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US study raises questions about HMO quality of care
THE LANCET
POLICY AND PEOPLE
US budget cut may end CDC gun-violence research
T
he National Rifle Association’s 2-year quest to end what it calls biased research into gun-related violence and firearms injuries funded by the US Centers for Disease Control and Prevention has apparently ended in success. As the result of the spending bill signed into law by President Clinton on Sept 30 that will fund CDC and the rest of the Department of Health and Human Services for the fiscal year that began on Oct 1, “whether or not we can find the funds to continue the research remains to be seen”, said a CDC spokeswoman. In 1995, the NRA, the leading US gun organisation, tried and failed to eliminate the budget for CDC’s entire Injury Control programme, which has funded numerous studies published in peer-reviewed journals linking violence to the legal posses-
sion of firearms. But in 1996, the NRA took a different tack, focusing specifically on the firearms research itself. As passed by the House in July, the spending bill that funds CDC docked the Injury Control Center’s US$43 million budget by $2·6 million—similar to the amount spent on the research. The bill also stipulated that the CDC not use any of its funding “to advocate or promote gun control” (see Lancet July 20, p 190). After deliberations with both the Senate and the White House, the $2·6 million was restored in the final spending bill, leaving the injury programme with the same amount of
funding it received last year. But negotiators stipulated that the restored money be used for research into and education on how to prevent traumatic brain injury. Since so much of the Injury Control budget is already committed to other projects, said the spokeswoman, the lack of funding could end the research. A spokesman for the NRA confirmed that was just what his organisation wanted. “Congress wanted them to stop doing biased political research on the firearms issue”, he said. Julie Rovner
US study raises questions about HMO quality of care
W
hether the chronically ill or poor person fares worse under managed care is a hot topic of debate in the USA. Although a new study could add fuel to the debate, it also underscores the challenge of assessing quality of care—particularly when based on data collected nearly a decade ago. A 4-year analysis comparing physical and mental-health outcomes of chronically ill adults in three cities found that elderly and poor patients receiving care in health maintenance organisations “had worse” physical outcomes than those treated by fee-for-service doctors (JAMA 1996; 276: 1039–47). Study authors from the New
England Medical Center, Tufts University School of Medicine, and the Harvard School of Public Health followed 2235 patients aged 18–97 with hypertension, noninsulin-dependent diabetes mellitus, acute myocardial infarction, congestive heart failure, and depression. The study found that a decline in physical health in elderly patients was more common in HMOs (54%) than in fee-for-service plans (28%). The gaps in health status were wider for the elderly and poor as well—68% of HMO patients had ill health compared with 27% of similar fee-forservice patients. The authors say the findings make clear that managed care poses greater risks for
vulnerable subgroups but critics question the methods used. The American Association of Health Plans, which represents the managed-care industry, complains that the study focuses on one measure that looks at whether or not patients believed that their health improved, stayed the same, or worsened. Looking at functional status—rather than clinical outcomes—could slant the result, critics argue. Although the study does not address the reason for the differences, some argue that it could be less hospital care, less access to specialists, or a longer time awaiting treatment. Janet Firshein
Congress moves to restrict medical-procedure patents
C
ongress has not outlawed patents for medical procedures, but it has taken a step in that direction. A part of the massive spending bill signed on Sept 30 stipulates that holders of medical-procedure patents will no longer have recourse against medical professionals who use these procedures for patient care. At the behest of Representative Greg Ganske (Republican, Iowa), a physician, the US House voted in July to bar new procedure patents for a year (see Lancet, Aug 3, p 329),
Vol 348 • October 12, 1996
rousing the ire of the pharmaceutical and biotechnology industries. A spokesman for the Biotechnology Industry Organisation said up to onethird of biotech patents could have been affected—including most relating to gene therapy. “It would have been the patent lawyer full employment act”, said David Schmickel, the organisation’s patent counsel. The compromise left the patents legal but ensures that they need not inhibit what the American Medical Association (which deems the patents
unethical) calls “the free flow of ideas in medicine”. Thus, medical professionals are free to use new procedures without fear of financial or legal repercussions. Among those most pleased are ophthalmic surgeons and a joint statement issued by ophthalmic specialty organisations hailed the new law as furthering the “Hippocratic obligation that physicians be teachers and freely share their medical knowledge.” Julie Rovner
1025
POLICY AND PEOPLE
US budget cut may end CDC gun-violence research
T
he National Rifle Association’s 2-year quest to end what it calls biased research into gun-related violence and firearms injuries funded by the US Centers for Disease Control and Prevention has apparently ended in success. As the result of the spending bill signed into law by President Clinton on Sept 30 that will fund CDC and the rest of the Department of Health and Human Services for the fiscal year that began on Oct 1, “whether or not we can find the funds to continue the research remains to be seen”, said a CDC spokeswoman. In 1995, the NRA, the leading US gun organisation, tried and failed to eliminate the budget for CDC’s entire Injury Control programme, which has funded numerous studies published in peer-reviewed journals linking violence to the legal posses-
sion of firearms. But in 1996, the NRA took a different tack, focusing specifically on the firearms research itself. As passed by the House in July, the spending bill that funds CDC docked the Injury Control Center’s US$43 million budget by $2·6 million—similar to the amount spent on the research. The bill also stipulated that the CDC not use any of its funding “to advocate or promote gun control” (see Lancet July 20, p 190). After deliberations with both the Senate and the White House, the $2·6 million was restored in the final spending bill, leaving the injury programme with the same amount of
funding it received last year. But negotiators stipulated that the restored money be used for research into and education on how to prevent traumatic brain injury. Since so much of the Injury Control budget is already committed to other projects, said the spokeswoman, the lack of funding could end the research. A spokesman for the NRA confirmed that was just what his organisation wanted. “Congress wanted them to stop doing biased political research on the firearms issue”, he said. Julie Rovner
US study raises questions about HMO quality of care
W
hether the chronically ill or poor person fares worse under managed care is a hot topic of debate in the USA. Although a new study could add fuel to the debate, it also underscores the challenge of assessing quality of care—particularly when based on data collected nearly a decade ago. A 4-year analysis comparing physical and mental-health outcomes of chronically ill adults in three cities found that elderly and poor patients receiving care in health maintenance organisations “had worse” physical outcomes than those treated by fee-for-service doctors (JAMA 1996; 276: 1039–47). Study authors from the New
England Medical Center, Tufts University School of Medicine, and the Harvard School of Public Health followed 2235 patients aged 18–97 with hypertension, noninsulin-dependent diabetes mellitus, acute myocardial infarction, congestive heart failure, and depression. The study found that a decline in physical health in elderly patients was more common in HMOs (54%) than in fee-for-service plans (28%). The gaps in health status were wider for the elderly and poor as well—68% of HMO patients had ill health compared with 27% of similar fee-forservice patients. The authors say the findings make clear that managed care poses greater risks for
vulnerable subgroups but critics question the methods used. The American Association of Health Plans, which represents the managed-care industry, complains that the study focuses on one measure that looks at whether or not patients believed that their health improved, stayed the same, or worsened. Looking at functional status—rather than clinical outcomes—could slant the result, critics argue. Although the study does not address the reason for the differences, some argue that it could be less hospital care, less access to specialists, or a longer time awaiting treatment. Janet Firshein
Congress moves to restrict medical-procedure patents
C
ongress has not outlawed patents for medical procedures, but it has taken a step in that direction. A part of the massive spending bill signed on Sept 30 stipulates that holders of medical-procedure patents will no longer have recourse against medical professionals who use these procedures for patient care. At the behest of Representative Greg Ganske (Republican, Iowa), a physician, the US House voted in July to bar new procedure patents for a year (see Lancet, Aug 3, p 329),
Vol 348 • October 12, 1996
rousing the ire of the pharmaceutical and biotechnology industries. A spokesman for the Biotechnology Industry Organisation said up to onethird of biotech patents could have been affected—including most relating to gene therapy. “It would have been the patent lawyer full employment act”, said David Schmickel, the organisation’s patent counsel. The compromise left the patents legal but ensures that they need not inhibit what the American Medical Association (which deems the patents
unethical) calls “the free flow of ideas in medicine”. Thus, medical professionals are free to use new procedures without fear of financial or legal repercussions. Among those most pleased are ophthalmic surgeons and a joint statement issued by ophthalmic specialty organisations hailed the new law as furthering the “Hippocratic obligation that physicians be teachers and freely share their medical knowledge.” Julie Rovner
1025