Noteworthy News Articles on Mental Health Topics, June 27-31,
2000
Fatal Accident Forces Debate Over Movement for Problem
Drinkers
Mia Penta, Associated Press, 6/27/2000
SEATTLE -- In March, Audrey Kishline allegedly drove her pickup truck the wrong way
down Interstate 90, smashing head-on into a car in an accident that killed a man and his
12-year-old daughter. Kishline, who police said had a blood-alcohol level more than three
times the legal limit, has since been charged with vehicular homicide. What makes the case
different from thousands of other drunken-driving cases is who Kishline was: The founder
of a national group that promotes moderate alcohol intake among problem drinkers. After
the accident, Kishline said she realized that Moderation Management, the organization she
founded in 1993, ''is nothing but alcoholics covering up their problem,'' said her lawyer,
John Crowley. Critics of the group agree, though members say Moderation Management is the
only realistic solution for problem drinkers who aren't alcoholics. Kishline, 43, was
charged with vehicular homicide, drunken driving and hit-and-run driving after the March
25 deaths of Richard Davis and his daughter, LaSchell. Kishline, who is scheduled for
trial in September, is seeking substance-abuse treatment at a western Oregon facility and
was unavailable for comment.
Until recently, Kishline functioned as a spokeswoman for Moderation
Management, which touts itself as an alternative to Alcoholics Anonymous. Members joining
the 50 volunteer-run groups are told drinking is learned and not a disease as they go
through a nine-step program. It bills itself as a ''supportive mutual-help environment
that encourages people who are concerned about their drinking to take action to cut back
or quit drinking before drinking problems become severe.'' Admitted alcoholics are
discouraged from the program, which allows nine drinks per week for women and 14 for men
and discourages drinking and driving. The problem is that Moderation Management is a
tempting alternative for alcoholics, who often cannot admit that they have serious
drinking problems, critics say.
''Moderation Management is built on an illusion,'' said George
Vaillant, professor of psychiatry at Harvard Medical School. ''It's hard for us in America
to realize that those with serious drinking problems can't go back to social drinking.''
Alcoholics who join and believe they are only problem drinkers may soon find themselves
out of control, said Richard Frances, medical director and chief executive at Silver Hill
Hospital in New Canaan, Conn. ''It's so attractive to patients, and quickly leads to a lot
of relapses,'' Frances said. That's what Elisa DeCarlo found. DeCarlo, a former leader of
a New York Moderation Management group, said she was constantly frustrated by members who
were using the group as an excuse to drink. ''The idea is good in abstract,'' said
DeCarlo, who has since left Moderation Management and quit drinking. ''It's just not a
realistic concept when you come down to it.'' Kishline, author of the 1994 book ''Moderate
Drinking,'' apparently agrees. Crowley said that if she is convicted, she plans to write
another book that will say moderation is not an option for people with serious drinking
problems.
Dr. Frederick Glaser, a member of the Moderation Management advisory
board and director of the division of substance abuse at the Brody School of Medicine,
said Kishline's statements made in the aftermath of a tragedy need to be taken with a
grain of salt. There are no accurate estimates of how many members are in
Moderation Management, but Glaser estimated that hundreds of people have gone through the
program and hundreds more seek help from it on the Internet. Group members also blame
Alcoholics Anonymous, which Kishline announced she joined in January, a few months before
her accident. The group asks members to strive for sobriety. ''Isn't it ironic that her
most extreme case of intoxication was after she quit Moderation Management?'' asked
Stanton Peele, a psychologist and another board member of Moderation Management. Peele
said he suspects that Kishline's statement blaming the program is her way to deal with the
recent tragedy. ''Someone shouldn't rule out an entire group based on her own failure,''
he said.
A spokeswoman for Alcoholics Anonymous declined comment Monday, saying
the program has a policy against discussing organizations outside of AA. Neither
organization should end up pointing fingers at each other, said Jeffrey Schaler, a
psychologist and adjunct professor at American University School of Public Affairs in
Washington D.C. ''A particular approach did not kill anyone,'' he said. ''The issue is of
personal responsibility."
Growth of Opium Dens Luring Tourists to Laos
Justin Pritchard, USA Today- 6/27/2000
VANG VIENG, Laos -- The throngs of Western travelers arrive as many as 300 a night,
dread-locked and shirtless, bearded and barefoot. Professing to travel on shoestring
budgets, they still are much more affluent than the locals, who might earn less than
$1,000 each year. These tourists of every tongue are following whispers about this latest
Shangri-La, a hamlet of 3,000 people where saw-tooth mountains protect an end-of-the-earth
simplicity -- and enough opium dens to recall days of yore. Or at least the drug-drenched
'70s. If not for opium, American Peter Wu would likely never have come to Vang Vieng. ''I
was hoping for a place with a bunch of old-timers laid out on mats, puffing away -- the
kind of place where you'd spend a few days,'' says Wu, 32, who travels Southeast Asia when
he's not writing advertising copy in Los Angeles. ''But instead, and because of the influx
of tourist dollars, it has less of a traditional feel and more of a drive-through
service.'' Westerners have long headed to the Far East in search of drug highs, notably
during the '60s and '70s. Now, the newest darling of that scene -- poor, landlocked Laos
-- is grappling with the changes these thousands of travelers will bring.
Raw and wild
The Laotian government is ecstatic that more people are coming. It had heralded 2000 as
''Visit Laos Year.'' Tourism has increased from 100,000 visitors in 1993 to 700,000 last
year, according to the Laotian Embassy in Washington. Newspapers estimate that could pump
nearly $100 million into the economy. However, the opium seekers are causing alarm, not
least because Laos recently agreed with the United Nations Drug Control Program (UNDCP) to
eliminate the crop by 2006. ''Tourists come to Laos for some kind of raw and wild
environment, something close to nature. Part of that is opium,'' says Sunai Phasuk, a
researcher at Chulalongkorn University in Bangkok, Thailand. ''The Lao government tries to
deny that, but this is the reality, and they have to find some way to solve the problem.''
Opium has deep roots in Laos, where for centuries the drug has played a central social and
economic role. Derived from the pods of the poppy, it is an important medicine and an
accepted diversion for the elderly. A sticky substance inside the poppy pod is processed
into dried blocks, which are smoked in bamboo pipes.
Laos, population 5.4 million, is the world's 3rd-largest opium producer
after Afghanistan and Burma. Though the illicit drug trade is not nearly as organized as
in the other two nations, opium production in Laos more than tripled from the mid-80s
through the mid-90s. The country produced about 123 tons in 1998, UNDCP says. More
than half of that was for domestic consumption, and the rest went to help produce five
tons of heroin for the U.S. and European markets. The new tourism does not account for all
of the increased production, but it does account for profound cultural changes in the
country. Children in Vang Vieng used to run away in fright at the sight of white skin.
Now, they sidle up to ask for a spare coin or two.
''The social fabric has changed dramatically,'' says Andrew Willis, a
Canadian who has lived in Vang Vieng for two years as a volunteer for the development
organization CUSO. What once was an early-to-bed town now stays awake for its guests.
Teenagers peddle ''ganja'' (marijuana) or coax wanderers into the ubiquitous dens, which
usually are behind shop fronts owned by Vietnamese businessmen. In just two years, Willis
has watched the number of motel-like guesthouses shoot from three to about 30. Likewise,
the number of restaurants has more than doubled. The whole town has been wired for
electricity, which inevitably meant the arrival of an Internet cafe. A similar phenomenon
is afoot in Muang Sing, a town near the Chinese border where backpackers also flock to hit
the bamboo pipe. These social changes might ultimately be the biggest concern. Locals
lament that teenagers are falling prey to the big money and loose morals that Western
travelers represent.
A negative impact
Young foreigners are having a ''clear negative impact'' on the very culture they come to
see and enjoy, according to Halvor Kolshus, the top UNDCP official in Laos. ''They are
often young people with liberal attitudes and ideas, concerned about the environment and
social issues,'' he says. ''Yet they . . . (send) a signal to otherwise
non-opium-using Lao youth who may think it is OK.'' He says Laos now has 63,000 opium
addicts. The Laotian government is trying to address the issue in part by agreeing to a
six-year, $80 million program funded by the USA, the European Union, and other donors
through the UNDCP. Much of the money is set for ''alternative development'' and road
building in the mountainous north. The idea is to give thousands of small-scale opium
growers other means to earn money. ''There is a strong political will at the highest
political level in Lao PDR (People's Democratic Republic) to end the production of opium
once and for all,'' says a UNDCP overview of the project, ''provided resources can be made
available to provide a decent life for the people trapped in the opium web.''
Thin profit margin
From a commercial standpoint, the trade in raw opium would seem to be attractive. The high
value and light weight of opium make it easy to transport, which is especially good in a
barter economy. ''If you looked at it as a crop, in certain situations, it has things that
make it desirable,'' says American anthropologist David Feingold, who has studied opium in
the region for 30 years and is working in Laos under a MacArthur Foundation grant ''(Laos)
is a country that has widespread malnutrition, very, very serious malaria problems,
cholera and tuberculosis. Given all those things, is this something they should worry
about?'' he asks. But the opium trade, in fact, is not all that lucrative. Laos produces
only raw opium, not the high-price refined version; the big profit margins are reaped
outside the country. Kolshus says Laos might be making only about $12 million a year off
the opium trade. That, plus the negative social impact, he says, is what has prompted the
Lao government to try to curb the opium trade. ''The higher up in the chain from producers
to heroin addicts, the higher the profit per unit,'' he says. ''A tiny percentage is left
for the opium growers, but at a high economic and social cost.'' Though not citing
specific figures, Kolshus says arrests of foreign smokers are on the rise in an effort to
control the problem. That's not the word in Vang Vieng, where sporadic arrests have
deterred neither den owners nor their clients. ''They have been reasonably reluctant to
arrest foreigners. They don't think that's going to help their image,'' Feingold says.
''Vang Vieng is treated sort of like this Club Med. It's not treated as part of real
life."
New Drugs, Counseling Strategies to Help People Stop
Smoking
Robin Eisner, ABC News, 6/27/2000
N E W Y O R K — Calling tobacco addiction a chronic disease, the federal
government today issued new physician recommendations, including novel drug and counseling
strategies, to help Americans quit smoking. "There has never been a better time for
health professionals to help their patients break free from the deadly chronic disease we
know as tobacco addiction," says U.S. Surgeon General Dr. David Satcher.
"Starting today, every doctor, nurse, health plan, purchaser and medical school in
America should make treating tobacco dependence a top priority." In response to the
guidelines, President Bill Clinton issued an executive order today that called for federal
agencies to send a message to staff to stop smoking, noting that smoke-free environments
and cessation programs are available to many federal employees. Clinton also said these
new guidelines should help clinicians and employers determine which quitting programs are
most effective. The new U.S. Public Health Service guidelines, which are an update of 1996
recommendations, represent two years of analysis by public- and private-sector experts on
smoking cessation techniques, says Dr. Michael Fiore, professor of medicine at the
University of Wisconsin Medical School in Madison and chairman of the federal panel that
issued the report. Eighteen scientists, clinicians and consumers reviewed some 3,000
articles from medical literature from 1995 to 1999 to provide the most up-to-date research
on effective techniques to help Americans kick the habit. After finding out which drug and
counseling methods work, employers should be more willing to pay for insurance coverage,
experts say.
Part of Routine Care
The new recommendations, like the older ones, are aimed at practicing physicians. They
suggest doctors include smoking cessation questions and advice as part of their routine
care of patients to help the 70 percent of smokers who want to quit each year and the 70
percent who visit a health-care setting annually. "In my view, a doctor isn’t
providing an appropriate standard of care for his or her patients if he or she
doesn’t ask two key questions — ’Do you smoke?’ and ‘Do you want
to quit?’ — and then work with that individual to make it happen," Fiore
says. The key item in the guidelines, explains Fiore, is a change in thinking about
tobacco dependence. "The view in the past has been it’s just some bad habit,
that if you had enough will power you should be able to overcome this on your own,"
Fiore says. "Our analysis shows tobacco use is similar to a chronic disease,
comparable to high blood pressure, high cholesterol and diabetes."
Prolonged Treatment Needed
Treating those diseases require multiple visits to the doctor over months and years and a
number of treatments to provide sustained remissions, Fiore says. Likewise, with tobacco
cessation, patients trying to quit need to see a physician or counselor over a period of
time. The success rate of the 20 million people who go cold turkey each year is around 5
percent to 7 percent, says Fiore. Adding the drug treatment and counseling programs
recommended in the guidelines increases the rate to 10 percent to 20 percent. Counseling
can be performed by nicotine addiction experts, and can involve individual or group
therapy, says Dr. Thomas Kottke, professor of medicine at the Mayo Clinic in Rochester,
Minn., who was a panel member. The research identified two new successful counseling
techniques besides traditional addiction treatment programs. One enlists the help of
family members, co-workers and others who have stopped smoking because research shows such
social support will improve the likelihood that a person will quit. Another technique
included in the new recommendations involves telephone-based counseling. Several places,
including the California Tobacco Control Program and the Mayo Clinic, have such a service.
Under these plans, patients can call a counselor 24 hours a day, says Kottke. Counselors
also call people trying to quit to monitor their progress. The new guidelines add three
medications to aid quitters. The 1996 guidelines included the nicotine patch and nicotine
gum. The current recommendations add the drug Zyban, a non-nicotine drug that helps
withdrawal symptoms; a nicotine nasal spray; and a nicotine inhaler. Zyban is often used
in conjunction with one or more nicotine products.
Increased Insurance Coverage
The guidelines open up the possibility that insurance companies will augment their
reimbursement for tobacco dependence treatment. "Virtually every insurance plan pays
for the outcomes of tobacco use, such as heart attacks, cancer, strokes, emphysema,"
Fiore says. But, he says, fewer than 50 percent of the plans, he says, cover the $200 to
$400 needed to effectively treat tobacco dependence.
"Doctors should be reimbursed for their time in providing counseling for
patients," as should the addiction counselors who provide the follow-up therapy, says
Kottke. Susan Pisano, spokeswoman for the American Association of Healthcare Plans, a
Washington-based trade organization that represents the managed care insurers, says the
guidelines should increase coverage because they represent a consensus about which methods
work. She says more than 60 percent of health plans cover tobacco cessation, but not all
offer comprehensive plans.
Release of Mentally Ill Killer After 18 Years Being Debated
Janan Hanna, Chicago Tribune- 6/28/2000
A judge Tuesday began hearing testimony on the delicate and controversial question of
whether a 37-year-old man who murdered his sister 19 years ago should be conditionally
released from a state mental health facility and sent to a less secure residential
facility. Paul Williams was 18 years old and a former mental health patient when he
was charged with killing his 21-year-old sister, Marguerite Mitchell, after becoming upset
that other family members were going on a vacation without him. Cook County Circuit Judge
Fred Suria found Williams not guilty by reason of insanity in November 1982 and placed him
in the custody of what is now the Illinois Department of Human Services for a period not
to exceed 40 years.
Now, doctors and administrators at the Elgin Mental Health Center,
where Williams has spent most of the last 18 years, said they believe he is mentally
stable and ready for a gradual re-entry into the community. Elgin officials petitioned the
court for a hearing on the question after Williams' treating psychiatrist and psychologist
concluded that he was fit for conditional discharge to Somerset House, a North Side
long-term treatment facility. Prosecutors vehemently oppose the request, insisting that
Williams, who has suffered from major depression with psychotic features, is dangerous.
Under the law, prosecutors have the burden of showing that Williams still poses a danger.
Assistant State's Atty. Virginia Bigane reminded Suria of the
heinousness of Williams' crime. Prosecutors say that after he strangled his sister in the
family's home at in the 8500 block of South Wood Street, he cut off her arms and legs,
threw them in various trash cans outside the home, and concealed her torso and head in the
basement. In an opening statement, and through the questioning of Williams' treating
psychiatrist, Bigane disclosed that Williams has a history of drug dependence; a history
of infractions while in the Elgin facility, including testing positive for drugs on four
occasions; and one escape from the facility for 24 hours in 1990. "Based on the
violence of the offense itself and the fact that the defendant has committed several
infractions while being a recipient of services at the Department of Human Services,
including taking drugs, we strongly oppose his conditional release," Bigane said
outside of court.
Assistant Public Defender Kulmeet "Bob" Galhotra, who
represents Williams, countered that three psychiatrists who have spent time with Williams
all agree that he is healthy and safe for conditional discharge. "This man has spent
more than half of his life in a mental hospital," Galhotra said. "I think the
doctors who know him best know what he's capable of doing and what he's not capable of
doing. They're in the best position to tell us that he is ready for outpatient
treatment." Galhotra also noted that Williams has left Elgin by himself on more than
60 occasions to attend counseling sessions, without incident.
For Jailed Mentally Ill, a Way Out
Kari Lydersen, Washington Post- 6/28/2000
CHICAGO – After sleeping on this city's streets for 28 consecutive days, Ellene
Price had had enough. But she couldn't turn to homeless shelters for lodging. Several had
barred her for bad behavior. A mental hospital where she was hearing voices released her
after a week. So, Price grabbed a female tourist by the neck and pushed her to the ground.
She was arrested, pleaded guilty to battery and was sentenced to a year behind bars –
joining more than a quarter of a million mentally ill people incarcerated in the country's
prisons and jails. For a while at least, jail was a relief. She had amenities she was
unable to keep before because of her mental illness. "I had a clean uniform, a water
fountain, a shower, a roof over my head," Price said. "But then it started
getting rough. The girls were fighting a lot, and I wanted to get out of there."
Jails are increasingly becoming the main psychiatric facilities for
people with mental illness, according to mental health experts. In this city, the Cook
County Jail houses the county's largest population of mentally ill people. In 1998, the
latest year for which figures are available, 283,000 mentally ill people were incarcerated
across the country in federal and state prisons and local jails, and almost 550,000 others
were on probation, according to the Justice Department. About 16 percent of mentally ill
people released from prison or jail are not ready to survive on their own, according to
the Justice Department, and many of them are soon in jail or hospitalized again.
Price served less than one-quarter of her punishment. Officials from
Thresholds, a unique national psychiatric rehabilitation center based in Chicago, went to
her sentencing judge and got Price an early release. They enrolled her as a
"member" in a program that offers intensive one-on-one counseling as well as
assistance in meeting daily needs. "People are released from jail with just a
prescription and the address of a mental health facility, which might have a month-long
waiting list," said John Fallon, director of the Thresholds Jail Program, which aims
to reach mentally ill people caught up in the cycle of incarceration, hospitals and the
streets. "It's almost guaranteed that they're going to fail the way things are set up
now." The Thresholds Jail Program was launched less than three years ago, serving 45
mentally ill people with funding coming primarily from Thresholds' own coffers. Last year,
the program received $495,000 from the Illinois Department of Mental Health and expanded
its staff from three to eight caseworkers. "We're looking at people who are off the
radar screen of mental health services," said Tom Simpatico, bureau chief of the
Illinois Department of Mental Health. "These are highly recidivistic people who are
not easily able to link up with community resources, so we need to find new solutions like
this which can get them back in care."
Thresholds staffers hope their program can become a model for other
states and receive enough government funding to serve the bulk of nonviolent mentally ill
people in jail. The program costs about $26 a day per person, compared with about $70 a
day to keep the same person locked up, or $400 daily to keep that person in a public
mental hospital. Thresholds identifies potential "members," as the patients are
called, by working with personnel at the Cook County Jail. Members must be nonviolent
offenders, and they must be willing to live on the north side of the city – where the
program is based – upon their release. They also must have a mental illness, such as
depression or schizophrenia, that responds to medication. Thresholds caseworkers accompany
members to their court dates and – as they did for Ellene Price – usually
convince judges to release the inmates from jail early into the program's custody.
Caseworkers helped get Price released Dec. 9 after only 11 weeks behind bars. Thresholds
workers then find affordable housing for the members, usually in hotels where others from
the program live. The workers visit members at least once a day, giving them their
medication, a $5 a day allowance and, for smokers, a daily allowance of cigarettes. They
take members shopping or help them do their laundry. They go on group outings to the
beach, baseball games or restaurants. Caseworkers are on call 24 hours a day and spend
hours in the middle of the night visiting or looking for a member if necessary. The
services are available for as long as the client needs them. So far the program has been a
measurable success in at least one area: Since it started in September 1997, none of the
45 members has been rearrested. Ronald Simmons, chief of adult forensic programs for the
state of Illinois, said Thresholds "does an outstanding job of assertive case
management. They have done an admirable job of keeping these people stable and functional
in the community."
At a May banquet, most members gave testimonials about how they have
avoided arrest and hospitalization since being in the program. One success story is
Richard Berry, a paranoid schizophrenic. Berry, a 43-year-old who has been arrested 137
times for minor offenses, has spent 11 of the past 20 years in mental hospitals, which he
says are plagued by vampires and hair grease in the food. He has 13 brothers and sisters
in the city but has no contact with them. Once, he was arrested for stabbing his mother
with a pair of scissors. But Berry hasn't been arrested or hospitalized since entering the
program almost a year ago. "Life is beautiful now," Berry said. "I have
money, clean clothes, food to eat, a place to stay. I feel glad to be alive." As she
explained during a trip to Burger King with Berry, Price is also doing well. She hasn't
been arrested in the six months since her release, she has a stable home and a boyfriend,
and she is looking for work. "If I didn't have Thresholds, I would still be in jail
and who knows what would have happened after that," Price said. "I'd probably be
somewhere deceased."
Report: Doctors and Insurers Should Beef up Anti-Smoking
Efforts
Associated Press, 6/28/2000
WASHINGTON-- A majority of Americans who smoke want to quit but get little help from
their doctors, who often don't even ask whether they smoke or offer treatments, according
to a report released Tuesday. The report by the U.S. Public Health Service urges
physicians to aggressively treat smoking just like any other chronic illness. The agency,
which summarizes new guidelines for getting people to quit, said spending as little as 3
minutes talking to patients about their smoking habit can dramatically raise the chance
that patients will eventually quit. "A doctor isn't providing an appropriate standard
of care for his or her patients if he or she doesn't ask two key questions -- 'Do you
smoke?' and 'Do you want to quit?' -- and then work with that individual to make it
happen," said Dr. Michael Fiore, a tobacco researcher at the University of Wisconsin
Medical School who headed a panel of private and public health officials that created the
guidelines. The American Medical Association said the report was a wakeup call for
doctors, who need to do a better job treating smokers.
Fiore said that 70 percent of the 50 million Americans who smoke have
tried to quit at least once. Over 20 million Americans will try to kick the habit this
year. Most will go cold turkey and only a million will succeed. The guidelines, which will
go out to doctors, health clinics, hospitals and health plans, urge physicians to treat
smoking no differently than other chronic disease such as diabetes and hypertension. They
should prescribe nicotine gums, inhalers or patches and refer smokers for counseling. The
combination of medicine and counseling -- especially frequent counseling -- is highly
effective in getting people to quit, the report said. If doctors, nurses and other
clinicians followed the guidelines, the number of people who quit annually would double to
2 million, said Fiore.
President Clinton called the new guidelines "an important tool to
help ... patients quit using tobacco products," and ordered federal agencies to use
the new guidelines in updating their tobacco cessation programs. The guidelines also
urged health insurance companies and government health programs to pay for tobacco
cessation treatments and counseling. Only about half of all insurers currently do so;
Medicare, the federal health program for seniors, doesn't cover anti-smoking treatments
and only 22 states provided Medicaid coverage for tobacco dependence treatments. Medicaid
is a state-federal health program for low-income people. Fiore said it only costs between
$200 and $400 for patients to get a medication and one or two counseling sessions. Nearly
70 percent of Americans are in health plans sponsored by their employers. Managed care
officials say that the decision to cover tobacco cessation programs is up to employers
since they will have to pay for the programs or pass the costs on to their workers.
"We emphasize prevention but we don't decide what to pay for -- the employers
do," said Susan Pisano, spokeswoman for the American Association of Health Plans,
which represents health maintenance organizations.
HMOs Move to Dump 700,000 Medicare Patients
Robert A. Rosenblatt & Sharon Bernstein, Los Angeles Times- 6/29/2000
WASHINGTON--Health maintenance organizations, complaining that payments
from the federal government are inadequate, say that they will cancel coverage next year
for more than 700,000 people enrolled in Medicare HMOs. Many of these older Americans will
lose the extra benefits provided by the HMOs, including low-cost coverage for prescription
drugs, which are not included in the regular Medicare program. Aetna U.S. Healthcare will
make the biggest cutbacks, it said Thursday, canceling coverage for more than 355,000
people in 14 states. The company is leaving seven Northern California counties where
15,280 people are enrolled in its Medicare HMO. Two other firms also announced cutbacks
Thursday. Foundation Health Systems will jettison 19,000 members, including 3,200 people
in central and Northern California. And Oxford Health Plans, which serves New York,
Connecticut and New Jersey, will exit eight mostly suburban counties and drop 7,200
members. Earlier this month, Cigna Corp. announced that it was leaving several markets
nationwide affecting more than 100,000 enrollees, including 17,000 in Los Angeles and
Orange counties.
The changes would take effect Jan. 1. Beneficiaries whose HMOs pull out
of Medicare would not lose insurance coverage. They could select another HMO if one is
available in their county, or return to the traditional Medicare system. "From the
beneficiary's standpoint, the real concern is volatility," said Tricia Smith, senior
health policy coordinator for AARP (formerly the American Assn. of Retired Persons).
"You elect to go into a health plan this year and then you are not sure if it will be
there next year." The projection that more than 700,000 people will lose coverage was
made in an industry survey released Thursday. The review of what HMOs plan to do next year
is an indication that many executives in the managed care industry no longer believe they
can make profits in the Medicare business. And it is a disappointment for members of
Congress and health policy analysts, who have hoped that HMOs could restrain the growth in
spending for Medicare, which covers 40 million people 65 and older and the disabled of all
ages. The HMO industry is hoping that complaints from beneficiaries angry about the
possible disruptions in care will convince Congress to use some of the growing budget
surplus to boost the government's payments for Medicare HMOs.
The industry survey did not identify specific companies, but Aetna and
the other firms made their own announcements in anticipation of a July 1 deadline to
inform the federal government of their plans for next year. At Santa Ana-based PacifiCare
Health Systems, whose Secure Horizons plan covers 1.1 million Medicare
beneficiaries--600,000 of them in California--a company source said that last-minute
negotiations with the federal government had persuaded them not to pull out of any markets
in California. Tyler Mason, a PacifiCare spokesman, said the firm is still considering
dropping coverage in other areas but has not yet made a decision. Earlier this month, the
company announced small reductions in services in the Midwest. Even seniors who do not
lose their HMO coverage in January are likely to face increased costs and changes in
benefits next year. Foundation Health plans to raise co-payments for prescription drugs
and office visits and Aetna also said that it may change premiums and benefits. With drug
costs rising at least 10% a year, the HMOs are limiting the amount of drugs they will pay
for, or imposing higher charges for brand-name products.
The hope that HMOs would restrain growth in spending for Medicare was
based on the theory that beneficiaries would be enticed to leave the regular Medicare
program, which allows them to select virtually any doctor or hospital but requires them to
make co-payments for office visits. Medicare does not cover expenses such as prescription
drugs, dental care and vision care. In return for joining HMOs, the beneficiaries would
promise to stay within the HMO's restricted networks of doctors and hospitals but they
would get extra benefits. About 16% of the nation's 40 million Medicare beneficiaries are
enrolled in HMOs, but the market share is much higher in California, where the enrollment
rate is 35%.
But the industry may be on a downward slide. For the first time since
Medicare HMOs began their operations in 1985, the number of people enrolled nationwide is
declining: 6.2 million people belonged to Medicare HMOs in June, a decline of more than
100,000 from the previous year. "It's both financially a disaster and a disaster for
the future health of the elderly," said Helen Schauffler, director of the Center for
Health and Public Policy Studies at UC Berkeley. Schauffler, a frequent critic of
for-profit HMOs, put the blame on Congress and the Clinton administration. Not only is the
Medicare HMO program underfunded, she said, but the old fee-for-service Medicare to which
hundreds of thousands of seniors must now return is outdated and expensive. The biggest
gap in the traditional system--lack of coverage for prescription drugs--is emerging as one
of the hottest issues of the political season, with Republicans and Democrats offering
competing plans. The House approved a GOP plan Wednesday that would begin coverage in 2003
on a voluntary basis, but President Clinton is threatening a veto.
HMOs will stay away from Medicare until they are convinced that they no
longer will lose money by participating, Schauffler predicted. "It's horrible that
health care has come down to a matter of economics, but that's the way it is,"
Schauffler said. "You can't blame them. It's a business decision. It has nothing to
do with health care." The industry, which will receive payments of $280 billion from
the government over the next five years, needs an additional $15 billion to operate
profitably and prevent further cancellations of service, said Karen Ignagni, president of
the American Assn. of Health Plans, which prepared the industry survey. Medicare HMOs have
been "overregulated and underpaid," she said at a news conference. The HMO
industry and the regulators at the Health Care Financing Administration, which oversees
Medicare, have had a long-running argument over whether the government pays the HMOs a
sufficient amount for taking care of Medicare enrollees.
Health care analyst Sheryl Skolnick said, when HMOs raise premiums and
co-payments, they are also trying to drive the sickest, most expensive patients out of the
system. "If they leave, then the average cost to provide care goes down," said
Skolnick, a managing director at Banc Boston Robertson Stephens in New York.
PacifiCare, which has more than half of its Medicare business in California, and other
health plans are staying in the state because they have a stronger economic position
compared with HMOs in the rest of the country. Spending in the regular Medicare program is
higher in Southern California, enabling HMOs to collect more from the government for each
beneficiary they enroll. The additional money means that they can offer a richer package
of benefits and attract more members--increasing their power to negotiate lower payments
with doctors and hospitals. "Many health care costs are relatively lower in
California . . . in large part because of managed care," said Peter Lee, president of
the Pacific Business Group on Health, a coalition of employers that negotiates with health
plans for its members. That means the Medicare HMOs can offer a richer package of benefits
in California.
Investors responded favorably to the news, pushing up HMO stock prices
across the board, with Aetna closing up $1.57, to $64.56, and Foundation Health gaining 31
cents to close at $14.31. Both trade on the New York Stock Exchange. "By doing what
they're doing, the managements are showing financial discipline," said Todd Richter,
a health care analyst with Banc of America Securities. "It's real nice providing
prescription drug coverage and vision care coverage for grandma, but if you can't make a
fair return on it, there's no reason to do it. They don't have an obligation to take care
of grandma at a loss."
Exploring a Dark Side of Depression Remedies
Janet Maslin, New York Times- 6/29/2000
From a 1996 drug advertisement in the Journal of Clinical Psychiatry: "A great day
for Dad. A great day for Mom. A terrific day for the family. Make it happen. The Zoloft
Saturday." For any of the estimated one in ten Americans who have been exposed to
Prozac or the other similar prescription medicines discussed in his blistering new book,
Dr. Joseph Glenmullen offers something none too welcome: reason to be anxious and
depressed. And even for anyone determined never to read anything with "Prozac"
in its title, he presents an important, deeply troubling examination of the means by which
these drugs have become so widely disseminated, and the possible long-term toll they may
take.
In a book that ensures he will never be the guest of honor at a
pharmaceutical convention, Dr. Glenmullen, a clinical instructor in psychiatry at Harvard
Medical School and a practicing psychiatrist, offers a wide-ranging and well researched
indictment. He begins by invoking the track record of Thorazine, the tranquilizer that was
greeted as a psychological panacea in the 1950's, later produced neurological side effects
in 40 percent of patients and was not burdened with an F.D.A. warning label until 1985.
What if Prozac and other, similar drugs that have begun to be linked with the same
symptoms had a comparable effect? In a book as readable as it is alarming, Dr. Glenmullen
crystallizes the evidence that these drugs, selective serotonin reuptake inhibitors (or
SSRIs), by manipulating the influx of serotonin in the brain, can create a
"backlash" by affecting the levels of other chemicals, notably dopamine. And he
shows how that process can yield such Thorazine-associated fallout as facial tics, memory
loss and body-stiffening parkinsonism. "The unfortunate irony is that drugs heavily
promoted as correcting unproven biochemical imbalances may be, in fact, causing imbalances
and brain damage," he asserts. "Will silent damage caused by a serotonin booster
accelerate the aging process and make some people more prone to develop neurological
symptoms later in life?"
It can and will be argued that such problems are rare and that the much
vaunted uplifting effects of these drugs are more significant than their potential
detriments. Even so, "Prozac Backlash" makes a tough, persuasive case that the
drugs are more dangerous than generally acknowledged, that patients and doctors are
insufficiently informed about the risks and that drug companies devote vast amounts of
money and energy to spin control. "When discussing brain cell damage caused by street
drugs such as amphetamines, cocaine or Ecstasy, researchers speak in the gravest terms,
warning of dread effects," writes Dr. Glenmullen, who presents abundant evidence of
how so-called independent researchers may prove to be on drug company payrolls. "Only
when referring to prescription drugs do they suggest that pruning nerve cells might be
'therapeutic.'" The book spends much time on the important role of euphemism in
Prozac's public relations. For instance, Dr. Glenmullen offers a lengthy discussion of the
difficulty patients may experience in trying to wean themselves from these drugs, even if
Eli Lilly, the company that manufactures Prozac, has run ads reading: "Like other
antidepressants, it isn't habit forming."
Along the way he mentions a 1996 symposium that Eli Lilly sponsored to
discuss this problem, and notes that one upshot of the meeting was a change in
terminology, so that no one need use the word withdrawal. "The sanitized term
'antidepressant discontinuation syndrome' is the kind of well-funded obfuscation doctors
and patients frequently face when trying to get honest, reliable information on these
powerful drugs," he writes. In the realm of euphemism, Dr. Glenmullen explains how
Prozac can claim that only two to five percent of users experience sexual dysfunction,
although other evidence places that number as high as 60 percent. The team that did the
original research on the drug simply never raised the issue. He also shows how
SSRI-related anxiety and jitters were minimized for this research by ignoring the fact
that many of the patients studied were also taking sedatives to control those symptoms.
An especially disturbing section of the book delves into a lawsuit
brought against Eli Lilly by survivors of a rampage by Joseph Wesbecker, who was the
company's worst nightmare: a Prozac user who went on the rampage in 1989 with an AK-47.
Fortunately for Eli Lilly, the 1994 trial was concurrent with the O. J. Simpson trial, the
facts were carefully manipulated, a secret settlement was made between plaintiffs and the
drug company even as the trial continued, and Prozac avoided a warning label about
possibly violent or suicidal behavior. All the particulars of this remarkable legal
travesty are laid out here. Like much else in "Prozac Backlash," the facts of
the Wesbecker trial are mostly available elsewhere. But the book's data come from a great
array of diverse sources, and Dr. Glenmullen has done a prodigious job of assembling and
illuminating it here. Her argues cogently and persuasively for better research, truly
independent research data, consumer skepticism about such drug company generated phenomena
as "National Depression Awareness Day" and less readiness on the part of
doctors, whose patients may see them only seldom because of insurance constraints, to hand
out antidepressants as an easy fix-it without follow-up visits or closer attention.
As a psychiatrist, Dr. Glenmullen shows a sharp bias for the benefits
of psychotherapy over psychopharmacology, and it is here that "Prozac Backlash"
is weak. When he offers case studies from his own practice, model patients seem to respond
magically to the doctor's Sherlock Holmsian acuity in pinpointing their problems.
("Do express elevators symbolize the fast track, which you have mixed feelings
about?" he asks a phobic executive, whose fear forces him to walk up to and down from
a 43-floor office. But a lengthy section of the book discusses herbal substitutes for
antidepressants, the importance of diet and exercise, 12-step groups, friends, family and
community as important in overcoming depression. These things can work, he says--even if
as much money is spent in the United States on promoting wonder drugs to doctors than on
all medical schooling and residency training combined.
Fairfax County Autism Program Ignites Battle Over Access
Victoria Benning, Washington Post-6/30/2000
Evan Ovaska sits in a corner of his playroom in his family's town house in Burke.
Spread before him are dozens of small cards with pictures of animals and other objects. In
another pile is a jumble of brightly colored magnetic letters. "What's this,
Evan?" asks instructor Moira Lozzi, holding up a card. Evan's blue eyes light up and
the 3 1/2-year-old's nimble fingers pull out the letters Z-E-B-R-A. Lozzi praises Evan and
rewards him with one of his favorite treats: a McDonald's french fry. Evan doesn't speak,
but the big smile on his face shows he knows he's done well. To Evan's parents, such
achievements are nothing short of miraculous. Evan has autism, and a year ago, he couldn't
communicate with his parents. Now, he is able to follow simple commands and express his
thoughts using pictures and letters. His parents hope he will learn to speak one day.
"He has come such a long way in a year," said his father, Jeff Ovaska. "It
is truly unbelievable."
But the treatment that appears to hold such promise for Evan is also a
battleground in the bitter fight over how much money school districts should spend on
educating students with disabilities. The Fairfax County school system is providing Evan
and nine other preschoolers with an intensive therapy being used with an increasing number
of young autistic children nationwide. The children are drilled over and over again on
skills ranging from sitting in a chair to recognizing colors, and rewarded each time they
succeed at a task. Each of the 10 children in the two-year-old pilot program is getting 30
hours a week of one-on-one home instruction, for 50 weeks a year. The annual cost per
child is about $30,000, compared with Fairfax's average per-pupil spending of $8,203. So
far, Fairfax educators, like researchers who have studied children in similar programs
elsewhere, have found the results encouraging.
But several parents of autistic children say it is inexcusable that
Fairfax is offering the program to only 10 children when at least 40 others with similar
problems could benefit from the approach, which could be their only chance for a normal
life. "What Fairfax County is doing--for all but a very small, fortunate handful--is
denying children with autism the only form of therapy shown to be clinically
effective," said Scott Greenspan, who tried to get his autistic son into the county
program in April but was told it was closed. "They're ruining children and ruining
families." Greenspan's 2 1/2-year-old son instead was offered a slot in a class for
autistic children that has one teacher and two assistants for every five children and
provides 12 hours a week of instruction during the school year. In the Washington area,
most school systems do not offer the home treatment at all. But some, such as Montgomery
and Howard counties, provide it and place no limits on enrollment, although children must
be evaluated before qualifying. Montgomery and Howard have contracted with a private
provider for the services. A Montgomery official estimated that about 30 children have
been treated in that county in the past five years.
Fairfax school officials say the 10 children in the district's program
were chosen based on the severity of their autism and other clinical factors. They say
they will wait a year, when the three-year pilot program ends and they have completed a
thorough evaluation, before deciding whether the effort should be expanded. But the cost
issue alone, they say, makes it unlikely that the district will provide the intensive
therapy to every family requesting it. "It's an issue of resources," said
Fairfax School Superintendent Daniel A. Domenech. "For us to be able to make this
available on a wide basis would require a significant increase in funds. Without any
additional funds, we'd be robbing Peter to pay Paul. Are we going to increase class sizes
for all our other students to do that? Not buy textbooks? What is it that we are not going
to do?" Fairfax school officials also say that the benefits of the treatment, known
as Applied Behavioral Analysis, are not always as dramatic as some parents believe and
that some autistic children need a different approach.
Similar disputes have erupted in communities across the country. In
some cases, parents have gone to court seeking to force school districts to provide the
autism treatment or reimburse them for the cost of obtaining it from private providers.
Several school districts have won such lawsuits, with courts ruling that although federal
law requires public schools to provide services to disabled preschoolers, it does not
mandate a program as elaborate as the ABA therapy. Fairfax won such a case last July, with
a federal judge ruling against parents who were seeking reimbursement for private
treatment.
Autism, a developmental disability that comes in many forms and degrees
of severity, usually appears during the first three years of life and impairs a child's
communication and social skills. The ABA therapy seeks to overcome the learning
difficulties of young autistic children by breaking down lessons into small steps and
reviewing each one repeatedly. For example, an instructor teaching a child to recognize
colors might start by focusing entirely on the color red. She would show the child a red
card, then ask him to "touch red." The drill would be repeated until the child
could respond correctly nine out of 10 times, and then the instructor would move on to
another color. Use of the therapy began to spread after a 1987 study by Ivar Lovaas, a
researcher at the University of California, Los Angeles, found that out of 19 preschoolers
who had undergone the treatment, 47 percent were attending a regular school by first grade
and all of them had made some progress. Since then, no other researcher has seen an
outcome quite that impressive. But many experts agree that the therapy has shown
remarkable results. "Before this, children with autism were thought to be
uneducable," said Marie Bristol-Power, who coordinates autism research for the
National Institute of Child Health and Development. "I don't think 'cure' is a word I
would use--even the children with the most dramatic progress will continue to need some
support. But this method is just really very good for a majority of children."
Parents in Fairfax's pilot program say their children have made
dramatic gains. Charles Nucciarone said his son Anthony, 3 1/2, did not speak or answer to
his name before he entered the program. Now, if you point to his father and ask,
"Who's that?" Anthony will respond, "Daddy." He also has started doing
skill drills on the computer. Sherri Schornstein said her daughter, 4 1/2, has gone from
being nonverbal and "oblivious" to being able to follow simple directions and
make statements such as "I want juice, please." She now knows her colors and
animals. Schornstein rejects the school system's arguments about the expense of expanding
the program. She said the needs of the typical Fairfax student pale next to those of
children like her daughter. "It isn't a fair argument to say your child needs a
computer in his classroom when my child is facing institutionalization," she said.
The estimate that at least 40 Fairfax preschoolers in similar
circumstances are being denied the ABA therapy comes from a group called Parents for
Autistic Children's Education, or PACE, which says the figure is based on parent surveys
it has conducted. School officials, however, say that the intensive home instruction is
not appropriate for all of those children and that some are better served in classrooms.
They also note that they are offering training in the ABA techniques to teachers working
in both settings. "There are many kids who could receive better results in a setting
where they are interacting with other children," said Patricia Addison, the county's
director of special education. The parents contend that although the investment in home
lessons is costly, it will save taxpayers money in the long run because the children will
need fewer educational and social services later. "I don't disagree with them that
it's a good investment, but we need the money now," Domenech said. "That's an
argument that needs to be made with the legislators who provide our funding."
Domenech noted that in New York, where ABA services are widespread, the state covers the
full cost of preschool special education.
The cost of special education for preschoolers is growing, as is
special education spending overall. Fairfax's school system provides services to 1,414
disabled preschoolers, some as young as 2; that compares with 850 disabled preschoolers a
decade ago. The county does not classify the children by disability. "We know there
are some tough choices to be made, but for a lot of autistic children, ABA is their only
chance," said Tom Urban, one of the founders of the parent group. Urban paid for his
son, now 6, to undergo 2 1/2 years of treatment in a private program after school
officials refused to provide the therapy. His son was in a regular kindergarten class
during the school year that just ended. "I saw what this program did for my son and
for many other children," he said. "It's not a miracle cure for 100 percent of
kids, but the statistics show it works."
New Study Assesses Risks For Receiving Mental Disability
Payments
U.S.Newswire, 6/30/2000
BALTIMORE-- Having a mental or addictive disorder was the most significant predictor of
receiving disability payments, according to a new study by researchers at the Johns
Hopkins School of Public Health. The researchers also found that those with less education
or lower incomes were more likely to receive mental disability payments. The report
appears in the July 2000 issue of Psychiatric Services, a journal of the American
Psychiatric Association. More than 35 million Americans, or one in seven, have disabling
conditions that interfere with their life activities. Working rates among the disabled
have dropped in recent years, causing an increase in the number of people receiving
disability payments. Those suffering from mental or addictive disorders comprise the
largest group collecting disability.
The Hopkins study is based on data from the National Institute of
Mental Health Epidemiologic Catchment Area (ECA) survey, and includes 11,981 people from
Baltimore, Md.; New Haven, Conn.; Durham, N.C.; and Los Angeles, Calif. Researchers
initially determined the rates of mental disorders and sociodemographic predictors of the
participants by using standardized interview questions to obtain DSM-III diagnosis. A year
later, the investigators returned to find that 2.2 percent of the initial group had
started to receive new mental disability payments. Those with less than an eighth grade
education were almost four times as likely to be receiving payments, while those whose
income was less than $5,000 per year were three times as likely. Those at risk for
receiving payments for a disability, however, were still more likely to suffer from mental
disorders than any other predictor, pointed out Anthony Kouzis, PhD, Assistant Professor
of Opthamology and Medicine at Johns Hopkins School of Medicine. The most common disorders
causing disabling conditions were panic disorder and schizophrenia. Kouzis said serious
mental illness often prevents people from performing their normal activities. ''Despite
the stereotypes, people receiving mental disability payments have psychiatric disorders
that could be treated, possibly allowing them to continue working or functioning
independently in the community,'' he said.
The study refutes the misperception that most people receiving mental
disability payments are addicted to alcohol or other drugs. ''Unlike what's been often
discussed in Washington or the news media, people suffering from alcohol or drug
dependencies are not those most likely to receive disability payments,'' said Kouzis. The
researchers found that those suffering from panic disorder, 5.1 percent, were most likely
to receive disability payments, while the rate for those suffering from alcohol dependency
was only 2.6 percent.
The authors, Drs. Anthony Kouzis and William Eaton, PhD, Professor of
Mental Hygiene at Johns Hopkins School of Public Health, say that a better understanding
of mental illness would help keep people off disability, or facilitate a quicker return to
work. ''Care and treatment services for conditions like depression aren't as plentiful as
they are for physical ailments like heart disease and cancer,'' said Kouzis. More funding
for preventive measures or workplace accommodations, such as counseling on the job and
more liberal leave, could ultimately reduce money spent on mental disability pay. |