Pay for Performance Study

A study by Peter K. Lindenauer, M.D., M.Sc., et al., published in last week's New England Journal of Medicine concludes that a combination of public reporting and pay for performance programs produce a modest improvement in health care quality over public reporting programs alone. (The entire study is available at the link.) The New England Journal editorializes that pay for performance is at the tipping point.

The Centers for Medicare and Medicaid Services (CMS) have a less nuanced view of the study's results, according to Government Health IT magazine. CMS notes that the Medicare pay for performance pilot has "saved the lives of 1,284 heart attack patients."

Caremark Merger Updates

• The Caremark shareholder meeting to consider the CVS merger deal will be held on February 20. (The CVS shareholder meeting is three days later.) As previously blogged, Caremark, in advance of the meeting, has sent shareholders proxy statements supporting the deal (and offering a special $2 dividend), and Express Scripts has sent them an exchange offer to those shareholders offering a different deal. This week, Caremark sent shareholders a letter commending the value of the CVS deal. Express Scripts issued a retort according to the Boston Globe.
  
• The Pirelli Armstrong Retiree Medical Benefits Trust brought a shareholder derivative action in federal court in Nashville, where Caremark is headquartered, challenging the CVS merger. This is the latest of several lawsuits pending over the merger. Express Scripts has filed a suit in Delaware where Caremark in incorporated challenging the breakup fee in the CVS merger deal.
  
• Reuters is reporting today that sixteen state legislators have written to the Federal Trade Commission warning about the anti-competitive aspects of the Express Scripts deal, which would combine the 2nd and 3rd largest prescription benefit managers. The FTC, which already has approved the CVS deal, must complete its review of the Express Scripts deal by February 2. In a related article, the Wall Street Journal reported yesterday about how shareholder votes can be swung by institutional investors borrowing shares. Much worse than hanging chads.

The President's Healthcare Proposal

The first question that Steve Barr received during his Washington Post Q&A yesterday was how would the President's healthcare proposal would affect the FEHB Program. Mr. Barr wasn't sure and he does not think that the proposal has legs. Nevertheless, it is an interesting proposal because it is so different from the current arrangement.

The FEHB Act provides for a government contribution and an enrollee contribution toward health benefits coverage. Under the current arrangement, the government contribution is excluded from income and employment taxation (Internal Revenue Code Sections 105 and 106), and the enrollee contribution is similarly excluded for employees based on OPM's premium conversion plan (IRC Section 125). Retirees are not eligible for this premium conversion plan, although NARFE has been pushing for a legislative fix to allow their participation.

Under the President's proposal, if enacted, the government contribution and the enrollee contribution would be taxable to both employees and retirees. Taxpayers with self only FEHBP coverage would receive a $7,500 standard deduction, and taxpayers with FEHBP family coverage would receive a $15,000 standard deduction. The deduction would be indexed to the consumer price index when it is fully implemented in 2009. If the actual FEHBP premium is below the standard deduction, the taxpayer wins and if the actual FEHBP premium is above the standard deduction, the taxpayer loses. Of course, in the FEHB Program, enrollees have an annual Open Season during which they could do their tax planning.

On Tuesday, Julie Goon, a special assistant to the President for economic policy, explained that

What this plan would do is give a flat, standard deduction for anybody who purchases any kind of health insurance, no matter how much the health insurance costs and no matter where they get it. It would be $15,000 for people purchasing family policy, $7,500 for people purchasing single policies. So if your employer is giving you insurance through your job, you get the standard deduction. If you go buy health insurance on your own, you get the standard deduction. If your policy costs $5,000, you still get $15,000 of compensation tax-free. If your policy costs $20,000, you still get $15,000 of compensation tax-free, using the family example.

The President was on the road today in Lee's Summit, Missouri (home of the FEHB plan, GEHA) advocating his plan.

Big News from the AHIC Meeting

VA Secretary James Nicholson announced at yesterday's American Health Information Community (AHIC) meeting that the Veterans Affairs Department and the Defense Department, which both operate hospital chains, plan to implement a joint, interoperable electronic health record system. Also at that meeting, the contractor teams seeking to develop a National Health Information Network, which will link electronic health record systems, demonstrated their prototypes/works in progress. More demonstrations will occur at next week's NHIN Forum. Finally, Secretary Leavitt officially accepted "thirty (30) consensus [health information technology interoperability] standards recommended by the Healthcare Information Technology Standards Panel (HITSP)" in September 2006.

More on the GAO Report

Reading the GAO report on FEHBP premium growth remains on my to do list but both the Federal Times and Steve Barr of the Washington Post are reporting this morning that the report criticizes OPM for declining the Medicare Part D subsidy and that Sen. Akaka plans to review the GAO report at a subcommittee hearing this Spring. In a statement released yesterday, Senator Akaka said that

"I will take a closer look at how OPM decisions affect health care premiums," Senator Akaka said. "Although OPM did a good job in keeping premium increases down in 2006, the GAO report clearly shows that if OPM had applied for and used the subsidy, premium growth would be reduced by 2.6 percent."

Duelling Healthcare Web Sites

Steve Case, AOL's founder, launched the pilot version of his Revolution Health web site yesterday while his competitor WebMD revamped its site . Both sites are consumer oriented. The Washington Post notes that WebMD already has "35 million unique visitors per month and about $170 million in annual revenue."

Revolution plans to charge about $100 a year for membership in return for which members will receive a call a nurse service, assistance with insurance claim disputes, and assistance with picking a health plan. I found it interesting that the Revolution health site includes a directory "over 700,000 doctors, 150,000 dentists, plus over 400,000 allied health professionals" and since yesterday it has received over 2000 viewer ratings on the listed providers.

GAO Releases Report on FEHBP Premium Growth

The U.S. Government Accountability Office (GAO) released today a report titled "Federal Employees Health Benefits [FEHB] Program: Premium Growth Has Recently Slowed, and Varies among Participating Plans" GAO-07-141. The report was prepared for Senator Daniel Akaka (D Hawaii) whose staff has announced, according to the Washington Post, that the Senator plans to examine this topic as chairman of the Senate Homeland Security and Governmental Affairs subcommittee with responsibility for the FEHB Program.

Sneak Preview on the State of the Union

The White House has released the health care proposals that President will make in his State of the Union address tomorrow night:

The President's Plan Includes Two Parts: Reforming The Tax Code With A Standard Deduction For Health Insurance So All Americans Get The Same Tax Breaks For Health Insurance And Helping States Make Affordable Private Health Insurance Available To Their Citizens.

1. The President's Plan Will Help More Americans Afford Health Insurance By Reforming The Tax Code With A Standard Deduction For Health Insurance – Like The Standard Deduction For Dependents. The President's primary goal is to make health insurance more affordable, allowing more Americans to purchase coverage. The President's proposal levels the playing field for Americans who purchase health insurance on their own rather than through their employers, providing a substantial tax benefit for all those who now have health insurance purchased on the individual market. It also lowers taxes for all currently uninsured Americans who decide to purchase health insurance – making insurance more affordable and providing a significant incentive to all working Americans to purchase coverage, thereby reducing the number of uninsured Americans.
   
   
   • Under The President's Proposal, Families With Health Insurance Will Not Pay Income Or Payroll Taxes On The First $15,000 In Compensation And Singles Will Not Pay Income Or Payroll Taxes On The First $7,500.
   • At the same time, health insurance would be considered taxable income. This is a change for those who now have health insurance through their jobs.
   • The President's proposal will result in lower taxes for about 80 percent of employer-provided policies.
   • Those with more generous policies (20 percent) will have the option to adjust their compensation to have lower premiums and higher wages to offset the tax change.
     
     
2. The President's Affordable Choices Initiative Will Help States Make Basic Private Health Insurance Available And Will Provide Additional Help To Americans Who Cannot Afford Insurance Or Who Have Persistently High Medical Expenses. For States that provide their citizens with access to basic, affordable private health insurance, the President's Affordable Choices Initiative will direct Federal funding to assist States in helping their poor and hard-to-insure citizens afford private insurance. By allocating current Federal health care funding more effectively, the President's plan accomplishes this goal without creating a new Federal entitlement or new Federal spending.

Currently, the health benefits tax exclusion is only available when the health insurance/benefits are purchased within the workplace. Under the President's proposal, the deduction would be available to those who purchase insurance outside the workplace, or individually. The White House anticipates that this change if accepted by Congress will generate a significant reduction in the number of uninsured Americans. To pay for this expansion, employer provided health benefit coverage that exceeds the applicable tax would be taxable for the first time.

Genetic Non-Discrimination

Earlier this week, Rep. Louise Slaughter (D NY) introduced in the House a bill that would prohibit genetic discrimination by insurers and employers (H.R. 493). The bill has 146 co-sponsors and the support of the Coalition for Genetic Fairness. Similar legislation has passed the Senate in recent years. Yesterday, the President expressed his support for such legislation:

I really want to make it clear to the Congress that I hope they pass legislation that makes genetic discrimination illegal. In other words, if a person is willing to share his or her genetic information, it is important that that information not be exploited in improper ways -- and Congress can pass good legislation to prevent that from happening. In other words, we want medical research to go forward without an individual fearing of personal discrimination.

This bill has legs as they say on the Hill.

Miscellany

• Leading health care and technology companies have joined together to offer free electronic prescribing to every M.D. in America. The initiative known as the National ePrescribing Patient Safety Initiative will begin national deployment in a month. "Interested physicians can visit the NEPSI web site, http://www.nationalerx.com/ to register for the program." Now there's some very good news for everyone.
• HHS Secretary Mike Leavitt issued a statement on H.R. 4. The Secretary is not pleased: "I am disappointed that a majority of House members discounted the overwhelming success of the Medicare Part D program over the last year and voted to pass HR 4."
• The U.S. Court of Appeals for the 4^th Circuit affirmed today Judge Motz’s decision that ERISA preempts the Maryland health insurance mandate that would have required Walmart to spend at least 8% of its payroll on health benefits or contribute an equal amount to a state fund. A copy of the opinion is available here. Yesterday, OPM issued a final FEHBP regulation on discontinuance of a health plan in the event of an emergency such as Hurricane Katrina. OPM finalized its proposed rule without change. Here's a link to the regulation.

Rep. Kennedy Prepares to Reintroduce the Wellstone Mental Health Parity Bill

Rep. Patrick Kennedy (D R.I.) and Rep. Jim Ramstad (R. Minn.) announced plans yesterday to reintroduce the Sen. Paul Wellstone Mental Health Equitable Treatment bill in the new 110th Congress. Since 2001, the U.S. Office of Personnel Management has required broader mental health parity for FEHB plan coverage provided that the member uses network doctors and facilities and cooperates with the plan's medical management requirements. According to the Providence Journal story, the legislation is modeled on the FEHB Program's mental health parity initiative. The devil will be in the details.

State of the Union

President Bush will be giving his State of the Union address next Tuesday January 23 to a joint session of Congress. The Wall Street Journal reports today that the President may propose capping the tax exclusion for employer provided health benefits and use the savings to fund tax credits and state pools to help cover the uninsured. The article includes this fascinating fact:

The current policy of excluding employer-provided health insurance benefits from employees' tax returns costs the government more than any other tax policy -- about $900 billion between 2006 and 2010, counting all health-related breaks. That is more than either the mortgage-interest deduction or the various breaks for retirement savings. Thus, even tinkering around the edges of the exclusion could produce large amounts of revenue for subsidizing coverage for lower-income people.

The new Congress is putting health care in the spotlight as well. Last week Senator Ted Kennedy (D Mass.), the Chairman of the Senate's Health, Education, Labor, and Pensions Committee, proposed covering all children and adults from age 55 to 65 under Medicare.(Of course, adults aged 65 and older already are covered under Medicare.) Today, three rather strange bedfellows, the Business Roundtable, AARP, and the Service Employees International Union joined together to announce a new campaign for making health care affordable called Divided We Fail. According to the Wall Street Journal, "a bipartisan group including Sen. Jeff Bingaman (D., N.M.) and Sen. George Voinovich (R., Ohio) plans to introduce legislation [tomorrow] that would provide grants to states to craft their own plans for helping the uninsured." The Hill newpaper reports that on Thursday "a group of healthcare-industry organizations, business interests and consumer groups will launch their Health Coverage Coalition for the Uninsured." This should be interesting.

The Battle for Caremark Rages On

Prescription benefit manager Caremark and its preferred suitor CVS today announced that when their merger deal closes the company will pay a special $2 per share dividend to common stockholders and will retire 150 million shares of common stock in order to optimize its capital structure. Express Scripts questioned the dividend's value to shareholders and it announced an exchange offer for Caremark stock on the following terms which align with Express Script's original offer

Under the terms of the Exchange Offer, Express Scripts is offering Caremark stockholders $29.25 in cash and 0.426 shares of Express Scripts stock for each share of Caremark stock. Based on closing stock prices on Friday, January 12, 2007, the Express Scripts offer has a value of $56.87 per share, or approximately $25 billion in the aggregate, and provides Caremark stockholders with a 7% premium to the current value of the CVS proposal.

Express Script is mailing the offer to all of Caremark's shareholders. The offer expires "at 12:00 midnight, New York City time, on Tuesday, February 13, 2007, subject to extension." Bloomberg notes that "Shares of CVS fell 15 cents to $31.79 at 4:17 p.m. in New York Stock Exchange composite trading. Caremark dropped 58 cents to $56.25 and Express Scripts shares climbed 88 cents to $65.71 in Nasdaq Stock Market composite trading."

WEDI Calls for NPI Contingency Plan

The compliance date for covered entities (health plans, health care providers, and clearinghouses) to use the National Provider Identifier is about four months away (May 23, 2007). The Centers for Medicare and Medicaid Services have yet to release an NPI dissemination policy. CMS has stated that beginning on that date it require that Medicare claims include the NPI. The Workgroup for Electronic Data Interchange (WEDI) has called upon the Secretary of Health and Human Services to "allow the use of legacy identifiers for 12 months after the Centers for Medicare and Medicaid Services enables access to the National Plan/Provider Enumeration System database" according to Medical Data Management magazine. Getting action probably will require Congressional pressure on CMS.

2008 Medicare Cut Projected at 10%

The complex Medicare law requires annual formulaic adjustments to physician reimbursement amounts under Medicare Part B. The Centers for Medicare and Medicaid Services (CMS) described the formula as follows:

The formula compares the actual rate of growth in spending to a target rate, which is based on such factors as the growth in number of Medicare fee-for-service beneficiaries and statutory or regulatory changes in benefits. If the actual rate of growth exceeds the target rate, the update is decreased; if it is less, the update is increased.

The formula has been producing payment reductions. For the past few years, Congress has waived the mandated reduction. The Tax Relief and Health Care Act of 2006 waived the 5.0% reduction that the formula would have required for 2007.

The AMA News is reporting that

Medicare pay to physicians will be reduced about 10% next year if current law remains unchanged, the Congressional Budget Office said Dec. 28, 2006, in its final cost assessment of the legislation that averted a 5% cut this year.

Future Congressional relief from the formulaic reductions may be complicated by the Democrat's new pay-go policy. As there are many federal annuitants with primary Medicare coverage enrolled in the Federal Employees Health Benefits Program, Medicare payment cuts are picked up by the FEHB Program for those enrollees. This should be interesting.

Older Boomer!?

In his column last week, the respected Newsweek columnist Robert Samuelson criticized the selfishness and cynicism of "older boomers (say, those born by 1955)." I don't mind being criticized as selfish or cynical (after all I live and work inside the Beltway), but I do question the older boomer label as applied to me. After all I was way to young for Woodstock! I was even surprised to learn yesterday in the Post that Grace Slick (who performed at Woodstock -- I saw the movie) is alive and painting. I thought that she had met the same fate as her friends, Jim Morrison and Janis Joplin.

On the Sidelines of the Battle for Caremark

John Snow, the CEO of the Nation's largest prescription benefit manager, Medco, observed this week that his company stands to benefit from the Caremark merger no matter which suitor, CVS or Express Scripts, prevails. According to Reuters, Snow said that "We've been getting calls from retailers asking how they can stay aligned with us as the possibility of a CVS-Caremark combination blooms. I think that is nothing but good for us and our customers." Although I have no idea whether this is a coincidental or related development, Medco's common stock price rose almost 10% this week from $53.67 last Friday to $58.71 today.

House Passes H.R. 4

This afternoon, the House passed H.R. 4, the bill that would require the Secretary of Health and Human Services to negotiate lower Medicare Part D drug prices by a vote of 255 - 170 (with 10 absentees). In a press conference today, the President's press secretary Tony Snow said:

First, there is a Medicare prescription drug bill that's making its way through the House, H.R. 4. Both the Congressional Budget Office and the Department of Health and Human Services -- their actuaries say the bill is going to have little or no effect on federal spending and provide no substantial savings to the government or Medicare beneficiaries. We have a Medicare prescription drug reform that has been saving people significant amounts of money, it is effective. If this bill is presented to the President, he will veto it.

Of course, the bill still must pass the Senate, but the Constitution (Art I, § 7) requires a 2/3s vote of the House (290 House votes) and Senate (67 Senate votes) to override a Presidential veto.

H.R. 4 Set for House Vote Tomorrow -- President Vows Veto

The House is set to vote tomorrow tomorrow on H.R. 4, the bill that would require the Secretary of Health and Human Services (HHS) to negotiate lower Medicare Part D drug prices. Yesterday, the Congressional Budget Office concluded that the bill will not lower Medicare Part D costs as also suggested by critics of the bill. (Finally the Washington Post and the New York Times have recognized that the VA relies on statutorily mandated pricing, rather than negotiations for its discounts and that the VA healthcare system is not analogous to Medicare).

Today, HHS Secretary Leavitt explained in the Washington Post why he opposes the bill, and later the President announced that he will veto the bill if Congress enacts it. (A similar bill, S. 250, was introduced in the Senate today.) It is highly unlike that Congress could overturn that veto with the required 2/3s vote.

The Battle for Caremark Widens

Express Scripts has filed a Delaware lawsuit seeking to void the $695 million breakup fee required by the CVS/Caremark merger agreement, according to the Wall Street Journal.

2005 U.S. Health Care Spending

A CMS study on 2005 U.S. health care spending was published today in Health Affairs. The abstract explains that

In 2005, U.S. health care spending increased 6.9 percent to almost $2.0 trillion, or $6,697 per person. The health care portion of gross domestic product (GDP) was 16.0 percent, slightly higher than the 15.9 percent share in 2004. This third consecutive year of slower health spending growth was largely driven by prescription drug expenditures [greater use of generic drugs]. Spending for hospital and physician and clinical services grew at similar rates as they did in 2004.

In contrast, the U.S. consumer price index (urban) increased 3.15% from December 2004 to December 2005. AHIP issued a press release on the study.

The Caremark Proxy Battle is Joined

Yesterday, after the Caremark board of directors spurned the Express Scripts merger proposal, Express Scripts announced that it is making four nominations to the Caremark board through a proxy vote effort. Today, it was revealed in an SEC filing that an Express Scripts subsidiary "bought 591,000 shares of Caremark Rx Inc. last month for almost $30 million." CVS is not pleased.

In a separate development, a federal judge in Nashville, TN, where Caremark is headquartered, has dismissed two shareholder suits challenging the CVS merger proposal "on grounds that [the suits] cover the same issues as a separate case pending in chancery court in Delaware," where Caremark is incorporated.

Acting CMS Chief Expresses Doubt About HR 4

The Washington Post reports that Acting Centers for Medicare and Medicaid Services Administrator Leslie Norwalk expressed doubts about the value of the bill -- H.R. 4 -- that would authorize her agency to negotiate Medicare Part D drug prices with manufacturers, echoing criticisms published in yesterday's New York Times (see 1/7 FEHBlog entry). The Department of Health and Human Services announced today that the current competitive system under which the private Medicare Part D drug plan sponsors negotiate with the manufacturers is producing lower Medicare Part D program costs. Of course, the sponsors of HR 4 beg to differ. The bill is expected to be put to vote on January 12 pursuant to Section 510 of H. Res. 6, which the House passed on January 5.

Caremark Board of Directors Rejects Express Scripts Proposal

Yesterday, Caremark's Board of Directors unanimously rejected holding discussion with Express Scripts over its merger proposal and "affirmed its strong commitment to Caremark's pending merger of equals with CVS Corp." In a detailed press release, Caremark further explained that

As a result of having received antitrust clearance, integration planning for a CVS/Caremark merger is underway, assuring achievement of synergies starting in 2007. Caremark and CVS have filed a joint proxy statement with the Securities and Exchange Commission and are proceeding forward to a vote on the pending merger at special shareholders meetings to be held in the first quarter of this year.

The Caremark proxy statement for this shareholders meeting can be viewed on the SEC website. is publicly available CVS expressed its appreciation of the Caremark Board's decision.

Express Scripts issued its own press release which seeks to rebut the Caremark Board's rationale for rejecting its proposal and announcing that

Express Scripts intends to file a proxy statement in connection with Caremark's special meeting of stockholders at which the Caremark stockholders will consider the CVS Merger Agreement and matters in connection therewith.

The Clock is Ticking on the First 100 Hours -- H.R. 4

On January 12, during the first 100 hours of the 110th Congress, the House of Representatives will consider H.R. 4, a bill with 189 co-sponsors and the AARP's backing, that would require the Secretary of Health and Human Services, beginning in 2008, to negotiate with drug manufacturer "lower" prices for Medicare Part D covered drugs without using a formulary. (A private Medicare Part D plan sponsor would be permitted to attempt to negotiate even lower prices.) The bill's objective is lower the cost of the Medicare Part D program in order to close the so-called doughnut hole in Part D coverage.

The New York Times and the Washington Post published articles today describing the flaws in this approach as articulated by critics. The New York Times also reported that HHS announced yesterday a lower long term projection of Medicare Part D costs -- "In July, the Bush administration estimated that payments to private plans offering the Medicare drug benefit would total $1.077 trillion from 2007 to 2016. Officials now estimate they will be $964 billion." According to the Times report, CMS Acting Administrator Leslie Norwalk attributed the reduction to lower drug costs in general and lower enrollment as seniors found alternate drug coverage, such as employer sponsored coverage.

Sen. Max Baucus, who chairs the Senate Finance Committee, plans to hold hearings on the issue soon according to the Washington Times.

President Nominates New OPM Deputy Director

On January 4, 2007, the White House announced that President Bush will appoint Howard Weizmann to be the Deputy Director of the U.S. Office of Personnel Management. Mr. Weizmann currently is the President of the Private Sector Council (PSC), a program of the Partnership for Public Service.

Mr. Weizmann's bio indicates that during the course of his carrier he has been Senior Vice President of the European Business Operations and Senior Vice President of Human Resources at Digex, Inc.; a Managing Consultant at Watson Wyatt Worldwide; Vice President in charge of Aetna Life Insurance Company's value-added consulting business; a compensation and benefits attorney with Drinker Biddle and Reath; and the Manager of Benefits Planning and in-house attorney for the Sun Oil Company.

Mr. Weizmann's nomination requires Senate confirmation. He will replace Dan Blair, who has become Chairman of the Postal Regulatory Commission (previously the Postal Rate Commission).

Caremark Merger News

Express Scripts has sent a letter to Caremark stockholders urging them to reject the CVS proposal to acquire CVS, which already has cleared Hart-Scott-Rodino anti-trust review. According to an AP report, "Analysts say Caremark managers prefer the CVS offer while shareholders like the Express Scripts deal better" as it offers a higher premium. In a press release, Tom Ryan, Chairman, President and CEO of CVS replied that "CVS remains resolute in its commitment to seeing our merger through." Meanwhile, the shareholder lawsuits against the CVS deal wind their way through the courts. This should come to a head soon.

110th Congress Set to Convene

The Democrat Party controlled 110th Congress will convene on Thursday January 4. Sen. Joe Lieberman of Connecticut and Rep. Henry Waxman of California will chair the Senate and House committees with oversight responsibility for the Federal Employees Health Benefits Program. According to Steve Barr's column in today's Washington Post, an aide to Sen. Daniel Akaka, who will chair the Senate's Oversight of Government Management, Federal Workforce, and District of Columbia subcommittee, "plans to review the federal employees health insurance program and how it sets premiums."

OPM Releases FEDVIP and FSAFEDS Open Season Numbers

OPM announced last week that 690,000 federal employees and annuitants enrolled in the new supplemental dental and vision plans (FEDVIP) during the recent initial Open Season. OPM also reported that FSAFEDS enrollment has grown to 226,000 as a result of the Open Season, which is a 26% increase in employees who have a health care or dependent care flexible spending account.

Steve Barr reports in today's Washington Post that one of OPM Director Linda Springer's new objectives is to explore "whether a program could be created to offer short-term disability insurance to federal employees."

Happy New Year!

Welcome to 2007! There are a few recent Government Accountability Office (GAO) reports that may catch your interest. On December 19, the GAO released a report on prescription drug manufacturer research and development efforts that clearly caught the attention of incoming House Government Reform Chairman Henry Waxman. No doubt, a GAO report on improvements needed in FDA oversight of direct to consumer advertising also will resonate with the incoming Congress. Finally, last Friday, December 29, the GAO released a report on the profitability of the federal government's long term care insurance program carrier, Long Term Partners LLC.