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Mr. Day then moved to the cost growth by population for Medicaid and long term care and annual growth in long term care costs . Cost growth is driven by increased numbers of people coming into the program and by medical inflation and in utilization of services. Medicare on the acute care side is not a health program but a sickness program. Compare growth in population and growth in utilization and there is an increase each year. Total medical expenditures by service from 1991 to projected 2004 show pharmaceuticals are the largest cost driver. Long term care costs are significant and these include institutions and home costs. Community based services is one of the most significant and successful programs. These programs provide significant assistance to people and have changed their lives in many ways. Federal rules covering pharmacy coverage and percent pharmacy expenditures by population in FY 2002 were discussed. Considerable discussion on copay set in federal regulation. Average monthly prescription costs FY 1998 thru FY 2002 showed aged, blind and disabled to be considerably higher than TAF PLE. The list of the ten top drugs by expenditure in FY 2002 for all populations was discussed. Cost control measures implemented in the pharmacy program and the drug utilization in the nursing home setting were considered. In his concluding comments, Mr. Day noted that Medicaid is second only to public education in the number of citizens impacted by its services. Federal Medicaid dollars in the Kansas health system will total over $1.058 billion in FY 2004. Janis DeBoer, acting secretary, Department of Aging distributed material on 1 ; long term care services, nursing facility and home and community based services for frail elderly Attachment 5 2 ; Kansas senior pharmacy assistance program Attachment 6 ; . Ms. DeBoer elaborated on the Department of Aging funding sources, their FY 2002 expenditures, customers served and their HCBS FE waiting list of 1, 036 on 1 31 03. She quoted monthly medicaid averages on customers served and expenditures per customer in FY 1998 through FY 2002 and had comparison graphs. Research on whether home and communitybased services were less costly than nursing home care and whether home and community-based services reduce nursing home placement was presented. Barb Hinton of Legislative Post Audit summarized the issues relating to drugs paid for by Kansas' Medicaid Program from the Performance Audit, Reviewing the Medicaid Program's use of Generic Drugs. Control of the type of drugs prescribed to help ensure that the program pays for the most costUnles s spe cifically noted, the individua l remarks record ed he rein have n ot bee n transcribe d verb atim. Individual rem arks a s repo rted here in have no t been subm itted to the individuals appearing before the committee for editing or corrections and testosterone.
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Special Measures to Accommodate Young Children A great advantage of providing dental care to young children is that no special armamentarium is required. To accomplish an effective examination, nothing more than good illumination and a dental mirror is required. The child can be effectively positioned on the parent's or dentist's lap, 66 eliminating even the need for a dental chair. When more intensive dental treatment is required, the equipment and materials employed are the same as for older children and adults. It is the capacity of the provider to relate to and successfully engage the young child, not the physical equipment, that is critical. Necessary Training for Providers and Families Significant training in oral health is needed by both medical and dental providers since health professional education to date has generally ignored the dental component of early childhood. Needed are new curricula and educational experiences for dentists, hygienists, physicians, and nurses in training at both the pre-and postprofessional degree level. Also needed are continuing education programs for existing providers. Core educational elements include components on common oral diseases of young children, risk assessment, anticipatory guidance, conducting an oral examination, preventive interventions, and disease suppression strategies. For dentists, additional training is needed in management of common dental presentations and customizing care to very young children. Dentists also need information and practical training regarding young children's development and communications skills as well as issues of cultural competency. Increasing public awareness that early dental care is important in limiting lifelong oral disease will require significant education of families. Adoption of the "age-one dental visit" as promoted by the Bright Futures coalition and professional groups will require a fundamental change in widely accepted public norms. The idea of individualized oral health care that tailors intensity of treatment to a child's level of risk is also novel and will require acceptance to be effective. Balancing the benefits and risks of home therapies including use of topical and systemic fluorides or use of prescribed antimicrobial agents will require that parents acquire sophisticated information. Prevention can be significantly enhanced if the public can become better informed about the impact of dietary and hygienic choices, use of protective devices to limit accidents, and impact of maternal oral health on the health of young children. Expanding Dental Insurance Coverage Dental insurance coverage is important because it helps reduce financial barriers to care.4 Many children, even those who enjoy medical coverage, do not benefit from dental coverage.58 Even when commercial dependent dental coverage is available, it may not be extended to very young children. Dental benefits are comprehensive for low-income young children covered by Medicaid or SCHIP, but these children frequently have difficulty accessing care. Dental coverage is generally not coordinated with medical coverage under private-and and zovirax.
N the administration of treatment medication for chronic obstructive pulmonary disease COPD ; , the inhalation route has been favored for the last 20 years. This technique enables the drugs to act directly on the airways, provided that the inhalation device is used correctly.1 Medication can be delivered as an inhaled aerosol in smaller doses, thus resulting in significantly fewer side effects than drugs delivered orally or intravenously.2 The effectiveness of an aerosol is largely dependent on how much of the medication actually reaches the small peripheral airways of the lungs. Particles that are too large or that are traveling too quickly will tend to impact with the walls of the upper airways, such as the throat, and therefore not reach the targeted airways. The size of the particles in an aerosol must be small, between 1 and 5 m, 83.
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The large United Kingdom trial was a cost-effectiveness one assessing whether psychodynamic interpersonal therapy or an SSRI antidepressant were an improvement on usual treatment in the real-life clinical setting. It did not, therefore, include a placebo arm.11 Conversely, 81% of eligible patients were recruited giving the trial good external validity. The 257 patients included in this trial had severe IBS unresponsive to usual treatment.12 There was no significant difference between the treatment and comparison groups in abdominal pain score at 1-year follow-up, but a highly significant improvement in health-related quality of life followed both SSRI antidepressant and psychotherapy compared to treatment as usual. Costs during the follow-up year were reduced in the psychotherapy group. The correct conclusion from this trial is that, compared to usual treatment, both SSRI antidepressants and psychotherapy led to improved healthrelated quality of life in the long term at no extra cost. After 3 months of treatment, the time course of most drug trials, the results of this trial showed that an SSRI antidepressant, when taken consistently for 12 weeks, was more effective than routine care there was no placebo comparison ; in all 5 outcome measures pain severity and frequency, distress severity, and mental and physical aspects of health-related quality of life ; . Since this was an effectiveness trial with high recruitment rate, the results are generalizable to all patients with severe, treatment-resistant IBS and directly relevant to clinicians. Thus, at the beginning of 2005 there was evidence of efficacy for both antidepressants and psychological treatments, but scientifically speaking the evidence was not strong. The 2 large trials found considerable benefits in the short term for those patients who adhered to antidepressant treatment. Both also found psychological therapies led to significant improvements on global measures of well-being and health-related quality of life that could not be explained by a comparable improvement of abdominal pain or improved depression. Surprisingly, patients with concurrent depression appeared to do less well with psychological treatments.
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