Commentary

Everybody knows that kids need “baby shots” – immunizations that protect against formerly common childhood diseases. The shots are required for school entry, so most children are up to date by the time that they are 5 years old.

But what many of their parents and grandparents don’t realize is that adults need immunizations as well. And the adults lag far behind the kids in getting the shots that they need.

A bill currently pending in the Georgia Legislature (SB 85) – which would permit pharmacists to administer some immunizations that are currently off-limits to them – might help rectify the situation.

Pharmacists are already authorized to give flu shots, so simply adding additional vaccines to the list should not be a problem.The Centers for Disease Control recommends that all adults have a “Tdap” shot, which combines the vaccines for tetanus, diphtheria and pertussis (whooping cough); that people over 60 have a shingles shot; and that those over 65 have a pneumococcus shot.

But in the most recent survey, fewer than two-thirds of adults had received a Tdap or a pneumococcus immunization, and fewer than 20 percent had received a shingles immunization. Rates are lower among African-Americans and Hispanics than among whites.

Adults with chronic conditions, such as diabetes, heart disease or HIV infection, may need additional immunizations, or the routine immunizations at an earlier age. And the CDC recommends a flu shot every year for everybody over 6 months old.

Teenagers need immunizations as well, including Tdap but also vaccinations that protect against pneumonia, meningitis and human papillomavirus (the virus that causes cancer of the cervix). However, teens are no more up to date than adults, and in Georgia they lag behind the national average.

One of the consequences is that we are suffering through a national whooping cough epidemic, with tens of thousands of cases reported since 2005. The disease is generally less severe in adults than in children, but adults can transmit the disease to children. Whooping cough is particularly severe in infants, in whom it can cause death.

Even if the bill becomes law, older adults and the parents of teens will need to be more conscientious about getting the shots they need – if not from a pharmacist or a private physician, then through the public health department, where immunizations are available at low cost. It is time for us adults to start acting like grown-ups!

Dr. Daniel S. Blumenthal is associate dean of Community Health at the Morehouse School of Medicine, works closely with the Centers for Disease Control and Prevention, and is a leading national expert on immunizations, and the racial, ethnic, and socioeconomic disparities in vaccination rates

We are at a point in the fight against cancer where decades of discoveries are translating into new diagnostic and treatment tools at an accelerated rate.

Unfortunately, this comes at a time when the agencies that fund cancer research face dire cutbacks.

Because Congress must make difficult decisions on what to cut, I went to Washington this week to speak to a committee of lawmakers about the relationship of the National Institutes of Health (NIH) to our nation’s cancer centers.

I felt it was important to offer tangible proof of the great strides that have been made in treating cancer because of NIH-funded research.

As the executive director of the Winship Cancer Institute of Emory University, and as a practicing radiation oncologist and cancer researcher, I see cancer patients every day. And I’ve seen how budget cuts are already slowing down the progress toward finding new cancer treatments that change a patient’s chances of beating the disease.

In Washington, I spoke on behalf of the Association of American Cancer Institutes, addressing members of the House Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies. The chairman of that subcommittee is Rep. Jack Kingston (R-Ga.), who’s from Savannah.

Rep. Kingston visited Winship in January 2012 and took away a new understanding of how research at a cancer institute translates directly into patient care. I urged other committee members to visit the cancer centers in their districts to see the outstanding work being done there.

The National Cancer Institute (NCI) is one of the NIH’s institutes. NCI awards its designation to cancer centers that demonstrate expertise in laboratory, clinical, and behavioral and population-based cancer research through successful competition for a Cancer Center Support Grant (CCSG). Winship first received NCI designation in 2009. It recently renewed its designation and CCSG through a competitive process, receiving a rating of “Outstanding” by a peer panel.

Winship is the first and only NCI-designated cancer center in Georgia.

While Congress continues to debate the remainder of the fiscal 2013 budget, NIH and NCI have prepared for cuts through fiscal 2021.

NIH will suffer a cut of $1.6 billion overall, with NCI losing approximately $250 million. These cuts will have a real impact on progress against cancer at Winship and other cancer centers. Continued progress in cancer research is dependent on the sustained efforts of highly skilled research teams at cancer centers across the country, supported by the NCI.

So much promise imperiled

A budget cut to NIH and ultimately NCI will decrease funding to cancer research in all parts of the country and affect many of the research teams working on new treatments and new cures. Rebuilding such teams, even after a short break in funding, could take years.

As an example, Winship has an outstanding research team making real progress understanding how to target newly discovered mutations causing lung cancer, the type of cancer causing the most deaths in our country.

We are seeing an increase in the number of lung cancer patients who have little or no history of tobacco use, and we are just beginning to understand the genetic risk factors of such individuals for developing lung cancer. A break in funding support of this and other projects could delay finding new and effective therapies for thousands of patients by years.

Our nation’s cancer patients deserve greater research attention to this deadly disease. More than 1.6 million Americans were diagnosed with cancer in 2012, with more than 570,000 people dying from the disease.

With 25 percent of all deaths in America caused by cancer — almost 1,600 per day — the disease is the nation’s second-leading cause of death. NCI estimates that 41 percent of individuals born today will receive a cancer diagnosis at some point in their lives.

But research has brought us to the point where we have better tools for treating cancer than ever before. At Emory’s Winship Cancer Institute, we are excited about the new proton beam therapy facility under construction in Atlanta, as well as the increasing number of our patients being enrolled in cancer clinical trials.

We also offer promising new therapies to patients in our specialized “Phase I” unit, which allows us to carefully study all the beneficial and any harmful effects of these therapies. We have offered such groundbreaking Phase I treatments to nearly 200 Winship patients per year.

We see that the impact of budget cuts through fiscal 2021 has already begun to affect our progress in research. Immediate effects will be felt in our research labs, with promising research slowed or even shut down; pending projects wiped off the boards; the next generation of bright young researchers unable to learn cancer research at the side of experts; and layoffs among trained cancer staffers, including those who coordinate clinical trials that test new cancer therapies.

At Winship, we enrolled more than 700 cancer patients, from all across the state of Georgia and beyond, in trials testing new treatments in 2012. We aspire to increase the number of cancer patients whom we can offer such hope, but we need sustained support to achieve this.

Cuts dangerous for economy

In addition to cancer centers, the NCI supports cancer research in communities all across America through the National Clinical Trials Network and its newly reorganized five cancer cooperative groups.

Twenty thousand to 25,000 patients participate in these network trials each year, and this research has defined many of the best treatments for today’s and tomorrow’s cancer victims. This research is well coordinated with our cancer centers and is necessary for outreach beyond our research universities into community medical practices, and for finding answers to some of the toughest cancer research questions as quickly as possible.

It is through this network that patients in such locations as southeastern Georgia are able to enroll in cancer clinical trials with their community oncologists.

Unfortunately, NCI support for these cancer cooperative groups has remained flat for more than a decade. Sustaining this support is critical to providing cancer patients the best access to the outstanding cancer care available through their participation in NCI-supported clinical trials.

NIH plays a vital role in our cancer centers’ research and also affects our nation’s overall economy. A United for Medical Research analysis released in January of 2013 projected the nation’s life sciences sector, which includes cancer research, would lose more than 20,500 jobs and $3 billion in economic output due to cuts to NIH.

These serious consequences for biomedical jobs and local economies mean that funding cuts will undermine U.S. competitiveness, at a time when other nations are aggressively boosting their investments in research and development.

We risk driving an entire generation of young cancer physicians and researchers out of the country — to practice their craft and advance their careers abroad — or out of the field altogether. At Winship, this threat is real, and we cannot afford to experience such loss. Such declines in funding will prevent Winship and other centers from quickly moving to a broader platform of personalized cancer care and research.

This personalized approach requires a time- and resource-intensive approach to every patients’ cancer to understand the very best plan for each patient’s care. This effort is well under way at Winship and other centers and will require a sustained and significant level of support to yield the positive results that we expect.

NIH’s full support of NCI-designated centers and their programs remains a top priority for our nation’s cancer centers. We are on a clear path to dramatic breakthroughs, both at Winship and at cancer centers throughout the country.

We have come too far in cancer research progress to lose Congress’ full support of NIH, and ultimately, NIH’s funding of NCI-designated cancer centers and the National Clinical Trials Network. Cancer patients and their families deserve the best that NIH, NCI and our cancer centers have to offer in order to provide lifesaving treatment.

Dr. Walter Curran is executive director of the Winship Cancer Institute of Emory University, the Lawrence Davis Professor and chairman of Emory’s Department of Radiation Oncology, and a practicing radiation oncologist.

Charles Hayslett

The recent closing of Calhoun Memorial Hospital in tiny Arlington, Ga., comes not just as another body blow to health and health care in impoverished areas of rural Georgia — but as a dagger to the heart of hopes for any kind of economic development or improvement. It also adds more weight to an anchor that already holds down the entire state’s economy.

As it happens, news of the Calhoun Memorial closing came as the Partner Up! for Public Health campaign was finalizing research and analysis on health and economic disparities in Georgia — research that had documented that Calhoun County was part of a cluster of counties in southwest Georgia that constitutes the least healthy region of the state.

Of 156 Georgia counties ranked by the University of Wisconsin in its annual County Health Rankings (three are too small to rank), Calhoun County ranked 154th for Health Outcomes. Its neighboring counties fared little better: Randolph ranked 147th, Quitman 149th,
Early 150th, Stewart 153rd, and Terrell 155th. Only Clay County escaped the Bottom Ten, coming in at 100th.

The underlying data are just as startling. The premature death rate for the seven-county region is nearly 14 percent worse than that of Mississippi, the state that ranks worst in the nation. It’s also 130 percent worse than the premature death rate in the healthiest area of Georgia, the five-county region of north metro Atlanta made up of Forsyth County (2nd in the Wisconsin report’s ranking of Health Outcomes), Cherokee (4th), Gwinnett (5th), Cobb (6th) and Hall (9th).

And while Calhoun County and its neighbors suffer with a premature death rate worse than the worst in the country, the north metro area boasts a rate better than the best-ranked state, Minnesota.

If that doesn’t tell you all you need to know about health disparities in Georgia, consider this: The low-birthweight rate in the southwest Georgia cluster is 14.3 percent versus 7.6 in the north metro area; the adult obesity rate is 34.2 percent versus 25.13 percent, and the teen birth rate is 76 births per 1,000 women aged 15-19 in southwest Georgia compared to 39 in the north metro counties.

All these conditions come with massive costs in health care, social services and lost opportunities. If all those costs were confined to southwest Georgia, the rest of the state might be able to dismiss the problem as simply a localized tragedy.

It is not. Those costs are — to use a dirty word — effectively “socialized” in a variety of ways: higher Medicaid expenditures for citizens of those counties, and higher state job tax credits that go to employers in poor counties, among others. Like it or not, the north metro Atlanta counties are stuck with a share of southwest Georgia’s tab.

This is not an appeal to spend less on Calhoun County and its sick and impoverished neighbors in southwest Georgia, let alone send a message that they’re on their own. Short of sawing the state in half at the “gnat line” and quit-claiming South Georgia to Florida, there exists a shared interest in continuing efforts to build the economy in that area.

We at Partner Up! for Public Health have long argued that people’s relatively poor health status and poor access to health services in rural Georgia constitute a major strategic threat to the economic prosperity of the entire state. We have also argued that state government needs, on some meaningful level, to integrate its health planning and economic development efforts (and, for that matter, education). Currently it does not.

This is not a new or radical idea. As far back as 1970, gubernatorial candidate Jimmy Carter talked about the importance of improving access to health care in rural areas as a prerequisite for economic growth. (As president a few years later, he sought and won passage of the Rural Health Clinic Services Act of 1977, which expanded access to care in rural areas nationally.)

As recently as 2004, Gov. Sonny Perdue’s Commission for a New Georgia produced a report that identified health care (along with education) as a fundamental building block for economic development. In an email exchange with me several months ago, the chairman of the task force that produced that report, David C. Garrett III, said he had told audiences at the time that “economic development in the absence of quality health care was an illusion.”

That was true in Carter’s day and in Perdue’s, and it’s true now. Just ask the folks in Calhoun County.

Charles Hayslett, CEO of Hayslett Group LLC, a public relations firm, is manager of Partner Up! for Public Health, funded by Healthcare Georgia Foundation.

Suzanne Newkirk

Looking at the lush greenery of the Georgia mountains or the enticing beaches and barrier islands along the Georgia coast, few people would describe the state as a desert, except for the thousands of Georgians who lack dental insurance or funds for basic preventive dental care.

The U.S. Department of Health and Human Services (HHS) defines a ”dental desert” as an area with a shortage of dental health professionals. As of 2011,  there were 49 million Americans living in dental deserts. According to HHS, it would take nearly 10,000 additional dental practitioners to meet the current needs of these Americans.

Georgia ranks among the top 10 states both in current population and rate of population growth. But with just one dental school, Georgia is ranked 46th among states for its number of dentists per capita. This means that too many people in Georgia don’t have access to dental care.

Regrettably, the Georgia Dental Association (GDA) denies there is a shortage of dentists in the state, despite the number of uninsured and low-income Georgians who seek emergency dental care at hospitals. Statewide in 2009, the 60,000 emergency dental visits cost taxpayers $25 million.

Lynne Slim

Administering dental care in an emergency room is prohibitively expensive and inefficient. And it doesn’t solve long-term dental problems . . . problems that are preventable.

Dental caries remains the single most common, chronic disease of childhood. When left untreated, caries (commonly referred to as cavities or tooth decay) results in pain, infection, distraction from learning, missed school days and sometimes an inhibition of general growth and development because of associated nutritional liabilities. Severe abscesses, caused by untreated decay, send many Georgians to emergency rooms.

Periodontal disease (which affects tissues around the teeth) is primarily a disease of adulthood – typically established during adolescence and continuing throughout life. It is the most common cause of adult tooth loss.

Low-income Georgians know only too well the impact these untreated diseases have on one’s overall health, speech, appearance and self-esteem.

Lack of access to dental care has become a national crisis. Thirty-five states now allow dental hygienists to provide care directly to patients; 15 permit direct Medicaid reimbursement from the state to dental hygiene providers. Forty-four states allow general supervision, meaning dental hygienists can provide care without the direct supervision of a dentist.

Because oral diseases are mostly preventable, many states are adjusting their rules to allow hygienists to provide services in nontraditional dental settings, such as clinics, nursing homes, hospitals, and facilities that treat people with developmental disabilities. But Georgia is not one of these states.

A former Georgia public health director said the state’s current rules governing hygienists “are among the most stringent in the nation.’’ This is bad news for low-income adults in Georgia because there are no viable government programs for adults. Unless low-income adults are lucky enough to find a dentist who accepts Medicaid for an emergency visit only — or are unlucky enough to be behind bars — they generally do without dental care.

In January 2010, the GDA voted to establish the Georgia Mission of Mercy, a two-day dental clinic to provide free access to dental care for about 2,000 adults unable to pay for treatment. This effort took 15 months of planning and involved 1,400 volunteers, including 300 dentists and 150 hygienists.

In August 2011, the event took place, with the first patient in line arriving 17 hours early. By early morning, thousands of people created a line 2,000 yards long. The two-day event provided $1.7 million in free dental care to 2,179 Georgians suffering from oral disease and pain. Along with providing dental care, the project’s goal was to educate patients and family members about the importance of dental hygiene.

While the GDA professes the importance of dental hygiene education, it fiercely restricts people’s access to dental hygienists.

It is estimated that by 2014, under the Affordable Care Act, 5.3 million more children will be entitled to dental benefits from Medicaid and the Children’s Health Insurance Program. Unfortunately, Georgia Gov. Nathan Deal has said he will not expand the Medicaid program under the ACA, even though the federal government has promised to pay 100 percent of the cost for the first three years and 90 percent thereafter.

Expanding the state-based health insurance program for poor Georgians in 2014 would provide health coverage for approximately 650,000 low-income people. About 20 percent of Georgians do not have health insurance, making Georgia one of the leaders in states with the most uninsured residents.

In July 2012 in Atlanta, dental providers, researchers, legislative leaders and health professionals gathered at a regional oral health conference sponsored by Morehouse School of Medicine, to focus on Georgia’s dental deficits and explore opportunities to improve access to oral health care.

Dr. David Satcher, a former U.S. surgeon general, and Dr. Louis Sullivan, a former U.S. secretary of health and human services, expressed support for the idea of dental therapists providing care in underserved communities.

Although Minnesota is currently the only state to license dental therapists, 20 states are actively exploring this innovative approach to expanding oral health care.

The American Dental Association (ADA) and its state dental associations vehemently oppose the creation of midlevel dental providers as a solution to the problem, denying there is a shortage of dentists. These groups usually win the legislative battles, but it’s the general public that loses out.

Of the 6,787 licensed dental hygienists in Georgia, many are unemployed due to an oversaturated market. And the state’s restrictive rules make it illegal for dental hygienists to provide services to the public without the direct supervision of a dentist, thus making dental care for low-income people even more cost-prohibitive.

A combined, consistent effort is urgently needed in Georgia to improve oral health care. If policymakers were to adopt legislation similar to that of Massachusetts, Georgia’s licensed dental hygienists could increase access to care for the poor and help lower the cost of preventable emergency dental visits, thus saving the state’s taxpayers millions of dollars, and expand employment for an existing workforce of licensed professionals.

Although the Georgia Dental Association asserts there is no lack of dentists in the state and continues to restrict hygienists’ ability to assist thousands of low-income people, eventually consumer advocates and oral health coalitions will persuade policymakers to make changes for the good of the public.

Until then, the dental forecast for Georgia is expected to stay hot and dry.

Suzanne Newkirk has been a dental hygienist for more than 30 years. She is is a periodontal therapist, dental hygiene coach and mentor, perioscopy instructor and national speaker. Ms. Newkirk is a member of the American Dental Hygienists’ Association, Georgia State Dental Hygienists’ Association and moderates the Perioscopy Users Forum on LinkedIn. www.perioscopyprofessionals.com

Lynne Slim is the periodontal therapy columnist for RDH magazine and an award-winning dental author who has published extensively in dental/dental hygiene journals. In 2003, she founded Perio C Dent, a dental practice management company that specializes in the incorporation of non-surgical periodontal therapy into the hygiene department of the general dental practice. She coaches dental hygienists and dentists in ultrasonic instrumentation and other advanced hygiene initiatives. She is owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist.

Peter Canfield

In the late 1980s, total health care fraud recoveries from whistleblower lawsuits averaged $5 million to $10 million a year.

Last year, the U.S. Department of Justice recovered a record $3.06 billion in health care fraud settlements and judgments — more than 80 percent of it in suits initiated by whistleblowers.

That says two things: Health care fraud is booming, but so is the power of its most effective opponent, the whistleblower.

In 1986, Congress rejuvenated the Civil War-era False Claims Act by permitting citizens with knowledge of fraud involving Medicare, Medicaid and other government programs to not only sue on behalf of the government but to be compensated for their part in fighting fraud with a portion of the funds recovered, typically 15 percent to 25 percent.

In the years since, the whistleblower has become the single most effective weapon in the fight against health care fraud.

Today, beyond the billions of dollars actually recovered each year in judgments and settlements, there is anecdotal evidence that just the potential threat of whistleblower lawsuits is saving billions more by encouraging pharmaceutical, medical device and other health care corporations to change their corporate culture and police themselves.

Whistleblower success has been met by efforts in the courts to whittle back whistleblower power. However, a rare bipartisan coalition in Congress has consistently rebuffed these efforts.

Major changes to the False Claims Act were enacted in 2009, expanding liability and making it easier to conduct investigations and win recoveries.  These changes were primarily intended to combat fraud in the nation’s financial markets but were made applicable across the board, including health care fraud cases.

Additional changes to facilitate whistleblower actions were made in 2010, in the Dodd-Frank Wall Street Reform and Consumer Protection Act, and, with specific attention to fraud in the health care industry, as part of the Patient Protection and Affordable Care Act.

Strengthening the federal power of whistleblowers has been accompanied by enactment of potent whistleblower statutes at the state level.  For many years, Georgia had a weak whistleblower law directed at Medicaid fraud.  Last year, with prodding from federal officials, the Georgia Legislature significantly encouraged whistleblower actions directed at fraud of all sorts at the state and local governmental level by enacting the Georgia Taxpayer Protection False Claims Act.

Blowing the whistle on health care fraud is not easy or trouble-free. A mere tip is not enough. A successful whistleblower case requires evidence, preferably documents. And although federal whistleblower cases are initially filed under seal, the whistleblower’s identity will eventually become known. Once that happens, the whistleblower often becomes a target, facing isolation, humiliation and loss of employment.

Federal and state whistleblower laws do offer special protection to the whistleblower, but it can be a long time coming, as whistleblower cases typically take years until resolution.

Yet, people with the stamina and courage to be whistleblowers continue to step forward. A 2010 study published by the New England Journal of Medicine on health care fraud whistleblowers suggested they are driven to do the right thing. Often, they have tried to fix the problem from the inside and failed.

The study revealed four common motivators: justice, public safety, integrity and self-preservation. Not one of the whistleblowers  interviewed for the study said financial reward was a primary driver for their action.

As one of the whistleblowers interviewed said in describing motivation, “It’s not an act of heroism. It’s not an act of bravery. It’s an act of responsibility.”

That said, the law is now framed so that when the fraud is substantial and the recovery is large, the whistleblower can also receive a substantial percentage of the recovery as reward for his or her involvement in stopping the fraud.

Because the process is usually long and difficult, potential whistleblowers on health care fraud are advised to be careful and deliberate before starting the process. A whistleblower is not required to have a lawyer to proceed, but having one is a good idea.  There are pitfalls to avoid and important requirements to follow, including restrictions on public disclosure if you wish to remain eligible for an award.

It’s advisable early on to talk with a lawyer who knows how to bring a False Claims Act case and can explain what’s at stake in doing so. That discussion should be without charge. False Claims Act lawyers work on contingency, which means their success is dependent upon your success.

Peter Canfield is a partner at Dow Lohnes PLLC in Atlanta whose practice has focused on protecting the constitutional rights of his clients, including the  reporters, authors, newspapers, broadcasters and other media organizations involved in exposing wrongdoing by and against the government. He has also served as a federal prosecutor and as a deputy district attorney.

For more information, visit whistleblowerprotection.com.