Joint Committee on Health Care Delivery and Financing

Joint Committee on Health Care Delivery and Financing • Maryland General Assembly Joint Committee on Health Care Delivery and Financing 2012 Interi...
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Joint Committee on Health Care Delivery and Financing



Maryland General Assembly Joint Committee on Health Care Delivery and Financing 2012 Interim Membership Roster Senator Robert J. Garagiola, Senate Chair Delegate Dan K. Morhaim, House Chair Senator Delores G. Kelley, Senate Vice Chair Delegate Shane Pendergrass, House Vice Chair Senate Members Edward J. Kasemeyer Roger Manno C. Anthony Muse E. J. Pipkin Catherine E. Pugh

House Members Donald 8. Elliott A. Wade Kach Peter F. Murphy Shirley Nathan-Pulliam Veronica L. Turner

Committee Staff Jennifer A. Ellick Linda L. Stahr

Joint Committee on Health Care Delivery and Financing 2012 Interim Report The committee met twice during the 2012 interim: September 19, and December 4. A third meeting scheduled for October 30 was cancelled due to Hurricane Sandy. At the meetings, the committee received briefings on long-term care and community support and services, medication shortages, and environmental pollution as a cause of illness. Summaries of the issues discussed follow.

Long-term Care and Community Support and Services On September 19,2012, the committee held a briefing on long-term care and community support and services. The briefing included presentations by the American Association of Retired Persons' Public Policy Institute, which gave an overview of its recent state scorecard on long-term services and supports; the Department of Health and Mental Hygiene (DHMH), which gave an update on long-term care in the State with an emphasis on Medicaid; and long-term care providers. The committee learned that Maryland scored an overall ranking of 24 in the state scorecard on long-term services and supports. With regard to the scorecard's four key dimensions, Maryland was ranked third in affordability and access; twenty-eighth in choice of setting and provider; thirty-third in quality of life and quality of care (due in part to the relatively high incidence of pressure sores reported in the State); and thirty-fourth in support for family caregivers (due in part to relatively few legal and systemic supports offered to family caregivers). At the State level, the number of individuals served by community-based long-term services and supports has been growing and is expected to continue to do so. New federal programs such as Community First Choice and the Balancing Incentives Program further expand and enhance community-based services for Medicaid recipients and providers. Meanwhile, DHMH is using technology - including two newly created tracking systems - to reduce paperwork, better coordinate services, and improve quality and efficiency. The committee recommends continued study of issues related to long-term care and community support, including quality of life and quality of care in nursing homes and in home health services; and the need for enhanced legal and systemic support for family caregivers.

Medication Shortages On December 4, 2012, the committee held a briefing on medication shortages. The briefing included presentations by staff to the Committee on Oversight and Government Reform of the U.S. House of Representatives; the Johns Hopkins Bloomberg School of Public Health;

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Department of Legislative Services

health care practitioners in hospital pharmacy, oncology, and emergency medicine; and a national association of pharmaceutical distributors. While occasional drug shortages have occurred in the past, frequent and persistent shortages started about two years ago. A survey by the American Hospital Association found that 80% of hospitals report delays in patient care due to drug shortages; 50% report that they could not provide the recommended treatment to some patients; and about 75% say they have had to ration certain medications. Most of the drugs affected are generic injectables, including those for chemotherapy, antibiotics, anesthetics, and electrolytes or nutritional drugs. The Johns Hopkins Bloomberg School of Public Health conducted a study of drug shortages for the U.S. Food and Drug Administration (FDA). In its study, the school found that, although there were a variety of reasons for drug shortages, problems at manufacturing facilities accounted for 43% of the disruption in the 2010 to 2011 period. The study reported that FDA can require notification of a drug manufacturing problem in certain circumstances but cannot require a company to make a drug; regulate how much of, and to whom, a drug is sold; or regulate price gouging. Since the study was completed, President Barack Obama has issued an executive order requiring broader reporting of manufacturing discontinuances, further expediting of regulatory review, and reporting of stockpiling and exorbitant pricing to the u.S. Department of Justice. Earlier notification is credited with reducing the number of drug shortages from 2011 to 2012. However, additional efforts to address the problem are needed and will need to be multifaceted, sustained, and involve multiple stakeholders. The committee learned that the drug shortage problem is exacerbated by pharmacies and wholesalers in Maryland and other states that sell scarce drugs to each other and mark up the price as the drugs move through the "gray market." According to a Congressional investigation, one chain of pharmacies and wholesalers in Maryland marked up prices from an initial $7 to $600, a markup of 8471 %. U.S. Representative Elijah E. Cummings has introduced legislation to expand the powers of national and state agencies to oversee distribution of crucial drugs. The legislation would create a national database of drug wholesalers and prohibit pharmacies from selling their stock to wholesalers. Currently, Maryland law and regulation allow pharmacies to sell 5% of their stock to other companies, rather than to individual patients or medical facilities. However, there are no requirements to report what percentage of a pharmacy's stock is sold to each type of customer. The investigation found that pharmacies were exceeding the limit and profited by selling shortage drugs to wholesalers. As a result of certain drug shortages, hospitals and doctors have had to turn to substitute drugs, which may not be as effective as the shortage drug, may have worse side effects, and are often more expensive. Anne Arundel Medical Center considered canceling some surgeries when the hospital was running low on a common drug used to help bring people out from under anesthesia. The Maryland Hospital Association reported that drug shortages have significantly increased costs for drugs, as hospitals are forced to buy drugs from repackagers, the gray market, and sources outside the United States. Use of drug compounders has also increased. Hospitals are also incurring higher personnel costs to manage their drug supply.

Joint Committee on Health Care Delivery and Financing 2012 Interim Report

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The Healthcare Distribution Management Association (HDMA) represents primary distributors, which sell only to appropriately licensed healthcare providers and entities. HDMA, in collaboration with its distributor members, manufacturers and providers, completed voluntary guidelines on improving communication between supply chain partners in the event of a product shortage. HDMA has supported enhanced distributor licensing standards to enhance the safety and security of the pharmaceutical supply chain. The committee recommends continued study of the medication shortage issue, including pharmaceutical distributor and pedigree requirements, pharmacy benefit manager requirements, the need for legislation regarding pharmacy sales to wholesalers, tracking medications from outside the State that come into the State, and possible sharing arrangements (as done for influenza vaccine).

Environmental

Pollution as a Cause of Illness

On December 4, 2012, the committee held a briefing on environmental pollution as a cause of illness. The briefing included presentations by the Anne Arundel Health System and DHMH. The committee learned that a 2005 study found hundreds of chemicals, pesticides, and pollutants - a majority of which cause birth defects, cancer, infertility, and/or toxicity to the brain and nervous system - in the umbilical cords of infants. Researchers have estimated that the costs of covering the health expenses of American children who were sick due to exposure to toxic chemicals and air pollutants exceeded $76 billion in 2008; these costs included those associated with lead poisoning, autism, intellectual disabilities, mercury poisoning, Attention Deficit Disorder, asthma, and childhood cancer. At the federal level, regulation is generally still focused on individual chemicals rather than cumulative hazards. States, including Maryland, have been increasingly active in chemical regulation - but face a number of challenges including lack of resources, imperfect science, and changes in federal funding and policies. The committee recommends continued study of this environmental health issue, including how to develop a more comprehensive approach to chemical and pollution that moves beyond the regulation of individual chemicals; how to better understand where exposures occur in the State; and how to address disparities in exposure and outcomes.

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