Rekindling the debate over medical malpractice: A group of researchers this week estimated that the annual cost related to medical liability is $55.6 billion — or 2.4 percent of the nation's healthcare spending. 

The figure includes payouts to patients who sue for malpractice; costs racked up as doctors practice defensive medicine to avoid lawsuits; administrative costs, including lawyer fees; and the costs related to lost work time.

The report, published Tuesday in Health Affairs, is certain to catch the eyes of Capitol Hill Republicans, who have long pushed for Congress to take up malpractice reform, including a cap on "pain and suffering" awards surrounding malpractice cases.

Democrats have countered that malpractice is a vital recourse for injured patients which, anyways, isn't contributing much to the nation's skyrocketing healthcare tab. The authors of the study said both sides are exaggerating their case.

“Physician and insurer groups like to collapse all conversations about cost growth in health care to malpractice reform, while their opponents trivialize the role of defensive medicine,” Amitabh Chandra, a co-author of the study and professor of public policy at Harvard’s Kennedy School of Government, said in a statement. "Our study demonstrates that both these simplifications are wrong — the amount of defensive medicine is not trivial, but it’s unlikely to be a source of significant savings."

The researchers are quick to concede that their cost estimate for defensive medicine — which they peg at $45.6 billion per year — is shrouded in "considerable uncertainty."

Still, they also note the value of having hard numbers to inform lawmakers as they continue their struggle to rein in the nation's astronomical healthcare spending.

“We cannot debate the potential for medical liability reform to bring down health care costs in any meaningful way without realistic cost estimates,” said Michelle Mello, the lead author and professor of law and public health at the Harvard School of Public Health.

"Some of the numbers bandied about in policy discussions were quite imaginative and we wanted a more defensible estimate."

Still plagued by a lack of primary care docs: More and more patients are rushing to the emergency room — not to their primary care doctor — for acute care—treatment, according to yet another Health Affairs report published this month. 

Twenty-eight percent of patients suffering acute symptoms — including fever, chest pain and stomach pain — went to the ER between 2001 and 2004, the researchers found. The trend is due largely to the dearth of available primary care doctors, combined with a lack of patient access to those physicians after-hours. 

"Primary care doctors have packed schedules and their offices are typically closed in the evenings and on weekends," Stephen R. Pitts, the lead author and an associate medical professor at Emory University School of Medicine, said in a statement. "Too often, patients can’t get the care they need, when they need it, from their family doctor."

Egg graders with the U.S. Department of Agriculture were present at two Iowa egg processors at least 40 hours a week before they were involved in a national salmonella outbreak, USA Today reports.

The staff charged with inspecting the size and quality of eggs at Wright County Egg and Hillandale Farms were also supposed to check for rodents and other disease-spreading vermin, the newspaper reports. But the USDA says its egg graders only look for vermin in the processing buildings where they're based.

The Senate is expected to take up food safety legislation this fall that would increase the Food and Drug Administration's authority. Rep. Rosa DeLauro (D-Conn.), chair of the House Appropriations Agriculture subcommittee, has asked the USDA for more information about what its egg graders knew of conditions at the plant.

"It has never been more clear that we need to pass strong FDA food safety legislation this year," said DeLauro. "In the long term, a single food agency is needed that focuses exclusively on protecting our food supply."

"USDA has been working to close gaps and improve the safety of the meat, poultry and processed egg products over which we have authority and the FDA is taking action to address the fact that they have not had all of the tools needed to prevent outbreaks in areas where they have authority, such as shell eggs," Agriculture Secretary Tom Vilsack told USA Today.

A new White House proposal to revamp Medicaid's drug rebate formula is drawing applause from the nation's pharmacists, who have long argued the current equation — though largely delayed by a court ruling — would underpay them for generic drugs.

The new proposal, issued Friday by the Centers for Medicare and Medicaid Services (CMS), would eliminate certain provisions defining both the "average manufacturers price" and the "federal upper limit" under Medicaid's drug rebate program.

The move — largely done in recognition of related provisions in the new health reform law — marks "a victory for patient care as it is delivered in America’s pharmacies every day," according to leaders of the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA), who issued a joint statement Friday.

"The end result is not an increase in reimbursement to pharmacy," the groups said, "but rather the lessening of cuts that previously would have involved pharmacies selling most generic drugs at a loss, thereby threatening their long-term ability to provide patient care."

Friday's proposal follows a long tug of war between Congress, CMS and the pharmacy lobby over how Medicaid drug rebates should be determined. 

The 2005 Deficit Reduction Act (DRA) required CMS to set Medicaid's federal upper limits (FULs) — which represent the maximum amount the program will pay for drugs — at 250 percent of the average manufacturers price (AMP) of the cheapest version of therapeutically equivalent drugs. But in 2007, after CMS finalized its rules for implementing the provision, the retail pharmacists (both NACDS and NCPA) sued. The groups were wary that the new formula would undervalue the true cost of many generics to pharmacists, forcing them either to take a loss or not offer those drugs at all. 

Several government reports backed those concerns. Post-DRA surveys conducted by both the Government Accountability Office (GAO) and the Health and Human Services Department found that AMP-based FULs would have set generic rates for many drugs at levels far below what pharmacies were paying for them. 

In December of 2007, a federal judge sided with the pharmacists, issuing a court injunction preventing CMS from implementing many of the changes. 

The issue has major cost implications for Medicaid, because pharmacies losing money on generic prescriptions would have every incentive to switch to more expensive branded drugs, resulting in higher costs for taxpayers.

In response, Democrats included language in their health reform law designed to better approximate the true cost of generics to pharmacists.

Under the law, CMS will determine FULs based on no less than 175 percent of the weighted AMP — which will be calculated according to utilization — rather than using an AMP based on the cheapest version of the drug. The weighted AMP is designed to be a more accurate gauge of the cost to retail pharmacies — not least because it excludes mail-order pharmacies.

Sen. Dianne Feinstein pushed back this week against the argument — aired recently by voices on both sides of the aisle — that she's obstructing a food safety bill moving through Congress.

"I have never expressed opposition to it, nor have I refused to allow it to move forward unless my BPA legislation is in the bill," the California Democrat wrote Friday in Politico. 

The "BPA" reference is to Feinstein's proposal to ban the use of Bisphenol A (BPA) in children's food and beverage containers. A toxic chemical linked to cancer, BPA is used in countless plastic products, including water and baby bottles. Feinstein is hoping to attach her amendment to a food safety bill Senate Democrats want pass later this year. 

The House sponsor of that legislation, Rep. John Dingell (D-Mich.), has already made crystal-clear his concerns that such an addition could sink the underlying bill — a proposal the 84-year-old Michigan Democrat has been pushing for years.

“Time is running out,” Dingell wrote to Feinstein in July. “Our choices are becoming increasingly clear, we can either find middle ground, or we can become obstinate in our views and fail to meet any of our goals."

The House passed the Dingell bill almost 14 months ago, by an easy margin of 283-142.

Former GOP Rep. Bob Barr (Ga.) this month also went after Feinstein for allegedly obstructing the bill. Her amendment, Barr wrote Wednesday in Politico, is "a poison pill" in the eyes of many lawmakers because "banning the use of BPA in food packaging would make canned and packaged food much less safe, even as it would make those products much more expensive, because there are simply no viable alternatives yet developed at a reasonable cost.

"Senate Majority Leader Harry Reid and the president need to take Feinstein to the woodshed and explain all this to her," Barr wrote.

In her response to Barr Friday, Feinstein took on both allegations head on.

"What I have asked for is the opportunity to offer an amendment to the bill that would ban BPA from children’s food and beverage containers," she wrote. "A simple up-or-down vote — that’s it."

As for Barr's claim that there are no alternatives to BPA: "This is inaccurate," Feinstein writes. 

"My amendment does not include a ban on general consumer products and cans. It would phase out BPA in children’s food and beverage containers: baby bottles, sippy cups, baby food and infant formula — all of which have alternative, safe, BPA-free packaging."

Senate leaders are hoping to take up the food safety bill later this month after Congress returns from its summer vacation.

Earlier in the year, Sen. Ron Wyden championed a provision of the new healthcare law allowing states to ignore certain requirements in the law — even the individual insurance mandate — as long as they create alternative systems pre-approved by the White House. 

This week, the Oregon Democrat explained (again) the thinking behind that provision. 

"When it comes to health policy, what works best for people in Tampa Bay, Florida, doesn't always work as well for the residents of Coos Bay, Oregon," Wyden writes Friday in the Huffington Post. "For states to really be empowered to be innovative the federal government has to be willing to give states a little leeway to implement their own approaches. 

"A state, for example, will struggle to offer a public option on its exchange if it has to follow the exact standards of the federal law that doesn't provide for one. And, of course, no state-based approach — no matter how innovative — can work if everyone who participates in the state program gets fined by the federal government for failing to comply with the federal mandate."

Under the Democrat's reform law, Wyden's waiver provision doesn't kick in until 2017. But the Oregon Democrat is already fighting to expedite that launch date, to 2014. 

"The reason for this," Wyden writes, "is that it's a lot less cost effective for states to implement their own approaches in 2017 if they also have to pay to implement the federally mandated approach in 2014."

Sen. Tom Harkin (D-Iowa) this week called for quick installation of new rules designed to rein the exploding career college industry, which feeds a large portion of the nation's growing need for healthcare professionals.

"There is evidence that too many of these institutions are driven more by the profit motive than their commitment to educating students," Harkin said in a Washington Post op-ed published Friday. "We must guard against for-profit schools that load up students with tens of thousands of dollars of debt in exchange for largely worthless degrees."

Stricter rules, added Harkin, who chairs the Senate Health, Education, Labor and Pensions Committee, "are urgently needed to take advantage of the strengths of for-profit institutions while avoiding their pitfalls."

The exploding growth of career colleges has raised eyebrows in Washington, not least because those schools got roughly $24 billion in federal tuition subsidies last year — a figure representing 23 percent of the $105 billion in Title IV education funding allocated in the 2008-2009 school year. 

Those subsidies have helped to fuel the enormous growth of career colleges, which have seen enrollment soar roughly 500 percent — from 365,000 students to 1.8 million students — in just the past few years, according to the Government Accountability Office (GAO).

Harkin said that, at certain schools, those subsidies represent as much as 90 percent of all revenues. "In some cases," he adds, "close to 30 percent of that federal investment is being spent on marketing and advertising to persuade students to enroll."

Such concerns have been agitated by recent reports revealing that shady marketing and recruitment practices — even fraud — are not uncommon in the industry. Some recruiters, the GAO found recently, were overpromising the salaries available after graduation, raising concerns that those students would be at risk of defaulting on federal loans at the taxpayers' expense.

In response, the Obama administration has proposed a series of rules designed to ensure that the schools are pumping out graduates employable enough to pay off the debts they incur. 

The industry has pushed back hard, arguing that a number of those proposals would hobble their recruitment and retention of students, leading to glut of workers in the fields being fed by for-profits.

Harkin, though, is backing those proposed rules. 

"New steps can ensure that these students get accurate information about the costs and likely outcomes of educational programs, while weeding out the programs that would leave them with debts they are unlikely to be able to repay," he wrote Friday. "The government should not be in the business of subsidizing for-profit institutions that leave students saddled with onerous debts they cannot repay and degrees or credentials that are of little value."

The issue is of particular importance to the growing health services sector, because career colleges train more than 40 percent of students receiving health degrees and certificates requiring two years of schooling or less, according to the latest survey from the National Center for Education Statistics.

Donald Berwick, head of the Centers for Medicare and Medicaid Services (CMS), is fighting back this week against Republican attacks on the new healthcare law.

Responding to recent GOP claims that the Democrats' reforms are a threat to Medicare, Berwick said Friday that, on the contrary, the healthcare law has made the program "stronger than it has been in years."

"It's no illusion to the seniors and people with disabilities who will pay less for prescription drugs, to the millions of Medicare beneficiaries who will have preventive care and check-ups covered without paying co-pays, or to the people who will be protected from fraud and abuse," Berwick writes in a Washington Post op-ed. "Under the act, Medicare is stronger than it has been in years, and seniors will get new benefits. That's no illusion; that's progress."

The comments are a direct response to another opinion piece penned last week by Michael Leavitt, head of the Health and Human Services Department (HHS) under former President George W. Bush. Also writing in the Post, Leavitt charged that the new healthcare reform law "has weakened" Medicare. 

"Worse," Leavitt wrote, "its changes create the perception of progress, making it more difficult to pursue the reforms that would put Medicare on sound financial footing so future generations of seniors will benefit."

The "perception of progress" was a reference to a recent projection from Medicare's trustees that healthcare reform will extend Medicare's solvency through 2029 — 12 years longer than predicted last year before the law was passed. 

Critics, including many Republicans, say that the math is illegitimate because it "double-counts" the savings generated under the bill, applying those funds both to extending the program and to extending coverage to the uninsured.

Berwick this week says that charge is "inaccurate and oversimplifies what is really going on." 

Rather, he argues, new savings and revenues under the law will go toward extending Medicare's trust fund, and any funds not needed immediately will be invested in Treasury bonds.

"These dollars are used to help cover other investments, such as expanding health coverage to 34 million uninsured people," he writes. "Later, when the trust fund needs to cash in its Treasury bonds, they are repaid, with interest."

Those are rules, he noted, "that Republican and Democratic administrations have used for decades."

Berwick also takes on the critics who claim that cuts to the Medicare Advantage (MA) program — under which the government pays private insurers to cover Medicare patients — threaten patient care.

The CMS chief notes that the Medicare Payment Advisory Commission has for years found that Medicare spends much more on MA patients than those in the traditional program — "without yielding measurably better health outcomes."

A part of those subsidies go to cover the marketing, salaries and other administrative costs at the for-profit companies, leading critics to wonder why the MA program exists at all.

"The new law eliminates these unwarranted subsidies," Berwick writes, "and, for the first time, financially rewards Medicare Advantage health plans that do a better job of providing quality care."

Berwick ends with a final jab at his GOP critics.

"I share Michael Leavitt's belief in the seriousness of the challenges before us," he says, "but I do not share his pessimism."

Worker health issues back on the radar: Advocates are pushing for shorter shifts for medical residents and mandatory flu shots for healthcare workers. Meanwhile, the U.S. Chamber of Commerce rings the alarm bell over mine safety legislation pending in Congress.

Sleep deprivation linked to medical errors: The Occupational Safety and Health Administration (OSHA) issued a statement late Thursday linking medical residents' long hours to a range of safety issues.

"We are very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents," said David Michaels, the Labor Department's OSHA assistant secretary. http://bit.ly/cNSSUf

The statement comes in response to a petition by Public Citizen, SEIU and others requesting that OSHA assume jurisdiction over the work hours of physician residents — and to put strict limits on what those hours can be. http://bit.ly/9OCmVi