- Email: [email protected]
Concerns Raised About Medicaid Drug Rebates to States
Gastroenterology News continued
that do not differentiate their fellowship positions into basic science and clinical science. If a program differentiates their research positions, they would designate them as basic science (no. 1 above) or clinical investigator (no. 2 above). Applicants may apply for one or more tracks in any given program(s). Programs that offer more than one track will have the option to have the research positions filled first, and in the order they choose. If unfilled, the research positions can revert, or change, to clinical track positions and be filled with clinical track applicants. In a similar fashion, applicants can apply for research positions, and if not matched, have the option to revert, or change, to a clinical track position. All matching between programs and applicants, including any reversions of positions, occurs during approximately 5 minutes of running time on the computer. Programs that offer a single track will not go through this stepwise reversion process. Overall, how a program categorizes its positions is
between the program and the applicants. This is part of the customized matching process that is available at NRMP. Programs list applicants’ names for, and applicants apply to, individual fellowship categories/positions at the time the rank order list is submitted and before the computerized matching program is actually run. Such a multiple option match offers greater flexibility for all programs and applicants. The Match establishes a uniform date for appointments to GI fellowships, encourages applicants and programs to consider all options before making commitments, and offers programs the greatest access to the applicant pool. It mitigates premature offers and applicants reneging on accepted positions. The Match levels the playing field and creates an impartial venue for matching programs and applicant preferences. It encourages movement and a more dynamic training experience for applicants seeking fellowship positions outside of where they trained during their residency. All of us in-
volved in GI fellowship training are delighted that the Match has returned for our programs and our applicants. For more information, please contact [email protected], or (301) 9412624.
Concerns Raised About Medicaid Drug Rebates to States
vices (CMS) for failing to monitor drug price data reported by drug makers, or ensuring that manufacturers provide adequate rebates to state Medicaid agencies, as required by law. To help control Medicaid spending on drugs, states receive rebates from pharmaceutical manufacturers through the Medicaid drug rebate program. Rebates are based on 2 prices – best price and average manufacturer price (AMP). Both reflect manufacturers’ prices to various entities, which include financial concessions and discounts. “In administering the program, CMS conducts only limited checks for reporting errors in . . . drug prices,” the GAO report noted. “There was considerable variation in the methods that manufacturers
used to determine best price and average manufacturer price, and some methods could have reduced the rebates state Medicaid programs received.” The report faulted the rebate program in particular because “[it] does not clearly address . . . manufacturer, payments that are negotiated by pharmacy benefit managers on behalf of third party payers.” The report notes that in determining best price and AMP, some manufacturers combined price reductions associated with particular sales, while others accounted for reductions separately. Separate treatment of the reductions resulted in rebates to states that were in some cases lower than they would have been had the reductions been considered together. Moreover, “some manufacturers made assumptions
A
larms have been sounded by Congressional watchdogs at the Government Accountability Office (GAO) regarding the prices paid jointly by federal and state governments for prescription drugs for lowincome Americans under the Medicaid program. In a recent report, the GAO concluded that lax oversight by federal health officials is helping fuel the Medicaid funding crisis by allowing U.S. and state governments to pay too much for those medicines. The agency asserted that “inadequate oversight” is allowing drug manufacturers to avoid a law that requires them to provide discounts to Medicaid. The investigators fault the Centers for Medicare and Medicaid Ser-
Deborah D. Proctor, MD Chair, AGA Match Ad Hoc Task Force Chair, AGA Training Subcommittee, Education and Training Committee Yale University School of Medicine
References 1. Niederle M, Roth AE. The gastroenterology fellowship match: how it failed, and why it could succeed once again. Gastroenterology 2004;127:658 – 666. 2. Lim JK, Shah SB. Restoring a gastroenterology fellowship match: a trainee perspective. Am J Gastroenterol 2004;99:1412– 1414. 3. Proctor DD. AGA Task Force recommends reinstating the national GI Fellowship Match. AGA Perspectives 2005;1:8 –9. 4. Gastroenterology rejoins the match. Frequently asked questions. July 2005. http:// www.gastro.org/wmspage.cfm?parm1⫽990.
781
Gastroenterology News continued
that diverged from the rebate agreement and CMS program memoranda that could have raised rebates,” stated the GAO. “States could have to repay any excess rebates if manufacturers revise their assumptions and request recalculations of prior rebates.” The GAO recommended that CMS “issue clear, updated guidance on manufacturer price determination methods, and price definitions.” The agency also recommended that CMS implement “systematic oversight” of manufacturer methods and a plan to ensure accuracy of reported prices and rebates to the states.
According to the GAO, drug spending will consume more than 10 percent of total Medicaid spending of roughly $300 billion this year. “Between January 2000 and June 2004, drug prices increased 22%” noted the report. “The problem is literally an epidemic, as many Americans are forced to risk their health by sharing drugs, skipping doses or doing without medicine altogether because it is simply too expensive. At the same time, rising drug prices are forcing states to make drastic cuts in medical assistance programs.” What’s more, noted the agency: ⬙The new Medicare drug benefit does not solve the prescrip-
tion drug problem. “One-in-4 Americans (70 million) do not have insurance covering prescription drugs. Of these, about 75% (52 million) are not eligible for Medicare, so the new federal law that takes effect in 2006 won’t help them at all.” The GAO report was requested by Sen. Charles Grassley (R-Iowa) and Rep. Henry Waxman (D-Calif.). “The Medicaid drug rebate program is quite simply a mess, a Medicaid mess,” Grassley told the Senate. “I urge my colleagues to consider this GAO report and its recommendations.” To view the report, see: www. gao.gov/cgi-bin/getrpt?GAO-05-102
Are 80 Hours Per Week Enough or Too Little for Residents and Fellows?
paired. Some recent studies demonstrated that medical errors correlate with work hours by residents. For example, interns working in a medical intensive care unit made significantly more serious medical errors if they worked frequent shifts of 24 hours or more than if they worked shorter shifts and worked fewer hours per week.3 Furthermore, the shorter shifts resulted in quantitatively more sleep
and qualitatively fewer attentional failures among the interns.4 In a mixedmethod multi-institutional study, residents across different specialties noted an important impact of sleep loss of the ability to perform a variety of functions well.5 However, a systematic review of 7 studies examining the effects of work hours on patient safety failed to demonstrate any clear relationship between work duty hours and patient safety.6 Further studies are needed to examine the impact of these restrictions on patient safety, continuity of care, and medical education for our trainees.7 Dr. Mark Babyatsky, Vice-Chair of Education, Program Director of the Internal Medicine Residency at the Mount Sinai Medical Center in New York, and a physicianscientist examining neuro-immune interactions in inflammatory bowel disease, believes that the advantages and disadvantages of the new rules still require ongoing evaluation, and that consensus will emerge over time. The reader is referred to the growing and widely cited literature in this topic.
E
ffective July 2003, the Accreditation Council for Graduate Medical Education (ACGME) established that residents and fellows (hereafter collectively referred to as residents) may not work more than 80 hours per week, averaged over 4 weeks. Moreover, there could not be more than 30 hours of in-hospital call or less than a 10-hour break between shifts. Since then, the ACGME has conferred occasional exemptions for programs to allow residents work 88 hours per week (almost exclusively for surgery residencies). At the same time, citations have been administered by the ACGME to programs that fail to comply with new work hour restrictions, with the number of citations totaling 135 from 2003– 2004. Many medical educators argue that training physicians is hampered by the new ACGME rules.1,2 Moreover, the actual time that all residents are able to devote to daily and weekly conferences and obtain the benefits of informal discussions that serve as a platform for medical education is im782
Mark Babyatsky, MD.
Stories by Les Lang
that do not differentiate their fellowship positions into basic science and clinical science. If a program differentiates their research positions, they would designate them as basic science (no. 1 above) or clinical investigator (no. 2 above). Applicants may apply for one or more tracks in any given program(s). Programs that offer more than one track will have the option to have the research positions filled first, and in the order they choose. If unfilled, the research positions can revert, or change, to clinical track positions and be filled with clinical track applicants. In a similar fashion, applicants can apply for research positions, and if not matched, have the option to revert, or change, to a clinical track position. All matching between programs and applicants, including any reversions of positions, occurs during approximately 5 minutes of running time on the computer. Programs that offer a single track will not go through this stepwise reversion process. Overall, how a program categorizes its positions is
between the program and the applicants. This is part of the customized matching process that is available at NRMP. Programs list applicants’ names for, and applicants apply to, individual fellowship categories/positions at the time the rank order list is submitted and before the computerized matching program is actually run. Such a multiple option match offers greater flexibility for all programs and applicants. The Match establishes a uniform date for appointments to GI fellowships, encourages applicants and programs to consider all options before making commitments, and offers programs the greatest access to the applicant pool. It mitigates premature offers and applicants reneging on accepted positions. The Match levels the playing field and creates an impartial venue for matching programs and applicant preferences. It encourages movement and a more dynamic training experience for applicants seeking fellowship positions outside of where they trained during their residency. All of us in-
volved in GI fellowship training are delighted that the Match has returned for our programs and our applicants. For more information, please contact [email protected], or (301) 9412624.
Concerns Raised About Medicaid Drug Rebates to States
vices (CMS) for failing to monitor drug price data reported by drug makers, or ensuring that manufacturers provide adequate rebates to state Medicaid agencies, as required by law. To help control Medicaid spending on drugs, states receive rebates from pharmaceutical manufacturers through the Medicaid drug rebate program. Rebates are based on 2 prices – best price and average manufacturer price (AMP). Both reflect manufacturers’ prices to various entities, which include financial concessions and discounts. “In administering the program, CMS conducts only limited checks for reporting errors in . . . drug prices,” the GAO report noted. “There was considerable variation in the methods that manufacturers
used to determine best price and average manufacturer price, and some methods could have reduced the rebates state Medicaid programs received.” The report faulted the rebate program in particular because “[it] does not clearly address . . . manufacturer, payments that are negotiated by pharmacy benefit managers on behalf of third party payers.” The report notes that in determining best price and AMP, some manufacturers combined price reductions associated with particular sales, while others accounted for reductions separately. Separate treatment of the reductions resulted in rebates to states that were in some cases lower than they would have been had the reductions been considered together. Moreover, “some manufacturers made assumptions
A
larms have been sounded by Congressional watchdogs at the Government Accountability Office (GAO) regarding the prices paid jointly by federal and state governments for prescription drugs for lowincome Americans under the Medicaid program. In a recent report, the GAO concluded that lax oversight by federal health officials is helping fuel the Medicaid funding crisis by allowing U.S. and state governments to pay too much for those medicines. The agency asserted that “inadequate oversight” is allowing drug manufacturers to avoid a law that requires them to provide discounts to Medicaid. The investigators fault the Centers for Medicare and Medicaid Ser-
Deborah D. Proctor, MD Chair, AGA Match Ad Hoc Task Force Chair, AGA Training Subcommittee, Education and Training Committee Yale University School of Medicine
References 1. Niederle M, Roth AE. The gastroenterology fellowship match: how it failed, and why it could succeed once again. Gastroenterology 2004;127:658 – 666. 2. Lim JK, Shah SB. Restoring a gastroenterology fellowship match: a trainee perspective. Am J Gastroenterol 2004;99:1412– 1414. 3. Proctor DD. AGA Task Force recommends reinstating the national GI Fellowship Match. AGA Perspectives 2005;1:8 –9. 4. Gastroenterology rejoins the match. Frequently asked questions. July 2005. http:// www.gastro.org/wmspage.cfm?parm1⫽990.
781
Gastroenterology News continued
that diverged from the rebate agreement and CMS program memoranda that could have raised rebates,” stated the GAO. “States could have to repay any excess rebates if manufacturers revise their assumptions and request recalculations of prior rebates.” The GAO recommended that CMS “issue clear, updated guidance on manufacturer price determination methods, and price definitions.” The agency also recommended that CMS implement “systematic oversight” of manufacturer methods and a plan to ensure accuracy of reported prices and rebates to the states.
According to the GAO, drug spending will consume more than 10 percent of total Medicaid spending of roughly $300 billion this year. “Between January 2000 and June 2004, drug prices increased 22%” noted the report. “The problem is literally an epidemic, as many Americans are forced to risk their health by sharing drugs, skipping doses or doing without medicine altogether because it is simply too expensive. At the same time, rising drug prices are forcing states to make drastic cuts in medical assistance programs.” What’s more, noted the agency: ⬙The new Medicare drug benefit does not solve the prescrip-
tion drug problem. “One-in-4 Americans (70 million) do not have insurance covering prescription drugs. Of these, about 75% (52 million) are not eligible for Medicare, so the new federal law that takes effect in 2006 won’t help them at all.” The GAO report was requested by Sen. Charles Grassley (R-Iowa) and Rep. Henry Waxman (D-Calif.). “The Medicaid drug rebate program is quite simply a mess, a Medicaid mess,” Grassley told the Senate. “I urge my colleagues to consider this GAO report and its recommendations.” To view the report, see: www. gao.gov/cgi-bin/getrpt?GAO-05-102
Are 80 Hours Per Week Enough or Too Little for Residents and Fellows?
paired. Some recent studies demonstrated that medical errors correlate with work hours by residents. For example, interns working in a medical intensive care unit made significantly more serious medical errors if they worked frequent shifts of 24 hours or more than if they worked shorter shifts and worked fewer hours per week.3 Furthermore, the shorter shifts resulted in quantitatively more sleep
and qualitatively fewer attentional failures among the interns.4 In a mixedmethod multi-institutional study, residents across different specialties noted an important impact of sleep loss of the ability to perform a variety of functions well.5 However, a systematic review of 7 studies examining the effects of work hours on patient safety failed to demonstrate any clear relationship between work duty hours and patient safety.6 Further studies are needed to examine the impact of these restrictions on patient safety, continuity of care, and medical education for our trainees.7 Dr. Mark Babyatsky, Vice-Chair of Education, Program Director of the Internal Medicine Residency at the Mount Sinai Medical Center in New York, and a physicianscientist examining neuro-immune interactions in inflammatory bowel disease, believes that the advantages and disadvantages of the new rules still require ongoing evaluation, and that consensus will emerge over time. The reader is referred to the growing and widely cited literature in this topic.
E
ffective July 2003, the Accreditation Council for Graduate Medical Education (ACGME) established that residents and fellows (hereafter collectively referred to as residents) may not work more than 80 hours per week, averaged over 4 weeks. Moreover, there could not be more than 30 hours of in-hospital call or less than a 10-hour break between shifts. Since then, the ACGME has conferred occasional exemptions for programs to allow residents work 88 hours per week (almost exclusively for surgery residencies). At the same time, citations have been administered by the ACGME to programs that fail to comply with new work hour restrictions, with the number of citations totaling 135 from 2003– 2004. Many medical educators argue that training physicians is hampered by the new ACGME rules.1,2 Moreover, the actual time that all residents are able to devote to daily and weekly conferences and obtain the benefits of informal discussions that serve as a platform for medical education is im782
Mark Babyatsky, MD.
Stories by Les Lang