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    <recommendedItem id="20100101_19_377"
                     title="Advisory Panel Rates Genomic Cancer Tests"
                     score="0.011"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/Medicare/tb/18269?impressionId=1265754288167"
                     
      &lt;p&gt;Some genomic tests aimed at identifying patients most likely to respond to cancer drugs won a thumbs-up from a Medicare advisory panel, but others didn&apos;t make the grade.&lt;/p&gt;
&lt;p&gt;As part of a national coverage determination under way at the Centers for Medicare and Medicaid Services, members of the Medicare Evidence Development &amp;amp; Coverage Advisory Committee (MEDCAC) last week rated the clinical value of several pharmacogenomic cancer tests now available.&lt;/p&gt;
&lt;p&gt;The tests would be used to select patients for treatment with drugs including tamoxifen, irinotecan (Camptosar), trastuzumab (Herceptin), and imatinib (Gleevec).&lt;/p&gt;
&lt;p&gt;CMS has not previously decided whether such tests should be reimbursed by Medicare, although testing is already routine for some of these treatments.&lt;/p&gt;
&lt;p&gt;The FDA-approved labeling for trastuzumab requires such testing. Imatinib&apos;s approvals include chronic myeloid leukemia featuring the BCR-ABL &quot;Philadelphia chromosome&quot; mutation, although the label doesn&apos;t explicitly mention testing.&lt;/p&gt;
&lt;p&gt;&quot;CMS is aware that the body of evidence on the role of pharmacogenomic testing in cancer continues to evolve,&quot; according to the agency&apos;s notice of the meeting.&lt;/p&gt;
&lt;p&gt;&quot;Recognizing the rapid accumulation of such evidence, CMS seeks guidance from the panel to inform future coverage determinations. We want to ensure that Medicare beneficiaries have access to any demonstrated improved health outcomes of pharmacogenomic testing, and are protected from inaccurate or inappropriate pharmacogenomic testing that could compromise therapy or increase the risks of adverse events during therapy.&quot;&lt;/p&gt;
&lt;p&gt;MEDCAC panelists were asked to rate their confidence in the clinical utility of five tests and in the scientific evidence available for review.&lt;/p&gt;
&lt;p&gt;The five tests cover: &lt;ul&gt; &lt;li&gt;Polymorphisms in the CYP2D6 drug-metabolizing enzyme for breast cancer patients who are candidates for tamoxifen&lt;/li&gt; &lt;li&gt;Polymorphisms in the UGT1A1 gene for colon cancer patients considered for irinotecan treatment&lt;/li&gt; &lt;li&gt;Presence of HER/neu epidermal growth factor receptor expression in patients with breast cancer, indicating suitability for trastuzumab&lt;/li&gt; &lt;li&gt;Presence of the BCR-ABL mutation in patients with chronic myeloid leukemia who would be candidates for imatinib&lt;/li&gt; &lt;li&gt;Mutations in the K-ras gene for metastatic colorectal cancer patients eligible for cetuximab (Erbitux) or panitumumab (Vectibix)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The 15 panel members assigned values of one to five, reflecting low to high confidence, to each test. A score of two reflected medium-low confidence, while a four meant medium-high confidence.&lt;/p&gt;
&lt;p&gt;Most of the panelists agreed that the evidence underlying the tests for CYP2D6 and UGT1A1 polymorphisms was still too scant for an assessment of their clinical value. Mean scores for these tests were 2.07 and 1.83, respectively, with nearly all votes either a one or two.&lt;/p&gt;
&lt;p&gt;But MEDCAC members were more confident that the usefulness of the other three tests for diagnostic and monitoring purposes could be evaluated. Mean scores for those tests were all well above four.&lt;/p&gt;
&lt;p&gt;For the HER/neu, BCR-ABL, and K-ras tests, since members believed the evidence was adequate for assessment, MEDCAC also voted on whether their use actually would improve health outcomes in cancer patients.&lt;/p&gt;
&lt;p&gt;A third ranking provided the committee&apos;s views on whether the conclusions could be generalized to the Medicare population and patients in the community.&lt;/p&gt;
&lt;p&gt;Mean scores for those rankings were all also above four, indicating the panel&apos;s support for these tests as clinically beneficial.&lt;/p&gt;
&lt;p&gt;On the other hand, when asked whether there was enough evidence to assess the utility of the BCR-ABL test in detecting treatment failure, panelists didn&apos;t think so. Most of those votes were twos, and the mean was 2.47.&lt;/p&gt;
&lt;p&gt;CMS has not given a time line for deciding whether to approve Medicare coverage for the tests.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_425"
                     title="AAN: Industrial Cleaner Again Tied to Parkinson Risk (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAN/tb/18338?impressionId=1265754288167"
                     
      TORONTO  --  The degreasing agent trichloroethylene (TCE) has been linked to increased rates of Parkinson&apos;s disease among industrial workers in yet another study, this time involving a large, well-studied group of World War II veterans.&lt;br&gt;
&lt;br&gt;Parkinson&apos;s disease developed in individuals with occupational exposure to TCE at more than five times the rate seen in those without such exposure (odds ratio 5.5, 95% CI 1.02 to 30), reported Samuel Goldman, MD, of the Parkinson&apos;s Institute in Sunnyvale, Calif.&lt;br&gt;
&lt;br&gt;Goldman described the research in a phone interview with &lt;em&gt;MedPage Today&lt;/em&gt;. It&apos;s scheduled for presentation here in April at the American Academy of Neurology&apos;s annual meeting.&lt;br&gt;
&lt;br&gt;A previous study in 2008 had fingered TCE as the most likely culprit behind a cluster of Parkinson&apos;s disease cases afflicting workers at a single industrial plant. (See &lt;a href=&quot;http://www.medpagetoday.com/Geriatrics/ParkinsonsDisease/7894&quot; mce_href=&quot;http://www.medpagetoday.com/Geriatrics/ParkinsonsDisease/7894&quot; target=&quot;_blank&quot;&gt;Trichloroethylene Implicated as Risk for Parkinsonism&lt;/a&gt;)&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Also, Goldman said, animal studies have found that TCE is selectively toxic to nigral dopaminergic neurons, the same type of nerve cell that progressively dies off in Parkinson&apos;s disease. He said the chemical&apos;s activity in rodent brains is very similar to that of MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), a dopaminergic neurotoxin commonly used to simulate Parkinson&apos;s disease in preclinical research.&lt;/p&gt;
&lt;p&gt;Goldman said the new study was the first population-based analysis to link TCE to the disease.&lt;/p&gt;
&lt;p&gt;It focused on 198 twin pairs in the National Academy of Sciences-National Research Council&apos;s World War II Twins Cohort, which comprises some 16,000 twin pairs overall.&lt;/p&gt;
&lt;p&gt;Members of the all-male cohort, who were born from 1917 to 1927 and served in the war, have been followed since the 1960s. Occupational histories for participants are available along with medical records from the VA healthcare system.&lt;/p&gt;
&lt;p&gt;In those pairs chosen for the current study, records showed that one twin had developed Parkinson&apos;s disease and the other had not. This design largely eliminates genetics as a confounding factor in the analysis.&lt;/p&gt;
&lt;p&gt;Goldman explained that occupational histories for each participant were reviewed by a blinded industrial hygienist and a preventive medicine physician to identify likely exposures to TCE and four other industrial chemicals: xylene, toluene, carbon tetrachloride, and tetrachloroethylene.&lt;/p&gt;
&lt;p&gt;As a single source of exposure, only TCE was significantly associated with development of Parkinson&apos;s disease, Goldman said.&lt;/p&gt;
&lt;p&gt;People working as aircraft mechanics, machinists, plumbers, and electricians likely had regular exposure to TCE, Goldman said. The chemical was commonly used as a &quot;spot&quot; cleaner to remove grease and oils from metal surfaces. It was also used for a time as a dry cleaning solvent, although tetrachloroethylene was more common for that purpose.&lt;/p&gt;
&lt;p&gt;Goldman said no increased risk was seen with xylene or toluene, but there were near-significant trends toward increased Parkinson&apos;s disease risk from carbon tetrachloride and tetrachloroethylene: &lt;ul&gt; &lt;li&gt;Carbon tetrachloride: OR 2.8 (95% CI 0.97 to 7.8)&lt;/li&gt; &lt;li&gt;Tetrachloroethylene: OR 9.0 (95% CI 0.78 to 103)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Twins exposed to either TCE or tetrachloroethylene were at significantly increased risk, with an odds ratio of 8.1 (95% CI 1.43 to 43) relative to individuals with no exposure to either chemical.&lt;/p&gt;
&lt;p&gt;Goldman said the analysis also examined whether duration of exposure was associated with increased risk. He said the results were in the same pattern as for the yes-no exposure analysis, but the findings were very uncertain because of the relatively small sample size.&lt;/p&gt;
&lt;p&gt;Occupational histories were available for only 99 of the 198 discordant twin pairs and some of the information was obtained by proxy rather than from the participant himself.&lt;/p&gt;
&lt;p&gt;Because of the wide confidence intervals even for the yes-no exposure analysis, the findings need confirmation in a larger study, he said, noting that the best approach would be a cohort study involving people with known, long-term exposure to TCE, compared with well-chosen controls.&lt;/p&gt;
&lt;p&gt;&quot;The study wouldn&apos;t have to be large,&quot; Goldman said. He estimated that 1,000 to 2,000 participants would be adequate to determine if the connection to Parkinson&apos;s disease is real.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Institute of Neurological Disorders and Stroke, the Valley Foundation, and the James and Sharron Clark Family Fund.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_423"
                     title="Week 31: Baucus Quotes Gandhi; Obama Wants $80 Billion HHS Boost"
                     score="0.011"
                     href="http://www.medpagetoday.com/Washington-Watch/Reform/tb/18337?impressionId=1265754288167"
                     
      &lt;p&gt;WASHINGTON  --  Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, likes to start hearings with a quote from a famous leader. This week, he quoted Mahatma Gandhi.&lt;/p&gt;
&lt;p&gt;&quot;Every worthwhile accomplishment . . . has its stages of drudgery and triumph; a beginning, a struggle, and a victory,&quot; said Baucus, who has been an integral part of the negotiations that stalled last month with Congress apparently just weeks away from passing a healthcare reform bill.&lt;/p&gt;
&lt;p&gt;The effort to enact healthcare reform &quot;has certainly seen its struggles,&quot; Baucus said. But he said he agrees with President Barack Obama, who urged Congress during his State of the Union address not to give up on passing comprehensive reform.&lt;/p&gt;
&lt;p&gt;&quot;We have gone well past this effort&apos;s beginning,&quot; Baucus said. &quot;We have endured our share of struggle. Now let us at last bring this bill to victory.&quot;&lt;/p&gt;
&lt;p&gt;Since the election to the U.S. Senate of Massachusetts Republican Scott Brown  --  a vocal opponent of healthcare reform  --  and the president&apos;s State of the Union message, which focused strongly on job creation and improving the economy, healthcare reform has been moved to a back burner.&lt;/p&gt;
&lt;p&gt;But &quot;I&apos;m very confident we&apos;re going to pass healthcare reform this year,&quot; Baucus said during Wednesday&apos;s hearing.&lt;/p&gt;
&lt;p&gt;Obama also urged Congress again not to give up on a bill when he spoke to Democrats at a question-and-answer session on Thursday.&lt;/p&gt;
&lt;p&gt;&quot;All that&apos;s changed in the last two weeks is that our party&apos;s gone from having the largest majority in a generation to having the second-largest majority in a generation,&quot; Obama said. &quot;We&apos;ve got to remember that.&quot;&lt;/p&gt;
&lt;p&gt;Although Baucus used most of his speaking time talking about healthcare reform, the purpose of this week&apos;s hearing was to question Department of Health and Human Services secretary Kathleen Sebelius about the $80 billion increase in funding for HHS requested in the &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/18248&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/18248&quot; target=&quot;_blank&quot; title=&quot;Obama&amp;#8200;Requests&amp;#8200;$80&amp;#8200;Billion&amp;#8200;Increase&amp;#8200;in&amp;#8200;Healthcare&amp;#8200;Funding&quot;&gt;president&apos;s 2011 budget&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;Under Obama&apos;s blueprint, HHS would receive $911 billion in 2011, most of which would be Medicare and Medicaid spending. But the National Institutes of Health (NIH) would also get a $1 billion boost for medical research, and there would be money for improving food, drug, and device safety, and to intensify efforts to help Americans quit smoking and get healthy.&lt;/p&gt;
&lt;p&gt;The President&apos;s budget doesn&apos;t make any provisions for healthcare reform should it be enacted.&lt;/p&gt;
&lt;p&gt;Healthcare spending now accounts for 17.3% of the nation&apos;s total spending, according to &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18302&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18302&quot; target=&quot;_blank&quot; title=&quot;In&amp;#8200;Bad&amp;#8200;Economy,&amp;#8200;Record&amp;#8200;Growth&amp;#8200;in&amp;#8200;Health&amp;#8200;Spending&quot;&gt;new data&lt;/a&gt; released by the Centers for Medicare and Medicaid Services.&lt;/p&gt;
&lt;p&gt;The recession of 2009, coupled with growing use of medical services, led to the fastest one-year growth in health spending since the 1960s, according to the CMS report.&lt;/p&gt;
&lt;p&gt;By 2019, national health spending is projected to reach $4.5 trillion and account for about 19% of gross domestic product (GDP), according to the report.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_399"
                     title="In Bad Economy, Record Growth in Health Spending"
                     score="0.01"
                     href="http://www.medpagetoday.com/Washington-Watch/Washington-Watch/tb/18302?impressionId=1265754288167"
                     
      &lt;p&gt;WASHINGTON  --  The recession of 2009, coupled with growing use of medical services, led to the fastest one-year growth in health spending since at least the 1960s, according to a report by the Centers for Medicare &amp;amp; Medicaid Services (CMS).&lt;/p&gt;
&lt;p&gt;In 2009, national health spending grew 5.7% to reach $2.5 trillion, according to preliminary estimates from CMS actuaries and economists published in &lt;em&gt;Health Affairs.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;That $2.5 trillion accounts for 17.3% of total GDP, which declined by 1% in 2009. In 2008, healthcare spending accounted for 16.2% of the GDP.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;By 2019, national health spending will reach $4.5 trillion and account for about 19% of the gross domestic product (GDP), according to the report.&lt;/p&gt;
&lt;p&gt;National heath expenditures have grown faster than the GDP for years. But in 2009, the bad economy, job losses, an increasing Medicaid population, and more people seeing a doctor powered the unprecedented growth.&lt;/p&gt;
&lt;p&gt;While the 2009 numbers are preliminary, the authors singled out job losses that resulted in more people qualifying for Medicaid. Spending on Medicaid grew by nearly 10% in 2009, twice as fast as the year before.&lt;/p&gt;
&lt;p&gt;Another spending growth driver: More people utilized healthcare services in 2009, in part because so many sought H1N1 pandemic flu vaccinations.&lt;/p&gt;
&lt;p&gt;Utilization of medical services grew at a rate of 1.5% in 2009, compared with just a 0.9% growth rate in 2009. That translated into growth in spending on physician and clinical services as well: up 6.3% compared with 5% growth in 2008.&lt;/p&gt;
&lt;p&gt;The report also found: &lt;ul&gt; &lt;li&gt;Hospital spending increased 5.9 percent in 2009 compared with 4.5 percent in 2008, and reached $760.6 billion.&lt;/li&gt; &lt;li&gt;Spending on prescription drugs reached $246 billion, up by 5.2% compared with growth of 3.2% the previous year. &lt;/li&gt; &lt;li&gt;Government spending on healthcare in 2009 outpaced private insurance company spending, despite subsidies in the stimulus bill that allowed recently laid-off workers keep their private health insurance plans through COBRA. The number of people with private insurance plans declined by 1% in 2009. &lt;/li&gt; &lt;li&gt;Growth in out-of-pocket spending slowed in 2009, which the study authors attribute to the recession. &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The good news is the economy is expected to grow in 2010, and analysts predict the growth rates in healthcare to be closer to the growth in GDP. Health spending is expected to decelerate to a growth of less than 4%, while GDP is anticipated to rebound to a 4% growth rate.&lt;/p&gt;
&lt;p&gt;However, that assessment may not be accurate because the estimate is based on a 21% cut in Medicare payments to physicians. Those cuts are slated to go into effect on March 1, but Congress is expected to vote at the last minute to stall the cuts  --  as it does every year.&lt;/p&gt;
&lt;p&gt;If Medicare payments for physicians hold steady  --  &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18094&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18094&quot; target=&quot;_blank&quot; title=&quot;AMA&amp;#8200;Pushes&amp;#8200;for&amp;#8200;Permanent&amp;#8200;Doctor&amp;#8200;Pay&amp;#8200;Fix&quot;&gt;either by Congress voting to put the cuts on hold for the next decade, or by voting to overhaul the sustainable growth rate (SGR&lt;/a&gt;)  --  healthcare spending would grow at a rate of about 4.7% in 2010.&lt;/p&gt;
&lt;p&gt;The authors point out the difficulty of forecasting future spending levels in the midst of a recession.&lt;/p&gt;
&lt;p&gt;&quot;How quickly economic growth rebounds, and to what extent, will affect the growth of healthcare spending over the next decade,&quot; the authors said.&lt;/p&gt;
&lt;p&gt;In addition, if a healthcare reform bill ultimately passes, new projections would have to be issued.&lt;/p&gt;
&lt;p&gt;&quot;Should such legislation ultimately be signed into law, there would undoubtedly be many changes in healthcare delivery and financing,&quot; they said.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_309"
                     title="Increasing Copays: Penny-Wise but Pound-Foolish? (CME/CE)"
                     score="0.007"
                     href="http://www.medpagetoday.com/Geriatrics/GeneralGeriatrics/tb/18173?impressionId=1265754288167"
                     
      &lt;p&gt;Raising seniors&apos; copayments for ambulatory care to offset increasing healthcare costs may backfire on insurers, researchers asserted.&lt;/p&gt;
&lt;p&gt;Seniors enrolled in Medicare plans that increased copayments had significantly fewer outpatient visits but spent more time in the hospital than patients in plans that left copayments untouched, according to Amal Trivedi, MD, MPH, of Brown University in Providence, R.I., and colleagues.&lt;/p&gt;
&lt;p&gt;Assuming an average reimbursement of $60 for an outpatient visit, seven annual visits per enrollee, and an average copay increase of $8.50 per visit, a plan should save $7,150 for every 100 enrollees, they noted in the Jan. 28 &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;But, assuming an average cost of $11,065 per hospitalization of a person 65 to 84, the researchers estimated that the costs for inpatient care would actually increase by $24,000 for every 100 enrollees in the year after copays are increased.&lt;/p&gt;
&lt;p&gt;Even using more conservative criteria, the increased costs for inpatient care would nearly double any savings from increasing copays, they argued.&lt;/p&gt;
&lt;p&gt;&quot;Cost-sharing has generally been thought to reduce total healthcare spending without harming health for the average person,&quot; the researchers wrote, but these results suggest increasing copays in Medicare beneficiaries &quot;may be a particularly ill-advised cost-containment strategy.&quot;&lt;/p&gt;
&lt;p&gt;Increasing copayments may be particularly harmful to older patients, they said, because they have lower incomes and are more likely to have poor health and greater out-of-pocket healthcare expenses than younger patients.&lt;/p&gt;
&lt;p&gt;To explore the issue in a Medicare population, Trivedi and colleagues compared the use of outpatient and inpatient care between enrollees in 18 plans that increased copays for ambulatory care and 18 that did not. The study included 899,060 patients.&lt;/p&gt;
&lt;p&gt;According to data from the Medicare Healthcare Effectiveness Data and Information Set from the Centers for Medicare and Medicaid Services, mean copays increased during the study period for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05) in the case plans.&lt;/p&gt;
&lt;p&gt;Mean copays remained stable at $8.33 and $11.38 for primary and specialty care, respectively, in the control plans.&lt;/p&gt;
&lt;p&gt;In both groups, there were increases in the number of ambulatory visits over time, but the increase was smaller in the plans that raised copays.&lt;/p&gt;
&lt;p&gt;There was also a rise in the number of hospitalizations, the proportion of patients who were hospitalized, and the length of time spent in the hospital in both groups, but there were larger increases in the plans that increased copays.&lt;/p&gt;
&lt;p&gt;Compared with the control plans, in the year after the increase in copays, case plans had: &lt;ul&gt; &lt;li&gt;19.8 fewer annual outpatient visits per 100 enrollees (95% CI 16.6 to 23.1)&lt;/li&gt; &lt;li&gt;2.2 additional annual hospital admissions per 100 enrollees (95% CI 1.8 to 2.6)&lt;/li&gt; &lt;li&gt;13.4 more annual inpatient days per 100 enrollees (95% CI 10.2 to 16.6)&lt;/li&gt; &lt;li&gt;A 0.7% increase in the proportion of enrollees who were hospitalized (95% CI 0.51% to 0.95%)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The findings were amplified among enrollees living in areas of lower income and education, black patients, and those who had hypertension, diabetes, or a history of myocardial infarction.&lt;/p&gt;
&lt;p&gt;Trivedi and colleagues noted some limitations of the analysis: it was not randomized, and unmeasured differences could have influenced the results.&lt;/p&gt;
&lt;p&gt;Also, the case and control plans could not be matched in a geographic area smaller than census region because of the small number of Medicare plans, and data were lacking on diagnoses, procedures, and costs associated with hospital admissions and outpatient visits.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Trivedi is the recipient of a Pfizer Health Policy Scholars Award and a career development award from the Veterans Affairs Health Services Research and Development Services.&lt;/p&gt;&lt;p&gt;The authors reported no relevant conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
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