R. Green, MD, professor of clinical medicine and director of the Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York. CD occurs in genetically predisposed persons because of an immune response to gluten, the protein component of wheat, rye, and barley, and affects about 1% of the US population; however, CD goes undiagnosed in many persons. Study findings were published in the December 2008 issue of the Journal of Insurance Medicine.An increase in the rate of celiac disease (CD) diagnosis resulted in a significant reduction in direct medical costs and utilization of health care services, according to a team of researchers led by Peter H. R. Green, MD, professor of clinical medicine and director of the Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York. CD occurs in genetically predisposed persons because of an immune response to gluten, the protein component of wheat, rye, and barley, and affects about 1% of the US population; however, CD goes undiagnosed in many persons. Study findings were published in the December 2008 issue of the Journal of Insurance Medicine.Using claims, encounter, and eligibility data of about 10.2 million enrollees in US managed care plans between January 1999 and December 2003, the researchers compared direct medical costs and use of selected health care services among 4 cohorts. The team identified 525 persons 62 years and younger who received a new diagnosis of CD, were continuously enrolled in the managed care health plan during the 12 months before diagnosis, and were not eligible for Medicare during the 3-year follow-up period. Three control groups were also identified: persons without a CD diagnosis but who exhibited 1 (cohort 1, N = 1109), 2 (cohort 2, N = 1038), or 3 or more (cohort 3, N = 980) systemic, GI, or nutritional manifestations of symptoms associated with CD.The researchers found that the direct medical costs of the CD-diagnosed cohort changed dramatically during the period. Overall, the mean medical cost per member per year (PMPY) increased from $8502 in the 12-month pre-diagnosis period to $12,024 in the 12-month post-diagnosis period, then decreased to $7133 and $7854 in the 24-month and 36-month post-diagnosis periods, respectively (Figure). The team attributed the rise in PMPY costs during the first post-diagnosis period primarily to an increase in facility inpatient care. The study authors suggested that a decline in facility inpatient and emergency department utilization resulted in the cost savings realized during the 24-month and 36-month post-diagnosis periods.

After reading your February, March, and April editorials, I would like to share the following thoughts concerning health care reform from the perspective of a pharmacist practicing for 32 years.

For all the (justified) apprehension about health care reform, the current momentum offers a rare opportunity to reorient the health care system around health and wellness. One of President Obama’s 8 principles for health care legislation is that it must invest in prevention and wellness. Education is needed on how to eat healthy and maintain wellness through disease prevention and early detection, with such efforts supported by physicians, health plans, employers, and the government. Changes are also needed in health plan design and physician education to support a new prevention/wellness paradigm. Possible areas of focus include:

It was the best of times, it was the worst of times.

I read with interest Dr Gregory Rutecki’s Top Papers Of The Month feature, “Treat Dementia in Elderly Patients With Caution” (CONSULTANT, January 2009, page 60). Elderly patients who live at home and those in long-term–care facilities often pose management challenges, whether they have evident Alzheimer disease or other diagnoses. While I am not in favor of bad medicine, consideration should be given to treating agitated, violent, and apparently angry and hostile persons with what works. I do not favor quieting noisy patients with drugs.

It results from reactivation of latent varicella-zoster virus (VZV) within the

This lesion had appeared in the right groin of a 60-year old man and had slowly enlarged over a month (A). Two years before this evaluation, he had undergone total prostatectomy with lymph node dissection for prostate carcinoma. Metastatic disease was found in a resected lymph node, and he underwent multiagent chemotherapy.

The patient is a 54-year-old man, a native of Poland who has lived in the United States for many years. A diagnosis of AIDS was made in 1994, when Hodgkin disease (nodular sclerosing Hodgkin lymphoma) was found in an enlarged cervical lymph node and he tested positive for HIV during his workup.

The 1990s were an exciting decade for the treatment of chronic kidney disease (CKD). The addition of angiotensin-converting enzyme inhibitors (ACEIs) and then angiotensin receptor blockers to the antihypertensive armamentarium helped preserve renal function and decrease proteinuria in patients with CKD.

In a recent AIDS Reader editorial, Joel E. Gallant called for clinicians who treat persons with HIV/AIDS to “become vocal advocates for routine HIV screening,

More Listings

Alzheimer disease (AD) is more than twice as likely to develop in elderly persons with orthostatic hypotension (OH) as in those without OH, according to a new study presented at the Annual Meeting of the American Academy of Neurology.

An 88-year-old man who had left hip repair after a fracture a few months earlier is now admitted to behavioral hospital because of implacable refusal to take medications, and because of poor food intake and ongoing refusal of rehabilitation. Ambulated with a walker before fracture but now barely ventures out of wheelchair even with rolling walker and therapist guidance.

How often has this happened to you? You are searching online for the answer to a clinical question, and you find what looks like a promising article. But when you try to access the article on the journal’s Web site, a message pops up stating that a subscription or payment is required.

It seems that every mother operates from a standardplaybook.