More than 90% of U.S. nursing homes were cited for federal health and safety violations in 2007, according to an HHS Office of Inspector General report released on Monday, the New York Times reports. The report found that deficiencies were cited for 94% of for-profit nursing homes, 88% of not-for-profit homes and 91% of government-run homes. HHS Inspector General Daniel Levinson said, "In 2007, for-profit nursing homes averaged 7.6 deficiencies per home, while not-for-profit and government homes averaged 5.7 and 6.3, respectively." For-profit homes account for approximately 66% of U.S. nursing homes, not-for-profit homes account for 27% and government-run homes account for 6% (Pear, New York Times, 9/30). According to the report, the most common deficiencies centered on quality of care measures, including treatment and prevention of bedsores and urinary tract infections. The most common quality of life issues involved housekeeping, maintenance and nutrition, with 43% of homes cited for problems with dietary services (Freking, AP/Boston Globe , 9/29). The report found that about 17% of nursing homes had deficiencies that caused "actual harm or immediate jeopardy" to residents. Of the 37,150 complaints inspectors received in 2007 about the condition of nursing homes, 39% were substantiated and about 20% of those verified complaints involved patient abuse or neglect. The proportion of nursing homes cited varied among states, ranging from 76% of homes in Rhode Island to 100% of homes in Alaska, Idaho, Wyoming and Washington, D.C. The average number of deficiencies per home ranged from 2.5 in Rhode Island to 13.3 in Delaware (New York Times, 9/30).The report's findings were included in a memorandum sent to CMS acting Administrator Kerry Weems (AP/Boston Globe, 9/29). Levinson issued a compliance guide for nursing homes on Monday stating that some facilities "have systematically failed to provide staff in sufficient numbers and with appropriate clinical expertise to serve their residents." He also said that he found cases in which nursing homes billed Medicare and Medicaid for services that "were not provided, or were so wholly deficient that they amounted to no care at all." In December, President Bush plans to institute a five-star system to be published on a federal Web site that will rank the overall quality of care at all U.S. nursing homes (New York Times, 9/30). The report is available online (.pdf).

Response CMS spokesperson Jeff Nelligan said, "The addition of stronger inspections and enforcement of quality-of-life requirements means that more of the serious deficiencies are being identified, even though many nursing homes also made improvements in their care" (Marcus, Bloomberg/Pittsburgh-Post Gazette, 9/30). Bruce Yarwood, president of nursing home trade group American Health Care Association , said, "We know we have to do a better job" but the inspection system "does not reliably measure quality" and "does not create any positive incentives." He added, "Inspectors are subjective and inconsistent. They interpret federal standards in different ways" (New York Times, 9/30).

Walgreen has agreed to pay $9.9 million to settle allegations by the Department of Justice and four states -- Florida, Massachusetts, Michigan and Minnesota -- that the company improperly billed Medicaid, DOJ said in a statement on Monday, the Miami Herald reports (Miami Herald, 9/30). According to DOJ, the allegations involved Medicaid claims for medications dispensed to beneficiaries who also had private health insurance. DOJ said that Walgreen charged the Medicaid programs in the four states the difference between the amount that private insurers paid for the medications and the amount that the programs would have paid for beneficiaries who did not have private health insurance (Kendall, Dow Jones/Wall Street Journal, 9/29). In those four states, Walgreen can bill Medicaid programs only for the amount of copayments for medications dispensed to beneficiaries who also have private health insurance, DOJ said. DOJ did not disclose whether Walgreen admitted any wrongdoing as part of the settlement (Miami Herald, 9/30).The allegations against Walgreen resulted from a whistle-blower lawsuit filed by Daniel Bieurance and Neil Thompson, two pharmacists in Minneapolis. Under the settlement, the pharmacists will receive a combined $1.44 million.

Comments Michael Polzin, a spokesperson for Walgreen, attributed the allegations that the company improperly billed Medicaid to "inadvertent ... errors" that resulted from a "unique requirement for Medicaid billing when Medicaid is a secondary insurer" (Walsh, Minneapolis Star Tribune , 9/29). He added that Walgreen has corrected the problem.Gregory Katsas, assistant attorney general for the civil division at DOJ, said, "This settlement confirms that we will vigorously pursue allegations of fraud and abuse in state Medicaid programs, which are funded, in part, by the federal government" (Kendall, Dow Jones/Wall Street Journal, 9/29).

Medicaid spending by states increased nationwide by 5.3% in fiscal year 2008 and enrollment increased by 2.1% largely because of the continuing economic downturn, according to an annual survey released on Monday by the Kaiser Family Foundation 's Commission on Medicaid and the Uninsured , Stateline.org reports. For the study, Kaiser researchers with KCMU and Health Management Associates surveyed the Medicaid directors of all 50 states between July 1, 2007, and June 30, 2008 (Vu, Stateline.org, 9/30). The survey found that in FY 2009, Medicaid enrollment is projected to increase by 3.5% and state spending is projected to increase by 5.8% (Reichard, CQ HealthBeat , 9/29). More than two-thirds of state Medicaid directors said there is an even chance they will experience a budget shortfall in FY 2009 (CongressDaily, 9/29). Vern Smith, former director of Michigan's Medicaid program and a principle with HMA, said, "Just when it looked like things would get better, a new economic downturn has pulled the fiscal rug out from under the states." He added that most states are restoring cuts made in previous years and increasing provider payments, but three states have reduced benefits this year because of unexpected budget shortfalls. Nevada and New York state in August reduced Medicaid payments to hospitals and nursing homes, and South Carolina this month announced cuts to physician and dentist payments. Smith said, "As state fiscal situations worsen, actions in these three states may be a harbinger of things to come" (Stateline.org, 9/30). According to Smith, "If the downturn is prolonged, and it contributes to large increases in Medicaid enrollment and spending, then [states] will have to look at options to rein in spending" (Anstett, Detroit Free Press , 9/30).According to a separate previously-released analysis, a 1% increase in unemployment translates to an increase of one million in Medicaid and SCHIP enrollment, an increase of $3.4 billion in combined state and federal Medicaid spending, and an increase of 1.1 million in the uninsured population because many people who lose employer-sponsored coverage do not qualify for Medicaid. The report on the survey noted that much of the data collection was conducted at the beginning of 2008, when the economy was stronger, allowing states to implement a variety of Medicaid improvements and expansions. Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of KCMU, said the survey likely understates the eventual effect on Medicaid of the poor economy. She said, "I think we have a somewhat rosier picture (in the survey) than the reality we've heard from the directors on the ground" (CQ HealthBeat, 9/29). The survey is available online .

AHIP Report In related news, America's Health Insurance Plans released a report on Monday that found Medicaid spending for long-term care will total $3.7 trillion in the next 20 years, Reuters reports. State programs will spend $1.6 trillion on long-term care while the federal government will spend $2.1 trillion during that period. According to the report, if current trends continue, annual Medicaid spending for long-term care would grow from $51.5 billion in 2008 to $115.6 billion in 2027. In addition, the number of states spending more than $1 billion on long-term care would increase from 15 to 25 (Dunham, Reuters, 9/29). The AHIP report is available online (.pdf).

Member of Parliament Barbara Hogan has been appointed South Africa's new health minister by the country's interim President Kgalema Motlanthe, the AP/Google.com reports (Nullis, AP/Google.com, 9/26). Hogan previously was chair of the influential finance portfolio committee (News24 , 9/26). According to the AP/Google.com, the previous health minister, Manto Tshabalala-Msimang, has been appointed to a position in the office of the president. Hogan's appointment "suggested a stark shift in South Africa's AIDS policy and was seen as a sign that Motlanthe would pursue his own course," according to the AP/Google.com (AP/Google.com, 9/26). According to Toronto's Globe and Mail , Hogan's first comments after her appointment indicated that HIV and tuberculosis will be her priorities. "I think the biggest challenge is HIV/AIDS and all the strains that it places on the health system," Hogan said (Nolen, Globe and Mail, 9/29). According to the New York Times , Hogan is a "welcome choice by groups that campaign for the distribution of antiretroviral medications" (Bearak, New York Times, 9/26). The Treatment Action Campaign praised Hogan as having "a reputation for being hard-working, competent and principled," adding that she had been one of the few members of parliament to address HIV/AIDS during the tenure of former President Thabo Mbeki, who resigned on Thursday. Hogan said that she was "deeply touched" by the reaction from HIV/AIDS advocates to her appointment (BBC News , 9/26).

Fatma Mrisho, executive director of the Tanzania Commission for AIDS , on Friday called on pregnant women living with HIV/AIDS in the country to regularly visit medical clinics in order to prevent mother-to-child transmission of the virus, the Daily News reports. Mrisho delivered the message in Tanzania's capital of Dar es Salaam during a briefing on the Children's Special Session International Conference, which will be held on Monday in the city. The conference, organized by the Regional Inter-Agency Task Team on Children and AIDS in Eastern and Southern Africa, will review progress and steps needed to increase the response to HIV/AIDS among children. More than 14 countries from across East and Southern Africa are expected to be represented at the conference. Mrisho said that by regularly attending clinics, women also would be able to access antiretroviral treatment for their children, which could help reduce Tanzania's child mortality rate. Mrisho noted that a survey by the country's health sector found that 11,000 children are living with HIV/AIDS in Tanzania. "To some extent, the big rate is caused by expectant mothers for failing to attend the medical clinic regularly for check-ups," Mrisho said. She added that stigmatization of pregnant women living with HIV/AIDS needs to be addressed because it prevents many women from attending clinics (Robi, Daily News, 9/27).

Nongovernmental organizations from 14 East African countries met recently in Kigali, Rwanda, for a two-day meeting to discuss future strategies against the HIV/AIDS epidemic in the region, the New Times/AllAfrica.com reports. The Eastern African National Networks of AIDS Service Organizations planned the meeting, during which the participating organizations discussed future plans for dealing with the virus, harmonized regional civil society HIV/AIDS initiatives and enhanced linkages between the groups. The meeting included groups from Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Rwanda, Seychelles, Somalia, Sudan, Tanzania, Uganda and Zanzibar. Aimable Mwananawe, chair of the Forum Against AIDS in Rwanda, said the meeting "helped us because we shared experiences from others and compared them with our realities here while we design our own strategic plans." He added that the need to share information about the implementation of major HIV/AIDS programs makes it "necessary to connect local NGOs to international NGOs so that they collaborate in their interventions."Rwanda's HIV/AIDS prevention programs -- particularly those aimed at women, pregnant women and other groups -- can serve as a positive example to other countries, according to Kekoura Kourouma, country coordinator of UNAIDS . Kourouma added that the programs are a "pilot example" for HIV/AIDS prevention (Kwibuka, New Times/AllAfrica.com, 9/29).

U.S. Ambassador to Papua New Guinea Leslie Rowe on Friday visited the newly established sexually transmitted infection clinic in the capital of Port Moresby, which also provides HIV testing and other services, the Papua New Guinea Post Courier reports. The clinic was set up by HOPE Worldwide Papua New Guinea and Family Health International and receives funding from USAID . According to statistics released by the clinic, five out of 75 people who access voluntary HIV testing and counseling each week at the clinic test HIV-positive. In addition, 1,250 people as of Friday had attended the clinic. According to clinic medical officer George Low, the HIV cases detected at the clinic occur among different age groups, including young people. He added that a large number of people test positive for STIs other than HIV at the clinic. During Rowe's visit, FHI Country Coordinator Nayer Kaviani said the clinic has become the first satellite clinic in Papua New Guinea that provides comprehensive and integrated services for people living with and affected by HIV/AIDS. Kaviani added that the country's Department of Health and the National Capital District Commission are involved in the clinic. Also during Rowe's visit, health department STI adviser Esorom Daoni said that by the end of the year, all provinces in Papua New Guinea should have HIV testing sites. He added that this means that 60% to 70% of HIV-positive people in the country should have access to antiretroviral drugs (Gerawa, Post Courier, 9/29).

The number of grandparents worldwide caring for grandchildren orphaned by AIDS has doubled during the past 10 years, with half of the globe's 15 million AIDS orphans being cared for by a grandparent, according to new research released on Sunday by the United Kingdom-based Help the Aged , the PA/Press and Journal reports. The figures also show that if this trend continues at a constant rate, the number of grandparents responsible for AIDS orphans will double again by 2015. David Clarke, international manager for Help the Aged, said, "These findings highlight the silent explosion of the number of grandparents fighting to keep their grandchildren alive." Clarke added, "Unrecorded, unrecognized and unsupported, these older people, many in their 80s and 90s, will struggle on less than a dollar a day to feed newborns, nurse sick toddlers and put children through school. Throughout their tireless battle, many grandparents tell us their greatest fear is not knowing what will happen to their grandchildren once they have gone." According to Help the Aged, there also are "gaping holes" in the amount of international aid that older people receive, with the needs of older caregivers being underreported or overlooked.The PA/Press and Journal reports that a UNAIDS report earlier this year found that the HIV/AIDS epidemic in sub-Saharan Africa has orphaned nearly 12 million children younger than age 18, suggesting that natural age distribution in many African countries had been "dramatically skewed" by the disease. Consequently, there are concerns that low-income grandparents lack enough food, sleep and medicine for themselves and have been forced to work in physically demanding jobs, carry out heavy domestic tasks and nurse sick grandchildren. Help the Aged said it plans to present a signed petition to the United Kingdom's International Development Secretary Douglas Alexander to call on the government to encourage the United Nations to work to ensure that older people are accounted for when HIV/AIDS progress worldwide is tracked.According to the Department for International Development , Alexander at the United Nations Global Summit last week called for more action to eradicate poverty and fight HIV/AIDS. A DFID spokesperson said, "We recognize the crippling burden that HIV and AIDS create across all parts of society in developing countries, which is why DFID recently made a commitment to spend" six billion British pounds -- or about $11 billion -- "up to 2015 on developing better health services to tackle the disease. In addition to this, our social transfer scheme gives families struggling to care for AIDS victims and their relations -- which are often the older generation -- a regular form of income" (Silverman, PA/Press and Journal, 9/29).

U.S. immigration officials on Monday announced new rules to ease and expedite visa processing for HIV-positive visitors, AFP/Yahoo! News reports. A law that made foreigners living with HIV/AIDS inadmissible in the U.S. was repealed when President Bush signed legislation reauthorizing the President's Emergency Plan for AIDS Relief in July (AFP/Yahoo! News, 9/29). HHS in 1987 placed HIV on a list of diseases barring entry into the U.S. Although that prohibition is separate from the congressionally imposed travel restrictions eased in the PEPFAR bill, federal health officials no longer were bound by law to keep HIV on the list with the signing of the PEPFAR bill (Kaiser Daily HIV/AIDS Report , 7/31). Under the new rules announced on Monday, HIV-positive applicants who meet "all other normal criteria for the granting of a U.S. visa" will have the opportunity to receive a temporary, non-immigrant visa from U.S. consular offices overseas, according to a statement from the Department of Homeland Security . Under previous regulations, HIV-positive people were barred from entering the U.S. unless they received a special waiver, according to AFP/Yahoo! News. In the statement, Homeland Security Secretary Michael Chertoff said that new visas under the new regulations will be "subject to criteria designed to ensure an HIV-positive person's activities while in the United States do not present a risk to the public health." He also noted that the department will be "accelerating the process by providing an additional avenue for temporary admission while maintaining a high level of security at our borders" (AFP/Yahoo! News, 9/29). A fact sheet about the new regulations is available online .

The HIV/AIDS epidemic in the U.S. "from the beginning" has been "wrongly filtered through shifting public and political views that tried to focus blame or susceptibility on populations of people defined by social and demographic factors," physician and columnist Kate Scannell writes in a Contra Costa Times opinion piece. CDC last month "reported that it had significantly underestimated" annual new HIV infections in the U.S., Scannell writes, adding, "In that new infections are occurring disproportionately in our communities of color, the CDC's upwardly revised estimates" of new HIV infections "sound an alarming note." According to Scannell, what is "just as clear is that resources currently dedicated to changing that reality are woefully inadequate and not targeted at the heart of the problem." It is "not surprising" that the country's epidemic is "worse than officials had expected," Scannell writes, adding that the U.S. has become "grimly aware" that the virus "knows no racial boundaries."The focus on social and demographic factors in the fight against HIV/AIDS "ostracized some communities and it made others feel safe," Scannell writes, adding that the virus "always transcended those overly-convenient stratifications because it was always about the exchange of drug needles, semen, blood, vaginal fluids and breast milk." According to Scannell, "All the while we devised prevention strategies, we should have been crossing demographic divides and focusing on these universal risk factors." She adds, "Behaviors and universal risks ... ought to be the focus so that people can understand and legitimately assess their risk." Scannell concludes that she wonders "how many people might have been spared their HIV infections had they not been under some false impression of safety, swayed by some public message that sacrificed information to politics or ideology" (Scannell, Contra Costa Times, 9/28).