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Sebelius, Solis Announce Nearly $1 Billion Recovery Act Investment in Advancing Use of Health IT, Training Workers for Health Jobs of the Future March 03, 2010 Grant Awards to Help Make Health IT Available to Over 100,000 Health Providers by 2014, Support Tens of Thousands of Jobs NationwideWASHINGTON, DC - Health and Human Services Secretary Kathleen Sebelius and Labor Secretary Hilda Solis today announced a total of nearly $1 billion in Recovery Act awards to help health care providers advance the adoption and meaningful use of health information technology (IT) and train workers for the health care jobs of the future. The awards will help make health IT available to over 100,000 hospitals and primary care physicians by 2014 and train thousands of people for careers in health care and information technology. This Recovery Act investment will help grow the emerging health IT industry which is expected to support tens of thousands of jobs ranging from nurses and pharmacy techs to IT technicians and trainers. The over $750 million in HHS grant awards Secretary Sebelius announced today are part of a federal initiative to build capacity to enable widespread meaningful use of health IT. This assistance at the state and regional level will facilitate health care providers' efforts to adopt and use electronic health records (EHRs) in a meaningful manner that has the potential to improve the quality and efficiency of health care for all Americans. Of the over $750 million investment, $386 million will go to 40 states and qualified State Designated Entities (SDEs) to facilitate health information exchange (HIE) at the state level, while $375 million will go to an initial 32 non-profit organizations to support the development of regional extension centers (RECs) that will aid health professionals as they work to implement and use health information technology - with additional HIE and REC awards to be announced in the near future. RECs are expected to provide outreach and support services to at least 100,000 primary care providers and hospitals within two years. "Health information technology can make our health care system more efficient and improve the quality of care we all receive," said Secretary of Health and Human Services Kathleen Sebelius. "These grant awards, the first of their kind, will help develop our electronic infrastructure and give doctors and other health care providers the support they need as they adopt this powerful technology." The more than $225 million in DOL grant awards Secretary Solis announced will be used to train 15,000 people in job skills needed to access careers in health care, IT and other high growth fields. Through existing partnerships with local employers, the recipients of these grants have already identified roughly 10,000 job openings for skilled workers that likely will become available in the next two years in areas like nursing, pharmacy technology and information technology. The grants will fund 55 separate training programs in 30 states to help train people for secure, well-paid health jobs and meet the growing employment demand for health workers. Employment services will be available via the Department of Labor's local One Stop Career Centers, and training will be offered at community colleges and other local education providers. “The Recovery Act’s investments are making a positive difference in the lives of America’s working families,” said Secretary of Labor Hilda L. Solis. “The investments announced today will ensure thousands of workers across the nation can receive high-quality training and employment services, which will lead to good jobs in healthcare and other industries offering career-track employment and good pay and benefits.” The HHS and DOL awards are part of an overall $100 billion investment in science, innovation and technology the Administration is making through the Recovery Act to spur domestic job creation in growing industries and lay a long-term foundation for economic growth. In addition to the 10,000 jobs the DOL grantees expect to fill with freshly trained workers, the health IT extension centers are expected to hire over 3,000 technology workers nationwide in the months ahead. Overall, the Administration investments in health IT and training will help significantly expand an emerging industry expected to support tens of thousands of secure, well-paid jobs nationwide. A complete listing of the state HIE, REC and job training grant recipients is as follows: State HIE Awards: State HIE Awardee Award Amount Alabama Medicaid Agency $ 10,564,789 Arizona Governor's Office of Economic Recovery $ 9,377,000 Arkansas Dept of Finance and Administration $ 7,909,401 California Health and Human Services Agency $ 38,752,536 Colorado Regional Health Information Organization $ 9,175,777 Delaware Health Information Network $ 4,680,284 Government of the District of Columbia $ 5,189,709 Georgia Department of Community Health $ 13,003,003 Office of the Governor (Guam) $ 1,600,000 The Hawaii Health Information Exchange $ 5,602,318 Illinois Department of Health care and Family Services $ 18,837,639 Kansas Health Information Exchange Project $ 9,010,066 Cabinet for Health and Family Services (Kentucky) $ 9,750,000 State of Maine/Governor's Office of Health Policy & Finance $ 6,599,401 Massachusetts Technology Park Corporation $ 10,599,719 Michigan Department of Health $ 14,993,085 Minnesota Department of Health $ 9,622,000 Missouri Depart of Social Services $ 13,765,040 Nevada Department of Health and Human Services $ 6,133,426 New Hampshire Department of Health and Human Services $ 5,457,856 Lovelace Clinic Foundation, New Mexico $ 7,070,441 New York eHealth Collaborative Inc. $ 22,364,782 Commonwealth of the NMI, Department of Public Health $ 800,000 North Carolina Department of State Treasurer $ 12,950,860 Ohio Health Information Partnership LLC $ 14,872,199 Oklahoma Health Care Authority $ 8,883,741 Pacific Ecommerce Development Corporation (American Samoa) $ 600,000 State of Oregon $ 8,579,992 Governor's Office of Health Care Reform Commonwealth of Pennsylvania $ 17,140,446 Oticina del Gobernador La Fortaeza (Puerto Rico) $ 7,770,980 Rhode Island Quality Institute $ 5,280,000 State of Tennessee $ 11,664,580 Utah Department of Health $ 6,296,705 Vermont Department of Human Services $ 5,034,328 Virgin Islands Department of Health $ 1,000,000 Virginia Department of Health $ 11,613,537 Health Care Authority (Washington) $ 11,300,000 West Virginia Department of Health and Human Resources $ 7,819,000 Wisconsin Department of Health and Family Services $ 9,441,000 Office of the Governor (Wyoming) $ 4,873,000 Total Award Amount $ 385,978,640 Regional Extension Center Awards: RECs Awardee Award Amount Altarum Institute, Michigan $ 19,619,990 Arkansas Foundation For Medical Care $ 7,400,000 CIMRO of Nebraska $ 6,647,371 Colorado RHIO $ 12,475,000 District of Columbia Primary Care Association $ 5,488,437 Fund for Public Health New York $ 21,754,010 Greater Cincinnati HealthBridge (Ohio-Kentucky) $ 9,738,000 Health Choice Network, Inc.,Florida $ 8,500,000 HealthInsight, Utah-Nevada $ 6,917,783 Iowa IFMC $ 5,508,019 Kansas Foundation for Medical Care Inc. $ 7,000,000 Key Health Alliance (Stratis Health), Minnesota – North Dakota $ 19,000,000 Lovelace Clinic, New Mexico $ 6,175,000 Massachusetts Technology Park Cooperation $ 13,433,107 MetaStar, Inc, Wisconsin $ 9,125,000 Morehouse School of Medicine, Inc., Georgia $ 19,521,542 New York eHealth Collaborative (NYeC) $ 26,534,999 University of North Carolina, Chapel Hill $ 13,569,169 Northern California Regional Extension Center $ 17,286,081 Northern Illinois University $ 7,546,000 Northwestern University $ 7,649,533 OCHIN Inc. (Primary), Oregon $ 13,201,499 Ohio Health Information Partnership $ 28,500,000 Oklahoma Foundation for Medical Quality, Inc. $ 5,331,685 Purdue University $ 12,000,000 Qsource (Tennessee) $ 7,256,155 Qualis Health, Washington - Idaho $ 12,846,482 Rhode Island Quality Institute $ 6,000,000 Southern California Regional Extension Center $ 13,961,339 Vermont Information Technology Leaders, Inc. $ 6,762,080 VHQC and the Center for Innovative Technology, for The Virginia Consortium $ 12,425,000 West Virginia Health Improvement Institute Inc. $ 6,000,000 Total Award Amount $ 375,173,281 Job Training Awards: Healthcare / High Growth Grant Recipient Award Amount Calhoun Community College $3,470,830 Mid-South Community College $3,391,053 South Arkansas Community College $3,520,612 Kern Community College District (KCCD) $2,768,572 Los Rios Community College District $4,988,561 Mt. San Antonio Community College District $2,239,714 San Diego State University Research Foundation $4,953,575 San Jose State University Research Foundation $5,000,000 San Bernardino Community College District $4,260,863 Youth Policy Institute $3,623,473 Spanish Speaking Unity Council $3,559,139 Otero Junior College $4,999,350 National Council of La Raza $3,457,516 Providence Health Foundation of Providence Hospital $4,953,999 DeKalb Technical College (DTC) $2,043,859 Governors State University $4,994,686 Indianapolis Private Industry Council, Inc. $4,885,812 Ivy Tech Community College of Indiana $5,000,000 Iowa Workforce Development $3,403,164 Maysville Community and Technical College $2,007,637 Louisiana Technical College, Greater Acadiana Region 4 $4,859,040 Southern University at Shreveport $4,296,308 Maine Department of Labor $4,892,213 The Community College of Baltimore County (CCBC) $4,928,654 Macomb Community College $4,971,642 American Indian Opportunities Industrialization Center $5,000,000 Northland Community and Technical College $4,996,844 MN State Colleges & Universities DBA Pine Technical College $4,230,950 South Central College $4,506,101 The Montgomery Institute $4,519,625 Full Employment Council $4,998,344 Crowder College $3,576,760 Maryville University - St. Louis $4,699,354 University of New Hampshire $2,944,732 Passaic County Community College $4,475,041 Fulton Montgomery Community College (FMCC) $2,865,657 Hudson Valley Community College (HVCC) $3,382,200 University Behavioral Associates, Inc. $5,000,000 Workforce Investment Board of Herkimer, Madison, and Oneida Counties $2,700,096 Goodwill Industries, Inc., Serving E. Neb and SW Iowa $2,007,846 Nevada Cancer Institute $3,262,676 Berea Children’s Home 4,927,843 BioOhio $5,000,000 Cincinnati State Technical and Community College $4,935,132 Columbus State Community College $4,605,303 Enterprise for Employment and Education $2,373,073 Trident Technical College $2,624,532 Florence-Darlington Technical College (FDTC) $4,346,351 The University of South Dakota $5,000,000 Centerstone of Tennessee, Inc. $5,000,000 North Central Texas College $4,150,005 San Jacinto Community College District $4,722,919 The University of Texas Medical Branch at Galveston (UTMB) $4,655,799 Shenandoah Valley Workforce Investment Board, Inc. (SVWIB) $4,951,991 Workforce Training and Education Coordinating Board $5,000,000 Total $226,929,446 Additional information about the state HIE and RECs may be found at http://HealthIT.HHS.gov/statehie and http://healthit.hhs.gov/extensionprogram Information about other health IT programs funded through the American Recovery and Reinvestment Act of 2009 can be found here: http://HealthIT.HHS.gov Information about Healthcare/High Growth Grants, and other DOL training programs is available at http://www.doleta.gov/. - whitehouse.gov New Senate Bill Would Put Off 21.2% Medicare...Pay Cut Now in Effect Until Oct. 1 March 03, 2010 Senate Democrats this afternoon introduced yet another bill designed to temporarily spare physicians the 21.2% Medicare pay cut that took effect today on account of partisan gridlock in Congress last week.The bill, which also extends expired unemployment benefits, subsidies for health insurance premiums, and various tax breaks, would postpone the effective date of the massive cut to October 1. Organized medicine has expressed outrage over the reimbursement reduction, arguing that it will force physicians to turn away Medicare patients and military families, whose coverage under TRICARE is based on Medicare rates. Last week, Senate Democrats unveiled legislation that would have postponed the effective date of the pay cut by 30 days, but Sen. Jim Bunning (R-KY) blocked the measure, saying sponsors hadn't provided a way to pay for its cost. That impasse angered the American Medical Association. "The Senate had over a year to repeal the flawed formula that causes the annual payment cut and instead they abandoned America's seniors, making them collateral damage to their procedural games," J. James Rohack, MD, the president of the American Medical Association, said today in a press release. Besides postponing the Medicare pay cut at a cost of $7.3 billion over 10 years, the new bill would continue assistance payments to state Medicaid programs authorized by last year's stimulus bill through June 30, 2011. If the Senate approves the so-called American Workers, State and Business Relief Act introduced today, the measure would go to the House. If Congress enacts the bill between now and March 12, physicians would not experience the 21.2% pay decrease for services rendered during that period. That's because the Centers for Medicare and Medicaid Services announced last week that it was instructing its carriers not to process Medicare claims for the first 10 business days of March. That delay would allow CMS to pay claims back to March 1 at the previous rate, assuming the pay cut is postponed. This CMS directive does not apply to claims submitted before March 1, which will be processed as usual at the previous rate. - Medscape Health reform is top ACP priority in annual status report March 03, 2010 The U.S. health care system is in such decline that major reforms are needed to address the high number of uninsured, dwindling number of primary care physicians and rising costs of administering care, the American College of Physicians concluded in a recent report.The political climate in Washington is too highly partisan and polarized for lawmakers to craft effective piecemeal reforms to address the health challenges facing the nation today, the ACP said in its annual "State of the Nation's Health Care" report. Those challenges include making health insurance coverage more affordable, available and secure; ensuring a sufficient supply of primary care physicians and specialists; and reforming payment and delivery systems to achieve better value. But such measures can be achieved, the internists' organization said, if lawmakers take the House and Senate bills passed late last year and agree on a legislative pathway to enact a final bill. "We shouldn't toss them out and start from scratch," said Robert Doherty, the ACP's senior vice president of government affairs and public policy. Instead, he proposed that lawmakers revise provisions that caused concerns -- such as state exemptions from public health expansions and a Medicare payment board that could require spending cuts. The bills' main provisions would expand affordable coverage, address primary care shortages, and implement needed payment and delivery reforms, he said. The ACP also recommended that: * Congress give preferred funding to discretionary programs that ensure a sufficient supply of primary care physicians. * Congress permanently end the cycle of Medicare physician payment cuts caused by the sustainable growth rate formula. * President Obama require that all federal health agencies and contractors develop plans to increase the number of primary care physicians and reduce administrative burdens. * The administration accelerate pilot tests of innovative models such as patient-centered medical homes and comparative effectiveness research. Congress is unlikely to achieve these goals with piecemeal bills, Doherty said. "We understand the appeal of passing a series of smaller bills. The problem ... is that small bills are likely to produce Swiss cheese reforms that do not work in practice." Other physician organizations, including the American Medical Association, also have called on lawmakers to find common ground between the House and Senate reform bills. AMA President J. James Rohack, MD, sent a letter Jan. 26 to President Obama and Congress renewing a call to enact reform legislation. The ACP also believes the Obama administration does not need to wait for legislation to begin implementing important changes. For example, a systematic review of the Centers for Medicare & Medicaid Services should be conducted to address unnecessary and ineffective paperwork requirements, the ACP said. "We are urging President Obama to use his executive authority to increase primary care work force capacity and to reduce the time that physicians and patients spend on administrative interactions that take time away from patient care," said ACP President Joseph Stubbs, MD. But primary care concerns are not the only ones that should be on the minds of lawmakers and the White House as they try to push reform over the finish line, specialists warn. Katie Orrico is a founder of the Alliance of Specialty Medicine, a coalition of national medical societies representing specialty physicians. She said Obama and Congress need to consider the reform needs of both primary care and specialty physicians. "The alliance is certainly in favor of reform and mindful that there are cracks in the current system, and that there is a need to shore up the primary care base," said Orrico, director of the Washington office for the American Assn. of Neurological Surgeons. But "we're concerned there's been too much focus on primary care, including on the coverage of preventive services, and that little or no attention has been paid, frankly, to the fact that you need a strong specialty work force as well." - American Medical News ID theft rule decision offers doctors a way out February 15, 2010 A recent federal court decision could offer physicians and other health professionals an avenue for relief from a Federal Trade Commission regulation requiring them to implement a formal identity theft prevention program or face penalties.The Dec. 1, 2009, ruling by the U.S. District Court for the District of Columbia blocked the commission from applying the "red flags" rule to lawyers. The decision prompted the American Medical Association and others to petition the commission in January for a similar exclusion for physicians and other health care professionals. The regulations, which have gone into effect but whose enforcement has been delayed until June 1, require entities that regularly extend credit or defer payment for services to adopt a formal policy for detecting and preventing identity theft. The FTC counts physician practices as creditors if they bill patients for past services or allow patients to set up payment plans. But in a case brought by the American Bar Assn., the court found that the FTC exceeded its authority in applying that interpretation to attorneys. "The court ruling sends a clear signal that the FTC needs to re-evaluate the broad application of the red flags rule," AMA President J. James Rohack, MD, said in a statement. The AMA and other medical organizations said in a Jan. 27 letter that if the ABA litigation produces an exemption for lawyers, health care professions should be exempted, too. The American Osteopathic Assn., the American Dental Assn. and the American Veterinary Medical Assn. also joined the petition. The FTC declined to comment on the request or on whether it would appeal the ABA ruling. Concerns from organized medicine that the unfunded mandate posed by the identity theft rule would unnecessarily burden physician practices and increase health care costs have prompted several delays in the rule's enforcement. But with the FTC firm in its position that the health care industry falls under the regulations' scope, those delays do little to alleviate doctors' concerns, said Shawn Martin, AOA director of government relations. "From our perspective, attorneys' offices and physician offices are no different as far as the business structure, and this [ruling] created a precedent for us to argue from," he said. "We will pursue all reasonable and feasible avenues to make sure our members can practice medicine in the least burdensome manner possible. This is a lot of hoopla for a $20 co-pay." Pathway to a reprieve? Legal experts said the ruling in favor of the ABA could be good news for the health care industry. The court concluded that the Fair and Accurate Credit Transactions Act, which authorized the FTC to promulgate the red flags rule, was intended to regulate financial institutions and transactions, not the privileged attorney-client relationship and the services lawyers provide. Nor did the practice of invoicing a client after rendering services make the attorney a financial institution or a creditor. "The same can absolutely be said that the long-standing, privileged relationship between a health care provider and his or her patient is very different from the relationship between a financial institution and a customer," said Lucy C. Hodder, chair of the health care practice group in Rath Young Pignatelli's Concord, N.H., office. "The decision should force some kind of pointed discussion between the FTC and the provider community," and it could give health care professionals sound footing to bring similar action, she said. As of this article's deadline, no lawsuit had been filed by health care organizations. Physicians also have a leg up on lawyers in that they already are subject to federal privacy and security regulations that have given doctors a heightened awareness of identity theft issues, Hodder added. But doctors have characteristics that could bolster the FTC position to include them in the fight against identity theft, said New York City-based health care lawyer Charles E. Kutner. Unlike attorneys, "doctors are in a unique position because they are in possession of two forms of confidential information that are protected by federal law: health information protected by [the Health Insurance Portability and Accountability Act], and financial information protected by these regulations. ... The government is saying we're not really imposing any great burden." Nevertheless, he agreed that the FTC may have overlooked existing efforts aimed, for instance, at protecting patient privacy and preventing Medicare fraud. "Identity theft is a major issue affecting all sectors of the economy, and what the FTC is trying to do is a worthwhile endeavor. But doctors shouldn't be a part of law enforcement. There are other ways." The AOA's Martin suggested incorporating the red flags requirements into the forthcoming transition to electronic medical records, which will include heightened security and breach notification measures. Meanwhile, unless the FTC alters the rules or legislative relief is secured, members of organized medicine are advising physicians to scope out warning signs of potential identity theft and be prepared to adopt a compliance plan by June 1. - American Medical News Curbing obesity: Doctors play key role February 15, 2010 Structured weight-loss plans with regular doctor visits were more effective at helping extremely obese patients lose weight than less-intensive programs, according to a study in the Jan. 25 Archives of Internal Medicine.In the two-year study, 390 Louisiana adults with a body mass index of 40 or greater were randomly assigned to two groups -- usual care condition and intensive medical intervention. Physicians instructed the 190 participants in the usual care condition group on how to use a weight management Web site and scheduled two annual visits with them. The intensive medical intervention of 200 participants involved a multiphase treatment. Physicians first recommended that patients adhere to a low-calorie liquid diet for up to 12 weeks. In the second phase, they recommended a highly structured diet, monthly visits with the doctor, weight-loss medication and group behavioral therapy sessions. The two programs were implemented at six practices across the state. During the study period through Jan. 30, 2008, researchers measured patients' weight loss and found progress in the medical intervention group comparable to that seen in patients who undergo bariatric surgery. The study found that 31% of patients in the medical intervention group lost at least 5% of their initial body weight. In the usual care group, only 9% lost at least 5% of their initial body weight. "Too often ... doctors see it as their duty to tell the patient to lose weight, and it's the patient's responsibility to go out and do that. The study shows if in your practice you put in place a program that helps patients, you can really achieve a lot of good," said Donna Ryan, MD, an author of the study and associate executive director for clinical research at the Pennington Biomedical Research Center in Baton Rouge, La. Fighting an epidemic The findings come as obesity continues to plague a nation in which two in three adults are either overweight or obese. And there are signs the epidemic is worsening. From 1990 to 2005, the obesity rate rose about 50%, said a study in the Dec. 3, 2009, New England Journal of Medicine. A Nov. 20, 2009, report by the Centers for Disease Control and Prevention showed that diabetes is striking hardest in states with the highest rates of obesity and poverty. 2 in 3 adults are overweight or obese. The government, physicians and others are beefing up their efforts to combat obesity. On Jan. 28, first lady Michelle Obama joined Health and Human Services Secretary Kathleen Sebelius and Surgeon General Regina Benjamin, MD, to announce the surgeon general's new grassroots effort to curb obesity. The plan urges Americans to make healthy lifestyle choices, encourages communities to become actively involved in creating healthier environments, and emphasizes the importance of physicians teaching patients about good health. On Feb. 5, HHS awarded more than $119 million to all 50 states to support efforts to reduce obesity, increase physical activity, improve nutrition and decrease smoking. The grants are part of a new health and wellness initiative, Communities Putting Prevention to Work, which is funded by the federal stimulus package. The first lady on Feb. 9 announced the Let's Move campaign to raise a healthier generation. The American Medical Association voiced its support for the campaign, saying it has long recognized the public health concern of obesity. The AMA is "committed to reenergizing our programs and communications this year to focus on children's' needs related to obesity prevention and management," said J. James Rohack, MD, Association president. As part of its fight against obesity, the AMA offers doctors practical tools, including the AMA Healthier Life Steps program, which helps doctors support patients in changing their diets, physical activity levels and use of alcohol and tobacco. Delaware internist James Lenhard, MD, said lack of adequate payment for services is one obstacle keeping doctors from implementing programs such as the intensive medical intervention detailed in the Jan. 25 Archives study. The low-calorie diet and weight-loss drugs sibutramine hydrochloride and orlistat used in the study often are not covered by health insurance companies, he said. Other obstacles in physicians' battle against obesity are limited time for office visits, limited recourses and the perception that patients are not motivated to lose weight, Robert F. Kushner, MD, wrote in a commentary published in same issue of Archives. He said physician training in obesity care and reorganizing health services for people with chronic conditions are needed to engage primary care physicians in obesity care. "Obesity is underrecognized and undertreated in the primary care setting," wrote Dr. Kushner, clinical director of the Northwestern University Comprehensive Center on Obesity in Illinois. - American Medical News AMA Establishes Physician Volunteer Registry for Haiti February 02, 2010 The American Medical Association (AMA) and the National Disaster Life Support Foundation have established a registry for physicians who wish to volunteer their services to the earthquake victims in Haiti.The registry was launched January 26 and is available online on the AMA's Web site. The registry is intended to assist the federal government and the private sector in the coordination of medical efforts. It is open to all physicians. Those wishing to offer their services can enter their specialty, availability, language skills, and previous disaster medicine experience. "Practicing physicians, we need you," AMA President J. James Rohack, MD, wrote in a blog post announcing the registry. "Two weeks may have lapsed since devastation struck those in Haiti, but let's not forget the hundreds of thousands who are still suffering and need our help." A Webinar with instructions on how to prepare for working in Haiti also can be accessed on the AMA's Web site. Meanwhile, the World Health Organization (WHO) has issued a list of needed medical supplies. Among the items most urgently needed are bandaging and adhesive tape, intravenous equipment, plaster of Paris for casting, suction tubing, suture silk, X-ray film, Foley catheters, aminophylline, atenolol, ibuprofen, paracetamol, bupivacaine, and ketamine. A complete list and instructions on how to donate medical supplies are available on the WHO Web site. In other medical news from Haiti, the Pan American Health Organization, WHO, the Centers for Disease Control and Prevention, the United Nations Stabilization Mission in Haiti, as well as Canada, Cuba, and other partners are working to establish an emergency surveillance system within Haiti. The focus there is now shifting from emergency response to primary healthcare. A situation room is being set up for national and international partners to "monitor and investigate cases and provide information to decision makers." Members of the Pan American Health Organization/WHO Health Clusters will gather and convey information through this system. - Medscape Today Medicare pay overhaul heats up as health reform moves to back burner February 02, 2010 With a comprehensive health system reform effort effectively on hold after the victory of a Republican Senate candidate in Massachusetts, physician organizations are mobilizing to prevent Medicare doctor payment reform from also becoming a casualty of the altered political landscape on Capitol Hill.The American Medical Association, other physician organizations and seniors groups were hoping to follow health reform passage with a long-term solution to the Medicare physician payment system, which is primed for a 21.2% cut starting March 1. But momentum on the broader reform effort came to a grinding halt when Massachusetts state Sen. Scott Brown defeated state Attorney General Martha Coakley in a Jan. 19 special election for the Senate seat vacated by the death of Democratic Sen. Edward Kennedy last August. Without the 60 votes necessary to overcome the threat of a Republican filibuster in the Senate, prospects for both the health reform bill and a permanent Medicare payment overhaul have become murkier. After the special election, Senate lawmakers floated a proposed five-year patch on Medicare physician pay. At this article's deadline, leaders were considering whether to insert the provision into legislation that would raise the national debt ceiling, a measure the House approved in December. But in a Jan. 21 news conference with AARP and the Military Officers Assn. of America, the AMA reiterated that it does not support any more short-term repairs to the broken sustainable growth rate formula. The groups hosted the event to warn of access problems for seniors and military families if the 21.2% cut goes through. They also unveiled new television ads that call on the Senate to adopt a House-passed permanent overhaul of the pay system. "We absolutely do not want a temporary fix," said Nancy H. Nielsen, MD, PhD, AMA immediate past president. "The price tag grows every time you do that. That's why we are in the $200 billion price tag range right now. That is not fiscally responsible. We do not want a five-year fix, or any short-term fix. We want a permanent fix." AARP said nearly 90% of people ages 50 and older tell the organization they are concerned that the current formula threatens access to care. "The House has done its part by passing a permanent fix," said AARP Executive Vice President Nancy LeaMond. "Now it's the Senate's turn." But the upper chamber, which rejected a similar solution last year, still does not appear likely to approve the House measure, said William Oldaker, a partner of Oldaker, Belair & Wittie, a Washington, D.C.-based law firm that specializes in government relations. "I don't think physicians are going to be able to do anything better than a five-year freeze." Taking a breather Brown's victory not only reduced the Senate Democratic caucus to 59, but it also took the wind out of the sails of Democratic negotiators who were closing the distance between the House- and Senate-passed reform bills. While the development does not kill the reform effort outright, it has put it on hold while Democrats mull what they consider less-desirable alternatives to their original plans. The House could just adopt the Senate-approved measure on its own, but House Speaker Nancy Pelosi (D, Calif.) has said she does not have the votes to make it happen. Senate Democrats could use a parliamentary tactic known as reconciliation to pass a more limited reform measure, whether as part of a deal to revise portions of the broader Senate bill that the House opposes or as a stand-alone bill. That tactic would allow simple majority approval in the Senate. But some policy experts said it was unlikely lawmakers would take that approach, as reconciliation is a complex procedure with a limited scope. "The problem with reconciliation is that it's for tax and budget items," said Robert Moffit, PhD, director of the Center for Health Policy at the Heritage Foundation, a conservative think tank in Washington, D.C. "The provisions would be subject to a point of order and could be stripped if they're not compatible with reconciliation rules. If you go that route, you could have a bill that ends up looking like Swiss cheese and could actually make the health system worse." Another option would be for the House to send the Senate a new bill with popular reform measures that appear to enjoy more bipartisan support. These include imposing limited cost controls, ending insurance denials based on preexisting conditions, establishing minimum benefits standards, and prohibiting lifetime and annual limits on benefits, said Rep. Raul Grijalva (D, Ariz.). "This approach ensures that much of what we sought to achieve with health care reform will be enacted without the need to re-engage a debate on how to fix the irredeemable Senate bill in the face of unrelenting Republican obstructionism." But several health advocates, including the AMA, insisted that comprehensive health reform could -- and should -- still be achieved. AMA President J. James Rohack, MD, sent a Jan. 26 letter to President Obama and Congress renewing a call to enact comprehensive reform legislation, repeal the Medicare physician payment formula, implement medical liability reforms and standardize insurance claims processing requirements. "While the Senate election in Massachusetts altered the political landscape, the issues that created the pressure to enact reforms must still be addressed," Dr. Rohack wrote. Still, the uncertain fate of reform in the aftermath of the Massachusetts election already has led some to declare that the related issue of permanent Medicare physician pay reform is also on life support. - American Medical News More EMRs are in physician offices, but use still lags February 02, 2010 Physicians increasingly are adopting electronic medical records systems, even before government economic incentives for doing so have kicked in. But a survey by the Centers for Disease Control and Prevention also found those doctors weren't yet doing a whole lot with the technology.The CDC's National Center for Health Statistics said an estimated 43.9% of doctors are using full or partial EMRs, up from 34.8% in 2007 and 41.3% in 2008. The use of what was described as "fully functional" systems also went up from 3.8% in 2007 and 4.4% in 2008, to 6.3% in 2009. The survey did not include systems used for billing. Experts said the survey showed that while more physicians are embracing health information technology, it's not a full embrace. Doctors are starting slowly, with individual functions such as electronic prescribing. "There's definitely progress and the question is, is it fast enough," said Anne-Marie Audet, MD, vice president for the Program on Quality Improvement and Efficiency at the Commonwealth Fund. The organization's own study of physician EMR use, released in November 2009, found usage rates similar to the CDC study. Experts don't expect the numbers found in the CDC study to accelerate significantly, despite the presence of a maximum $44,000-per-physician tax incentive through the American Recovery and Reinvestment Act, and other incentives from Medicare and Medicaid set to begin in 2011. "One thing the stimulus has done is it's gotten [the vendors] a lot more phone calls," said Bruce Carlson, publisher of Kalorama Information, a market research firm in New York that focuses on health information technology. "A lot of questions, but only a limited amount of buying." Carlson said barriers to adoption for physician practices, including a disruption to work flow and a preliminary loss of productivity, are so strong that "the stimulus alone is not going to push the issue." But vendors are creating systems that will produce a quicker return on investment, which is more of a motivator than the incentive funds, he said. Carlson said many physicians have adopted EMRs because they were attracted to relatively simple functions such as e-prescribing and computerized physician order entry. Generational and geographic factors also play into whether a physician adopts a system, experts said. That explains why there is a large gap between the percentage of doctors who reported having an EMR system and the percentage of physicians who said they have only what is defined as a basic system -- one that includes patient demographic information, patient problem lists, clinical notes, prescriptions orders, and lab and imaging results. For example, only 20.5% of office-based physicians had what the CDC termed a basic system. That was up from 16.7% in 2008 and 11.8% in 2007. A fully functional system, which still hasn't reached a double-digit percentage of doctors, has everything that a basic system includes, plus more, such as warnings of drug interactions or contraindications, medical history and follow-up, and orders for tests. Impacts on adoption Dr. Audet said many office-based physicians have been persuaded by various research showing that EMRs could make billing more efficient and drive up revenue. Adding to the financial benefits were reimbursements for quality reporting and e-prescribing for Medicare and Medicaid patients, she said. With government incentives starting in 2011 for EMR use, adoption rates are expected to rise, said Chun-Ju Hsiao, PhD, a researcher who helped write the CDC study. Kalorama's Carlson said incentives will have an impact but won't be the primary driver that will close the gap between those who use EMRs and those who don't. And, he said, the incentives will have even less of an impact on closing the gap between basic and fully functional EMR use. A December 2009 report by the market research firm, which interviewed health IT vendor executives, found that the market for EMRs was $12 billion in 2008 and is expected to rise to $25.4 billion by 2013. But the majority of the increase represents sales to hospitals. A trend of practices being purchased by hospital groups that buy, or heavily subsidize, EMR systems for the practices has helped push physician adoption, experts said. Many experts have said that even with the incentives, the cost of a system -- and the loss of revenue a practice can expect when installing and adjusting to it -- still have many physicians believing an EMR is an expensive investment with little return. Dr. Audet agreed that incentives are not going to lead to an overnight interest in adoption. But that doesn't mean they won't be effective. "If we only see a 10% increase in adoption during the first wave of incentives," she said, "I don't think we should say, 'Well, this is a failure.' Actually, it would be pretty good. But it's going to inform the next wave." - American Medical News Phishing schemes are becoming sneakier in targeting doctors February 02, 2010 A faculty physician at the University of California, San Francisco, Medical Center received an e-mail last fall appearing to be from the hospital's information technology staff. The e-mail requested the doctor's login information in order to perform routine security upgrades to the system. Because it seemed like an ordinary request, the physician sent the information.But that e-mail wasn't from his hospital's IT administrators. It was from a scammer, and by responding, the physician had unwittingly exposed the personal information of more than 600 of his patients. This type of scam has become so common it's earned its own nickname: "spearphishing." Like phishing, this scam is carried out via a fictitious e-mail that looks legitimate. But unlike phishing, in which missives are sent to as many e-mail accounts as possible, spearphishing targets a specific population by posing as someone with whom the e-mail recipient routinely conducts business and exchanges information. Scammers are getting craftier, experts say. Instead of getting an e-mail with an attachment from a bank you never do business with or a magazine to which you've never subscribed, the spearphishers are sending e-mail that looks like it comes from your employer, your insurance company or someone else with whom you do business. "The best way to convert data to cash is ID theft," said Tom Cross, manager for X-Force Advanced Research, IBM's data theft research team. Medical records provide a comprehensive portfolio for individual identification, and that can be sold, he said. How spearphishing works The scams generally unfold in one of two ways. The scammer sends a legitimate-looking e-mail requesting information such as credentials, login information or account information, then uses that to gain access to your files, accounts or records. Or the e-mail may include a link to a Web site that looks like the real thing, but clicking on it plants a virus on your computer. Or worse, clicking the link downloads software that provides the hacker with remote access to your computer or network. Rod Rasmussen, president and chief technology officer of the security firm Internet Identity, based in Tacoma, Wash., said once scammers gain access to your computer, they can watch everything you do, including logging into financial accounts or accessing patient information. One recent phishing case was carried out by scammers who posed as the Centers for Disease Control and Prevention and sent e-mails to patients and doctors claiming everyone had to register at an online H1N1 vaccine database. A link in the e-mail took unsuspecting recipients to a Web site that looked as if it was operated by the CDC. A warning issued later by the real CDC indicated hackers were likely sending malicious software downloads to victims' computers. The way the phony UCSF and CDC attacks were carried out is becoming all too common, said Rick Howard, director of security intelligence at VeriSign iDefense, a cyber intelligence research firm. The scammers are growing more sophisticated by creating e-mails and Web sites that are increasingly realistic looking, he said. No one has done an exact count or study on how far spearphishing has spread, but those within the security industry say it's pervasive. Many times scams directed at physicians are facilitated by disgruntled employees who can identify parties that commonly reach the practice by e-mail, such as hospitals, contracted insurers, billing clearinghouses and technology vendors, Howard said. What can you do to protect yourself? Telling the difference between e-mail from a legitimate site and a fraudulent one can be difficult, said Robert Siciliano, an identity theft consultant and CEO of IDTheftSecurity.com, which sells anti-virus and security software. But there are some red flags, as well as some safeguards. An obvious first sign is if the e-mail comes from a company with which you have no business, such as a bank where you don't have an account asking for account information. Recent phishing scams have appeared to be from social networking sites such as Facebook or online retailers such as eBay or Amazon. If the e-mail appears to be from a familiar company or institution, close examination of the e-mail addresses or URLs can sometimes reveal clues of a scam, Siciliano said. For example, an e-mail appearing to be from Bank of America could contain a URL for Bank of Americas, with an "s." But even if you think it's legitimate, you should never click on a link sent through an e-mail, Siciliano said. Instead, bookmark commonly visited sites, and use that link whenever you receive an e-mail requesting you click through. Jorge Rey, director of information security and compliance for the Miami-based accounting firm of Kaufman, Rossin & Co., said calling to verify the source named in the e-mail is also a good idea. Even if it's a source to whom you have provided personal information before and someone who routinely e-mails you, don't send the information via e-mail. Rey said another red flag is an e-mail attachment that contains the extension ".exe." The extension is used for an executable file, which could contain a virus. But it's never a good idea to download files sent via e-mail regardless of the extension, he said, because many hackers have the ability to change the file extensions to something not as obvious. If your system is exposed to a virus, the scammers will likely gain access to patient lists and use those to target your patients. Doctors should make it a habit to remind patients the practice will never ask for personal information via e-mail, experts say. Physicians should also make their employees aware of possible scams, especially those staff members who routinely communicate with insurers and financial institutions. Organizations need to instill in people that falling for one of these scams is nothing to be ashamed of; otherwise they might be afraid to report the incident, Rey said. The damage can usually be minimized when immediate action has been taken, he said. - American Medical News Medicaid, CHIP payments to be reviewed by new federal commission February 02, 2010 A newly appointed commission will examine how Medicaid physician pay affects access to care by Medicaid patients and those in the Children's Health Insurance Program, among other issues.The Medicaid and CHIP Payment and Access Commission, or MACPAC, will be chaired by Diane Rowland, ScD, executive director of the Kaiser Commission on Medicaid and the Uninsured. The U.S. comptroller general appointed the panel's 17 members Dec. 23, 2009. MACPAC was created by a provision of the Children's Health Insurance Program Reauthorization Act, signed by President Obama in February 2009. The act instructs the panel to examine the effect of Medicaid pay and other factors on the access and quality of care received by Medicaid and CHIP enrollees. "It's clearly one of the things that Congress put in specifically that they would like to have looked at," Rowland said. MACPAC also will examine the impact of Medicaid and CHIP policies on the health system as a whole. She expects the panel will investigate access to pediatric specialists and state disparities in access to care. MACPAC does not yet have federal funding. However, the national health system reform bills would provide at least $11 million for the commission to hire a staff and carry out its mandate. MACPAC board members will not be paid a salary. Rowland -- who will retain her position on the Kaiser commission -- expects MACPAC to advise Congress on Medicaid, as the Medicare Payment Advisory Commission does for Medicare. Rowland said MACPAC could serve a critical role if Congress adopts a health reform bill with a provision to cover a projected 15 million additional people -- mostly adults -- in Medicaid over a decade. Four physicians will serve on MACPAC. They include its vice chair, David N. Sundwall, MD, a family physician and executive director of the Utah Dept. of Health. Dr. Sundwall said he wants to examine how to improve public health through Medicaid and CHIP. The programs could, for example, strengthen incentives for pregnant women to obtain prenatal care, he said. Another physician on the panel said he hopes to advise Congress on how best to use technology to improve the delivery of care in Medicaid and CHIP. Steven Waldren, MD, director of the center for health information technology at the American Academy of Family Physicians, said making Medicaid less bureaucratic and easier to participate in is also important. "It's not all about the money." Rowland, Dr. Sundwall and Dr. Waldren acknowledged the possibility that Congress might ignore MACPAC's recommendations because of politics or budget concerns. That's why the commission has to make "recommendations that can be acted on," Dr. Waldren said. Rowland said Congress asked for MACPAC, so hopefully lawmakers will listen to the panel. "The advantage that this group has is they have a reporting relationship to Congress." MACPAC -- unlike previous Medicaid panels -- is permanent and has a strong list of members, said Jocelyn Guyer, co-executive director of the Georgetown Center for Children and Families at Georgetown University's Health Policy Institute in Washington, D.C. That should increase the importance of the commission's reports, she said. American Medical Association policy supports a federal Medicaid committee to advise the Centers for Medicare & Medicaid Services and Congress on program policies that impact physicians and patients. - American Medical News Physician offices projected to see a decade of significant job growth January 15, 2010 The number of physicians, administrators and allied health professionals employed by medical practices is expected to increase substantially from 2008 to 2018. Hospital employment will grow more slowly, according to Bureau of Labor Statistics projections.What's unclear is where the physicians will come from to fill those positions, and how practices, given current payment trends, will be able to hire the number of staff the bureau projects will be required. "The population is aging and growing, and, no matter how you're going to slice it, we're going to need more folks," said Mark Doescher, MD, MSPH, director of the WWAMI Rural Health Research Center at the University of Washington. "More and more care that used to be done on an acute short-stay hospitalization is now outpatient." Experts are concerned that these projections will mean that current shortages of doctors and nurses will get worse. "We have coming work force issues that are very real and that we are going to have to grapple with," said Dr. Doescher. The situation for physician offices might be further complicated by the fact that registered nurses in this setting tend to be older than those who work in hospitals, so they may be retiring at a faster rate, experts said. "I don't know how physicians are going to do it," said Peter Buerhaus, PhD, RN, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University in Nashville, Tenn. The American Medical Association recognizes the existing shortage of physicians in many specialties and regions. The Association also supports basic nursing education opportunities, work force incentives and other efforts to increase the supply of registered nurses. The Bureau of Labor Statistics, a division of the U.S. Dept. of Labor, projected on Dec. 10, 2009, that from 2008 to 2018 the civilian labor force will grow by 12.6 million and total employment will increase by approximately 15.3 million jobs. Health care and social assistance will add approximately 4 million positions, with 772,200 of these in physician offices. About 109,300 of these new jobs will be for physicians, and 106,500 for registered nurses. In addition, 107,600 additional medical assistants will be needed, along with 248,700 office and administrative support positions. The Bureau of Labor Statistics does not break down these numbers by type of physicians or practices. But experts suspect that much of the growth of physician jobs will be in primary care specialties, which are already seeing work force shortages. "There's not a financial incentive to go into primary care. Unless primary care doctors are compensated, there won't be the physicians to coordinate the level of care," said Brian McCartie, vice president of business development for Cejka Search, a health care executive and physician search firm based in St. Louis. "A lot of our clients are very worried about primary care." High demand is also expected in geriatrics and other specialties, such as orthopedic surgery, that provide treatment for age-related conditions. Many of the administrative positions are expected to be added to larger practices or health systems. The only position in a physician's office not expected to increase is file clerk, primarily because electronic medical records are becoming more common. "This is the story of increasing complexity in health care, and why solo practices and small practices are having such difficulties with the business of medicine," said David N. Gans, vice president of innovation and research for the Medical Group Management Assn. "Existing practices are getting larger and adding sophistication. They are reducing their transcription staff and the number of medical records clerks. They are adding IT staff and technicians." Hospital job growth is expected to continue, but on a more modest scale. Hospitals will add 571,000 staff over the next decade, including 274,200 registered nurses, but only 9,600 physicians and surgeons, the Bureau of Labor Statistics projects. Some experts say the bureau's numbers run counter to their own experiences. For instance, physician search firms report an increase in the proportion of requests from hospitals, and a decrease from medical practices. "The trend we're seeing is a shift back to hospital employment of physicians, and I don't see that changing any time soon," said Jim Stone, managing partner of a physician search company, the Medicus Firm. Physicians can also expect employment opportunities in the offices of other health care professionals, such as optometrists, audiologists, mental health professionals, and physical, occupational and speech therapists. According to bureau projections, approximately 2,200 physician jobs will be added in those settings. Another 9,800 physician jobs will be added at outpatient care centers. The federal government is expected to hire an additional 2,100 physicians. State and local governments will hire another 1,200. Although projections indicate more jobs will be created than people added to the labor pool, the Bureau of Labor Statistics says this does not necessarily mean a worker shortage, since individuals might hold more than one job. But other surveys have found that health care institutions are already having work force concerns. One survey, released Nov. 16, 2009, by AMN Healthcare Services Inc., in partnership with the National Council on Physician and Nurse Supply, found that nearly all hospital CEOs believed there was a shortage of physicians, nurses and allied health professionals. In addition, the vacancy rate for physician jobs was 11%. About 6% of nursing jobs went unfilled, as did 5% of jobs for allied health professionals. - American Medical News Part-time work appeals to pediatricians January 15, 2010 Part-time work is continuing to gain favor among physicians, with new studies showing that the trend is spreading to pediatricians. At the same time, more part-time positions are becoming available for ob-gyns in the academic setting.Two surveys published online Dec. 14, 2009, in Pediatrics show that more pediatricians, including those nearing retirement age, are considering part-time work. And a study in the January Obstetrics & Gynecology found that growth in ob-gyn departments at U.S. medical schools in recent years has been accompanied by an increase in part-time faculty positions. "It seems as though there is a growing acceptance of reduced hours of work within the [pediatrics] field," said William Cull, PhD, director of the Division of Health Services Research at the American Academy of Pediatrics and an author of the Pediatrics studies. Cull found that the number of pediatricians of all ages who reported working part time increased from 15% in 2000 to 23% in 2006. The figures were drawn from surveys of national random samples of about 1,600 AAP members. Part-time options have become attractive in recent years as physicians seek to balance work and family. The increase in the number of women in the work force also has spurred growth in part-time slots. Pediatricians in part-time jobs reported greater levels of satisfaction than full-time employees, researchers said. Part-timers were more satisfied with hours worked per week, their time for administrative work, relationships with colleagues and work environment. They also were more likely to be satisfied with the additional time spent with their children and friends and for community activities and spiritual needs than were full-time colleagues. Part-time pediatricians spent about 25 hours a week in direct patient care compared with about 39 hours a week for full-time pediatricians. A second study in Pediatrics focused on part-time work among pediatricians age 50 and older, and found that abbreviated hours become more common as physicians age. Among pediatricians 65 to 69, 27% worked part time. The number of part-timers increased to 35% between age 70 and 74. Data collected from surveyed physicians indicated that career satisfaction was the most important factor -- cited by 77% -- influencing them to consider working beyond traditional retirement age. Financial needs or obligations were cited by 62%. More part-time opportunities for ob-gyns In the ob-gyn faculty study, researchers queried chairs of the departments of obstetrics and gynecology at 125 allopathic medical schools in the U.S. Two-thirds predicted that the number of faculty positions -- a mean number of 29 positions in 2008 -- would grow during the next five years, especially for part-time faculty and entry-level assistant professors who are generalists or maternal-fetal medicine specialists. Researchers also found that 84% of ob-gyn departments had part-time faculty positions. "Faculty were happier and more satisfied with part-time work," said lead author William Rayburn, MD, professor and chair of the Obstetrics and Gynecology Dept. at the University of New Mexico, Albuquerque. Part-time work is seen as providing the opportunity for greater balance between work and family, he said. "Institutions are now developing policies to optimize recruitment and promotion of part-time faculty, because the future of academic medicine is dependent more on maintaining part-time faculty members," the researchers wrote. Anthony Knettel, a spokesman for the Assn. of Academic Health Centers, a national nonprofit group based in Washington, D.C., was not surprised by the findings. The rise in the number of women physicians already had increased the demand for more flexible work schedules, he said. "Now I think we are seeing a trend of older physicians shifting to part-time work to help meet the needs of communities who are desperate for physicians," he said. Pediatrics is a particularly problematic area, he noted. "An [AAHC] staff member returned from Tulsa, Okla., last week and reported that the children's hospital there is having trouble recruiting specialists. It doesn't have to be a small, rural community that is having difficulty attracting a specialist in pediatrics; medium-sized cities are also having a problem." - American Medical News Senate-passed health reform bill faces tough negotiations with House January 06, 2010 Discussions between the House and Senate over health system reform legislation are beginning, with Democratic lawmakers attempting to reconcile two substantially different measures while holding onto the razor-thin margin of support each bill has in its chamber.The Senate approved the Patient Protection and Affordable Care Act by a party-line, 60-39 vote on Dec. 24, 2009, after nearly a month of debate and several procedural barriers that required 60 votes to overcome. Negotiators now must find a consensus between it and the Affordable Health Care for America Act, which the House passed 220-215 on Nov. 7, 2009. The two bills both would extend health coverage to most Americans through a combination of individual and business mandates, health insurance reforms, and new government coverage subsidies. Democrats predicted they would be able to hammer out a compromise that would garner a majority of support in the House and the 60 votes needed to move to final consideration in the Senate. But the tight margins of support for the legislation in each chamber forced Democratic leaders to make late concessions to holdouts within their caucuses, changes that could make future negotiations more difficult. The final Senate measure, for instance, dropped a public option -- still present in the House bill -- that has proven to be one of the most divisive issues. Late changes in both bills regarding government coverage of abortion services also nearly stalled the legislation and could torpedo the conference process if a consensus cannot be reached. Republican lawmakers pledged to try to prevent Congress from sending President Obama a reform measure that is a product of the current versions. Only one Republican voted for the House bill; none voted for the Senate measure. "This fight isn't over. My colleagues and I will work to stop this bill from becoming law," said Senate Minority Leader Mitch McConnell (R, Ky.). "That's the clear will of the American people, and we're going to continue to fight on their behalf." Last call for changes Negotiations between the House and Senate pose the last chance for lawmakers and lobbies to effect revisions. Groups representing physicians, seniors, drugmakers and others supported the legislation but are looking for changes before backing the final product. The American Medical Association supported passage of both the House and Senate bills but is pushing for key revisions during the conference process. While the Senate vote "closes one chapter of the legislative process, the hard work is not yet done," said AMA President J. James Rohack, MD. The Senate measure, for instance, includes a provision for an independent Medicare advisory board that the AMA opposes. The board could subject physicians to new spending targets that would lead to additional future payment cuts on top of any already required by Medicare statute. If negotiators decide to retain the advisory board provision, the AMA is asking for revisions that would more fairly spread out the burden of reducing Medicare spending, permit legitimate spending increases, and ensure the panel is transparent and accountable. The American College of Physicians supports the concept of the panel but also wants revisions to mandate a certain level of physician representation on the board, allow Congress more easily to override the board's mandates and stipulate that savings requirements apply to all Medicare participants. The AMA is also looking for modifications to a Senate provision that would base Medicare physician pay, in part, on quality and efficiency measures, starting in 2015. The Association is arguing that such measures -- and the risk-adjustment methods needed to make them work -- are not yet well-developed. Proposals in both bills aimed at banning new physician-owned hospitals will continue to face strong opposition from the AMA and others. "In allowing the attack on physician-owned hospitals to remain in the health care bill, nothing is gained. The only results are incredibly negative economic impact and loss of health care access," said Molly Sandvig, executive director of Physician Hospitals of America. Physician organizations claimed some success in helping modify the legislation originally released by Senate leaders to the version that finally passed the upper chamber. The California Medical Assn., for instance, initially made a statement of opposition to the Senate bill. But it softened its stance somewhat after bill handlers made several changes, including dropping plans to fund a primary care and general surgery bonus by cutting Medicare pay to specialists, impose a 5% tax on elective cosmetic surgery, and implement a Medicare enrollment fee. Still, the association is looking for more. "We have serious concerns with the Senate bill, which does not do enough to protect access to care for senior citizens and other California patients," said J. Brennan Cassidy, MD, CMA president. Neither bill would repeal the Medicare formula that determines physician pay, nor would they implement a temporary patch to avoid upcoming cuts. Congress has until the end of February to send legislation to the White House preventing a 21.2% cut from taking effect. The House has already passed legislation permanently repealing the sustainable growth rate formula that helps determine physician pay, and physician organizations are calling on the Senate to do the same before March 1. As part of its conditional support for the Senate health reform bill, the AMA will not back a final bill unless Congress is on track to pass a permanent SGR repeal before the 2010 cut takes effect. - American Medical News ICD-10 deadline causing worry, even 3 years away January 06, 2010 The American Medical Association met last month with several other industry organizations and government agencies in an effort to ensure physicians are as ready as possible for the next mandated version of diagnostic codes.Doctors, hospitals and payers need to adopt an updated version of the International Classification of Diseases code sets, ICD-10, by Oct. 1, 2013. As a prerequisite to the ICD-10 move, entities by Jan. 1, 2012, need to adopt updated electronic transaction standards, known as 5010, under the Health Insurance Portability and Accountability Act. The original compliance dates were much sooner -- April 1, 2010, for HIPAA 5010 and Oct. 1, 2011, for ICD-10 -- but were moved back due to a regulation released last January by the Bush administration in its final days in office. Despite having the additional time to get up to speed, the AMA is worried that physicians are still facing a costly and aggressive time line for implementing ICD-10. "The AMA strongly supports upgraded HIPAA transactions to improve the efficiency and effectiveness of the health care system," said Nancy Spector, the AMA's director of electronic medical systems. But the move to ICD-10 "will impact many business processes within a physician's practice, including documentation of a patient's visit, research activities, public health reporting, quality reporting and administrative transactions." Spector made the comments during a Dec. 10, 2009, meeting in Washington, D.C., held by the National Committee on Vital and Health Statistics, an advisory committee that makes recommendations to the Dept. of Health and Human Services. The AMA has also reached out to a handful of organizations that are necessary partners for ensuring a successful transition to ICD-10, hosting a stakeholder meeting on Dec. 4, 2009, with America's Health Insurance Plans, the BlueCross BlueShield Assn., the American Dental Assn., and the Healthcare Billing and Management Assn., among others. At that meeting, the AMA outlined its plans for physician outreach in 2010 and discussed barriers to implementation, the most notable of which is cost. According to estimates by the Medical Group Management Assn., the average cost of upgrading to ICD-10 for a three-physician practice will be $84,000. Spector said the AMA has concerns as to whether physicians will realize the projected return on investment for the initiative. "Because 50% of physician practices have fewer than five physicians, and yet account for 80% of outpatient visits, the AMA is very sensitive to issues that impact physicians' resources, costs and reimbursement," she said. AHIP supports the code set upgrade but is also asking for more time, said association spokesman Robert Zirkelbach. Throughout 2010, the AMA intends to develop an ICD-10 fact sheet series to give an overview of the process and to compare the new code sets to ICD-9. The document will also review concepts such as crosswalking, which involves transferring and applying some of the codes from the older system to the newer one. In addition, the Association will be developing an ICD-10 implementation tool kit, as well as a code set conversion tool. The Centers for Medicare & Medicaid Services has developed a national standard system for crosswalking, called general equivalency mapping, that health care organizations can follow. But CMS has not mandated the use of that system, which could potentially cause problems, said Robert Tennant, a senior policy adviser with MGMA. Tennant was present at both of the December policy meetings discussing ICD-10 and 5010. "The inevitability is that we will have to use these crosswalks," said Tennant. "But the health plans may say it's up to them to decide how to map these codes." Zirkelbach said insurers are aware of those concerns and that AHIP will be trying "to bring more uniformity to the process." Tennant did credit CMS with attempting to connect with stakeholders to maintain an open dialogue as it presses forward. He said the agency does not appear willing to commit to any contingency plans nor to extend the deadlines any further, meaning Medicare will be ready to start testing the 5010 transaction standards by Jan. 1, 2011. Federal officials and other ICD-10 proponents say the upgrade must happen because the current system is nearly 30 years old, and its approximately 16,000 procedure and diagnosis codes are insufficient. ICD-10 has roughly 155,000 codes, including about 68,000 diagnostic codes. - American Medical News American Diabetes Association Revises Diabetes Guidelines January 06, 2010 The American Diabetes Association (ADA) revised clinical practice recommendations for diabetes diagnosis promote hemoglobin A1c (A1c) as a faster, easier diagnostic test that could help reduce the number of undiagnosed patients and better identify patients with prediabetes. The new recommendations are published December 29 in the January supplement of Diabetes Care."We believe that use of the A1c, because it doesn't require fasting, will encourage more people to get tested for type 2 diabetes and help further reduce the number of people who are undiagnosed but living with this chronic and potentially life-threatening disease," Richard M. Bergenstal, MD, ADA president-elect of medicine & science, said in a news release. "Additionally, early detection can make an enormous difference in a person's quality of life. Unlike many chronic diseases, type 2 diabetes actually can be prevented, as long as lifestyle changes are made while blood glucose levels are still in the pre-diabetes range." The A1c test, which measures average blood glucose levels for a period of up to 3 months, was previously used only to evaluate diabetic control with time. An A1c level of approximately 5% indicates the absence of diabetes, and according to the revised evidence-based guidelines, an A1c score of 5.7% to 6.4% indicates prediabetes, and an A1c level of 6.5% or higher indicates the presence of diabetes. For optimal diabetic control, the recommended ADA target for most people with diabetes is an A1c level no greater than 7%. It is hoped that achieving this target would help prevent serious diabetes-related complications including nephropathy, neuropathy, retinopathy, and gum disease. Unlike fasting plasma glucose testing and the oral glucose tolerance test, A1c testing does not require overnight fasting. Compliance with screening may therefore be improved through use of the A1c test, which can be determined from a single nonfasting blood sample. Recommendation Changes for 2010 Specific changes in the 2010 Clinical Practice Recommendations are as follows: * A section on diabetes related to cystic fibrosis has been added to "Standards of Medical Care in Diabetes." New evidence has shown that early diagnosis of cystic fibrosis-related diabetes and aggressive treatment with insulin have narrowed the gap in mortality between patients with cystic fibrosis with and without diabetes and have eliminated the sex difference in mortality rates. New recommendations for the clinical management of cystic fibrosis-related diabetes, based on a 2009 consensus conference, will be published in 2010 in a consensus report. * Revision of the section "Diagnosis of Diabetes" now includes the use of the A1c level for diabetes diagnosis, with a cutoff point of 6.5%. * The section formerly named "Diagnosis of Pre-diabetes" is now named "Categories of Increased Risk for Diabetes." Categories suggesting an increased risk for future diabetes now include an A1c range of 5.7% to 6.4%, as well as impaired fasting glucose and impaired glucose tolerance levels. * Revisions to the section "Detection and Diagnosis of GDM [Gestational Diabetes Mellitus]" now include a discussion of possible future changes in this diagnosis, according to international consensus. Screening recommendations for gestational diabetes are to use risk factor analysis and an oral glucose tolerance test, if appropriate. Women diagnosed with gestational diabetes should be screened for diabetes 6 to 12 weeks postpartum and should have subsequent screening for the development of diabetes or prediabetes. * Extensive revisions to the section "Diabetes Self-Management Education" are based on new evidence. Goals of diabetes self-management education are to improve adherence to standard of care, to educate patients regarding appropriate glycemic targets, and to increase the percentage of patients achieving target A1c levels. * Extensive revisions to the section "Antiplatelet Agents" now reflect evidence from recent trials suggesting that in moderate- or low-risk patients, aspirin is of questionable benefit for primary prevention of cardiovascular disease. The revised recommendation is to consider aspirin treatment as a primary prevention strategy in patients with diabetes who are at increased cardiovascular risk, defined as a 10-year risk greater than 10%. Patients at increased cardiovascular risk include men older than 50 years or women older than 60 years with at least 1 additional major risk factor. * Fundus photography may be used as a screening strategy for retinopathy, as described in the section "Retinopathy Screening and Treatment." However, although high-quality fundus photographs detect most clinically significant diabetic retinopathy, they should not act as a substitute for an initial and dilated comprehensive eye examination. Retinal examinations should be carried out annually or at least every 2 to 3 years among low-risk patients with normal eye examination results in the past. * Extensive revisions to the section "Diabetes Care in the Hospital" now question the benefit of very tight glycemic control goals in critically ill patients, based on new evidence. * Extensive revisions to the section "Strategies for Improving Diabetes Care" are based on newer evidence. Successful strategies to improve diabetes care, which have resulted in improved process measures such as measurement of A1c levels, lipid levels, and blood pressure, include the following: o Delivery of diabetes self-management education. o Adoption of practice guidelines developed with participation of healthcare professionals and having them readily accessible at the point of service. o Use of checklists mirroring guidelines, which help improve adherence to standards of care. o Systems changes, including providing automated reminders to healthcare professionals and patients and audit and feedback of process and outcome data to providers. o Quality improvement programs, in which continuous quality improvement or other cycles of analysis and intervention are combined with provider performance data. o Practice changes, which may include access to point-of-care A1c testing, scheduling planned diabetes visits, and clustering dedicated diabetes visits into specific times. o Tracking systems with either an electronic medical record or patient registry to improve adherence to standards of care. o Availability of case or (preferably) care management services using nurses, pharmacists, and other nonphysician healthcare professionals following detailed algorithms under physician supervision. "The most successful practices have an institutional priority for quality of care, involve all of the staff in their initiatives, redesign their delivery system, activate and educate their patients, and use electronic health record tools," the guidelines authors conclude. "It is clear that optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of dedicated health care professionals working in an environment where quality care is a priority." - Medscape AAN Guideline Recommends Against TENS for Chronic Low-Back Pain January 06, 2010 A new evidence-based review from the American Academy of Neurology concludes that transcutaneous electric nerve stimulation (TENS) is not recommended for use in treating chronic low-back pain but adds that TENS should be considered to treat diabetic neuropathy.The report, from the academy's Therapeutics and Technology Assessment Subcommittee, was published online December 30 in Neurology. Authors on the new document are Richard M. Dubinsky, MD, MPH, from Kansas University Medical Center in Kansas City, and Janis Miyasaki, MD, MEd, from Toronto Western Hospital, Ontario, Canada. "In the highest-quality studies of chronic low back pain, there was no benefit of TENS compared to sham or placebo TENS, leaving us to conclude that it is of no benefit, and make a recommendation that it should not be used for chronic low back pain," Dr. Dubinsky told Medscape Neurology. In diabetic polyneuropathy, some studies showed slight benefit, he added. "We concluded it should be considered in the treatment of diabetic polyneuropathy." Systematic Review TENS has been used to treat neurologic and other disorders for decades, the authors write. The biologic basis of its analgesic effect is not known, but it is used is based on the gate theory of pain, they note. In this assessment, the authors carried out a systematic literature search of Medline and Cochrane Library up to April 2009, looking for controlled clinical trials in which TENS was used to treat pain associated with neurological conditions. Acute low back pain not normally seen in neurologic conditions was not considered in this review. All but 1 of the studies excluded patients with known causes of low-back pain, such as pinched nerves, severe scoliosis, severe spondylolisthesis, or obesity. "We only found 2 conditions that had adequate rigor in the research, and that was chronic back pain and diabetic polyneuropathy," Dr. Dubinsky said. The studies included showed conflicting results in chronic low back pain. Two class 2 studies showed benefit, but 2 class 1 studies and another class 2 study showed no benefit. "Because the Class I studies are stronger evidence, TENS is established as ineffective for the treatment of chronic low back pain," they write. Two class 2 studies suggested that TENS is probably effective in treating painful diabetic neuropathy. The only specific neurologic cause of chronic low-back pain in which TENS was studied was multiple sclerosis, for which TENS was not shown to be of benefit. The document makes 2 main recommendations: * TENS is not recommended for the treatment of chronic low-back pain because of a lack of proven efficacy (level A, 2 class 1 studies). * TENS should be considered for the treatment of painful diabetic neuropathy (level B, 2 class 2 studies). The document also gives some guidance on the need for further research into TENS, Dr. Dubinsky noted. Among their recommendations were determining what the best paradigm is, in terms of current, pulse-width, and frequency, and then using it in patients who are naive to TENS so that they will be truly blinded to treatment allocation, and studying TENS in patients with well-defined neurological conditions. Absence of Evidence In an editorial accompanying the new document, Andreas Binder, MD, and Ralf Baron, MD, from the Division of Neurological Pain Research and Therapy in the Department of Neurology at Christian-Albrechts-Universität Kiel, Germany, write that the conclusions of Dr. Dubinsky and Dr. Miyasaki "may heat up the discussion on the usability of TENS and may be viewed as supporting the critics who questioned the value of TENS in pain therapy. "However," they add, "absence of evidence is not evidence of absence. The clinical impact of meta-analyses is always limited by the quantity and quality of conducted trials." TENS has had a long-standing role in pain management, is easy to handle, has a favorable benefit-to-risk ratio, and can be discontinued easily if it is not efficacious — all "desirable properties when treating pain," they write. The new document calls for further trials and even provides "clearcut recommendations for their conduction," they note. "This updated evidence-based review is valuable in providing the limits of our evidence base," Dr. Binder and Dr. Baron conclude. "Nevertheless, it is not unreasonable to take a practical position that, in spite of the relatively weak scientific and clinical evidence, TENS still represents a valuable therapeutic alternative in neurologic pain disorders. "Taking the favorable benefit-risk ratio when compared with other pain relieving methods into account, TENS remains a valuable part in the armamentarium of pain therapy." - Medscape CDC Reports Show Downward Trend in Current Smokers, Rates of Secondhand Smoke Exposure January 06, 2010 The US Centers for Disease Control and Prevention (CDC) have issued 2 reports, both published in Morbidity and Mortality Weekly Report and reprinted in the December 23/30 issue of the Journal of the American Medical Association, on smoking trends and secondhand smoke exposure in 2008."Approximately one in five U.S. adults smoke cigarettes, and certain subpopulations have disproportionately higher prevalences of smoking," write S. R. Dube, PhD, from the CDC Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, and colleagues. "Cigarette smoking continues to be the leading cause of preventable morbidity and mortality in the United States. Full implementation of population-based strategies and clinical interventions can educate adult smokers about the dangers of tobacco use and assist them in quitting." An analysis of data from the 2008 National Health Interview Survey showed that the proportion of US adults who were current cigarette smokers decreased by 3.5% during 1998 to 2008, from 24.1% to 20.6%. However, there was no significant change in that proportion from 2007 (19.8%) to 2008 (20.6%). Of current cigarette smokers in 2008, 79.8% (36.7 million) smoked every day and 20.2% (9.3 million) smoked some days. An estimated 45.3% of smokers (20.8 million) had stopped smoking for at least 1 day during the preceding 12 months because they were trying to quit. Of about 94 million persons who had smoked 100 cigarettes or more during their lifetime, more than half (51.1% [48.1 million]) were no longer smoking. In 2008, the highest prevalence of smoking was in adults at least 25 years of age with low educational attainment (41.3% for persons with a General Educational Development certificate and 27.5% for those with less than a high school diploma vs 5.7% for those with a graduate degree). The lowest quit ratios in 2008 were in adults with education levels at or below the equivalent of a high school diploma (range, 39.9% - 48.8%). During the 10-year period examined, smoking cessation for adults with low educational attainment did not change. "Because persons with lower educational attainment generally have higher rates of smoking and are less likely to quit, evidence-based programs known to reduce smoking should be intensified among these groups," the study authors write. "Health-care providers should take education level into account when communicating about cessation and smoking hazards to these patients." An accompanying CDC editorial note indicates at least 5 limitations of this report: self-reported estimates of cigarette smoking were not confirmed by biochemical tests, possible underestimates for certain racial/ethnic populations, a lack of generalizability to institutionalized populations and the military, limited information was available on former smokers, and small sample sizes were included for certain population groups (eg, American Indians/Alaska Natives). "Effective population-based strategies for preventing tobacco use and encouraging tobacco use cessation (including enforcing bans on advertisement) are outlined in the World Health Organization's MPOWER package," the editorial states. "Despite partial bans on some forms of advertisement, the tobacco industry continues to conduct targeted marketing toward socially disadvantaged subgroups and vulnerable populations, such as persons with low socioeconomic status and youths. Offering and providing effective cessation counseling and treatments are integral to reducing the smoking epidemic, especially in subpopulations with high rates of smoking." Report on Secondhand Smoke Exposure The second report analyzed 2008 Behavioral Risk Factor Surveillance System data from 11 states and the US Virgin Islands (USVI) on secondhand smoke (SHS) exposure. "State variation exists in the prevalence of current smoking, in non-smoker exposure to SHS, and in the prevalence of persons who have completely smokefree rules for their homes," write A. Malarcher, PhD, from the CDC Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, and colleagues. "SHS causes immediate and long-term adverse health effects in nonsmoking adults and children, including heart disease and lung cancer, and SHS exposure occurs primarily in homes and workplaces," the authors note. "Smoke-free policies, including not allowing smoking anywhere inside the home (i.e., having a smoke-free home rule), are the best way to provide protection from exposure to SHS." SHS exposure in homes varied widely among states, from 3.2% in Arizona to 10.6% in West Virginia. For indoor workplaces, the range was from 6.0% in Tennessee to 17.3% in the USVI. Most persons surveyed reported having smoke-free home rules (from 68.8% in West Virginia to 85.7% in the USVI). This report also provided 2008 findings for Behavioral Risk Factor Surveillance System–based state-specific estimates of current smoking in 50 states, the District of Columbia, and 3 territories (Guam, Puerto Rico, and the USVI). There was marked variation in self-reported cigarette smoking prevalence (range, 6.5% - 27.4%). "Additional legislation is needed to increase the number of smoke-free workplaces and other public places," the report authors write. "Health-care providers should continue to encourage persons to make their homes completely smoke-free." The accompanying CDC editorial note points out at least 4 limitations of these findings: the failure to survey persons without any telephone service or with only wireless telephones, that the estimates for cigarette smoking and SHS exposure were based on self-report, a median response rate of only 53.3%, and the determination of SHS exposure only for the 7 days preceding the survey. "Enacting legislation that eliminates smoking in indoor work spaces and public places and encouraging persons to implement smoke-free home rules will protect persons from exposure to SHS," the editorial states. "The Institute of Medicine recently concluded that SHS exposure can cause acute myocardial infarction (AMI) and that communities that enact smoke-free policies realize a reduction in hospitalization for AMI among the general population. All persons, including those with an increased risk for heart disease, can protect themselves from SHS exposure by avoiding indoor areas that allow smoking." - Medscape Medicare Buy-in Plan Runs Into Strong Opposition December 15, 2009 If you're confused about the healthcare reform proposal in the US Senate to allow citizens aged 55 and 64 years to buy in to the Medicare program, you're in good company.The details of the plan, first announced last week by Senate Majority Leader Harry Reid, D-Nevada, as part of a compromise to win over senators opposed to a "public option" — a federal health insurance plan to compete with private insurers — are shrouded in secrecy. Reid is waiting for the Congressional Budget Office to complete a cost analysis of the measure before providing specifics. Even the No. 2 Democrat in the Senate, Richard J. Durbin of Illinois, said he was "in the dark" about aspects of the plan. What is known about the measure has engendered rapid and fierce opposition from healthcare providers, including the American Medical Association, the American Hospital Association, and America's Health Insurance Plans, mainly because Medicare reimbursement rates are inadequate. In broad strokes, Reid's compromise would expand Medicare eligibility to people aged 55 to 64 years who are uninsured or paying high premiums in the individual market. Most of those with employer-provided coverage would not be eligible. Buy-in Plan Condemned The American Medical Association, which had supported the bill passed by the House of Representatives that would create a public option, was quick to condemn the Medicare buy-in idea. "The AMA has longstanding policy opposing the expansion of Medicare given the fiscal projections for the future," AMA president J. James Rohack, MD, said in a statement. "Currently, the flawed Medicare physician payment formula will cause a drastic 21% cut to physicians caring for Medicare patients in January, and 22% of Medicare patients looking for a new primary care doctor are having trouble finding one." The Mayo Clinic, often cited by Obama as a model of what healthcare reform might look like, condemned the buy-in proposal in stark terms. "The current Medicare payment system is financially unsustainable," the group said in a statement posted on the Mayo Clinic Health Policy Blog last week. "Any plan to expand Medicare, which is the government's largest public plan, beyond its current scope does not solve the nation's health care crisis, but compounds it. "Expanding this system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across the country. A majority of Medicare providers currently suffer great financial loss under the program. Mayo Clinic alone lost $840 million last year under Medicare. As a result of these types of losses, a growing number of providers have begun to limit the number of Medicare patients in their practices." Writing in Monday's USA Today, American Hospital Association President Richard J. Umbdenstock described the buy-in plan this way: "Imagine living in a house with a crumbling foundation and trying to repair it by adding more bedrooms." "Making millions of non-seniors eligible for Medicare, at the same time that millions more Baby Boomers are reaching retirement age, will further weaken the program and put many hospitals at tremendous risk," Umbdenstock said. "Their ability to provide other critical services their communities need — such as trauma care, emergency care, disaster readiness and more — would be jeopardized. And, one key reason health care costs are higher for everyone is that Medicare does not pay its fair share of the cost of care. Reform should end this 'cost shift,' not make it worse." Health insurers, who opposed the House bill because of its inclusion of a government-run public option plan, quickly opposed the Senate buy-in idea. "This would add millions of new people to a program everyone agrees is going broke," a spokesman for America's Health Insurance Plans said in a statement. Legislators Weigh In Several legislators weighed in on the proposal on the Sunday talk shows yesterday. Some potential supporters of the buy-in proposal have been reticent in their endorsements because so few details are known. "The whole reason we're doing this bill is to bring down cost, first for the American people in healthcare, and secondly for the deficit," Democratic Sen. Claire McCaskill of Missouri said on Fox News Sunday. "So until we get the numbers back from the Congressional Budget Office, we're all on hold." If the Congressional Budget Office finds the bill would increase the national debt of patients' out-of-pocket expenses, she would "absolutely" vote against it, she said. A few were enthusiastic about the idea. Rep. Anthony Weiner, D-NY, called it "the mother of all public options.... Expanding Medicare is an unvarnished, complete victory for people like me who support a single-payer system. Never mind the camel's nose — we got his head and neck in the tent," he told the New York Times last week. That sentiment was what disturbed Sen. Ben Nelson, D-Nebraska, about the buy-in. "I'm concerned that it's the forerunner of single-payer — the ultimate single-payer plan, maybe even more directly than the public option," he said yesterday on CBS' Face the Nation. Nelson previously said he won't support the bill unless fellow Democrats establish a firewall to ensure no public money goes toward abortion coverage. Sen. Judd Gregg, R-Vermont, said the plan could push patients out of private insurance. "The sickest 55-year-olds will seek to join Medicare and no one knows what it will ultimately cost." Speaking on Fox News Sunday, Gregg cited a new study released December 11 by the Centers for Medicare and Medicaid Services. It found that national health spending from 2010 to 2019 would total $35.5 trillion. That is $234 billion more than the amount projected under current law. To pay for coverage of the uninsured, the bill would impose new fees on health plans, drug manufacturers, and medical device companies, Chief Actuary Richard S. Foster said. The fees would "generally be passed through to consumers in the form of higher drug and device prices and higher insurance premiums." Republicans have been staunch in their opposition to a public option or buy-in. "If the Titanic is sinking, the last thing you want to do is to put Grandma and more of your family on the boat," said Charles E. Grassley, Republican Senator of Iowa, in the New York Times last week. Yet Reid's hopes that the Medicare buy-in might win over some moderates, such as Joseph Lieberman, appear to be sinking. The independent Connecticut senator, whose vote would be needed to block a Republican filibuster of healthcare reform, said he is staunchly opposed to the proposal. "It has some of the same infirmities that the public option did," Lieberman said yesterday on CBS' Face the Nation. "It will add taxpayer costs. It will add to the deficit. It's unnecessary. The basic bill, which has a lot of good things in it, provides a generous new system of subsidies for people between ages 55 and 65, and choice and competition." - Medscape Today H1N1 vaccine problems prompt government to review emergency preparedness December 15, 2009 West Virginia family physician Stephen Sebert, MD, is waiting for vaccine that may not arrive.In early October, his multispecialty practice received influenza A(H1N1) vaccine for about 100 employees who interact with patients. But that was it. His patients still need to be immunized, and Dr. Sebert wonders if he will get another shipment of vaccine. "We were telling patients, 'Get [the vaccine] any place you can.' But now I don't think anyone has it," he said. Similar scenarios of vaccine shortages and distribution woes have played out from New England to the West Coast as the H1N1 virus spread nationwide. Even as the epidemic begins to wane and states prepare to lift restrictions on H1N1 vaccinations, some physicians lack supplies of vaccine. The government has taken note. On Dec. 1, Health and Human Services Secretary Kathleen Sebelius called for a review of the federal government's system for handling public health emergencies. In a speech to the AMA's National Congress on Health System Readiness in Washington, D.C., she told several hundred physicians and public health experts that the nation's outdated vaccine technology is a "fundamental problem" and that gaps exist at every stage of the vaccine development process. The goal, she said, is to modernize production to improve stockpiling and manufacturing, and to create more advanced distribution practices. The government review -- expected to be completed in early 2010 -- will examine all aspects of public health emergencies, including terrorist attacks and natural disasters. But the catalyst for the call to action was H1N1, said Nicole Lurie, MD, MSPH, assistant secretary for preparedness and response at HHS, who is leading the review. Dr. Lurie urged physicians and the public not to expect sweeping reform immediately. "In four months we can't fix everything. ... But we can take a systems perspective, look at where the most vulnerable points in the system are, and look at the kinds of policies and investments we need to make to address those things," she said in an interview. Vaccine distribution gaps HHS was expecting 189 million doses of H1N1 vaccine to be created and delivered. As of Dec. 7, 63.9 million doses had been shipped to the states; another 72.6 million doses are available and waiting for state orders, according to the Centers for Disease Control and Prevention. The remainder is still in production. Although vaccine production and distribution has increased in recent weeks, the CDC remains short by millions of doses. Government officials point to a virus that grew too slowly in outdated egg-based vaccine technology. The shortage was no surprise to John J. Lanza, MD, PhD, MPH, director of the Escambia County Health Dept. in Florida. "Most of us were saying to ourselves, 'This [projection] is too good to be true. They're never going to be able to get it out this quickly,' " said Dr. Lanza, noting that manufacturers were swamped by balancing production of vaccines for both seasonal flu and H1N1. During her Dec. 1 speech, Sebelius noted the recent opening of America's first cell-based vaccine plant. Novartis is scheduled to begin the plant's operation in 2011 in North Carolina. The facility will be able to produce vaccine for a significant number of Americans within six months of the onset of a pandemic and will help end the nation's reliance on egg-based technology, she said. "This is a big step. But it's only one step." With seasonal flu vaccine, physician practices order and receive shipments directly from the manufacturer or distributors. But H1N1 vaccine allocation is managed by state and local health departments. State health departments send orders to the CDC, then a CDC contractor ships vaccine to the health departments, which in turn distribute it to physicians. Vaccine allocation is based on a state's population. Each week, the CDC prepares a report on the amount of vaccine available for order. Distribution methods differ by state and county. In Florida, Dr. Lanza said vaccine distribution ran so smoothly that the state health department wants to open H1N1 vaccination to people outside the CDC's high-risk groups. He said priority was given to physicians, followed by schools. Only recently did the department begin allocating vaccines to pharmacies, he said. Similarly, the North Dakota Dept. of Health announced Dec. 7 that physicians and public health units with sufficient H1N1 vaccine supplies could offer vaccinations to the general public. Shortages still exist But elsewhere, some doctors continue to struggle to get vaccine. Physicians in Kentucky do not have enough doses to vaccinate their high-risk patients, including pregnant women and children, said Ardis Dee Hoven, MD, chair-elect of the AMA Board of Trustees and an infectious disease specialist in Lexington, Ky. "There are doctors in my community, including me, who are very frustrated. We don't know when we're going to get doses of the medicine. ... Our patients are equally distraught," Dr. Hoven said. She supports the government's review of how public health emergencies are handled but said the process should include discussions on what can be improved at the community level. As the latest round of the H1N1 epidemic begins to wane, health care leaders are reminding physicians and the public of the continued importance that everyone -- particularly those in priority groups -- be vaccinated against the virus. On Dec. 7, HHS launched a new national public service announcement campaign with the Ad Council that features television, radio, online banners and outdoor advertisements in English and Spanish, encouraging Americans to get vaccinated. "The concern is we're probably in for another wave of H1N1," Dr. Hoven said. "What we don't want to have happen is complacency." - American Medical News Leasing market for medical offices hits downturn December 15, 2009 Would you like a golf club membership with your medical office lease? How about a few months of free rent? Fresh paint for the walls? How about just lower rent?"Everybody is renegotiating their leases," said Tom Dalcolma, a partner in Street Sotheby's Medical Realty Advisors in Columbus, Ohio. "It's clearly a tenants' market." The real estate slump, combined with tighter credit, means that fewer medical office buildings are being built. But after a previous construction boom, there is still more supply than demand. So rents are creeping downward, and vacancy rates are going up. These are the conclusions of the Medical Office Research Report published by the real estate investment company Marcus & Millichap. The report looked at the second half of 2009. For physicians who rent space, this means it's a good time to look for a better deal. But those who lease to others might need to take extra steps to keep tenants happy. The report said the market for medical office buildings is "much more stable than traditional office properties." But vacancy rates have gone up and are expected to continue to increase, despite the fact that fewer medical office buildings are being built and some projects have been canceled. Approximately 10.1 million square feet of medical office space are scheduled for completion this year, a decline of 30% from 2008. Only 7 million square feet are expected to be built in 2010. "We have seen a little bit of a dip in occupancy, but not a lot," said Gordon Soderlund, senior vice president for strategic relationships with DASCO Companies, a medical building developer and manager in Palm Beach Gardens, Fla. "Physicians generally don't move that often, and a lot of hospitals have suspended capital projects." Rents down nationwide Rents also went down in most areas of the country, because fewer practices are expanding into new space. Some practices are becoming smaller while others are closing. These market changes have resulted in a decline in the average asking price for medical office building rent. Nationally, the per square foot costs declined from $24.90 in the third quarter of 2008 to $23.90 in the third quarter of this year, according to Marcus & Millichap. Only rents in Texas inched up, from $22.67 to $22.86. Near term predictions are for average rents nationally to go down further, to $23.42. The difference between asking rents and the amount physicians actually pay is unknown. Many experts say it's a good time for renters to ask the landlord to renegotiate your lease, even if there is still time left on it. Landlords may be amenable to locking in a lower rate if the lease is extended, although they can be understandably hesitant. Long-term leases can be attractive to future investors, but reduced rents cut the value of the building, making it more difficult to sell or refinance. Those who negotiate medical office leases say if the landlord won't lower the rent, physicians may be able to get lower property-related expenses or other perks. "There are other benefits [owners] can bring to the table," said Ken Scheper, finance director of Alliance Primary Care in Cincinnati. He is renegotiating several leases for his medical group. Landlords might be willing to throw in a few months of free rent, provide money to update the space, cover common-area maintenance charges, or pay for something like a golf or health club membership. "If you lower the rents, you are actually devaluing the building," Soderlund said. "A two-year membership at a golf course -- that may not even get documented or show in the lease itself. It's not being deceptive, because a landlord is still collecting these rents, but they happen to offer some incentives or concessions to keep a tenant." Time to look elsewhere -- or expand? If the lease cannot be changed, experts say, it might be worthwhile to shop for other spaces that may be inexpensive enough to justify buying out the remainder of the existing lease. It also may be a good time to think about expanding the practice space, experts said, because new developments might require lower commitments of time and money. For example, on Oct. 15, Oaks Development Group announced the launch of a physician incubator space in a 20,000-square-foot medical building under construction in Palm Coast, Fla. Incubator spaces, common in industry and high-tech fields, are intended to provide an economically supportive environment for new business start-ups. The Oaks project includes eight offices, totaling 2,200 square feet, that have been designed as shared space equipped with the basics, such as exam tables and high-speed Internet. Only a one-year commitment is needed, rather than the standard five- or 10-year lease many practices sign. Plus practices can rent an office for as little as two half-days a week. Various office-sharing arrangements are common among practices or with hospitals, but many experts say such an arrangement with a developer is unusual. "We saw a lot of physicians reluctant to commit to a long-term lease. This allows them to put their toe in the water and see what revenues are going to be like," said Charlie Barker, Oaks' director of development. While this is one example of how national medical office trends may work to the advantage of physicians who rent, physicians who own medical office space are on the other end of the equation. For owners, now more than ever, customer service is key. "First and foremost, [owners should] make sure that they are very, very in tune to the needs of the tenants," Soderlund said. "If your service is the top quality, they will be more likely to renew, and it will be harder for them to leave." Experts recommend that owners make sure exteriors, entranceways and lobbies are maintained. Carpeting may need to be replaced regularly because of heavy foot traffic. Periodic tenant surveys also may help identify needs. - American Medical News Most Primary Care Practices Too Small to Reliably Measure Performance December 15, 2009 Few primary care physician practices active in the Medicare program are large enough to reliably measure 10% relative differences in common measures of quality and cost performance, according to a study published in the December 9 issue of the Journal of the American Medical Association."It is unlikely that individual primary care physicians annually see a sufficient number of eligible patients to produce statistically reliable performance measurements on common quality and cost measures, calling into question whether their performance can be differentiated with respect to national benchmarks," write David J. Nyweide, PhD, from the Centers for Medicare and Medicaid Services, Baltimore, Maryland, and colleagues. "This limitation might be overcome by measuring the collective performance of primary care physicians at the practice in which they work." The aim of this study was to determine whether primary care physicians working in a group practice collectively see enough Medicare patients annually to detect meaningful differences between practices in ambulatory quality and cost measures. The researchers used the Healthcare Organization Services database to link primary care physicians to their physician practices. Patients who visited primary care physicians in the 2005 Medicare Part B 20% sample were used to estimate Medicare caseloads per practice. Caseloads needed to detect 10% relative differences in costs and quality were calculated for the following: national mean ambulatory Medicare spending, rates of mammography for women aged 66 to 69 years, hemoglobin A1c testing for patients with diabetes aged 66 to 75 years, preventable hospitalization rates, and 30-day readmission rates after discharge for congestive heart failure. Performance Cannot Be Reliably Measured in 65% Dr. Nyweide and his team report that roughly 65% of all primary care physicians active in the Medicare program work in practices with insufficient numbers of beneficiaries to reliably differentiate their practice's performance from national quality and cost benchmarks. Only the largest primary care physician practices had sufficient caseloads to measure significant differences in performance, and such practices are the least common, they point out. Specifically, the researchers found that primary care physician practices had annual median caseloads of 260 Medicare patients (interquartile range [IQR], 135 - 500), 25 women eligible for mammography (IQR, 10 - 50), 30 patients with diabetes eligible for hemoglobin A1c testing (IQR, 15 - 55), and 0 patients hospitalized for congestive heart failure. No practices with fewer than 6 primary care physicians had enough patients to reliably detect a 10% relative difference in costs or any quality measure. Approximately 9% of practices with 6 to 10 physicians had enough patients to detect a 10% relative difference in costs, but less than 3% of such practices could do so with mammography or hemoglobin A1c testing. About half of practices with 11 to 20 physicians had enough patients to detect a 10% relative difference in costs, but fewer than 30% of these could do so for any quality measure. About half of the practices with 21 to 50 primary care physicians had enough patients to detect differences in costs, mammography, and hemoglobin A1c testing. Only those practices with more than 50 physicians had sufficient caseloads to detect significant differences in costs, mammography, and hemoglobin A1c testing, the authors report. However, none of the practices, regardless of their size, had sufficient caseloads to detect relative differences for preventable hospitalization or 30-day readmission after discharge for congestive heart failure. Study Limitations The study has several limitations, the authors write. For one, it is a challenge to match physicians to their practices in a given year because of physician turnover. In addition, although larger groups of primary care physicians may be desirable to measure performance, it may be better for patients to receive their care in smaller practices. The authors conclude that the results of the study call into question the wisdom of pay-for-performance programs and quality reporting initiatives that focus on differentiating the value of care delivered to the Medicare population by primary care physicians, adding, "Novel measurement approaches appear to be needed for the twin purposes of performance assessment and accountability." In an accompanying editorial, Donald M. Berwick, MD, from the Institute for Healthcare Improvement, Cambridge, Massachusetts, writes that effective sample sizes contract when the focus is on specific diseases or patient subpopulations and suggests that Nyweide and colleagues, by relying on highly focused quality metrics, are viewing care through a tiny keyhole. "If valid quality metrics could be constructed that cross conditions, more patients could contribute relevant data," he suggests. More information could be gleaned if data were aggregated from Medicaid and private insurers in addition to Medicare. In addition, patients should be asked about their experiences, Dr. Berwick comments. Finally, the ability to measure and track individual patients' health and function over time and place should be expanded, he writes. "Measuring a mammography rate or the frequency of assessment of glycated hemoglobin is a far cry from measuring true aims: health, function, and comfort." - Medscape Today CDC Warns of Increasing Pneumococcal Disease Associated With H1N1 Flu December 01, 2009 Rates of serious pneumococcal infections associated with H1N1 influenza are increasing around the country, the Centers for Disease Control and Prevention (CDC) announced today.Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, led a press briefing. According to Dr. Schuchat, in the Denver metropolitan area, 1 of 10 active bacterial core surveillance sites where investigation into this issue is ongoing, the number of cases of invasive pneumococcal disease has tripled compared with the 5-year average for the month of October. "Most of that increase has been in adults under the age of 60," Dr. Schuchat noted. "The findings in Denver probably reflect findings that are occurring in other parts of the country where the surveillance hasn't been as intensive," she added. The findings highlight the fact that "pandemics put us at risk for not just flu problems but also bacterial pneumonia problems," and they also point to the need for prevention efforts, Dr. Schuchat said. Only about 25% of high-risk adults younger than 65 years have received the vaccine that protects against pneumococcal disease, she said. Dr. Schuchat also commented on the H1N1 influenza vaccine supply, stating that supplies continue to increase, with an estimated 21.2 million doses available for the states to order, with less than a quarter of doses available as an intranasal spray. Several states are planning major activities after Thanksgiving to promote more vaccination in targeted groups such as adults with chronic health conditions and children, Dr. Schuchat said. Regarding the safety of the H1N1 vaccine, Dr. Schuchat noted that "so far, everything that we've reviewed is extremely reassuring," with patterns similar to that observed with the seasonal flu vaccine. Of all the reports that have come into the Vaccine Adverse Event Reporting System (VAERS), about 94% of adverse events were classified as not serious and mostly involve redness at the injection site. To date, there are no indications of Guillain-Barré syndrome or allergic reactions to the H1N1 vaccine. A total of 10 reports to the VAERS have come in about possible Guillain-Barré syndrome cases potentially related to the vaccine, which, considering the number of doses administered, is not considered notable, she said. - Medscape Today Liability premiums stay stable, but insurers warn this might not last December 01, 2009 For the fourth straight year, medical liability insurance premiums have eased nationwide.That's according to the annual Medical Liability Monitor survey, which showed 94% of premiums holding steady or dropping in 2009. Fifty-eight percent of premiums had no change, up from 50% in 2008. Another 36% of premiums fell, down from 43% last year. While those figures are encouraging, physicians and insurance executives say premiums still must shrink from sky-high levels. Insurers expect improvements to continue into next year but are cautious of some potentially unfavorable trends suggesting that results could be short-lived. "It does ease the pain, but the pain is still there because rates are still dramatically higher" than they were before rising in the early 2000s, said Robert D. Francis, chief operating officer of The Doctors Company, a Napa, Calif., physician-owned liability insurer that participated in the survey. Meanwhile, jury awards are climbing steadily, counteracting the major premium reductions needed to get back to more reasonable pre-2000 levels, he said. "So we're getting to the end of the point where rates are going to keep coming down," Francis said. Florida saw significant rate reductions, as much as 22% in some regions. But it topped the charts again this year with the highest rates nationwide for internists, general surgeons and ob-gyns, at $57,859, $191,422 and $201,808, respectively. The Monitor asked carriers to report manual rates as of July 1 for mature claims-made policies with $1 million/$3 million limits for those specialties. But increases have slowed significantly. Only 6% of premiums nationally went up in 2009 -- down from 7% in 2008 and 16% in 2007 -- with nearly all premium hikes under 10%. Competition also was up. No company withdrew from any state, and more than 10% of survey participants began writing business in new states. Treading lightly Insurers are proceeding cautiously, however, given past experience. An overall dip in the frequency of lawsuit filings -- 30% or more in some parts of the country -- remains the driving force behind the premium moderation, said Lawrence E. Smarr, president and CEO of the Physician Insurers Assn. of America, a trade group for doctor-owned and -operated liability companies. Liability premiums that increased in 2009 mostly saw a hike of less than 10%. "But we've seen this happen before in the 1980s, when claims unexpectedly dropped off, and it was followed by a rapid rise" that culminated in the spikes of the 2000s, he said. "For this reason, insurers are being very cautious and taking reductions only when they are truly justified." For now, the decline in claims appears to be drowning out a rise in severity and litigation expenses, said Joseph M. Inwald, editor of the Monitor's 2009 results and president of Inwald Consulting Services, a Michigan-based insurance consulting firm. But frequency is leveling off or rising in some areas, and if claims costs catch up to or outpace lawsuit filings, it could pressure insurers to raise premiums to keep up, Inwald warned. When asked by the Monitor, some insurers said "never event" reporting and electronic medical records could trigger more claims. Francis said tort reform has contributed significantly to the drop in frequency, although its staying power remains questionable, causing some insurers to hold back on cuts until reforms are confirmed by the courts. Premiums did not decline as precipitously in Illinois and Georgia, he noted, where damage caps are being challenged in the states' highest courts. Still, some say the survey results indicate tort reform's success. The premium cuts Ohio physicians saw in 2009 and the preceding three years coincided with a series of reforms lawmakers passed from 2002 to 2005, including a $350,000 noneconomic damage cap, said Tim Maglione, senior director of government relations for the Ohio State Medical Assn. Claims since have dropped 34% statewide, and three times the number of companies are now competing, compared with earlier in the decade. "Is medical liability insurance still very expensive for many specialties? Yes," Maglione said. "But all these things add up to what we think is a really good case study for the cause and effect between a state legislature enacting meaningful tort reform and a more stable insurance marketplace for physicians." In states without tort reform, patient safety improvements have helped moderate premiums, Francis said. But AMA Chair-elect Ardis Dee Hoven, MD, said the recent stability "will be short-lived in states without meaningful medical liability reform." The AMA is seeking inclusion of medical liability reforms in federal comprehensive health system reform. A House bill that would eliminate certain antitrust exemptions for liability insurers could hurt their ability to share data and effectively price premiums, the PIAA's Smarr said. Insurers "will have to be more conservative in pricing policies because more uncertainty means more risk, and that translates to higher prices for doctors." - American Medical News The Comeback of AIDS Activism December 01, 2009 After the first case was reported in 1981, America soon found itself in the middle of an AIDS crisis. For the next several years, the country was on high alert: men and women were dying quickly and painfully. Activists groups like ACT UP made headlines with disruptive and shocking protests demanding better care. TV shows devoted very special episodes to safe sex, and the global health community seemed united in its effort to eradicate AIDS.But 28 years is a long time to be in crisis mode. And thanks to the 1996 development of the antiviral cocktail, a combination of drugs that largely stemmed the fatal and fast-moving elements of the disease while eliminating many of its highly visible indicators, the feeling of immediate danger that spurred so many people to action is now gone. "When I was diagnosed, I was told I had a year left and I would have done anything if I thought it would've saved my life," says Regan Hofmann, the editor in chief of POZ magazine, who received her diagnosis in 1996. "But then three months later they said, 'You're going to be OK, you might even have a normal life span'. . . I was no less adamant about wanting to fight HIV/AIDS, but the urgency was gone." Since that time, free condoms have largely disappeared from bars; red ribbons, once so ubiquitous at awards ceremonies, are rarely seen, and other health issues—from obesity to cancer—have taken up space in the public consciousness. "In my early days as a board member and earlier, there was a great deal of concern, worry, angst about HIV that has settled into this kind of benign complacency," says Marjorie J. Hill, CEO for the Gay Men’s Health Crisis. Many people, she says, thinks AIDS can be treated with a pill, and that living with the disease is now similar to living with diabetes or heart disease. Of course, HIV/AIDS is not nearly under control: it affects 33 million people worldwide, and in America, it's the No. 1 killer for women under 35, according to the MAC AIDS fund. The Centers for Disease Control reports that new infections have not declined in the past decade, and while people under 30 are at the greatest risk, so are those in their 50s and 60s. As patients living with HIV/AIDS get older, more potential side effects of the drug cocktails become apparent, including premature aging and dementia. And while many people think AIDS as a medical condition is no big deal, people are still afraid to confront it. "The stigma against people with HIV is still so strong," says Hofmann, who notes that fear of social consequences has kept many patients silent. But now, there's evidence of new life in the AIDS movement. Under the current administration, the government has issued the first increase in dollars spent on domestic HIV prevention in nine years and renewed an almost decade-dormant social marketing initiative by the CDC. President Obama is also said to be actively working towards a national AIDS strategy. "There's been a lot of interest, advocacy, and excitement around that," says Hill, who notes that currently there's no over-arching system organizing all the government's AIDS initiatives. "Not only is it duplicative, they can't tell you in a quick answer whether or not mental health and HIV prevention programs in place in one area of the government match with the HIV testing program, match with the treatment adherence program. Our national AIDS strategy would say that we have to have the government coordinate and collaborate resources," she says. Administrative changes are not the only signs of life from the reemerging AIDS movement: this year, four ACT UP groups across the country reformed after several years of silence, in part as a reaction to the complacency even within AIDS administration and care groups. "AIDS service groups in the beginning were very hands on with activism, and now for the most part are quite removed. It is dependent on people with AIDS to hold them accountable," says Bob Bowers, a spokesperson for ACT UP Wisconsin, which now has 15 members after reforming in May following about 10 years of inactivity. "There are grave issues that have been festering for years and needed to be addressed." Moreover, younger activists who were largely too young for the initial AIDS panic are harnessing the power of the Internet to spread the word. "Younger people are engaging us at a very different level—a very digital level," says LaMont Evans, CEO for the Healthy Black Communities Organization, which cosponsors National Black HIV/AIDS Awareness Day. "We have people sending us videos they've done via MySpace and Facebook." Zachary Barnett, the 29-year-old development director for Covalent Immunology Foundation, a new charity dedicated to finding a vaccine for AIDS, is on the forefront of younger activists who are starting to come to the cause for the first time. "A lot of younger people are now starting to lose their friends to the epidemic, and they're starting to retell the story," says Evans. And with the lifting of the HIV travel ban at the end of October—a restriction on entry for noncitizens that was in place for 22 years—AIDS activism is about to come back to America in a big way. It has just been announced that the XIX International AIDS Conference will be held Washington, D.C., in July 2012. One of the largest AIDS symposiums in the world, this is the first time the conference has been on U.S. soil. "We now stand on the side of science and fairness on this issue," says Nancy Mahon, executive director of the MAC AIDS Fund. - Newsweek Some specialists will see extra cuts in Medicare pay November 16, 2009 Some specialty groups are loudly protesting new Medicare payment policies that will boost some primary care rates starting next year at the expense of rates for certain specialty services.In the 2010 physician fee schedule, the Centers for Medicare & Medicaid Services adopted several major changes to the practice-expense portion of the relative value unit system that determines pay for individual services -- along with more minor changes to the work and liability insurance RVUs. Because any changes must be budget-neutral, the expected results are modest increases in average Medicare pay for physicians traditionally considered to be in primary care, but larger reductions in average pay for some other specialists. Coupled with the prospect of an across-the-board 21.2% cut to the conversion factor starting Jan. 1, the revisions represent a potentially fatal hit for some practices, especially those that provide imaging services, specialty organizations warned. CMS agreed in the final rule to phase in the RVU changes over four years, but the specialists said the cuts still go too deep too quickly. One big change for physicians who provide imaging services is a decision by CMS to increase the imaging equipment utilization rate assumption within the practice-expense RVUs. The amount of time Medicare assumes that advanced diagnostic imaging equipment is in use during physician office hours will rise from 50% to 90% over the next four years, decreasing the amount the program pays for each service. As a result, radiologists face an average 5% cut in Medicare payments next year and additional cuts over the following three years. That would be on top of a 23% reduction in medical imaging rates from the Deficit Reduction Act of 2005, which the American College of Radiology said already has produced a $13.8 billion hit against the specialty. Physicians said the cuts could harm patients by increasing wait times for imaging exams. "It is hard to believe that our practice expense per hour would be less in four years to provide these services," said Bibb Allen, MD, chair of the ACR's Economics Commission. "We are certainly disappointed with the CMS payment rule. We think this will limit beneficiaries' access to imaging services." Freestanding imaging centers in rural sections of the country, such as Alabama, where Dr. Allen is based, will be hit the hardest by these cuts, he said. The situation, he added, could lead some centers to close. Cardiologists, who will be paid less because of the utilization rate change as well as other practice-expense RVU revisions, face an average cut of 8% next year and more cuts over the following three years. This will significantly reduce access to cardiovascular services, the American College of Cardiology warned. "Private-practice cardiologists are taking a significant cut, and they're going to have lay off staff and close some services," said Alfred Bove, MD, ACC's president. "Some of the practices may even have to go under, and we'll see reductions in Medicare services to patients." Both ACR and ACC are members of the Access to Medical Imaging Coalition, which issued a Nov. 3 news release stating the payment revisions could mean huge reductions for certain nonhospital services, including a 48% pay cut for pelvic CT scans, 46% for MRI scans of the chest or spine and 27% for cardiovascular-related services. The coalition also warned that facilities may close, harming patient access. Tim Trysla, the imaging coalition's executive director, said surveys showed offices use imaging equipment far less than the agency estimates. "By pegging the utilization rate at 90%, CMS is adopting policy that isn't supported by data. While CMS clearly missed the mark with this rule, we are committed to working with the agency to provide informative data that regulators can use to determine an accurate and responsible utilization rate." The ACC also said the CMS practice-expense information is flawed. "We've talked to CMS several times over the past few months, but they've said they need to stick with their data," Dr. Bove said. "Our position is the data they've collected is wrong and needs to be reviewed." Survey data in dispute The CMS based some of its RVU changes on new information from the Physician Practice Information Survey, a joint effort led by the American Medical Association and including 72 specialty societies -- among them the ACR and ACC -- and other professional health care organizations. More than 7,000 physicians responded to the PPI survey, of which about 3,600 provided practice cost information. The AMA said it provided specialty societies with frequent briefings throughout the effort. While the specialty societies vowed to continue pressing CMS to obtain better rates, some physician organizations said they were pleased with the primary care portion of the final fee schedule and the methodology used to determine the 2010 rates. "The PPI is a much more valid way of gathering data and provides a more current methodology," said Lori Heim, MD, president of the American Academy of Family Physicians. "If you want to establish a strong health care system, we need to have a strong primary care base, and the funding bases in the system currently don't do that. So this is a good step in the right direction." The American College of Physicians also supports the PPI data and appreciates the attention being paid to undervalued primary care services, said Brett Baker, ACP's director of regulatory affairs. But he called for an ongoing process so CMS can listen to and consider concerns brought by the specialty community. The AMA defended the methodology behind the PPI survey, saying it met all the criteria CMS established to replace existing practice-expense data. "This group effort was spearheaded by the AMA at the request of national medical specialty societies and Medicare, and it is the first time in nearly a decade that this information has been updated for all medical specialties," said AMA President J. James Rohack, MD. The RVU changes were not the only major revisions in the final fee schedule. CMS finalized a proposal to remove the cost effect of physician-administered drugs from the calculation of the Medicare physician pay formula, a move that will mitigate future across-the-board reductions. But Dr. Rohack said Congress still must adopt a permanent solution for the flawed Medicare payment system. - American Medical News Adult Primary Care Visit Frequency, Quality, and Duration Increasing November 16, 2009 Adult primary care visit frequency, quality, and duration increased between 1997 and 2005, with modest relationships noted between visit duration and quality of care, according to the results of a retrospective analysis reported in the November 9 issue of the Archives of Internal Medicine."Two of the most pressing goals for the US health care system are to deliver higher-quality care and to lower costs," write Lena M. Chen, MD, MS, who was with the Veterans Affairs Boston Healthcare System, Massachusetts, at the time of the study and is now with the University of Michigan Health System, Ann Arbor, and colleagues. "It is unclear if increasing pressure on primary care physicians to be more efficient has affected visit duration or quality of care. We sought to describe changes in the duration of adult primary care visits and in the quality of care provided during these visits and to determine whether quality of care is associated with visit duration." Using a nationally representative sample of office-based primary care physicians in the United States, the investigators found that between 1997 and 2005, primary care visits by adults aged 18 years or older increased from 273 million to 338 million each year, or 10% on a per capita basis. Mean visit duration increased from 18.0 to 20.8 minutes (P < .001 for trend), with a 3.4-minute increase for general medical examinations. For the 3 most common primary diagnoses, visit duration increased by 4.2 minutes for diabetes mellitus (P = .002 for trend), 3.7 minutes for essential hypertension (P < .001 for trend), and 5.9 minutes for arthropathies (P < .001 for trend). For the early period (1997 – 2001) compared with the late period (2002 – 2005), quality of care improved for 1 of 3 counseling or screening indicators and for 4 of 6 medication indicators. Time needed to provide appropriate counseling or screening was typically 2.6 to 4.2 minutes, whereas providing appropriate medication therapy was not associated with longer visit duration. "Adult primary care visit frequency, quality, and duration increased between 1997 and 2005," the study authors write. "Modest relationships were noted between visit duration and quality of care. Providing counseling or screening required additional physician time, but ensuring that patients were taking appropriate medications seemed to be independent of visit duration." Limitations of this study include an inability to determine the factors associated with racial/ethnic differences in time spent per visit, duration of the outpatient visit self-reported by physicians or staff, inadequate capture of illness complexity and severity, and limited quality measures. "Although it is possible that physicians have become less efficient over time, it is far more likely that visit duration has increased because it takes more resources or time to care for an older and sicker population," the study authors conclude. "Improvements in quality of care will likely require a combination of investments in systems such as electronic health records, greater use of other professionals such as nurse practitioners, and better reimbursement to primary care physicians for the extra time spent." - Medscape Today Pulmonary Embolism and Drug Reactions Top List of Diagnostic Errors November 16, 2009 Pulmonary embolism and drug reactions or overdose are the most common diagnostic errors committed or observed by physicians, according to a survey of general practitioners and specialists, the results of which are published in the November 9 issue of the Archives of Internal Medicine.This sample of diagnostic errors represents "the largest reported case series of diagnostic errors to date and affords valuable insights into the types of errors that physicians are committing and witnessing," write Gordon D. Schiff, MD, from the Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues. The goals of the study were to identify commonly missed diagnoses, to delineate recognizable patterns and themes, and to apply the new Diagnostic Error Evaluation and Research taxonomy tool for analyzing cases. Researchers asked physicians to recall 3 clinically significant diagnostic errors that they had seen or committed, to estimate how often they had seen those errors, and to rate the clinical impact or outcome of each error. A diagnostic error was defined as any mistake or failure in the diagnostic process leading to a misdiagnosis, missed diagnosis, or delayed diagnosis. Physicians readily offered information on diagnostic error. "This readiness suggests that diagnostic error is not unusual in clinical practice, and actively soliciting such cases represents an opportunity for tapping into a hidden cache of medical errors that are not generally collected by existing error surveillance and reporting systems," according to the authors. The survey analyzed 583 cases of diagnostic error reported anonymously by 283 physicians — 47% were primary care physicians — from 22 institutions in 6 states. Physicians reported an average of 2.2 errors each. These physician respondents had been in practice an average of 9 years. Of these 583 errors, 30% directly involved the reporting physician and 68% were witnessed by them. In all, 28% of these errors were rated as major in severity, 41% as moderate, and 31% as minor or insignificant. Only 8% of the errors were considered common, with 35% rated as occasional, 26% as infrequent, and 27% as rare. After pulmonary embolism (4.5% of total) and drug reactions or overdose, including poisoning (also 4.5%), the next most common missed diagnoses were lung cancer (3.9%), colorectal cancer (3.3%), acute coronary syndrome, including acute myocardial infarction and breast cancer (each 3.1%), and stroke (2.6%). At 20.2%, all types of cancer together constituted the largest disease category. Errors in the testing phase, including failing to order, report, or follow-up on laboratory results, occurred most frequently (44%), followed by clinician assessment errors, such as failure to consider and overweighing competing diagnoses (32%), history taking (10%), physical examination (also 10%), and referral or consultation errors and delays (3%). Inadequate follow-up of abnormal imaging studies emerged as a leading cause of diagnostic error. "Certainly, ensuring reliable follow-up of abnormal test results represents a "low-hanging fruit" ripe for improvement," write the authors. They note that the testing and assessment categories overlapped. "One of the important insights to emerge from our review involves the overlapping and clustering of certain patterns of errors, patterns that may be useful to consider when designing error reduction and prevention strategies." According to background information in the study, diagnostic errors are frequent; autopsy data show error rates of 10% to 15%. Such errors can result in patient injury and are the leading cause of medical malpractice litigation. - Medscape Today Liability reform demos must have patient safety element November 16, 2009 The competition will begin in December for states and health systems seeking federal grant money designed to improve patient safety and reduce medical liability pressures on physicians through innovative approaches.While considering recommendations from a recent advisory committee meeting, Agency for Healthcare Research and Quality officials made it clear that patient safety will be an essential element of any liability proposal they will consider for grant dollars. States and health systems "will have to collect data to show the innovation worked and had an impact on liability claims and the cost of malpractice insurance, as well as on patient safety. So we are looking at both sides of the equation," said AHRQ Director Carolyn M. Clancy, MD. "Ultimately, to get a grant under this program, applicants have to evaluate the impact on patient safety. That is the overarching objective." In September, President Obama authorized the Dept. of Health and Human Services to set aside $25 million for the pilot projects. Demonstration grants of up to three years and $3 million each will be awarded on a competitive basis to states and health systems whose programs are primed for implementation and evaluation. Applicants also may qualify for up to $300,000 for a one-year planning grant for an innovation that is still being developed. Proposals may be submitted beginning Dec. 20 and are due by Jan. 20, 2010. Projects that undergo an AHRQ peer review and are approved could launch within the next year. The agency will look at a number of criteria to determine who receives the money. "But in terms of specific innovations, we are not being prescriptive here," Dr. Clancy said. That's a good thing, said American Medical Association Board of Trustees member William A. Hazel Jr., MD. He served on the AHRQ National Advisory Council's Subcommittee on Patient Safety and Medical Liability Reform, which met Oct. 26 to advise the agency on promising approaches. "The criteria should be broad in order to bring in innovation, and we think it's important that everything is on the table," Dr. Hazel said. Exploring new ideas The AMA continues to favor noneconomic damage caps. But it also supports the testing of a range of alternatives to help cut down on defensive medicine practices and costs -- and ultimately improve health care quality and safety, Dr. Hazel said. The subcommittee discussed some of those ideas, including health courts and early disclosure and compensation programs. The panel also heard from state health officials and hospital systems who were invited to share their experiences with existing programs. For instance, some programs require the reporting of adverse medical events and seek to identify high-risk practices. The AMA has long advocated for patient safety improvements, Dr. Hazel said. But he added that medical liability reform plays an equally important role in bettering the health care system. "If we are just doing patient safety, we are not taking advantage of the grants to address the medical liability issues that President Obama has said need to be addressed," he said. "And if we just do what we are already doing in another setting, we are going to lose the opportunity to tie these things together to really achieve reform." But some medical liability proposals would not fit the bill, according to some participants in the debate. "The idea is that these projects should be directly related to reducing medical errors and an analysis of how to reduce systemic errors in general," said Susan Steinman, director of policy for the American Assn. for Justice. The national trial lawyers trade group participated on the AHRQ subcommittee. "Not a lot of liability projects would fall into that category. Some are simply designed to take away patients' rights," such as specialized health courts, she said. A focus on liability claims also may not be what the administration intended. "That's a legitimate concern if we're talking about insurance reform, but that's not what HHS was directed to do," Steinman said. Tying liability to safety Just how tight the connection between patient safety and medical liability will have to be for a grant proposal to pass muster remains unclear, said Michelle Mello, a professor of law and public health at Harvard University School of Public Health in Boston. She also served on the AHRQ subcommittee but spoke on her own behalf. In addition, applicants face a rather ambitious three-year timetable in which to show an impact on patient outcomes as well as on liability claims, both of which take time to process, she said. "There are some measures we can use, though, that might be more likely to measure the culture of patient safety. You can reasonably expect when an institution is going to do something good, doctors might feel more confident." Collaboration and creativity will be key, said Janet Corcoran, a senior consultant with Common Good, a nonpartisan coalition that developed the health court concept. Because grants are open only to states and health systems, the organization would partner with other interested parties not only to implement models for resolving disputes more efficiently, but also to find ways to share any relevant information about medical errors. Likewise, state medical societies are not eligible for individual grants but may participate in programs launched by others. Given the limited time and funding, applicants might consider building on existing structures, Dr. Hazel said. If a particular project requires a statutory change, for instance, that could pose a barrier to approval. At the same time, however, brand-new ideas may require testing in a different, more unconventional setting. "We want to make sure these are set up to be good, successful projects and not set up to fail," he said. - American Medical News Health care fraud a challenge to system reform November 16, 2009 Widespread health care fraud continues as lawmakers work to overhaul the health system and tackle long-term financing issues. As scrutiny over fraud intensifies, so must physicians' attention to their own billing and business activities, experts say.An annual audit of the Health Care Fraud and Abuse Control Program, a joint effort of the Depts. of Health and Human Services and Justice, showed federal enforcement activities yielding $1 billion in fraud settlements and judgments in 2008, mostly from Medicare and Medicaid false claims. Other big cases targeted illegal referrals and kickbacks by physicians and hospitals, improper off-label promotion by pharmaceutical companies, and medically unnecessary services. Most federal attention is fixed on organized crime groups, where intentional participation by physicians is rare, said Louis Saccoccio, executive director of the National Health Care Anti-Fraud Assn. Still, "doctors are going to have to be careful who they do business with and be more protective of their own business information, because these groups can get a hold of their billing information to file false claims." The level of recoupment in 2008 slid from the $1.8 billion retrieved in 2007, but experts agreed that the figures typically fluctuate based on when particular major cases happen to be resolved and subsequently reported. More potential prosecutions are in the works. The study showed that 957 new criminal health care fraud investigations were opened in 2008, up from 878 in the previous year. Prosecutors opened 843 civil cases in 2008, compared with 776 in 2007. A total of 2,911 civil and criminal cases were pending in 2008, up from 2,355 in 2007. The $1 billion in recoveries represents a mere fraction of the scope of fraud plaguing the health care system. And as criminal tactics evolve, funding, technology and information-sharing are going to be key in the government's fight, Saccoccio said. Although an exact figure is difficult to pin down, he estimated that 3% to 10% of the nation's roughly $2.3 trillion annual health care expenditures are lost to fraud. "If we're going to reform the system in other ways, we have to go after the fraud aspect," and so far most of the health system reform proposals pending before Congress have taken a stab at addressing the issue, Saccoccio said. "We're going to see much more of a focus on anti-fraud activities not just legislatively, but also in terms of the [federal] strike forces," which are coordinated HHS-Justice teams that operate locally to root out fraud. More fraud, more tools Legislation introduced Oct. 28 by Senate Judiciary Committee Chair Patrick Leahy (D, Vt.) and fellow panel members suggest that federal authorities need more help when it comes to curbing fraud. The Health Care Fraud Enforcement Act would bolster fraud prevention provisions included in broader health system reform legislation pending in the Senate. It would give prosecutors more funding -- $20 million a year through 2016. It also would give enforcement officials the ability to prosecute a broader range of fraud activities and impose harsher penalties. 957 criminal health care fraud investigations were opened in 2008, up from 878 in 2007. "We all know rooting out waste, fraud and abuse in both government and private programs is critical to making health reform work," said Sen. Ted Kaufman (D, Del.), a co-sponsor of the bill. "There's more work to be done, however, and [this bill] is an important part of that effort." Researchers at the George Washington University School of Public Health and Health Services and the National Academy for State Health Policy said in a recent study that scrutiny of potential fraud in both public and private health insurance programs is critical if authorities are going to be successful in attacking widespread fraud. "And in the case of the private sector, it's not just confined to doctors and hospitals. It is potentially the behavior of the insurance industry itself," said Sara Rosenbaum, chair of GWU's Dept. of Health Policy and lead author of the study, released Oct. 27. Such behavior may include insurers systematically denying or underpaying claims, or even rescinding coverage. Federal reporting systems tend to capture fraud data only from public health care programs, such as Medicare and Medicaid. Requiring private insurers to report could help quantify and address the full scope of the problem, Rosenbaum said. The National Health Care Anti-Fraud Assn. also has advocated more information-sharing between public and private insurance programs, a provision that was included in the health system reform bill approved by the Senate Health, Education, Labor and Pensions Committee, Saccoccio said. Existing fraud controls, particularly in public programs, often confuse payment errors with intentional fraud, and future prevention tools must distinguish between the two, Rosenbaum added. "A program error is not a good thing, but it's not fraud, and we should stop talking about it as fraud, which has real legal consequences," she said. For example, physicians could face civil liability under the federal False Claims Act for having sloppy billing practices misidentified as fraud. - American Medical News Arizona Hospital and Healthcare Association CEO Announces Retirement October 29, 2009 John Rivers, president and CEO of the Arizona Hospital and Healthcare Association (AzHHA), has announced that he will retire on Jan. 13, 2011, his 65th birthday. Rivers, who has led the hospital advocacy organization since 1986, announced his retirement plans to the Association's Board of Directors on Oct. 22. As AzHHA's CEO, Rivers also serves as a member of its Board of Directors and as president of the AzHHA Education Foundation and its Service Corporation.The Association's Board of Directors has appointed a committee that will conduct the search for a new CEO. The committee will be comprised of AzHHA's 2010 officers as well as two past Association chairmen. It includes: Dan F. Ausman, AzHHA secretary-treasurer & president, Abrazo Health Care, Phoenix; Norman A. Botsford, AzHHA 2010 chairman & healthcare consultant, Tucson; Dan Coleman, past AzHHA chairman & retired health system CEO, Prescott; Thomas C. Dickson, FACHE, immediate past chairman & CEO, Banner Thunderbird Medical Center, Glendale; Bruce Pearson, FACHE, AzHHA chairman elect & executive vice president/CEO, John C. Lincoln Hospitals, Phoenix; and Brian Turney, past AzHHA chairman & president and CEO, Kingman Regional Medical Center. "I have enjoyed tremendous support from the AzHHA board," Rivers said. "Their commitment to high quality healthcare in Arizona has allowed the Association to accomplish much on behalf of hospitals and the people they serve." During Rivers' tenure at AzHHA, the Association led several successful ballot initiatives to increase tobacco taxes and expand access to healthcare services for the poor. He also has played an active role in shaping the American Hospital Association's (AHA's) health policy agenda. Prior to joining the Association in March 1986, Rivers served eight years as regional director of the AHA in Kansas City, Missouri. He also was a lobbyist for AHA in Washington, D.C., and served as legislative assistant to a U.S. Congressman. Active in numerous civic and community activities, Rivers serves as a member of the: Phoenix 100 Rotary Club; Gift of Life Board of Directors; Campaign Cabinet for the Valley of the Sun United Way; Board of Directors for Central Arizona Shelter Services; and United Blood Services Community Leadership Council. - AHHA Media Release Practices lose financial ground as recession outpaces productivity October 29, 2009 When faced with payment cuts, physicians traditionally work longer hours or hire additional staff to help keep up revenue. But those strategies have reached their limit, a report from the Medical Group Management Assn. shows.After hitting a peak in 2007, the median revenue a practice collected per full-time-equivalent physician took a 7.8% dive in 2008, according to the MGMA report on multispecialty practices, released in October. While the organization also surveys single-specialty practices, the association views multispecialty practices as a proxy for overall economic trends for outpatient health care. The amount of gross revenue taken in by multispecialty practices per full-time physician steadily increased from $463,637 in 1998 to $690,032 in 2007, as annual productivity gains that often ran into the double digits helped lift revenues, mostly by single-digit percentages. But gross revenue dipped to $637,677 in 2008. "These data demonstrate the trickle-down effect that a tough economy can have on a collection of businesses that are already stressed by crushing administrative burdens," said William Jessee, MD, MGMA's president and CEO. The decline in revenues reflects the effect of the economic recession. But the MGMA and some physicians said it also reflects how physicians no longer are able to extend their days to make up for reduced payments with more volume. "We're working 12- and 13-hour days, and we get told we should work more and see more patients. We cannot. There is only so much you can do in a day," said W. Jeff Terry, MD, a urologist in Mobile, Ala. And there are only so many patients to see. The number of patients seen dropped 11.3% and outpatient procedures dropped 9.9% in 2008, according to the MGMA survey, which covered 383 practices in 43 states. "Some people who do not have health insurance are just not going to come in," said Steve Furr, MD, a family physician in Jackson, Ala. And more of those who do come in are paying out of pocket. Physicians say they continue to see regular patients who have lost coverage, which has helped contribute to a 13% increase in bad debt carried by medical practices. "Patients don't have the money, but you're not going to turn them away," Dr. Terry said. Adding to the decline is insurance companies paying a decreasing percentage of physician fees. In 1998, physicians collected an average of 68.4% of their stated charges after fees were discounted by insurers and other third-party payers. Collection amounts declined to 59.5% in 2008, according to the MGMA survey. "We're doing more and more of [insurers'] paperwork for less reimbursement," said Nancy Church, MD, an ob-gyn in solo practice in Chicago. Many practices already are cutting their budgets. The MGMA survey reflected a nearly 3% slide in operating costs per full-time-equivalent physician. Still, operating costs as a percentage of revenue jumped two points to 63.3%, the highest total ever recorded in the survey's 10-year history. Expenses related to practicing medicine have long outpaced any growth in practice income, squeezing margins further. Total revenue grew by 46% over the past decade, but operating costs increased 54%. This is primarily a result of the increasing costs associated with staffing, particularly costs of employee health insurance, the MGMA found. "Practice expenses continue to go up. Our rent is going up. We're paying more for our own medical insurance," said Bob Dannenhoffer, MD, a pediatrician in a two-doctor practice in Roseburg, Ore. "But we're not looking for people to lay off. We're just hanging in there as best we can." Physicians say, however, that seeing more patients to compensate for decreases in reimbursement and other economic pressures is no longer possible. They are taking other action, such as scrutinizing all expenses. Investments in new equipment are being delayed, and calls are being made to negotiate better deals for everything from rent to liability insurance. For example, when Dr. Furr was looking at the various outlays made by his five-physician practice, he decided to ask the company providing the group's liability insurance if there was anything they could do to cut costs. He was told the group's premiums would be lowered by 20% for each physician completing 12 hours of continuing medical education, saving the practice $25,000 a year. Some physicians are merging with other groups or asking hospitals to buy their practices. For instance, Dr. Terry merged his group of eight urologists with a two-physician radiation oncology practice. "We did it because of what we were seeing," Dr. Terry said. "Our incomes were going down. Our rent was going up. We merged to help with the overhead and be able to hire a full-time office manager. It helps the bottom line." Some physicians said that although medical practices are taking economic hits, the health system is still doing better than most sectors of the economy. "We as physicians are still far better off than most of our patients," Dr. Dannenhoffer said. "Our revenue is a little lower than it was last year, but there are a lot of patients whose incomes are so much lower than last year." Still, "we don't think we have seen the bottom yet," Dr. Furr said. "It's scary. Most of us have never lived through a time like this before." - American Medical News Dispose of Unwanted Drugs Safely at Sunnyslope Community Day October 29, 2009 For safe disposal of unused prescription drugs, North Valley residents are urged to bring their left over pills and potions to the parking lot adjacent to John C. Lincoln Desert Mission headquarters at 9201 N. 5th St., Phoenix, between 10 a.m. and 2 p.m. on Saturday, Nov. 14.The “safe drug disposal event” is part of Sunnyslope Community Day, with merchants and community organizations offering food, door prizes, community information and fun for families. “This is an excellent opportunity to keep prescriptions and over-the-counter preparations out of the hands of curious children and pets, as well as out of the environment,” said Cheryl Dodson, RN, a nurse at John C. Lincoln North Mountain Hospital and one of the event’s organizers. “Help prevent drug abuse or accidental poisoning and protect the environment. Bring your unwanted drugs to 9201 N. 5th St. on Nov. 14, between 10 and 2, and we will dispose of them safely for you.” Among the organizations and businesses participating in Sunnyslope Community Day are Vogel Townhomes, Sunnyslope Family Services Center and Maricopa Integrated Health System, El Gran Taco, Victory Chapel, Scramble, Sunnyslope Skate Club at Sunnyslope Mennonite Church, Sunnyslope Community Center, Sunnyslope Village Alliance, Sunnyslope Historical Society, Literacy Volunteers of Maricopa County, Sunnyslope Fire Station #7, John C. Lincoln Health Network and Desert Mission, H&R Block and Acacia Library. The Desert Mission Food Bank at 9229 N. 4th St. will be open from 8:30 to 11:30 a.m. on the second Saturday of each month (including on Sunnyslope Community Day) for Bargain Basket sales. No eligibility is required to purchase a $15 offering of 10 pounds of meats or a $10 offering of pantry staples. Grinder’s Coffee Co., located at 17 E. Dunlap Ave., stays open late on the second Saturday of each month and features live music from 6 until 10 p.m. On Nov. 14, Grinder’s will feature Hacksaw’s Blues and Full Moon Jazz. Free parking is available at Bank of America (9325 N. 7th St.), the southwest corner of 5th St. and Hatcher, Assistance League of Phoenix (9224 N. 5th St.), Cowden Center (9202 N. 2nd St.), or Sunnyslope Transit Center (8927 N. 3rd St.). The free Phoenix Neighborhood Circulator and a John C. Lincoln shuttle will be available to event-goers who are also encouraged to walk or ride bicycles. For more information about Sunnyslope Community Day, contact Christina Plante at Christina.plante@JCL.com or 602-870-6060 ext. 1174. Download a map and event descriptions at www.sunnyslopecommunity.org. - John C Lincoln Primary Care Physicians Key in Preventing Major Depression in the Elderly October 29, 2009 Primary care physicians are emerging as the front line in efforts to reduce the growing numbers of depressed elderly.Researchers from the University of Rochester, New York, report that the elderly patients at greatest risk for depression onset have early factors that are among those routinely assessed in primary care visits. These include minor or subsyndromal depression, history of major or minor depression, and impaired functional status. The data on impaired functional status are noteworthy, because they suggest that functional disability, rather than medical illness burden, is the more important risk factor. "Primary care physicians should be aware that patients with these risks are at high risk of developing new episodes of major depression. They should ask about current and past depressive symptoms and episodes in functionally impaired older patients," lead author Jeffrey M. Lyness, MD, told Medscape Psychiatry. The study was published online October 15 in the American Journal of Psychiatry. Need to Increase Capacity According to senior author Yeates Conwell, MD, the findings reinforce the importance of the role of primary care practitioners in the detection and treatment of late-life depression. In addition, he told Medscape Psychiatry, the study data also show there are common factors that predispose to depression in older adults that can be picked up on in a primary care setting. "This gives us early indications of how to identify older people who may be more likely to develop clinically significant depression and therefore intervene to prevent it. The findings should provide added fuel to the argument for routine screening for depression and adaptation/adoption of collaborative care models that extend the capacity of primary care providers to detect and manage even subsyndromal depression," said Dr. Conwell. The observational cohort study enrolled 617 patients aged 65 years or older from practices in general internal medicine, geriatrics, and family medicine. All participants were without current major depression. Of these, 405 patients completed the 1-year follow-up examination. The researchers used the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (SCID), to determine incident major depressive episodes. During the follow-up period, 33 participants (5.3%) developed major depression. The researchers found that a high-risk subgroup consisted of subjects with combined variables of minor or subsyndromal depression, functional disability, and a history of major or minor depression. On-Site Mental Healthcare Not Available According to the investigators, assuming a treatment with 100% efficacy, treating 5 subjects in the high-risk group would prevent 1 episode of incident major depression (number needed to treat, 5). "Although useful to guide the optimal targeting of interventions, our findings underestimate the number needed to treat values for any interventions likely to be available for the foreseeable future," the authors write. The authors suggest that antidepressant medications and psychosocial treatments be considered for subjects in the high-risk subgroup. "As practices move toward adopting chronic disease management approaches based on electronic medical records, it will be straightforward to identify and 'flag' patients at risk for incident depression. Such patients could be followed closely over time using cost-effective methods, such as telephone-based depression symptom scales," they write. "Many studies have shown that on-site mental healthcare in primary care settings is a helpful treatment approach," Dr. Lyness said. "Unfortunately, national and local policy and funding decisions have not been made based on such data, so in most settings such on-site mental healthcare is still not available." Dr. Conwell said the study suggests that psychiatrists — and mental healthcare providers more generally — need to be establishing partnerships with the primary care community, advocating for adequate support for collaborative care models and extending them to include the notion of primary prevention. - Medscape Today Could ‘medical homes’ improve health care? October 29, 2009 A thousand miles from the health care debate in Washington, Dr. Don Klitgaard and his colleagues are carrying out their own reform in a small Iowa community.They’ve reorganized their clinic so nurses bird-dog patients whose health problems, if ignored, could send them to the emergency room. And for all their patients, they’ve invested in a computer system that tracks leading indicators of health problems, like blood pressure and blood sugar readings. It’s not just country medicine for the 21st century. Policymakers from President Barack Obama on down have praised such experiments as key to getting better quality without costly complications. But change doesn’t come easy. In a traditional practice, the doctor is the center of universe. In the new model, he or she is part of a team. Turning a doctor’s office into a “medical home” — what they call their model — starts with an attitude shift. Upfront resources and perseverance are also needed. Klitgaard is wondering if Congress will do enough for primary care doctors, the ones expected to carry out the transformation. Medicare, the government health program for seniors, doesn’t pay for the care coordination, monitoring, and coaching of patients that are part of his model. “We’re probably breaking even,” says Klitgaard, 41, of the Myrtue Medical Center in Harlan, Iowa. “Some patients who maybe wouldn’t have come in before are coming in. But if you threw the cost of electronic health records in there, we’ve probably lost money.” Health care overhaul rhetoric, meet health care system reality. To see why Klitgaard’s experiment is important, consider some basics from Health Care Economics 101: # Three-fourths of Medicare’s budget goes to less than one-fourth of its clients, patients with five or more chronic conditions, such as diabetes, heart failure or lung disease. They average 14 different doctors a year. Some juggle dozens of prescriptions. Put primary care doctors like Klitgaard on the front end, the theory goes, and they could make sure patients see the right specialists, avoid duplicative tests, get proper medications and prevent the worst complications of chronic illness, such as diabetes-related blindness. “Our system has gotten very good at paying for things to be done to patients, as opposed to keeping patients from having to have things done to them,” said Dr. Ted Epperly, chair of the American Academy of Family Physicians. If primary care doctors are the lynchpin for success, that’s not what the system favors. Primary care physicians average $186,000 in pay a year as compared with $340,000 for specialists. So, no surprise that medical school graduates flock to the specialties, leaving the country with a worsening shortage in primary care. Canada has a 50-50 mix of primary care doctors and specialists. In the United States, primary care doctors make up just 30 percent. Patients at the clinic seem happy with their care at the seven-doctor practice, which serves Harlan, population 5,400, and the broader area near the Nebraska border. Kathleen Kloewer, 75, a self-reliant woman who worked the farm with her late husband and cared for seven children, says phone calls from the nurse keep her motivated to maintain her health. She has diabetes, high blood pressure and elevated cholesterol. “We stay more on top of things, and I don’t let myself run way down before I go in on my own to see the doctor,” she said. “I used to find myself getting awful tired, and then I’d go in and find out I should have been there sooner.” Paul Jensen, 69, retired from managing gas stations, has Type 1 diabetes and wears an insulin pump. He’s teamed up with a diabetes educator at the clinic who has the same condition and also wears a pump. She’s been able to adjust his pump so well that his blood sugar tests now approach readings that people without diabetes get. “It keeps me out of the hospital,” said Jensen. Before the clinic offered diabetes education, he used to drive 135 miles to Ames every three months to see a specialist. Jensen is adamant: he’d sooner lose his doctors than his diabetes nurse. “People are looking for healing and wellness,” Klitgaard said, “not just diagnosing or curing.” Not only has the medical home approach improved patient satisfaction, there’s evidence it improves quality. In 2006, before the changes at the Harlan clinic, 55 percent of the patients with high blood pressure had levels below 140/90, considered fair control of the disease. By 2008, that had risen to 79 percent. Among the diabetes patients, 72 percent had moderately well controlled blood sugar levels at the outset. Two years later, it was 84 percent. It’s too early to say if such gains will save the health care system money. The health care bills in Congress call for pilot programs to test the concept of medical homes, and quickly propagate it, if successful. The legislation also aims to alleviate the shortage of primary care doctors. The Senate bill calls for changes in medical education so some federal money flows to community-based training centers that would turn out more primary care physicians. However, most federal money would keep going for specialist training. Primary care doctors will also get a raise, with the Senate bill providing a 10 percent boost in Medicare fees. Is it enough? “Ten percent will help, but what you may really need is a 50 percent increase in Medicare payments,” said Fitzhugh Mullan, a George Washington University professor who studies the medical workforce. Former Medicare administrator Mark McClellan, once a primary care doctor who served as Medicare administrator under President George W. Bush, gives the legislation a “B” or “B minus” overall on the issue. “The steps are in the right direction,” said McClellan, “but I wouldn’t say it’s enormous leaps and bounds.” - Associated Press IDF Releases New Guidelines on Diabetes Management October 29, 2009 The International Diabetes Federation (IDF) announced the release of several new guidelines related to diabetes management here at the IDF 20th World Diabetes Congress. These include the first-ever international guidelines on the management of diabetes in pregnancy and guidelines on the use of self-monitoring of blood glucose (SMBG) among type 2 diabetic patients not being treated with insulin.Pregnancy and Diabetes Guidelines Call for Universal Screening Lois Jovanoviè, MD, CEO and chief scientific officer of Sansum Diabetes Research Institute in Santa Barbara, California, and clinical professor of medicine at the University of Southern California-Los Angeles Medical Center, is one of the authors of the IDF Global Guideline on Pregnancy and Diabetes. "The guidelines were created with evidence-based medicine. Then we asked an international group [of experts] to give us their opinion," she told Medscape Diabetes & Endocrinology. "There was no international standard [for the diagnosis and management of gestational diabetes], said Dr. Jovanoviè. "There was no consensus, there was a lot of confusion, women were suffering, and their pregnancy outcome was affected by having no standard by which to judge whether their diabetes was worth treating or not. This is the first time there is a worldwide consensus." A key message of the new guidelines, according to Dr. Jovanoviè, is the importance of universal screening. "Look for hyperglycemia in pregnancy," she said. "Preconceptional counseling [also] has to be universal. . . . For a [primary care] physician who has a [patient] in child-bearing years, the first question should be: Are you interested in getting pregnant again?" Self-Monitoring of Blood Glucose in Noninsulin-Treated Type 2 Diabetes The IDF Guideline on Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes was developed in a manner similar to the IDF pregnancy guidelines. Their highlights include the following: * SMBG should be considered at the time of diagnosis but should only be used when patients, their caregivers, and/or their healthcare providers have the knowledge and willingness to incorporate findings into the diabetes management plan. * SMBG should be considered a part of ongoing diabetes self-management education. * SMBG protocols should be individualized. * Patients and their healthcare providers should agree on how to use SMBG data. * Tools used to measure SMBG must be easy to use and accurate. Unique Features of Guidelines Both sets of guidelines have key features that differentiate them from guidelines on the same topics put out by other diabetes associations, such as the American Diabetes Association (ADA), said Dr. Jovanoviè. "The ADA hopefully will change soon, but right now they don't subscribe to the philosophy of universal screening [in pregnancy]. They talk about selective screening. Our guidelines not only talk about universal screening but almost assume that every woman has diabetes [and] doing the testing is to reassure her that she doesn't. So, it's a paradigm shift. The second major difference is the [IDF] recommendation that it be a 1-step [oral glucose tolerance] test, not a 2-step test [as currently recommended by the ADA]. The ADA also have the criteria for diagnosis [of gestational diabetes] very high to minimize the number of women identified. The strategies in the [IDF] guidelines actually increase the number of women that would be identified and therefore offer treatment worldwide with 1 standard of care." According to a coauthor of the SMBG guidelines, David Owens, MD, from the Cardiff University Diabetes Research Unit in the United Kingdom, a unique feature of the IDF SMBG guidelines is that they clarify the role of SMBG in diabetic patients who are not receiving insulin therapy. "For the noninsulin-treated individuals, [other guidelines] say that it's a good idea to incorporate SMBG, . . . but there is no real clarity as to what to do about it. That's where we've tried to extend the story more toward what the patient can do about it in their circumstances. . . . There are [other] guidelines that suggest that maybe there's no reason to monitor blood glucose in the noninsulin-treated, and they say that . . . you need to look at the current evidence and see its limitations. Many of those publications are really not designed to ask [that] question." - Medscape Today PACEHR SELECTS TECHNOLOGY PARTNERS TO ACCELERATE ARIZONA’S EHR ADOPTION AND MAXIMIZE ARRA STIMULUS FUNDS October 15, 2009 The Purchasing & Assistance Collaborative for Electronic Health Records (PACeHR) today announced the selection of e-MDs and Noteworthy Medical Systems, Inc. as technology partners to provide accessible and affordable electronic health records (EHR) to small and medium-sized group practices in Arizona. The partner agreement will help drive EHR adoption and, thereby, enable clinicians to qualify for financial incentives in accordance with the federal Health Information Technology for Economic and Clinical Health (HITECH) Act, as well as strengthen the foundation for statewide health information exchange (HIE).The unique PACeHR program was launched as a response to the critical need of small to medium medical practices to accelerate EHR adoption, improve quality, safety and efficiency, and promote a community of information sharing. Nearly 95 percent of primary care is delivered in practices with less than five physicians and only 4 percent to 9 percent of the state’s nearly 7,000 primary care physicians are automated. To address this gap, PACeHR, a Phoenix-based non-profit organization acting on behalf of medical practices and other stakeholders, was established. PACeHR aims to leverage economies of scale, strategic partnering and the power of web-based technologies to assure that every clinician in Arizona will have access to an affordable, interoperable, certified, web-based electronic health record solution and services. PACeHR’s goal is to deliver software and services to three quarters of the Arizona primary care market—nearly 7,000 physicians in more than 2,000 practices—over the next three years. According to Anita Murcko, M. D., PACeHR project director, the technology partners e-MDs and Noteworthy were selected by a 20-member selection panel comprising 16 clinicians, as well as Gartner analysts and legal and business experts. They evaluated 14 vendors during a six month evaluation process. “Physicians will be much more confident in their EHR purchases knowing that the PACeHR selection panel included clinicians who evaluated the EHR solutions based on a host of criteria including scalability, interoperability and long-term use,” said panel member Anil Goud, M.D., an internist and hospitalist at a 14-doctor internal medicine group in Phoenix. “Many smaller practices have not yet digitized because of cost, fear of buying the wrong system, and concern that vendors will ignore their needs once the contract is signed.” Under the partner agreement, all licensed healthcare providers are eligible to subscribe to web-based EHRs and practice management solutions from e-MDs or Noteworthy. Early adopters that subscribe prior to July 1, 2010 will benefit from expanded assistance from PACeHR to meet and apply for ARRA stimulus funds. Added Goud, “When you are a small practice, you are at the mercy of the vendor as to the timing of implementation, upgrades, support and their willingness to listen to technology enhancement requests. As a large purchasing group, PACeHR ensures that small and medium-sized physician practices will have equal access to vendors and receive excellent service. Additionally, the collaborative organization provides the opportunity for groups using the same technology to share and promote best practices to improve quality of care, patient safety and administrative efficiencies.” “e-MDs’ and Noteworthy’s web products met our core functional requirements and demonstrated rapid deployability, affordability and overall ease of use,” said Murcko, who is also medical director for informatics at the Arizona Health Care Cost Containment System, the state’s Medicaid agency. “Coupled with their commitment to collaboration and development, e-MDs’ and Noteworthy’s CCHIT Certified® solutions offer practices the modularity, flexibility and scalability needed to meet the distinct needs of each practice for today and tomorrow.” “In addition to targeting primary care practices, we are also reaching out to community clinics and long-term care, behavioral health and correctional facilities serving the uninsured and other special populations,” said Roger A. Hughes, PACeHR’s board president and executive director of St. Luke's Health Initiatives, a public foundation in Phoenix. “Every physician practice and care provider organization is unique and PACeHR is committed to offering participants the technology options that best suit their needs.” To date, 10 Arizona practices representing 30 clinicians have signed letters of intent to purchase EHRs through the PACeHR program. Two physician practices will go live by the end of the year and the remainder will complete EHR deployment during the first half of 2010. About PACeHR The Purchasing & Assistance Collaborative for Electronic Health Records (PACeHR) is a non-profit organization incorporated to accelerate EHR adoption by small and medium-sized physician group practices in Arizona. Acting on behalf of participating medical practices and other stakeholders, PACeHR leverages web-based technologies, economies of scale and strategic partnering to foster effective implementation and use of affordable, interoperable EHR systems to improve quality, safety and efficiency, and promote a community of information sharing. For more information, visit http://www.azhealtherecord.gov/PACeHR/Default.aspx. - PACeHR Physician job search strategy shifts as Internet booms, economy busts October 15, 2009 When orthopedic surgeon John Kemp, MD, looked for a job fresh out of residency 22 years ago, he used a lot of paper and stamps mailing resumes to practices in areas of the country where he wanted to work, not knowing if there was even a job available.A year ago, when Dr. Kemp decided it was time to leave private practice in Littleton, Colo., he turned to listings on the Internet -- no paper, no stamps, no guessing if someone had an opening. On Aug. 1, he started as director of sports medicine at Avera Marshall Regional Medical Center in Marshall, Minn. The Internet "gives you a lot more selection and, therefore, a lot more options," Dr. Kemp said. In-house recruiters handling doctor hiring are feeling the same way. A recent survey of 166 recruiters at hospitals and physician groups found that most rely heavily on Internet job postings, as well as word-of-mouth, to locate physicians for open positions. They were using physician search firms less than other tools, citing both the cost and complaints that the firms did not gather up enough qualified candidates. The survey of members of the Assn. of Staff Physician Recruiters,released Sept. 1, was conducted by The Medicus Firm -- a physician search firm with offices in Dallas and the Atlanta area. Among other findings: recruiters not only wished firms would "charge less," but some hoped "they would go away and never come back." "I don't think it is necessarily a huge surprise that [recruiters] have some negative feelings" toward search firms, said Jim Stone, managing partner of Medicus. He is also a member of the board of directors of the National Assn. of Physician Recruiters. Stone said that even despite recession-related cutbacks, many hospitals and large groups in recent years have invested in developing in-house recruiting capabilities. According to the Medicus study, the percentage of in-house recruiters who regularly used external firms dropped from 55.1% in 2008 to 49% this year. And search firms nationwide are noticing the drop. "I do see that the volume of searches is down, and institutions are doing more recruiting directly as opposed to working with a firm," said Brian McCartie, vice president of business development for Cejka Search, a health care executive and physician search firm based in St. Louis. Recognizing changes in the market, search firms are revising their fee models and promoting more services -- including use of Internet job boards -- to attract clients. Stone said that given the difficulty of filling physician positions, search firms can play a part even if that role is being just one of multiple means employed to find doctors. In-house recruiters surveyed pointed most often to the Internet as the most effective way to find physicians, with 74 agreeing on the online approach, an increase from the 68 who said this in 2008. Only 15 recruiters said working with a search firm was the most effective technique, a decrease from the 25 who said that in 2008. Recruiters most often said they work with search firms "very infrequently." "The Internet has become such a huge player in recruitment, not just for doctors but for everybody, as more and more people become technically savvy," said Scott Manning, director of human resources and provider recruiting at MedPro, a 260-physician multispecialty practice based in Phoenix. If job-hunting physicians "work only with search firms, they are reducing their exposure to a lot of places that don't use them," said Marci Jackson, director of physician and provider recruitment for Southwest Medical Associates, a UnitedHealth Group-owned multispecialty practice in Las Vegas. Jackson works with search firms when she has a position that is difficult to fill or when she has multiple openings. Recently her practice used search firms to help find a pulmonary critical care physician and staff a new anesthesiology department. Recruiters often are using their own hospital or practice Web site or other online job boards -- avoiding the thousands of dollars in fees charged by search firms. In-house recruiters also are taking advantage of social media. Twitter, for example, has search tags, including "#jobs" and "#physician," that point to job openings. Geisinger Health System in Danville, Pa., launched a Facebook page in January with videos of physicians talking about working there and living in the area. Setting up the Facebook page "was actually a request from one of our physicians who thought it would be a great way to connect with younger physicians," said Cindy Bagwell, associate vice president for Geisinger's professional staffing department. "It is hard to say if [the page] in and of itself caused a physician to pick up the phone and call us. We're just trying to be in a lot of different venues to get our message out there. I still think it remains to be seen if it will generate some interest." Search firms said they are taking steps to adjust to shifts in the industry. Companies are experimenting with various fee models, such as charging institutions monthly flat rates or working with others associated with the process to develop various combinations of placement fees. Job search firms also are bumping up the services they believe add value and reduce the time it takes to recruit a physician. For instance, many search firms visit with clients that are hiring as well as with candidates, to assess suitability before putting a name forward. "We spend a lot of time with the candidate to make sure that the opportunity matches what a physician actually needs," said Phil Miller, spokesman for physician placement firm Merritt Hawkins & Associates, headquartered in Irving, Texas. Merritt Hawkins is one of many search firms that posts jobs it's handling onto Internet boards. In fact, that's how Dr. Kemp found Avera Marshall Regional Medical Center. "I didn't single out Merritt Hawkins," Dr. Kemp said. "Like most physicians, I started off with an Internet search. Once I started clicking on jobs, that led to working with a search firm." The online nexus of the doctor, the hospital and the search firm worked out for all involved. Avera found its candidate. Dr. Kemp got the job. And Merritt Hawkins got paid for finding a physician. - American Medical News Physician job search strategy shifts as Internet booms, economy busts October 15, 2009 When orthopedic surgeon John Kemp, MD, looked for a job fresh out of residency 22 years ago, he used a lot of paper and stamps mailing resumes to practices in areas of the country where he wanted to work, not knowing if there was even a job available.A year ago, when Dr. Kemp decided it was time to leave private practice in Littleton, Colo., he turned to listings on the Internet -- no paper, no stamps, no guessing if someone had an opening. On Aug. 1, he started as director of sports medicine at Avera Marshall Regional Medical Center in Marshall, Minn. The Internet "gives you a lot more selection and, therefore, a lot more options," Dr. Kemp said. In-house recruiters handling doctor hiring are feeling the same way. A recent survey of 166 recruiters at hospitals and physician groups found that most rely heavily on Internet job postings, as well as word-of-mouth, to locate physicians for open positions. They were using physician search firms less than other tools, citing both the cost and complaints that the firms did not gather up enough qualified candidates. The survey of members of the Assn. of Staff Physician Recruiters,released Sept. 1, was conducted by The Medicus Firm -- a physician search firm with offices in Dallas and the Atlanta area. Among other findings: recruiters not only wished firms would "charge less," but some hoped "they would go away and never come back." "I don't think it is necessarily a huge surprise that [recruiters] have some negative feelings" toward search firms, said Jim Stone, managing partner of Medicus. He is also a member of the board of directors of the National Assn. of Physician Recruiters. Stone said that even despite recession-related cutbacks, many hospitals and large groups in recent years have invested in developing in-house recruiting capabilities. According to the Medicus study, the percentage of in-house recruiters who regularly used external firms dropped from 55.1% in 2008 to 49% this year. And search firms nationwide are noticing the drop. "I do see that the volume of searches is down, and institutions are doing more recruiting directly as opposed to working with a firm," said Brian McCartie, vice president of business development for Cejka Search, a health care executive and physician search firm based in St. Louis. Recognizing changes in the market, search firms are revising their fee models and promoting more services -- including use of Internet job boards -- to attract clients. Stone said that given the difficulty of filling physician positions, search firms can play a part even if that role is being just one of multiple means employed to find doctors. In-house recruiters surveyed pointed most often to the Internet as the most effective way to find physicians, with 74 agreeing on the online approach, an increase from the 68 who said this in 2008. Only 15 recruiters said working with a search firm was the most effective technique, a decrease from the 25 who said that in 2008. Recruiters most often said they work with search firms "very infrequently." "The Internet has become such a huge player in recruitment, not just for doctors but for everybody, as more and more people become technically savvy," said Scott Manning, director of human resources and provider recruiting at MedPro, a 260-physician multispecialty practice based in Phoenix. If job-hunting physicians "work only with search firms, they are reducing their exposure to a lot of places that don't use them," said Marci Jackson, director of physician and provider recruitment for Southwest Medical Associates, a UnitedHealth Group-owned multispecialty practice in Las Vegas. Jackson works with search firms when she has a position that is difficult to fill or when she has multiple openings. Recently her practice used search firms to help find a pulmonary critical care physician and staff a new anesthesiology department. Recruiters often are using their own hospital or practice Web site or other online job boards -- avoiding the thousands of dollars in fees charged by search firms. In-house recruiters also are taking advantage of social media. Twitter, for example, has search tags, including "#jobs" and "#physician," that point to job openings. Geisinger Health System in Danville, Pa., launched a Facebook page in January with videos of physicians talking about working there and living in the area. Setting up the Facebook page "was actually a request from one of our physicians who thought it would be a great way to connect with younger physicians," said Cindy Bagwell, associate vice president for Geisinger's professional staffing department. "It is hard to say if [the page] in and of itself caused a physician to pick up the phone and call us. We're just trying to be in a lot of different venues to get our message out there. I still think it remains to be seen if it will generate some interest." Search firms said they are taking steps to adjust to shifts in the industry. Companies are experimenting with various fee models, such as charging institutions monthly flat rates or working with others associated with the process to develop various combinations of placement fees. Job search firms also are bumping up the services they believe add value and reduce the time it takes to recruit a physician. For instance, many search firms visit with clients that are hiring as well as with candidates, to assess suitability before putting a name forward. "We spend a lot of time with the candidate to make sure that the opportunity matches what a physician actually needs," said Phil Miller, spokesman for physician placement firm Merritt Hawkins & Associates, headquartered in Irving, Texas. Merritt Hawkins is one of many search firms that posts jobs it's handling onto Internet boards. In fact, that's how Dr. Kemp found Avera Marshall Regional Medical Center. "I didn't single out Merritt Hawkins," Dr. Kemp said. "Like most physicians, I started off with an Internet search. Once I started clicking on jobs, that led to working with a search firm." The online nexus of the doctor, the hospital and the search firm worked out for all involved. Avera found its candidate. Dr. Kemp got the job. And Merritt Hawkins got paid for finding a physician. - American Medical News Senate Finance Committee Passes Healthcare Reform Bill October 15, 2009 The Senate Finance Committee today passed a massive healthcare reform bill in a mostly partisan vote that foreshadows continued vociferous debate in Congress as both chambers continue to craft legislation.All 13 Democratic members of the committee, along with 1 lone Republican, Sen. Olympia Snow (ME), voted for the bill. The remaining 9 Republican committee members cast nays. "This is a balanced, commonsense plan for reforming healthcare," said Finance Committee Chairman Sen. Max Baucus (MT), a Democrat, adding, "It guarantees that no American goes broke because he gets sick." Ranking committee member Sen. Charles Grassley (IA), however, summed up Republican opposition today when he said the bill was "moving on a slippery slope toward government control of medicine." The bill takes the revolutionary step of requiring most Americans to obtain health coverage, but it also offers subsidies to help the cash-strapped pay for it. Likewise, the legislation would require all but small employers to either cover their workers or pay a penalty into a fund for subsidizing their coverage. The bill also creates state-based markets for health insurance called exchanges, expands coverage under Medicaid and the Children's Health Insurance Program (CHIP), and curbs health-plan practices deemed abusive, such as denying coverage based on preexisting conditions. The bill would reduce the number of uninsured Americans in 2019 by 29 million, leaving 25 million nonelderly adults — a third of them illegal immigrants — without coverage, according to the Congressional Budget Office (CBO). The bill makes no provision for a government-sponsored health plan — the controversial "public option" — but instead authorizes member-owned "co-op" health plans as an alternative to private insurance. Some Democrat committee members such as Sen. John Kerry (MA) and Sen. Jay Rockefeller (WV) continued to voice support for the public option, suggesting the notion hasn't died yet. "A public option is necessary because the insurance industry doesn't know how to stop itself," said Sen. Rockefeller. "You have to put up an impediment to slow them down. That is the public option." While the bill would cost $829 billion, the CBO projected that it would reduce the federal deficit by $81 billion over 10 years through spending cuts and increased revenue, such as "play or pay" contributions from employers. Republicans, though, are decrying what they view as hundreds of billions of dollars in new taxes and fees. Republican committee member Sen. Jim Bunning (KY) said that the plan wasn't achieving the proper bang for its buck because it leaves 25 million people uninsured. "That is hardly universal coverage," noted Sen. Bunning. Long Legislative Path Toward Healthcare Reform The vote by the Senate Finance Committee represents just 1 milepost in the slog toward an overhauled healthcare system, and as several committee members noted, the bill passed today may dramatically differ from a bill that eventually comes before the entire Congress. The Finance Committee bill now must be merged with legislation passed earlier by the Senate Health, Energy, Labor, and Pensions (HELP) Committee into a unified bill that the entire Senate would consider. This blending process could be contentious because the HELP bill calls for a government-sponsored health plan. And the HELP bill also is more expensive, adding $597 billion to the federal deficit through 2019, according to the CBO. Other than those differences, the 2 Senate committee bills are similar in terms of individual and employer mandates, subsidies, state-based health insurance exchanges, expanded Medicaid coverage, and tighter regulation of health plans. Any unified bill approved by the Senate then must be harmonized with reform legislation approved by the House. That job would fall to a Senate-House conference committee. Three House committees have drafted the "America's Affordable Health Choices Act," or HR 3200, but it has not yet come to the House floor for a vote. HR 3200 resembles both Senate bills for the most part, but like its HELP counterpart, it calls for a government-sponsored health plan, setting the stage for more debate between public-option advocates and opponents of what they call "socialized medicine." The House legislation extends coverage to more Americans than the 2 other bills, leaving only 17 million uninsured by 2019. A conference committee bill would go before both chambers of Congress for a final vote. If it gets a double stamp of approval, the bill would then go to President Obama, who could sign or veto it. Democrats Denounce Analysis of Bill Commissioned by Health Insurance Industry The deliberations of the Senate Finance Committee Tuesday heated up a few degrees when several Democratic members criticized a report released Monday by the accounting firm of PricewaterhouseCoopers that claimed the committee bill would boost the cost of private health coverage by 111% over 10 years. Under the status quo, this cost would rise by only 79%, according to the report, commissioned by America's Health Insurance Plans, an industry association. Sen. Kerry said the analysis was seriously flawed because it ignored many aspects of the bill that would lower the cost of coverage. "The insurance industry ought to be ashamed of this report," said Sen. Kerry, calling it a last-minute attempt to muddy the waters. Likewise, Sen. Rockefeller described the report as "politicking for corporate gain at its worst." For its part, AHIP issued a statement Tuesday saying, "While we agree with the objective of the current proposal, we are concerned about its workability and cost." - Medscape Medicaid pay could be cut again when stimulus money runs out October 15, 2009 Federal stimulus funding has helped state Medicaid programs avoid drastic reductions in eligibility and physician fees, but program directors already are contemplating such cuts when the additional federal support runs out at the end of next year.States faced unprecedented financial pressures in fiscal 2009, which ended on June 30 for most states. They experienced a surge in new Medicaid enrollees and a historic decline in tax revenues. States coped by trimming or freezing Medicaid fees and restricting benefits, among other actions, according to a ninth annual survey of state Medicaid directors released Sept. 30 by the Kaiser Family Foundation and Health Management Associates. Medicaid enrollment grew by 5.4% in fiscal 2009 -- the highest rate in six years -- while total program spending increased by 7.9%, the fastest pace in five years. The enrollment spike was the main reason spending grew, according to report co-author Vernon K. Smith, PhD, principal with Health Management Associates. "As more people lost their jobs and lost their health coverage, more people became eligible." Meanwhile, state revenues plummeted: Tax collections dropped by 16.6% in the 12 months leading up to June 2009, according to U.S. Census Bureau statistics. This contributed to a 6.3% decline in the state portion of Medicaid spending -- the first in the program's history, Smith said. But the 2009 Medicaid cuts would have been much worse without the most recent federal stimulus package, Smith said. "Without any doubt, we would have seen widespread cuts to eligibility. Cuts to benefits and provider payment rates would have been much, much more severe." Twenty-nine states said they would have cut Medicaid eligibility had the stimulus act not prohibited them from doing so as a condition of accepting the additional Medicaid funding, the report said. Fourteen states had to reverse enacted cuts to obtain the federal money. Despite the stimulus, states are far from being on solid financial ground, Smith said. The additional federal Medicaid funding expires on Dec. 31, 2010. State revenues probably would not rebound for a year or two even under an immediate economic recovery, and Medicaid enrollment likely would remain steady for many months to come, he added. Medicaid directors are worried about conditions when the stimulus funding runs out. For example, Nevada would need to find about $240 million in fiscal 2010 to maintain its existing Medicaid program, said Charles Duarte, administrator of the Division of Health Care Financing and Policy at the Nevada Dept. of Health and Human Services. New York would have to find about $6 billion for its Medicaid program, said Deborah Bachrach, the state's Medicaid director. Some said Medicaid cuts that were unthinkable a few years ago may be necessary. Duarte said Nevada might reconsider a list of potential cuts he prepared last year that weren't implemented -- including wholesale elimination of eligibility groups, restricted home- and community-based benefits, and reduced hospital and physician Medicaid pay. "This could affect access, but we're at the point where that may be a secondary consideration." Bachrach said physician Medicaid pay is an obvious target. New York increased payments by more than 50% in recent years in an effort to get them closer to Medicare levels. "That is one of the goals that may be shortchanged as a result of the plummeting resources." Medicaid pay on the chopping block Nine states cut physician Medicaid fees in fiscal 2009, and 13 have adopted pay cuts for fiscal 2010 -- the most since the Kaiser Family Foundation and Health Management Associates began tracking doctors' fees in 2004. But the situation could have been -- and still could be -- much worse. Although legislatures have closed billions in budget gaps, they could face combined deficits of $350 billion in their 2010 and 2011 budgets, according to Robin Rudowitz, principal policy analyst for the Kaiser Commission on Medicaid and the Uninsured. Also, spending and enrollment projections for 2010 don't add up, Smith said. State budgets predict an average 6.3% growth in Medicaid spending, but enrollment is expected to grow by 6.6%, the report found. State budget shortfalls are likely so large as to prevent states from matching expected enrollment growth with general funds, he said. Washington state physicians, like those in California and Utah, saw Medicaid fees reduced for 2009 and 2010. "We had some increases the session before, and they took those increases away," said Jennifer Hanscom, spokeswoman for the Washington State Medical Assn. The report found that some states, such as Maine, managed to boost Medicaid pay for office-based physicians for 2009 and 2010. But Maine's increases came at the expense of hospital-based physicians, said Andrew MacLean, deputy executive vice president of the Maine Medical Assn. Other states' Medicaid rates essentially are holding steady. South Carolina trimmed Medicaid fees for physicians in 2009 before reversing the cuts for 2010, said Gregory Tarasidis, MD, president-elect of the South Carolina Medical Assn. But continued budget deficits could threaten those fees, he said. Balking at the expansion price tag Smith said state Medicaid directors are confident that the program could provide quality coverage to millions more low-income people without health insurance. But they're concerned that Congress will ask states to shoulder too much of the cost. The House and Senate health system reform bills would expand Medicaid eligibility to any citizen earning 133% or less of the federal poverty level. Seventeen states offer some coverage to childless adults, but it is often very limited. The House bill would pay for the expansion using only federal funds, but the pending Senate bill would provide less federal support to states that already enacted Medicaid expansions, such as New York. "In essence, we're being penalized for the decisions we've made in past years to invest state dollars to cover people who are very low-income individuals," Bachrach said. Smith said states probably are waiting to see what Congress does on reform instead of adopting their own health care expansions. "If you go ahead and enact a change now, you will not be rewarded in the future." - American Medical News Resident duty hours: Does more sleep mean safer care? October 15, 2009 "Oh, I forgot all about that," Monal Joshi, MD, responded to a question from a senior resident during morning report. The internal medicine intern, entering the 25th hour of a 30-hour shift at Rush University Medical Center in Chicago, had overlooked a patient's test result.The slip was quickly caught by a supervisor, and no harm was done. But was the resident's momentary lapse due to fatigue? Dr. Joshi had at least two hours of sleep the night before -- pretty good for when she's on call. Some other members of the five-person Rush internal medicine residency team looked worse for wear as their shifts neared the end one day last spring. Third-year medical student Shikha Wadhwani rested her hand on her head, blinking slowly and yawning widely, as the others went through their reports. But Yoojin Kim, MD, an intern who slept from 3:30 a.m. to 6 a.m., looked bright as a fluorescent light as she sped through her patient reports. Sleep scientists say staying awake for more than 16 hours decreases the ability to concentrate, impairs memory and hinders the ability to do tasks such as tracking test results on a monitor. Yet sleep deprivation does not affect everyone the same way. Such is the enigma of the debate on whether resident duty-hour limits have helped patients. Six years have passed since the Accreditation Council for Graduate Medical Education cut resident workweeks to 80 hours. The council also restricted shifts to 24 hours of call plus six hours of patient transition and educational activities. Some health leaders said cutting back the weekend-long shifts and 120-hour workweeks that were common before the 2003 rules would yield a safety benefit -- fewer patient deaths and fewer complications. But it is hard to make a definitive, evidence-based argument that the work-hour limits have improved patient outcomes, experts said. More adjustments could be on the way. The ACGME is examining whether to adopt a 16-hour shift or mandate a five-hour nap in each 30-hour shift. Those are among changes recommended by an Institute of Medicine panel in a report issued in December 2008. The ACGME could propose new rules next February, taking effect as early as July 2011. The American Medical Association supports the 80-hour workweek. Its Council on Medical Education will deliver a report at the November Interim Meeting with recommendations about the IOM report. Examining impact on safety Kathlyn E. Fletcher, MD, has published systematic reviews of work-hour safety studies and is part of a team helping the ACGME sort through more than 5,000 articles on residency education published since the 2003 rules took effect. "There is not much evidence to suggest mortality has gotten worse. At worst, it has not changed and, at best, maybe it has gotten better," said Dr. Fletcher, interim section chief of general internal medicine at the Clement J. Zablocki Veterans Affairs Medical Center in Wisconsin. "The studies that have looked at things like complications are more difficult to interpret. Some studies find more complications, and some find fewer complications, and some have shown no change. There's probably a finer look that needs to be taken, but at this point, it looks pretty positive." Two of the biggest studies of clinical outcomes to date, published in the Sept. 5, 2007 Journal of the American Medical Association, highlight the equivocal nature of the evidence. The time-series studies, done by the same research team, looked at 30-day mortality among nearly 320,000 VA patients and more than 8.5 million Medicare patients from 2000 to 2005. The duty-hour rules were associated with a significant mortality improvement for VA medical patients, but no change for VA surgical patients. In the Medicare population, mortality did not significantly improve or worsen. Vineet Arora, MD, who is working with Dr. Fletcher on the literature review, said more sleep does not automatically mean safer care. "Whenever you restrict hours, there will be more handoffs," said Dr. Arora, associate program director of the University of Chicago Pritzker School of Medicine's internal medicine residency program. "There are more handoffs in ... teaching hospitals now, and we know they can lead to patient harm. One of the difficult things to isolate in a complex system is what is the contribution of handoff error to patient harm? "You have the tradeoff between having a fatigued doctor who knows the patient well and a well-rested doctor who may not know the patient. How good is the handoff that the well-rested doctor can take over very well for the fatigued doctor who signed out?" John R. Potts III, MD, general surgery residency program director at the University of Texas Medical School at Houston, said the safety evidence does not support shorter shifts. "The data to say that patient care has improved since the 2003 duty hours were instituted is completely lacking," Dr. Potts said. "I don't think anybody would reasonably argue that a better-rested doctor would not typically make better decisions. But the counterargument, though, is that we do have multiple levels of oversight of graduate medical education in this country. "You can only provide 24-hour care with reduced duty hours by increasing the number of handoffs, and there is a hopefully small but still universally recognized fumble error in handoffs. So it becomes a question of the lesser of two evils." The sleep-versus-handover tradeoff is one that residents struggle with daily. "The 30-hour requirement made it very challenging sometimes, because I needed to be out at 1 p.m.," said Jessica Rouse, MD, who completed a family medicine residency at Fletcher Allen Health Care in Vermont this year. She now practices in Middlebury, Vt. "If I had a couple of hours in the middle of the night, I thought, 'Is it worth it to get a one- or two-hour nap in to be much more efficient in the morning rounds, or should I use that time to do paperwork?' Because when those 30 hours were up, I wanted to make sure everything was done so that I could hand off my patients all tucked in." Many experts said the recommendation for a five-hour nap in a 30-hour shift was unrealistic, because residents might work during that time. The IOM's recommendations were based principally on sleep science, said Maureen Bisognano, who served on the panel and is executive vice president and chief operating officer of the Institute for Healthcare Improvement in Massachusetts. The measured effect of the 2003 work-hour rules on patient outcomes was less clear, she said. "It was a difficult thing to get our hands on in the six years since the new rules took effect, because I don't think the science points us in one clear direction or the other," Bisognano said. Testimony and data from the aviation and trucking industries showed that learning would not be impaired, "but patients would be safer because they would not be in the hands of fatigued providers." Safety hard to measure Bisognano argued that reducing medical-resident fatigue alone might not be sufficient to improve patient safety in teaching hospitals. "It's a system of safety, and it all needs attention," she said. "Unless we get to that point where we are looking at the whole system, then incremental change in one piece or another won't give us the kind of change we need and that we owe our patients." Robert Wachter, MD, chief of the medical service at the University of California, San Francisco, Medical Center, said it is no surprise that the purported advantages of better-rested residents have not shown up strongly when studied. "One of the challenges in the safety field is that it's pretty hard to measure safety," said Dr. Wachter, a leading patient safety researcher. "It's possible [the ACGME work-hour rules] had some good effects in terms of safety, and it's just not a signal we've been able to detect so far." Dr. Wachter opposes moving to a 16-hour shift, because it would shorten the handoff process, interrupt continuity of care and worsen residents' learning experiences. "Too much additional regulation may harm as much as help." Even if moving to a 16-hour shift and giving residents more time off would improve patient safety, some residents prefer the current work schedule. "If you're doing 16-hour shifts, maybe you go home to your own bed at like 11 p.m.," said Dr. Kim, now a senior resident at Rush. "You're dead tired, and you have to come back the next day at 7 a.m., and maybe you get five hours' sleep. "I feel like on my post-call days, I get to go home and I don't have to think about anything for the rest of the day. I get home by 1 or 2, then I sleep for 14 hours straight -- and I love it." - American Medical News Infectious Disease Hospitalizations on the Rise in the U.S. October 15, 2009 Infectious disease hospitalizations in the United States increased by more than 6% between 1998 and 2006, according to a report in the October 1st Clinical Infectious Diseases.However, hospital deaths due to infections have been declining. "Infectious diseases, many of which may be preventable, are still a major contributor to healthcare expenditure, morbidity, and mortality," Dr. Krista L. Yorita Christensen from the Centers for Disease Control and Prevention, Atlanta, told Reuters Health in an email. "Certain groups are at increased risk for infectious disease hospitalization, and patterns vary by socio-demographic factors such as age, sex, and race/ethnicity." Dr. Christensen and her colleagues used data from the Nationwide Inpatient Sample for 1998-2006 to analyze the epidemiology and trends of infectious disease hospitalizations in the United States. The annual hospitalization rate for infectious diseases increased by 6.4% during this interval, the authors report, from 152.5 (per 10,000 population) in 1998 to a high of 166.7 in 2005. (The 2006 rate was 162.2 per 10,000 population.) The greatest increases in hospitalization rates were among individuals aged 40-59 years and among patients reporting Hispanic race/ethnicity. Age-specific hospitalization rates were highest among children under 5 years and among the oldest adults (aged 60 and over), the researchers note. Overall, females had a higher infectious disease hospitalization rate than males, but the rate differences varied by age. Males in the youngest age groups and in those aged 40 years and older had higher hospitalization rates, while females aged 5-39 years had higher hospitalization rates. When analyzed by ethnicity, the highest hospitalization rates were seen in patients reporting black race, followed by those reporting white or Hispanic race, with the lowest hospitalization rates found in Asian/Pacific Islanders. The in-hospital fatality rate among infectious disease hospitalizations declined from 4.1% in 1998-2000 to 3.8% in 2004-2006, the investigators say, and was similar for male and female patients. Fatality rates generally increased with age group. The largest proportion of hospitalizations for infectious diseases occurred in the winter months, and lower respiratory tract infections were the most common diagnoses. "For both young and older patients, vaccination plays an important role in the prevention of infectious disease hospitalizations," Dr. Christensen said. "Other interventions include breastfeeding to increase immune resistance in infants, precautions against nosocomial transmission of infectious diseases, and education for both providers and parents on antimicrobial resistance." - Reuters Health Information CBO Report Raises Estimate of Savings From Medical Malpractice Reform October 15, 2009 Medical-liability reforms such as capping noneconomic damages and tightening the statute of limitation for filing a suit would trim $54 billion from the federal deficit over 10 years, largely by curbing defensive medicine, according to a report released Friday by the Congressional Budget Office (CBO).Overall, tort reform would reduce the nation's healthcare spending by 0.5%, the report stated. Forty percent of these savings would stem from lower malpractice insurance premiums for providers. The rest of the savings would result from lower use of healthcare services, as providers would order fewer tests and procedures intended simply to avoid a lawsuit. The CBO estimate of tort reform's potential to reduce the deficit is roughly 10 times greater than what it projected last December (a reduction of $54 billion instead of $5.6 billion). At that time, the agency said that evidence about the extent of defensive medicine — and how tort reform could reduce it — was murky. However, more recent research suggests that "lowering the cost of medical malpractice tends to reduce the use of health care services," according to the latest CBO report. Many States Have Already Enacted Tort Reform Proposals in the Study The CBO's number-crunching assumes that 5 tort-reform proposals are enacted nationally: * Cap noneconomic damages — in other words, for pain and suffering — at $250,000; * Cap punitive damages at $500,000 or 2 times the award for economic damages, whichever is greater; * Modify the so-called "collateral source" rule so that juries who are setting malpractice awards must subtract the income that injured plaintiffs collect from health, life, and automobile insurance and workers' compensation, or at least be informed of that income; * Set the statute of limitations for filing a malpractice suit at 1 year for adults and 3 years for children from the date an injury is discovered; * Replace "joint-and-several" liability, which makes any defendant in a suit liable for all the damages, with a fair-share rule that sets damages for a defendant in proportion to his or her share of responsibility for the injury. The CBO notes that many states have already adopted such reforms, with roughly one third limiting noneconomic damages and two thirds rewriting their laws on joint-and-several liability. Tort Reform Could Reduce Malpractice Insurance Premiums by 10% Although the CBO now believes that tort reform would significantly curb defensive medicine and its cost, the agency's numbers are still far short of the savings claimed by some advocates for tort reform. For example, a 2007 study by the National Center for Policy Analysis, a conservative think tank, put the annual cost of defensive medicine in 2005 between $100 billion and $178 billion. In contrast, the CBO priced defensive medicine in 2009 at $6.6 billion. However, healthcare providers would enjoy a 10% cut in their malpractice insurance premiums if tort reform was enacted, according to the CBO. In Miami, where premiums are the highest in the nation, that reduction would save $5800 for a general internist currently paying a base rate of roughly $58,000, according to Michael Matray, editor of Medical Liability Monitor. Minnesota general internists, whose base rate is $4500 per year, would save $450. The $54 billion that tort reform shaves from the federal deficit over 10 years includes not only $41 billion in reduced spending for Medicare, Medicaid, and other government programs but also $13 billion in increased tax revenue. The CBO reasoned that decreased private-sector spending on healthcare would cut the cost of employer-based coverage, which represents taxable compensation. As a result, taxable wages would increase, boosting federal tax revenue. - Medscape Medical News Are old drugs the future of personalized medicine? October 15, 2009 Shaping the future of personalised medicine is not all about developing expensive new drugs - it will also mean revisiting older, cheaper medicines armed with new genetic knowledge.Recent discoveries of genetic clues as to why medicines work better in some patients than others suggests combining new tests with old drugs will be a cost-effective approach - attractive to governments and insurance companies, experts say. "There are two sides to personalised medicine - there is work in looking for new gene clues for the design of new drugs, and we are also doing a lot of work on currently used medications," said Colin Palmer of Dundee University, whose role as head of pharmacogenomics puts him at the heart of work to use genetic information to personalise medicine. "We're trying to get rid of the one-size fits all approach ... and create more effective drugs tailored to the individual." Few believe it is possible to make all drugs work for all patients all the time, but experts say the current situation - where many patients do not get any benefit - demands action. Its easy to see why. According to a report by PricewaterhouseCoopers earlier this year, patient response rates to medicines "can be very low - varying from 20 percent to 75 percent, depending on the drug". It is no surprise that industry is under pressure to improve efficacy and safety, thereby making drugs more cost-effective. It is already the case that more and more new drugs, particularly for cancer, are coming to market with a so-called companion diagnostic - a test allowing doctors to determine if a patient has the right genetic makeup to respond to treatment. In Europe, there are around a dozen drugs - including GlaxoSmithKline's Ziagen for HIV and AstraZeneca's lung drug Iressa - that require the use of companion diagnostics. And in the United States, the Food and Drug Administration requires patients be tested for genetic variants before taking Pfizer's HIV drug Selzentry, Eli Lilly and Bristol-Myers Squibb's Erbitux for colorectal cancer and Roche's Herceptin for breast cancer, among others. GENETICS AND GENERICS But these are new and highly pricey drugs - and experts say payers may be more encouraged by recent studies which show genetic clues being found for response rates in generic drugs. "In the last year or so people have been beginning to find gene markers in much more common areas," said Donald Singer, a professor of clinical pharmacology and therapeutics at the University of Warwick's medical school. "We are really on the cusp at the moment in terms of the cost effectiveness." While pharmaceutical companies would rather promote new drugs, he believes a better approach for payers may be to revisit old drugs armed with greater genetic knowledge. A study published last week showed that common asthma drugs - salbutamol, a popular inhaler medicine also known as Ventolin, and salmeterol, an ingredient in Glaxo's Advair - do not work in patients with a particular genetic make-up and may make things worse. Another study showed that about half of patients given the generic drug tamoxifen as a hormone therapy in breast cancer have a genetic variation which helps them metabolise the drug - meaning they are likely to respond well - but 8 percent have a gene type which means it will not work. Palmer's team is also investigating the genes involved in defining whether a patient can respond well to statins, a class of drugs used by millions of people to try to lower cholesterol. In some of these areas, scientists say a relatively cheap and easy test, such as a cheek swab or blood test, could be carried out to see ahead of time whether a patient is likely to respond well to the medicine usually prescribed. "From the point of view of governments, testing and then going for the older off-patent drugs could be more cost-effective, rather than ploughing money into new ones," Singer said. Experts in this field point to rapid acceleration in genetic technology since 2003 when scientists completed the Human Genome Project - a decade-long race to sequence all the DNA in people. Some companies already offer a "genotyping service", where you can send in a DNA sample and, for a fee, they give you a typing for as many as a million genetic variants. For now such information is not widely useful without the ability to act on it, but as studies on common medicines reveal more about how and when they work, clinical knowledge about how to exploit those genetic variations to best effect is growing. "In real life what you really want is to be able to go to your doctor, get a blood test which could lay out a genetic map, and then they prescribe based on the test results," said Singer. - Reuters Stricter self-referral rules may end some physician contracts with hospitals October 01, 2009 Sweeping changes to the federal anti-self-referral rules, approved more than a year ago, will take effect Oct. 1, potentially causing many physician-hospital arrangements to fall out of compliance if doctors are not prepared. Being unaware of the Stark law revisions or the structure of a particular deal will not excuse physicians from liability, legal experts say."What the changes did was make it much more difficult for physicians and other entities providing designated health services, primarily hospitals, to do joint ventures around hospital services," said Boston attorney Lawrence W. Vernaglia, co-chair of Foley & Lardner LLP's national health care payments, fraud and abuse, and compliance work group. "Stark is a strict-liability statute. So even if you have the most innocent of intentions, you are still subject to the grossest of penalties, as if you meant to violate the law." The Stark law generally prohibits physicians from referring patients to entities in which they have a financial stake, with certain exceptions. The Centers for Medicare & Medicaid Services in an August 2008 final rule instituted broad revisions to the Medicare hospital inpatient prospective payment system that will restrict: * So-called "under arrangements," in which hospitals contract with physician-owned entities to provide a wide range of ancillary services, such as clinical labs or imaging services. * Per-use or "per-click" payments for equipment and space leases. * Compensation deals based on a percentage of revenue generated by space or equipment use. The regulation changes were delayed one year from the original Oct. 1, 2008, implementation date. Attorneys representing physicians and hospitals said many of these arrangements would have to be restructured to avoid federal penalties. Some deals may have to be unwound completely. "Medicare really took a broad cut at reforming its self-referral regulations and really wanted to tackle what it saw as potentially abusive arrangements" that could lead to improper referrals and overutilization, said Thomas Hoffman, the American College of Radiology's associate general counsel. "CMS anticipated that with the under-arrangement change, players were going to look for other buckets to fit into for exceptions. And that's where the per-click and lease-arrangement changes come into play." Readying for restructure Historically, CMS rules treated physician-hospital arrangements for ancillary services as an indirect compensation relationship that qualified for a variety of safe harbors under Stark, said San Francisco attorney Daniel A. Cody, who works with physicians and hospitals on such arrangements. Under the final rule, however, physician groups will be considered to have a direct ownership stake in the designated health services they provide, effectively barring referrals unless they can meet stricter ownership exceptions under Stark. "The problem is, there are much more limited exceptions for ownership arrangements," said Cody, a partner at Reed Smith. Doctors likely will have to restructure contracts to narrow the scope of services they perform for a hospital, he said. For example, a physician-owned entity may need to limit its clinical services but still could conduct billing and management activities. Many contracts include provisions allowing physicians to amend or dissolve a deal to comply with a change in law, he added. Vernaglia said physicians still can lease equipment or space they own, but they may have to consider unbundling such services from other arrangements. Doctors also may have to adjust the compensation structure to a flat fee, such as a per-month payment. Any change in compensation must reflect fair market value, he noted. Because such physician-hospital deals have been a long-accepted practice, Vernaglia recommended that doctors "first look hard at the older deals that have been around for 10 or 15 years and that you are complacent about. Those are the deals that will come back and bite you." Vernaglia noted that doctors have little legal recourse against alleged Stark violations. He pointed to a January ruling in which the 3rd Circuit Court of Appeals found that a hospital ran afoul of the Stark law because it did not update its contract with an anesthesiology group to reflect a change in the services provided by the physicians. Because of the alleged Stark law violation, the court in Kosenske v. Carlisle HMA also allowed a false claims case to proceed against the hospital and physician group. That case is still pending. Impact on patient care Meanwhile, some physician organizations expressed concern that the rule changes will limit access to care. In an Aug. 9 letter to CMS, the American College of Cardiology said the physician-hospital arrangement prohibitions "may unnecessarily eliminate some physician-owned services that enhance access to high-quality cardiovascular care." The organization -- while generally supportive of CMS efforts to prevent abuse -- is asking the agency once again to defer the Oct. 1 implementation deadline and consider whether certain deals "provide benefit to the Medicare program and should perhaps be exempted." The American Medical Association, in various letters to CMS, also advocated against the revisions. The Association said the additional regulatory layers unnecessarily complicate physician practices, driving up health care costs and possibly eliminating long-standing, nonabusive relationships that can create more efficient care. But the American College of Radiology's Hoffman said access limitations are unlikely, because doctors have options to restructure in a way that ensures continuity of care. The organization supported the changes but also requested the extension until Oct. 1 to give doctors time to adapt. "Are the [restructured deals] going to be as economically attractive? Perhaps not. But doctors should not rule out looking at them," Hoffman said. "They have to structure what is best for patient care." - American Medical News Mindful Communication Education May Help Prevent Burnout in Primary Care Physicians October 01, 2009 Mindful communication education may help prevent burnout in primary care physicians, according to the results of a before-after study reported in the September 23/30 issue of the Journal of the American Medical Association."Physician burnout has been linked to poorer quality of care, including patient dissatisfaction, increased medical errors, and lawsuits and decreased ability to express empathy," write Michael S. Krasner, MD, from the University of Rochester School of Medicine and Dentistry and Olsan Medical Group in Rochester, New York, and colleagues. "Even though the problem of burnout in physicians has been recognized for years, there have been few programs targeting burnout before it leads to personal or professional impairment and very little data exist about their effectiveness." Physicians' Personal Well-Being Improved The goal of this study was to examine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, reduction in psychological distress and burnout, and improvement in the capacity to relate to patients. In Rochester, New York, from 2007 to 2008, a total of 70 primary care physicians took part in a continuing medical education (CME) course including mindfulness meditation, self-awareness exercises, narratives concerning meaningful clinical experiences, appreciative interviews, didactic material, and discussion. After participating in an 8-week intensive phase, which included 2.5 hours per week and a 7-hour retreat, the physicians took part in a 10-month maintenance phase, which consisted of 2.5 hours per month. Primary endpoints measured at baseline and at 2, 12, and 15 months were mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales). During the educational program and follow-up, participants had improvements in the following: * mindfulness (raw score improved from 45.2 - 54.1; raw score change [delta], 8.9; 95% confidence interval [CI], 7.0 - 10.8); * burnout o emotional exhaustion (raw score, 26.8 - 20.0; delta, −6.8; 95% CI, −4.8 to −8.8); o depersonalization (raw score, 8.4 - 5.9; delta, −2.5; 95% CI, −1.4 to −3.6); o personal accomplishment (raw score, 40.2 - 42.6; delta, 2.4; 95% CI, 1.2 - 3.6); * empathy (raw score, 116.6 - 121.2; delta, 4.6; 95% CI, 2.2 - 7.0); * physician belief scale (raw score, 76.7 - 72.6; delta, −4.1; 95% CI, −1.8 to −6.4); * total mood disturbance (raw score, 33.2 - 16.1; delta, −17.1; 95% CI, −11 to −23.2); and * personality o conscientiousness (raw score, 6.5 - 6.8; delta, 0.3; 95% CI, 0.1 - 5); o emotional stability (raw score, 6.1 - 6.6; delta, 0.5; 95% CI, 0.3 - 0.7). Improvements in mindfulness correlated with improvements in total mood disturbance (r = −0.39; P < .001), perspective taking subscale of physician empathy (r = 0.31; P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = −0.32 and r = 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and r = 0.25, respectively; P < .001). "Our study demonstrated that primary care physicians participating in a CME program that focused on self-awareness experienced improved personal well-being, including burnout (emotional exhaustion, depersonalization, and personal accomplishment) and improved mood (total and depression, vigor, tension, anger, and fatigue)," the study authors write. "They also experienced positive changes in empathy and psychosocial beliefs, both indicators of a patient-centered orientation to medical care that has been associated with patient-centered behaviors such as attending to the patient's experience of illness and its psychosocial context and promoting patient participation in care." Study Limitations Limitations of this study include lack of randomization or a control group; before-and-after design, limiting inferences about intervention effects; self-selection of participants; inability to determine how changes in self-report measures affected actual clinical care; and inability to prove that the observed improvements were caused by any or all of the components within the intervention. In addition, the course took place in a single location, with experienced course facilitators, potentially limiting generalizability. The study authors recommend testing these findings in randomized controlled trials involving different specialties of practicing physicians. "The skills cultivated in the mindful communication program appeared to lower participants' reactivity to stressful events and help them adopt greater resilience in the face of adversity," the study authors conclude. "Further study will be necessary to investigate the effects on practice efficiency, patients' experience of care, and clinical outcomes." Future Benefits of Mindfulness Training In an accompanying editorial, Tait Shanafelt, MD, from the Mayo Clinic in Rochester, Minnesota, notes that national healthcare reform will likely create many new challenges for physicians during the next decade. "Although many physicians may be tempted to respond to this challenge by retreating from work (e.g., more time off, reduced scope of practice, retirement), the study by Krasner and colleagues demonstrates that training physicians the art of mindful practice has the potential to promote physician health through work," Dr. Shanafelt said. "Physicians continue to control the most sacred and meaningful aspect of medical practice—the encounter with the patient and the reward that comes from restoring health and relieving suffering. Reminding physicians of this fact and helping them recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients." - Medscape Senate's 10-year health fix would cost $856B September 16, 2009 Sen. Max Baucus on Wednesday brought out the much-awaited Finance Committee version of an American health-system remake — a landmark $856 billion, 10-year measure that starts a rough ride through Congress without visible Republican backing.The bill by Baucus, Democratic chairman of the Senate panel, would make major changes to the nation's $2.5 trillion health care system, including requiring most people to purchase insurance coverage or pay a fine and prohibiting insurance companies from charging more to people with more serious health problems. "This is a unique moment in history where we can finally reach an objective so many of us have sought for so long," said Baucus, of Montana. "The Finance Committee has carefully worked through the details of health care reform to ensure this package works for patients, for health care providers and for our economy." Consumers would be able to shop for and compare insurance plans in a new purchasing exchange. Medicaid would be expanded, and limits would be placed on patients' yearly health care costs. The plan would be paid for with $507 billion in cuts to government health programs and $349 billion in new taxes and fees, including a tax on high-end insurance plans and fees charged to insurance companies and medical device manufacturers. But the bill fails to fulfill President Barack Obama's aim of creating a new government-run insurance plan — or option — to compete with the private market. It proposes instead a system of nonprofit member-owned cooperatives, somewhat akin to electric co-ops that exist in some areas of the country. That was one of many concessions meant to win over Republicans. In other ways, including its overall cost and payment mechanisms, the bill tracks closely with the priorities Obama laid out in his speech to Congress last week. White House press secretary Robert Gibbs called the legislation an "important building block" that "gets us closer to comprehensive health care reform." Baucus is still holding out hope for GOP support when his committee votes on the bill, probably as early as next week. "This is a good bill. This is a balanced bill," he told reporters at a Capitol Hill news conference. Earlier, Senate Majority Leader Harry Reid, D-Nev., said, "Everyone should understand it's just the beginning, but it's a good beginning." The measure represents the most moderate health care proposal in Congress so far, compared to legislation approved by three committees in the House and the Senate's health panel. Obama's top domestic priority is to revamp the health care system to provide coverage to nearly 50 million Americans who lack it and to rein in rising costs. The bill includes provisions to keep illegal immigrants from obtaining health coverage through the new insurance exchanges — reflecting the White House's newly stringent stance on the issue after a Republican House member interrupted Obama's speech last week to accuse him of lying about it. The bill also would prevent federal funds from being used to pay for abortions except in cases of rape, incest, or if the life of the mother would be endangered. It's all but certain that the Baucus provisions will not be the last word on either of those volatile issues. The bill would set up a verification system to make sure people buying insurance in the exchanges are U.S. citizens or legal immigrants, using Social Security data and Homeland Security Department files. The bill would impose penalties for fraud and identity theft. While only legal residents would be able to buy coverage through the exchanges, illegal immigrant parents would be able to get insurance for their U.S. born children. The bill would prohibit abortion from being included in any minimum benefits package. However, plans in the exchange could offer unrestricted coverage for abortions, provided that no funds from government subsidies are used to pay for them. Women who want coverage for abortions would have to pay for it with their own money. Wednesday's bill release follows months of negotiations among Baucus and five other Finance Committee senators dubbed the "Gang of Six" — Republicans Chuck Grassley of Iowa, Mike Enzi of Wyoming and Olympia Snowe of Maine, and Democrats Kent Conrad of North Dakota and Jeff Bingaman of New Mexico. Enzi said he couldn't support the Baucus bill and preferred an incremental approach. In the end, Democrats believe Snowe may be the only Republican to support the bill, though she wasn't ready to commit her support. "This is a first step in the process," Snowe said as she promised to continue to work with Baucus and Democrats on coming up with bipartisan legislation. The bill drew quick criticism from Republican leaders. "This partisan proposal cuts Medicare by nearly a half-trillion dollars, and puts massive new tax burdens on families and small businesses, to create yet another thousand-page, trillion-dollar government program," said Senate Minority Leader Mitch McConnell, R-Ky. "Only in Washington would anyone think that makes sense, especially in this economy." Many liberals and labor groups also have concerns. Some wanted Baucus to include a public option, while others fear that, in his effort to hold down the price of his bill, Baucus didn't do enough to make health coverage affordable to working-class Americans. Sen. Jay Rockefeller, D-W.Va., a member of the Finance Committee, said that he couldn't support the bill in its current form. Gerald McEntee, president of the American Federation of State, County and Municipal Employees, called it "deeply flawed." Baucus' plan, released as a detailed 223-page summary, aims to make health insurance more affordable for self-employed people and those working for small companies, who now have the biggest problems in getting and keeping coverage. People insured through large employers would not see major changes, but some of their health care benefits would be nicked to help pay for the cost of the plan. The Baucus proposal would limit to $2,000 a year the amount people can contribute to flexible spending accounts, which are used to cover copayments and deductibles not paid by their employers. That provision would raise $16.5 billion over 10 years. Everyone covered through an employer would learn the full costs of their health benefits, which starting next year would be reported on employees' W-2 tax forms. Although family coverage averages about $13,000 a year most workers don't know how much their employer is paying. Not carrying insurance could result in a steep fine, as much as $3,800 per family, or $950 for an individual. People who can't afford their premiums would be exempted from the fine. The plan proposes a $6 billion annual fee on health insurance providers, which would recoup some of the profits the companies expect to make from millions of new taxpayer-subsidized customers. Unlike the health care bill written by majority Democrats in the House, which permanently rolls back scheduled cuts in Medicare payments to doctors, the Baucus plan only suspends the reductions for one year. That trims more than $100 billion from the cost of the bill, but has already led to criticism from the American Medical Association. The legislation makes no changes in medical malpractice laws. It does incorporate Obama's call for federal funds for state experiments on alternatives to malpractice lawsuits. Democratic leaders are aiming for votes in the full House and Senate this fall. - msnbc.com Young adults key to financing health reform September 16, 2009 As health-care legislation advances through Congress, the young adults who were so vital to President Obama's election are emerging as a significant beneficiary of his top domestic priority, but they are also likely to play a major role in funding any reform.In a campaign-style rally Thursday at the University of Maryland at College Park, Obama will aim to tap his richest vein of support -- voters younger than 30 -- to help sell his reform plan to a more skeptical general public. "We're at an important turning point in our push for real reform," read the e-mailed invitation, "and it's critical that we seize this moment." A 2008 study by the Urban Institute found that more than 10 million young adults ages 19 to 26 lack health insurance coverage. For many of those people, health-care reform would offer the promise of relatively inexpensive individual policies, which do not exist in many states today. The trade-off is that young people would no longer be permitted to bet on their good health: All the reform legislation before Congress would require individuals to buy at least minimal coverage. Another bill will be introduced Wednesday by the chairman of the Senate Finance Committee. Sen. Max Baucus (D-Mont.) will offer in it a proposal to keep premiums manageable: a bare-bones catastrophic policy that would protect young people from financial calamity while providing basic preventive care. Drafting young adults into any health-care reform package is crucial to paying for it. As low-cost additions to insurance pools, young adults would help dilute the expense of covering older, sicker people. Depending on how Congress requires insurers to price their policies, this group could even wind up paying disproportionately hefty premiums -- effectively subsidizing coverage for their parents. An array of Democratic senators continued to complain Tuesday about the affordability of reform, insisting that the final package should include much larger tax credits to help people cover the cost of insurance premiums. "I want to make clear that in its current form I cannot put my support behind the Finance bill -- it will not have my vote," said Sen. John D. Rockefeller IV (D-W.Va.). Fines for the uninsured In part, young adults are uninsured because they are less likely to work for employers who offer coverage; they may not qualify for public programs such as Medicaid; and even the skimpiest private insurance plans may be too expensive alongside hefty student loan payments and credit card debt. But some young people -- nicknamed the "young invincibles" -- are also likelier than other Americans to assume that they won't need health insurance or to decide that they'd rather spend their money on other things. To discourage that attitude, the Finance Committee bill would fine individuals who do not purchase coverage. An early draft of the proposal set the penalty at $750 or $950 per year for single people, depending on income. But according to various insurance experts, even the least expensive plan under the bill could cost more than $100 per month, making it cheaper for people to pay the fine than to buy insurance. All the bills seek to blunt the additional cost to young adults, mainly through subsidies, but it is not clear what effect that would have. "The primary question is what the premium is and what people get for that," said Mark McClellan, director of the Engelberg Center for Health Care Reform at the Brookings Institution and a former senior Bush administration official. Adding preventative care to a catastrophic policy makes the Finance Committee bill's bare-bones coverage more appealing, McClellan noted. But for many young adults, health care will become a significant new expense. "It's important for people to know what they're getting into," he said. But it's also essential that young, healthy people participate, said Linda J. Blumberg, a health-care expert at the Urban Institute, because the requirement that people have insurance "is really a mechanism for financing health-care reform." Benefits and pitfalls The more people steered into the system through such a mandate, Blumberg and others explained, the lower the total subsidies that the government must provide to keep insurance affordable. But if young people slip through the cracks -- or if Congress, facing political pressure, provides generous exemptions from the mandate -- then the government and people who buy coverage will face higher costs. The Finance Committee proposal also focuses on broadening access to health insurance. For uninsured people without affordable employer coverage, it would open new insurance "exchanges," offering a menu of options at different cost and benefit levels. Additionally, all adults with incomes below 133 percent of the federal poverty level -- or about $14,400 for an individual -- would be eligible for Medicaid. One group that policy experts worry could be squeezed by reform is young adults with health problems, whose incomes are not high enough to afford the expensive policies they may need to manage chronic conditions. Blumberg said young adults with asthma, diabetes, hay fever and even high school sports injuries are systematically rejected by insurers in states without protections for people with preexisting conditions. Krisja Hendricks, 28, is a waitress in Brooklyn whose thyroid cancer was diagnosed shortly before she graduated from college, while she was still covered under her father's plan. Crohn's disease was later diagnosed, causing insurers to turn her away. She finally found a health plan for $245 per month, but she just discovered that it will not cover the tests she needs to monitor her health. "I'm willing to pay $400 a month, even though that's a lot," she said. "But I know I have to. I really don't think everyone should required to." Loyal group receives little attention According to a Washington Post-ABC News poll last week, young adults are more optimistic about the outcome of health-care reform than those age 30 and older, but they are evenly divided on the cost implications, with 32 percent expecting their costs to decline and 27 percent expecting an increase. About 52 percent of young adults support the idea of the individual mandate, about the same proportion as in other age groups. But in terms of the overall package, the under-30 group broadly supports the Democratic effort, with 60 percent favoring the proposed reforms vs. 42 percent among older adults. And while the number is down from its high point, 63 percent of under-30s approve of Obama's overall job performance, significantly more than in other age groups. Given the implications of reform, advocates for young voters wonder why they haven't commanded special attention from the White House and Congress, as have seniors, union households and industry stakeholders. "We can do our part, but we need to hear from the people who are making the policy decisions," said Heather Smith, executive director of Rock the Vote, a nonprofit group aimed at drawing young people into the political process. Along with other pro-reform organizations, Rock the Vote has begun a national advertising and grass-roots campaign to educate young adults about the emerging legislation. But Smith said she was frustrated that Obama offered few assurances to young adults in his speech before Congress last week, instead chastising as "irresponsible" those who don't buy coverage. The under-30 crowd remains by far the president's most loyal following, Smith noted. "He needs to talk to them," she said. "Writ large, they are struggling; they are the uninsured." - msnbc.com CDC: H1N1 flu vaccine to be ready by early October September 16, 2009 The H1N1 flu vaccine will be available earlier than had been expected, the director of the nation's top disease agency told CNN on Monday."We think the first doses of some of the vaccine forms should be available in about three weeks," said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention. Previously, the CDC had been predicting the vaccine would not be available before middle or late October. Frieden said that the vaccines appear to confer protection from the virus eight to 10 days after they are administered. The news about the vaccine against H1N1, also called swine flu, comes a week after researchers concluded that a single injection would suffice to protect against the virus. Health officials are urging that pregnant women, school-age children and anyone with underlying health conditions, like diabetes, heart disease or lung disease, get the swine flu shot. Frieden said it appears that health workers will be able to administer the H1N1 vaccine at the same time that they administer the shot against seasonal flu. The symptoms of seasonal flu are similar to those of swine flu, and patients and their caregivers need not know which one they have, he said. "The key messages are the same in either case: If you're sick, stay home," he said. "If you're severely ill -- and that means you have trouble breathing, you have severe illness, your fever comes back or you have one of those underlying conditions like diabetes or people with special health care problems, like children with disabilities, that make it difficult for them to breathe -- then see your doctor right away." The timing is important because 11 states already are reporting widespread flu activity. "We wish we had the vaccine today," Frieden said. He said flu vaccines have a good safety record. "Literally, hundreds of millions of people have gotten the flu vaccine, and certainly my kids will be getting the H1N1 vaccine when it becomes available for everybody." Frieden's two children are ages 5 and 15. - cnn.com 50 million new patients? Expect doc shortages September 16, 2009 Among the many hurdles facing President Barack Obama's plan to revamp the nation's health care system is a shortage of primary care physicians — those legions of overworked doctors who provide the front line of medical care for both the sick and those hoping to stay healthy.As Massachusetts' experience shows, extending health care to 50 million uninsured Americans will only further stress the system and could force many of those newly insured back into costly emergency rooms for routine care if they can't find a primary care doctor, health care observers said. Massachusetts, home of the nation's most ambitious health care law, has seen the need for primary care doctors shoot up with the addition of 428,000 people to the ranks of the insured under a 2006 law that mandates health care for nearly all residents. To keep up with the demand for primary care doctors, the country will need to add another 40,000 to the existing 100,000 doctors over the next decade or face a soaring backlog, according to Dr. Ted Epperly, president of the Kansas-based American Academy of Family Physicians. "It's like giving everyone free bus passes, but there are only two buses," he said. The need for more primary care doctors comes as the country's shortage of all doctors is expected to worsen, according to a study by the Association of American Medical Colleges, which found the rate of first-year enrollees in U.S. medical schools has declined steadily since 1980. If current patterns persist, the study shows the country will have about 159,000 fewer doctors than it needs by 2025. A raft of ideas has been proposed to ease that pressure — from boosting loan repayment programs for medical students studying primary care to narrowing the salary gap between primary care doctors and specialists like brain surgeons and cardiologists. All the efforts have a single objective — increasing the number of primary care doctors to give them spend more time with the patients who need them the most. As part of his health care overhaul, Obama has stressed the need to "elevate the profile of family care physicians and nurses as opposed to just the specialists who are typically going to make more money." Obama has said that more insured Americans will require both an increase in primary care doctors and a team approach to care. "If you look at what's happening in some states, like Massachusetts, where they tried to create a universal system — and they haven't quite gotten there yet — they have had a problem with an overload of patients," he said in July. He even chose as his pick for U.S. surgeon general Dr. Regina Benjamin, who has made her name delivering primary care to poor and immigrant communities in Alabama. Benjamin also worked in the National Health Service Corps, a program that helps young doctors pay off medical school loans by serving in poorer communities. In a 2008 survey of physicians, the Massachusetts Medical Society found the average wait time to see an adult primary care doctor was 50 days, with some doctors reporting wait times for new patients of up to 100 days. That's compared to 2005, before the law was signed, when the average wait was 47 days and the longest was 87 days. The society also found a drop in the number of primary care doctors accepting new patients. In 2008, 42 percent had closed their practice to new patients compared with 33 percent in 2004, before the law was signed. Family doctors need a raise Part of the problem is that those trained to intervene after a heart attack typically earn more than those who help prevent the heart attack from happening in the first place, said John Auerbach, the Massachusetts Medical Society's immediate past president. "We have devalued the work of what a primary care physician does," he said. Epperly, of the American Academy of Family Physicians, said primary care doctors need a 30 percent pay increase. The average family doctor makes about $160,000 year, he said. A 30 percent increase would bring them over $200,000, compared with the average $300,000 for a specialist, he said. When Dr. Robert Flaherty launched a private practice in 2001, he soon found himself cramming in as many patients as possible to make ends meet, leaving little time to discuss with them the steps they could take to prevent future health troubles. "I constantly felt that conflict of going faster than I should," said Flaherty, 40, who gave up his practice after four years for a hospital post. "Everyone knows if you want to make a decent living, become a specialist; if you want to be banging your head, go into primary care." Massachusetts is trying to expand access to primary care by encouraging doctors to adopt a team approach by relying more heavily on nurse practitioners and health educators for basic care and counseling, said Massachusetts Health and Human Services Secretary Dr. JudyAnn Bigby. Nurse practitioners already figure prominently in the operation of private clinics set up in pharmacies, offering basic services like flu shots and treatments for minor ailments. CVS Caremark Corp. and Walgreen Co., which operate hundreds of the clinics around the country, say they are faster than a visit to a primary care doctor and less expensive than a trip to the emergency room. The state also offers loan repayments up to $75,000 for new doctors who agree to work in community health centers for three years. So far, 70 new doctors have signed up. Another way to expand primary care is to have some specialists provide the equivalent of primary care, according to Dr. Georges Benjamin, executive director of the American Public Health Association. He said obstetrician-gynecologists essentially serve as primary care physicians for many women — a model that could be used for patients who rely on other specialists. Ryan Van Ramshorst is the kind of young primary care doctor advocates say the country needs to fill the gap. A fourth-year medical student at Baylor College of Medicine in Texas, Ramshorst is doing his residency in general pediatrics. "When I wrote on my medical school application that I wanted to help people, I really meant it," he said. The federal National Health Service Corps, the same program that helped Regina Benjamin, is helping him, covering two years of his tuition and expenses in exchange for him spending at least two years in a clinic in an underserved area. Ramshorst said he's thankful for the opportunity but said plans to expand the corps — the Obama administration has announced $200 million in federal stimulus funds to boost the corps by 3,300 doctors and clinicians — is no replacement for adding more primary care doctors and increasing pay. "We need something with a bigger scope," he said. - msnbc.com Homocysteine Lowering Cuts Mortality in Early-Onset CAD Patients September 16, 2009 Patients with early-onset coronary artery disease (CAD) and elevated homocysteine levels who took folic acid/B vitamins long term had significantly lower mortality than those who did not take this homocysteine-lowering therapy, according to the results of a new Israeli study [1]. Dr Aviv Mager (Rabin Medical Center, Petah Tivka, Israel) and colleagues report their findings in the September 15, 2009 issue of the American Journal of Cardiology.Mager told heartwire : "Our results suggest that patients with CAD and elevated homocysteine at baseline may benefit from taking folic acid in doses similar to the ones we used." He added, however, that they found no effect of the homocysteine-lowering therapy on mortality in those with normal plasma homocysteine levels. He believes that the findings support the hypothesis that elevated homocysteine "is a coronary risk factor, rather than simply a risk marker." Many Negative Trials: Could Genetics Play a Role? He acknowledges that the benefits of homocysteine-lowering therapy remain controversial but said that many of the prior prospective studies in this field that have failed to show any benefit of this approach, either as primary or secondary prevention, were performed in predominantly Anglo-Saxon populations, and "it would be interesting to see if genetic background plays a role." Noting that this study was conducted specifically in Israeli subjects and that differences among populations in relation to homocysteine and CAD are "well documented," he suggests that future prospective studies should be performed in other ethnic groups. There are also a number of other possible reasons for the discrepancies between this study and prior prospective ones, he says, including: shorter follow-up of the prospective studies compared with the current one, which followed patients for a median of 115 months; a relatively high weekly dose of folic acid in the current study; and differences in patient selection. "Our findings in patients with elevated homocysteine levels add to the growing body of evidence of a beneficial effect of folate-based therapy on outcomes," Mager and colleagues state. They add that their results are consistent with findings from a Nurses' Health Study analysis, which also had long-term (14-year) follow-up, and with results in hemodialysis patients and heart-transplant patients, as well as a couple of trials showing a reduction in the incidence of major adverse events with folate therapy after PCI. Screen CAD Patients for Hyperhomocysteinemia In their study, Mager et al included 492 patients with early-onset CAD who had homocysteine measured at baseline. Hyperhomocysteinemia was defined as a homocysteine level above 15 µmol/L, a standard cutoff point, said Mager. Participants were also screened for the C677T mutation in the methylenetetrahydrofolate-reductase gene, thought to be a common cause of hyperhomocysteinemia and conferring increased risk of CAD in certain ethnic groups, but not in others. Patients received folic acid as 5-mg tablets three to seven times a week. Mager explained that this dosing schedule was chosen because this relatively high dose of folic acid was the only one available in Israel at the time, but the results show it to be safe. They also took vitamin B12 sublingually at 1 mg/week or orally at 0.25 to 0.4 mg per day. Vitamin B6 was added at the physician's discretion. Of the patients, 46 (9%) died during follow-up. Treatment was associated with a significantly lower all-cause mortality in patients with homocysteine levels above 15 µmol/L (4% vs 32%, p<0.0001), but not in those with lower homocysteine levels (5% vs 7%, p>0.05). The following factors were independently associated with all-cause mortality: vitamin therapy (hazard ratio 0.33, p=0.046), elevated homocysteine levels (HR 3.5, p=0.013), and older age (HR 1.1, p<0.0001 for an increment of five years.) The methylenetetrahydrofolate-reductase genotype was not associated with outcomes, however. "Our findings imply that patients with CAD should be screened for elevated fasting plasma homocysteine and that those with hyperhomocysteinemia may benefit from homocysteine-lowering vitamin therapy," Mager and colleagues say. But they add that "because we studied only patients with CAD, we cannot comment on the potential value of homocysteine-lowering therapy in all subjects with hyperhomocysteinemia. Further research is necessary." - heartwire UA Surgeons Perform Islet Cell Transplants at UMC: September 02, 2009 Surgeons at The University of Arizona Department of Surgery are the first in the Southwest to perform successful auto-islet cell transplants in patients with severe chronic pancreatitis. The dual procedure, which involves removing the pancreas and then putting the patient’s insulin-producing pancreatic islet cells back into the body, was performed this month at University Medical Center on two women in their mid-40s.One woman, from Tucson, underwent the procedure Aug. 6; the other patient, who traveled to Tucson from Cincinnati, Ohio, had the surgery performed Aug. 13. The innovative procedure alleviates the pain from pancreatitis, while avoiding surgically induced diabetes. “Chronic pancreatitis can be extremely painful,” said Horacio Rilo, MD, professor of surgery and director of Cellular Transplantation at the UA. “Although a pancreatectomy (removing the pancreas) usually is effective in relieving the debilitating pain in patients when all other treatments fail, it induces permanent diabetes, requiring patients to take insulin shots or use an insulin pump for the rest of their lives.” In an auto (meaning "self") islet transplant after a total pancreatectomy, the patient's own insulin-producing beta cells contained in clusters called “islets” are isolated immediately from the removed pancreas and then put back into the patient’s liver, where they lodge in small blood vessels and release insulin. “By removing the pancreas and infusing the islet cells back into the body to reduce the risk of surgically induced diabetes, the patient has potential for a much better quality of life,” said Dr. Rilo. During both operations, the pancreas was removed by the UA Department of Surgery transplant team, led by Rainer Gruessner, MD, professor and surgery department chairman, and included Tun Jie, MD, assistant professor of surgery. The organ was rushed to a specially designed laboratory “clean room” where Dr. Rilo and his team at the UA Cellular Transplantation Institute harvested the islet cells. Then the cells were brought back to the operating room, where Dr. Gruessner infused the cells into the patient’s liver through the portal vein. There they will graft and mimic the function of the removed pancreas and produce insulin. Telemedicine technology was used to provide constant communication between the operating room and the laboratory. "The procedure utilizes patients’ own islet cells, which eliminates any threat of rejection and substantially reduces or averts the risk of the patient developing diabetes,” explained Dr. Gruessner. “Had the islet cells not been infused, the patient would likely suffer from a very severe form of diabetes that is particularly difficult to manage and prone to secondary complications of diabetes, such as heart disease, stroke, blindness and vascular diseases.” Dr. Rilo, a leading expert on islet cell transplantation, recently opened a state-of-the-art “Class 10,000” clean room at the UA for isolating and transplanting the insulin-producing cells of the pancreas. A Class 10,000 clean room facility maintains a positive-pressure environment to ensure that when entering the laboratory, air flows out of the clean room facility, limiting the possibility of contaminants entering the room. The pancreas is located in the middle of the abdomen, surrounded by most of the abdominal organs such as the liver, spleen and stomach. The organ produces enzymes (exocrine pancreas) essential for digestion and secretes insulin (endocrine pancreas) that controls blood-sugar levels. Chronic pancreatitis (CP) is an inflammation of the exocrine pancreas that causes irreversible scarring and eventually the destruction of islets. CP can be caused by many things, including hereditary disorders, autoimmune conditions, cystic fibrosis, trauma to the pancreas or heavy alcohol use. Transplant surgeon Dr. Jie said, “Auto islet transplant is an effective treatment for chronic pancreatitis, but is offered only at a handful of medical centers worldwide. With so few centers offering this procedure, we will be able to help patients not only from Arizona, but from all over the U.S.” Dr. Gruessner added, “In the future, we will expand the program to treat children with rare familial chronic pancreatitis and type 1 diabetes.” - Arizona Health Sciences Center Organized medicine aims to strengthen liability provisions in reform bill September 02, 2009 When lawmakers get back to considering health system reform legislation this fall, physicians seeking relief from medical liability pressures will be looking to revise and fortify protections that made it into the House Energy and Commerce Committee's latest version of the House reform bill.An amendment offered by Reps. Bart Gordon (D, Tenn.), Jim Matheson (D, Utah) and Nathan Deal (R, Ga.) would offer financial incentives to states that enact certain liability alternatives that meet federal standards -- as long as they do not limit attorneys' fees or impose damage caps, which President Obama and many congressional Democrats oppose. The provisions were wrapped into an amendment offered by Rep. Mike Doyle (D, Pa.) and approved by the Energy and Commerce Committee in a July 31 voice vote as part of a deal between Democratic leaders and the conservative Democratic Blue Dog Coalition. The Commerce version must be reconciled with two other measures that lack medical liability reforms before the full House can take up the bill. The liability provisions lack details. But in general, qualifying states would need to show that their reforms: * Make the medical liability system more reliable through the prevention or prompt and fair resolution of disputes. * Encourage the disclosure of medical errors. * Maintain access to affordable liability insurance for physicians. Other approved options outlined in the amendment include laws requiring the filing of an expert opinion, or certificate of merit, on the validity of a case before it can proceed. It also would support early-offer programs, in which doctors or other health care entities compensate patients for alleged medical errors without going to court. The incentive payments, while not specified, would need to be used to improve health care in the states. The Dept. of Health and Human Services secretary would submit to Congress an annual report on the progress and effectiveness of states' liability laws. A separate amendment offered by Rep. Frank Pallone Jr. (D, N.J.) and agreed to by a July 20 voice vote would limit liability for physicians who volunteer across state lines in federally declared emergency or disaster situations. American Medical Association President J. James Rohack, MD, said the AMA was encouraged by the vote to add medical liability reforms to the House bill, "as it is needed to reduce unnecessary costs to the health system. ... This is an important step in the right direction." Representatives of organized medicine and other tort reform advocates say the measures, if passed, would be key to reducing health care costs driven by frivolous lawsuits and litigation expenses. The AMA continues to favor noneconomic damage caps. But the Association plans to press for other comprehensive measures to help cut down on defensive medicine practices. Uphill battle Some resistance may lie ahead, however. "The next big step is to see whether we can keep the [Energy and Commerce] language in the House bill when it reaches the floor, and we'd like to think that because it passed unanimously that it won't be controversial," said Mike Stinson. He is chair of the Health Coalition on Liability and Access, a broad group of physician organizations that includes the AMA, as well as patients, liability insurers and other health care entities that advocate for medical liability reform. "But stripped out were definitions of those [certificate-of-merit requirements and early-offer programs], so it's still very vague," he said. "And if it goes through as is, we're looking at an extensive lobbying effort to define them adequately in regulation." Energy and Commerce Democrats were able to sustain opposition to several other proposals containing liability alternatives that have won the support of organized medicine. Struck from the Gordon amendment was a provision that would have allowed physicians to apologize to patients for bad treatment outcomes without those statements being used against them in court. Also stripped from the amendment were provisions supporting medical review panels and voluntary alternative dispute resolution mechanisms. Another excised proposal would have allowed state pilot programs to offer liability safe harbors for doctors who adhere to evidence-based guidelines. Lawmakers voted down a separate amendment proposed by Deal that would have shielded emergency doctors in general from liability if they referred nonemergent patients elsewhere. Rep. Michael Burgess, MD (R, Texas) unsuccessfully pushed an amendment modeled after Texas' 2003 reforms, which capped noneconomic damages at $250,000 for physicians and included a range of other liability reforms, such as expert witness qualifications. "In the end, the part that probably killed it on arrival was the fact that it included caps," Stinson said. Although disappointed that the other measures did not succeed, the HCLA "will continue to focus on realistic goals and look at alternatives to at least help some of those states that are still in lousy situations but don't have the ability to pass reforms," he said. There is a modest role that tort reform can play in restraining health care costs, said Michelle Mello, a professor of law and public health at Harvard University School of Public Health in Boston. A recent study she co-authored noted that defensive medicine costs are difficult to estimate. "But even if we conservatively estimate it at 1%" of all health care spending, or $22 billion per year, "that's still a lot of money," Mello said. - American Medical News HHS to dole out $1.2 billion for health IT grants September 02, 2009 The Obama administration will make available nearly $1.2 billion in federal grants to create a large network of regional health information technology centers and state-based entities to support physicians and hospitals as they acquire and implement electronic health records systems that meet federal standards.Physicians and hospitals need to have an EHR system in place that meets "meaningful use" standards if they hope to be eligible for the billions in Medicare and Medicaid bonuses available starting in 2011 through the economic stimulus package adopted earlier this year. The grants announced Aug. 20 by the Dept. of Health and Human Services and Vice President Joe Biden are designed to provide a supportive framework to help entities meet those standards, which will be proposed before the end of the year. David Blumenthal, MD, the national health information technology coordinator, said the new money is intended to help create a national, private and secure EHR system. "The grants are designed to help doctors and hospitals acquire electronic health records and use them in meaningful ways to improve the health of patients and reduce waste and inefficiency," he said. "They will also help states lead the way in creating the infrastructure for health information exchange, which enables information to follow patients within and across communities, wherever the information is needed to help doctors and patients make the best decisions about medical care." Helping small practices Under the first of the two new grant programs, nearly $600 million will be used to establish approximately 70 health IT regional extension centers. The entities will offer technical assistance, guidance and information on best practices to help physicians and hospitals more quickly become meaningful EHR users. The regional centers will focus on helping primary care clinicians, with a particular emphasis on individual and small-group practices. Clinicians in such practices deliver the majority of primary care services but have the lowest rates of EHR adoption, and the least access to resources to help implement and use such systems, according to HHS. "Expanding the use of electronic health records is fundamental to reforming our health care system," said HHS Secretary Kathleen Sebelius. "Electronic health records can help reduce medical errors, make health care more efficient and improve the quality of medical care for all Americans." The performance of each regional center will be evaluated every two years by an HHS-appointed panel of experts. EHR industry observers are encouraged by the centers, which they say will help physicians and hospitals select certified paperless records systems that offer the best value for their needs. "That guidance definitely needs to be there, because most providers are struggling with what they need to do, and how to do it," said Bruce Taffel, MD, vice president and chief medical officer for SharedHealth, a vendor of health information products and solutions based in Chattanooga, Tenn. "I think these extension centers will be a helpful piece of this." The regional extension center grants will be awarded on a rolling basis, with the first awards issued in fiscal 2010, HHS said. Focus on interoperability The second grant program will provide more than $560 million to states starting next fiscal year through cooperative agreements to create a widespread and sustainable health information exchange. Legal, financial and technical support is necessary to enable secure exchange of sensitive patient data across health care systems, according to HHS. The program will help fund efforts at the state level to implement directories and technical services to enable interoperability within and across states. Some health IT experts say such assistance is vital in helping physician practices become meaningful users. "I think this has tremendous potential to help improve the health IT infrastructure of the country," said Marc Probst, chief information officer with Intermountain Healthcare, a nonprofit system of hospitals and clinics based in Salt Lake City. "A large concern is clearly the ability for people who don't have technical expertise to implement these systems," said Probst, who also is a member of the Health Information Technology Policy Committee, an advisory board established this year that makes recommendations to Dr. Blumenthal and his staff. "In just about every interview I've had with doctors, physician groups and even hospital chains, the ability to exchange data between systems was high on everyone's list." Probst said he's very concerned about physician groups and hospitals who may not have the resources to implement an EHR that meets meaningful use standards, though he believes the policy committee's recommendations approved by Dr. Blumenthal earlier in August will be very close to what the Obama administration proposes in regulation later this year. Dr. Blumenthal said more announcements will be made within months regarding additional grant programs to assist with EHR implementation. - American Medical News Medicare pay for services by nonphysicians comes under scrutiny September 02, 2009 Medicare is paying millions of dollars for claims on services that are performed by nonphysicians who are not properly trained or qualified, according to a report released Aug. 5 by Dept. of Health and Human Services investigators.The HHS Office of Inspector General examined Medicare Part B data for the first quarter of 2007 to determine how often the program paid for services billed by physicians but performed by nonphysicians, through a provision known as "incident to" services. Under this rule, physicians are allowed to bill for a treatment performed by a nonphysician, as long as that worker has the appropriate training, certification and licensure. Physician assistants, nurses, medical technicians and medical assistants are included in the nonphysician category. For this study, OIG only looked at cases where a physician used the "incident to" rule to bill more than 24 hours worth of services in a single day. Nonphysicians who were not appropriately qualified performed 21% of the services that physicians billed but did not perform personally, OIG found. Medicare paid $12.6 million for approximately 210,000 of these inappropriate services during the first three months of 2007. These nonphysicians did not possess the necessary licenses or certifications, had no verifiable credentials, or lacked the training to perform the service, the agency said. OIG also found that nonphysicians with inappropriate qualifications performed 7% of invasive services billed by physicians who did not perform them. The "incident to" rule is a useful tool for busy physicians and "a billing mechanism that is widely used," said Abby Pendleton, a partner with Health Law Partners in Southfield, Mich. But it could place patients at risk for receiving care from someone who is not qualified. Billing for nonphysician-provided services at the full physician fee schedule amount is allowed if those services are directly supervised by a physician. This means that the doctor must be present in the office suite and available to provide assistance, though it does not always mean he or she must be present in the room while the procedure is being performed. The Medicare fee schedule often prompts physicians to bill under their own name rather than having a nonphysician bill for a service, Pendleton said. "They try to accomplish 'incident to' billing if they can because of the additional revenue." American Medical Association policy supports Medicare payment to physicians for all services provided by supervised physician assistants and nurse practitioners, in accordance with applicable state laws. AMA policy adds that "the ultimate responsibility for these services rests with the physician." For physicians who billed more than 24 hours of services in a day, half of the procedures billed were not personally performed by the physician, OIG discovered. During the three-month period in 2007, Medicare paid $105 million for approximately 934,000 services that physicians personally performed, and about $85 million for 990,000 services that nonphysicians conducted. Nonphysicians performed almost two-thirds of the invasive treatments that physicians billed to Medicare. Although OIG's sample represents a small percentage of physicians -- 3,165 of the 805,401 physicians who billed Medicare in the first three months of 2007 -- the agency said it is concerned about the potential widespread scale of the practice. "Services performed by unqualified nonphysicians represent a risk to Medicare beneficiaries," OIG wrote. Suggestions for CMS The physical therapy industry also expressed concern about how big the "incident to" problem might be. OIG reported that nearly half of all rehabilitation therapy services it surveyed was performed by unqualified therapists. The American Physical Therapy Assn. said it is alarmed by the findings. "To ensure high-quality care, physical therapy services should be furnished by licensed physical therapists and physical therapist assistants under the direction and supervision of a physical therapist," said R. Scott Ward, PhD, APTA president and a PT in Salt Lake City. Because the problem might be more widespread, OIG made three recommendations to the Centers for Medicare & Medicaid Services. The advice includes changing the "incident to" rule to ensure that when physicians do not personally perform services for which they are billing Medicare, those services must be performed by another licensed physician or a nonphysician with the appropriate training. CMS agreed with this recommendation, saying in a response letter to OIG that it is "currently in the process of clarifying the manual policies." The Medicare agency did not agree, however, with an OIG recommendation that physicians who bill for services they did not perform should use a code modifier on Medicare claims. While it did not object to the underlying objective, CMS cited the difficulty of crafting a definition of what is "personally performed," because incidental services often are shared by physicians and staff. - American Medical News Half of large practices net bonuses from Medicare P4P demo September 02, 2009 The Obama White House has indicated it will continue the move toward more pay-for-performance in Medicare, despite mixed results for physicians in the P4P demonstrations it inherited from the previous administration.On Aug. 17, the Centers for Medicare & Medicaid Services disclosed findings from three ongoing programs -- including first-year results from a small-practice demonstration -- and announced the start of three new value-based purchasing demonstrations. Third-year results were revealed for the Physician Group Practice Demonstration, which is in its fifth year of operation and is slated to end March 31, 2010. Although CMS has extended the demonstration twice beyond its initial three-year limit, the agency said it does not anticipate extending the program again. All 10 of the large physician groups participating in the program achieved benchmark performances on at least 28 of 32 quality-of-care measures, which cover diabetes, congestive heart failure, coronary artery disease, hypertension and cancer screening. Groups can receive up to 80% of the savings they generate for Medicare by reducing medical complications and hospitalizations. But only five groups in the third year received performance bonuses, totaling $25.3 million. One group that achieved benchmark performances on all 32 measures -- Park Nicollet Health Services in St. Louis Park, Minn. -- did not receive a bonus. Four of the 10 groups that participated have not yet received a bonus despite the investments they made in quality improvement. Forsyth Medical Center in Winston-Salem, N.C., is one of them. "We were disappointed with that, of course, because that would have helped us offset the cost of some of the programs that we created," said Nan Holland, RN, MPH. She is senior director of clinical services with Novant Medical Group, which manages Forsyth Medical Center. Holland said the program's weakness lies with its so-called efficiency component. CMS initially had stated that the 10 physician groups could share in any savings generated. But after having already recruited the groups for the program, the agency altered the requirements. Under the revised rules, a practice would receive a payout only if savings on care for Medicare enrollees exceeded 2% in a given year, against a specified baseline. "We're compared to other systems of organized care in the Minneapolis area, of which there are very good systems," said David Wessner, CEO of Park Nicollet Health Services, explaining why his group did not exceed the 2% threshold. CMS changed the requirements before it launched the physician group practice program because it wanted to make sure that any Medicare savings came from the groups' direct participation in the demonstration and not from unrelated fluctuations, said John Pilotte, director of the division of payment policy demonstrations at CMS. That also was requested by the Office of Management and Budget under the Bush administration. The upside of P4P The late change by CMS initially caused some of the groups to question their involvement. "We all had second thoughts," said James Rogers, MD. "It gave us all concern about how stable the project is." Dr. Rogers is medical director for the demonstration project and department chair for primary care at St. John's Health System in Springfield, Mo., which earned a bonus of about $3.1 million in the third year of the project. But the groups felt assured about moving forward after meeting with CMS and airing their concerns, Dr. Rogers said. Some of the groups were able to build up some capital even after accounting for expenditures for quality improvement. "We've had to invest in modest training and data reporting, but not to the extent that it would completely wipe out the bonus," said Barbara Walters, DO, senior medical director with the Dartmouth-Hitchcock Medical Center in Lebanon, N.H. The medical center earned a bonus of $3.6 million for year three. Dr. Walters said one of the best aspects of the program has been connecting with the other nine groups to share best practices. "It's been an excellent experience," she said. "Most of us have been able to achieve the benchmarks and have at least met or exceeded targets. Every year, more of the groups have been able to demonstrate the ability to get quality care and bonus payouts." Even practices that have not done well enough to pull down bonuses have found value in the project. "I think the organization got a lot of out of the programs we created that we think will extend well beyond the demonstration project," Forsyth Medical Center's Holland said. New P4P programs So far, performance bonuses have flowed only to large groups and hospitals, but that changed this year. CMS announced first-year results for the Medicare Care Management Performance Demonstration, now in its third year of operation. Almost all of the 610 participating small and solo physician practices are being paid a total of $7.5 million for meeting quality standards through the use of health information technology. The average payment per practice was $14,000, and some practices earned as much as $62,500. The goal of the small-practice program is to promote the use of health IT to improve the quality of care for beneficiaries with chronic conditions, CMS said. Doctors who meet clinical performance standards are eligible to receive financial rewards. In addition, the demonstration provides a bonus to practices that use a certified electronic health record. Twenty-three percent of practices were able to submit at least some of the measures from a certified EHR, CMS reported. Hospitals in the Hospital Quality Incentive Demonstration raised their overall quality scores in five clinical areas by an average of 17.2% over four years. CMS also announced on Aug. 17 the start of three additional Medicare value-based purchasing demonstrations. The agency will oversee two programs to evaluate the concept of gainsharing between hospitals and physicians. Another demonstration will determine if financial incentives can improve the quality of nursing home care. "What we learn from the various Medicare demonstrations help to achieve the administration's goals of paying for high quality and efficient health care in America," said Jonathan Blum, director of CMS' Center for Medicare Management and acting director of the Center for Health Plan Choices. "Building on these findings, we will aggressively test new demonstration concepts to continue to meet these goals." - American Medical News County's mental-health system failing September 02, 2009 Dennis Winters sits in his apartment clutching a teddy bear, something a psychiatrist gave him years ago to make him feel less lonely.Decades of punishing mental illness have often left Winters feeling lonely. Most days he watches television into the night and scribbles his thoughts into notebooks. "I'm just hanging on by a thread," he said. Arizona taxpayers spent $360 million this year to help Maricopa County residents like Winters. But a nearly 30-year-old lawsuit, billions of dollars spent and a series of bureaucratic transformations haven't changed a basic fact: Most of the county's 23,000 patients with serious mental illness aren't getting better. The number of seriously mentally ill people in Maricopa County has exploded in recent years, growing by 94 percent since 2000. It will grow another 45 percent by 2015, according to state estimates. There are few widely accepted national standards for mental-health care, making it difficult to compare the performance of states or even counties within Arizona. Different systems track data in a variety of ways. But by the standards it has set for itself, Maricopa County's system has declined. The annual state audit of the system's performance that was released this year found it fails nearly all of its patients on key measures: placing them in stable housing and providing them with a job or other meaningful activity. Among those who have not been in jail or hospitalized for their illness, the system failed 86 percent. Among those who have, it failed 83 percent. Interviews with patients, providers, state officials and company executives reveal instability at every level of the system. Despite multiple calls from consultants to do so, service providers do not track whether individual patients are getting better. The results are deadly: Nationally, the life expectancy of a mentally ill person is 25 years shorter than that of a healthy person. In Maricopa County, their life expectancy is 32 years shorter. Without a place to live, a job or supportive friends and family, the county's mentally ill often wind up homeless or in jail. Winters is 58. He once had a good job and close friends. But after more than three decades in the system, he now holes up in a subsidized apartment, hanging on to his ragged plush toys. "It's like knowing that this teddy bear is going to love me no matter what," he said. "The worst thing is being alone, and having the risk of that part of me that just wants to give up. Holding on the idea that there's a way out keeps us alive." Substantial declines Modern mental-health care starts with the presumption that anyone with a serious mental illness can recover, though some will recover better than others. Most private insurance policies offer limited benefits for mental health, so people who have serious mental illnesses in Maricopa County are likely to wind up in the public system. The system consists of several layers. At the top is the Department of Health Services, which is responsible for providing care to Arizonans with mental illness. Since the 1990s, DHS has subcontracted the job to the private sector by creating regional behavioral-health authorities. Two years ago, the state replaced the company that served Maricopa County, ValueOptions, amid widespread dissatisfaction with the quality of care. Magellan Health Services, a for-profit company based in Connecticut, received the three-year contract to run the system, which also includes patients with more moderate metal illness, children and people in treatment for substance abuse. At $1.5 billion, it is the largest mental-health care contract in America. Magellan pledged to transform the system. Where ValueOptions had owned the county's clinics itself, Magellan pledged to spin them off into independent networks of providers, giving patients more choices and clinics more control. Magellan said the move would improve the quality of care. But the changes brought even more instability. Instead of improving under Magellan, according to the most recent audit, patient care has gotten worse. The declines are substantial and occur in every aspect of care. • Patients don't have adequate teams of doctors, psychiatrists and counselors. • Treatment plans, considered the foundation of a successful recovery, are incomplete and often changed without patients' knowledge or input. • Patients are overseen by case managers whose patient loads can exceed the national standard of 30 cases by 60 percent or more. Magellan officials acknowledge the need to improve the quality of care on a variety of measures. But they also say the findings do not reflect substantial gains made since late last year, when the audit was conducted. More than half of the audit's quality indicators have no bearing on whether a patient's condition improves, officials said. Other indicators, such as clinic staffing levels, have improved. "The system is not in crisis. The system is in transformation," said Dr. Richard Clarke, CEO of Magellan of Arizona. Magellan has planned several new initiatives to improve performance. Clarke's team is working with the state to post clinic performance data online for public viewing, encouraging better results through competition. Case managers will receive better training on suicide prevention. And patients with multiple recent hospitalizations are beginning to get extra attention from Magellan staff. Eventually, Clarke said, the system will develop tools to track whether patients are improving - if Magellan remains in place. A 20-year nightmare In 1990, Tempe native Deborah Ferry watched her first husband pick up a gun and take his life. That's when the nightmares started. About once a week, Ferry dreams she is standing over his body, scrubbing blood off the walls of their Sacramento home. The blood won't wash off. There's just too much. Ferry moved to Nebraska after her husband's death. Desperate and grief-stricken, she spent time in a state mental hospital. Eventually she recovered enough to live on her own. She married Roy Ferry, and they moved to Arizona to be closer to her family. When Magellan took over the Maricopa County system, Ferry decided to enroll. She hoped to find a stable provider that would help her receive counseling for post-traumatic stress. Instead, Ferry has had six psychiatrists and eight case managers in the past two years. "I don't even know who the current person is," Ferry said. "They were supposed to call this morning, but they never did. That's par for the course." Even before her first husband's death, Ferry struggled with schizoaffective disorder, a broad diagnosis that for Ferry means bouts of severe depression and obsessive-compulsive behavior. She also hears voices. Ferry hoped to recover under Magellan. Instead, she has been fighting the bureaucracy. Last year, she was running out of medications when her private psychiatrist announced he would no longer accept Medicare. Ferry called Magellan to see if they could see her in two to three weeks. They said they could see her in three months. Ferry borrows money from her 83-year-old mother to help pay for private therapy. She is entitled to subsidized therapy, but case managers haven't stayed with her long enough to get it for her. They rarely do. Last year, 71 percent of patients changed case managers. Burnout is often cited as a reason for the rampant turnover. The heavy load means case managers respond to patients' needs in a timely manner only 40 percent of the time, down from 59 percent before Magellan took over, according to the audit. High turnover also results from case managers changing clinics, getting promoted or moving out of state. For patients, the result is always the same: a new case manager, three or four times a year, who knows nothing about their case beyond what they have read in medical records. In constant flux The instability that Ferry feels day to day begins at the highest levels of the mental-health system, where tumultuous change has been the norm for 20 years. In 1989, the Arizona Supreme Court agreed with the plaintiffs in Arnold vs. Sarn. The lawsuit alleged that Arizona failed to provide Maricopa County with comprehensive health care for those with serious mental illnesses as required by state law. Two years later, the state launched the first of many plans to resolve the lawsuit. The first Maricopa County service provider, non-profit ComCare, filed for bankruptcy in 1997, forcing the state to briefly take over. ValueOptions won the contract in 1998, and held it for nine years. Magellan has had the contract for two years. Now plaintiffs in Arnold vs. Sarn want the state to drop Magellan and have the Department of Health Services oversee clinics directly. Constant change isn't limited to the big vendors. Since 1993, nine different people have led DHS. The most recent, Will Humble, was named interim director in January. Seven different people have led the DHS behavioral-health division in that time. Dr. Laura Nelson took the job in April 2008. Nelson acknowledged the high turnover at her agency. "It's a constant struggle, especially under the budget conditions we're in, to hold on to good staff," she said. The instability trickles back down to patients, with each new director, agency head and contract provider bringing changes to policies and procedures. As a result, the services patients receive are frequently changed or even eliminated without their knowledge. A steady hand People with mental illnesses can recover. Stable care is usually a key to successful treatment. Amy Sather, 35, endured an abusive childhood that left her in foster care and group homes from the age of 13. At 19, she was pregnant, on food stamps and suffering the effects of bipolar disorder. Later, she lost custody of her daughter and became homeless. But over a period of years, Sather received treatment from Maricopa County's public mental-health system that made a significant difference. A caseworker helped her get subsidized housing. Counselors helped her control the symptoms of her disease. She eventually regained custody of her daughter, got a job working as a peer mentor for other people with mental illnesses and earned her bachelor's degree in social work. Today she is happily married, lives in a five-bedroom house in south Phoenix and works for the Department of Behavioral Health Services as a liaison between the state and individuals and families with mental illnesses. Sather faced the same turnover that plagues most patients. But she found a rare point of stability in the system: She saw the same nurse practitioner for more than 10 years. The practitioner prescribed medicines and helped Sather put her life back together. "She supported me," Sather said. Sather knew how to navigate the system better than most, having worked as a case manager for ValueOptions before becoming a peer mentor. She also benefited from a strong ethic and a desire to provide a better life for her daughter, Hayley. "Every morning she'd wake up and go to work, no matter what had happened the night before," said Hayley, 15. "Paint that smile on and keep on trucking." Still, Sather says, consistent care provided a foundation for her to recover. "I got lucky," she said. Not paying attention Despite the hundreds of millions of dollars spent, at no level does the system track whether individual patients are improving. A patient like Dennis Winters can languish in the system for 30 years, gradually declining, and no one beyond the latest manager of his current clinic will ever know. "They spiral down in their crisis to the point where once they're finally served and treated appropriately, they've lost so much ground," said Anne Ronan, longtime lawyer for the plaintiffs in Arnold vs. Sarn. "They're out of school. They've lost their job. And if someone had just responded appropriately when the obvious signs were there, they would be back on their feet." Delayed treatment can result in trips to urgent-care facilities or even hospitalizations, which cost far more than clinical services. The primary measure of the system's performance comes from the Office of the Court Monitor, a taxpayer-funded branch of state government established to monitor Maricopa County's compliance with Arnold vs. Sarn. The court monitor audits a sample of individuals each year, asking hundreds of questions about their care. State officials and various service providers have recognized the need for improvements but downplay the audit's findings. They say it's based on an old model of treatment, and makes unreasonable demands of providers. Still, the audit was developed with the state's input. And state officials agreed that audit findings would be binding. Between annual audits, DHS receives dozens of weekly and monthly reports from Magellan about the system's performance. But the data is largely self-reported, and its reliability has been questioned. Magellan is now working with the state to put together a "dashboard" that lets executives see, at a glance, how various clinics perform on a variety of measures. In the near future, Clarke said, those results will be available for all to see online. Humble said the dashboards mark the beginning of a more accountable system. "That could be used to spur competition, but also to hold (providers) accountable for the services that they're providing and the money they're getting," he said. A steady decline Before he relied on teddy bears for companionship, Dennis Winters was a hairdresser known for his quick wit and mordant sense of humor. He worked at upscale salons in Scottsdale and had plenty of friends. "He was very outgoing," said Anna Kashey, a fellow hairdresser who met Winters in 1992. "He was very nice, very warm." Winters has always struggled with depression and a mood disorder and entered the system more than 30 years ago after suffering symptoms of depression. When his mother became ill in the mid-1990s, he quit working to take care of her. She died shortly thereafter, and Winters' mental health started to decline. For two years, Winters says, he lived in a house with no electricity or water. Eventually he became homeless, staying at the YMCA and at shelters. Through it all, he continued to receive care through the county mental-health system. Medical records from earlier this decade list Winters' goals: reclaim his beauty license, buy a house, get into a relationship. Instead, he declined. Winters had frequent disagreements with doctors and case managers over the quality of his treatment. Records show several therapists became frustrated with Winters' windy, tangential mode of speaking and his frequent complaints about the quality of care he received. So they quit being involved in his treatment. "Due to the level of conflict that keeps occurring which interferes with therapeutic progress," one therapist wrote, "I must remove myself from your case." When ValueOptions was treating Winters, his clinical team at the time gave him a progress report on his goals. It was blank. Today, Winters says he wants treatment from a center that specializes in dissociative identity disorder. After his mother's death, he lost track of time and sometimes re-emerged with a different personality. Winters' clinical team, he says, has failed to help him recover. "More and more," he said, "I feel like the chances of me ever leading a normal life are zero." The money factor Given the county's rapid growth of the seriously mentally ill population, state officials say they don't have the resources they need to provide adequate care. In 1995, the state formally agreed to provide a wide variety of services to the mentally ill as required by the Arnold vs. Sarn lawsuit. Three years later, a review found that it would cost more than three and a half times as much as the state was then spending to meet those obligations. Instead, the system's budget has been cut. In the most recent fiscal year, Magellan's contract was reduced by about $10 million. DHS has absorbed $55 million in cuts in the past two years and faces additional cuts this year. Chris Heller, a former director of a clinic in Maricopa County, said the state has asked too much of Magellan and its predecessors. "They dangle a billion and a half dollars out there and one of those companies comes along and bites, because they're going to try to make it work," Heller said. "And they get in here and they realize it's a lot of money, but it's not nearly what it takes. It's not all the vendor. The state is cutting an unrealistic deal." Progress report Maricopa County Superior Court Judge Karen O'Connor has asked the state to prepare a progress report. A status conference in the Arnold vs. Sarn case is scheduled for Sept. 17. For all its faults, Amy Sather said, the system can help people get better. "I meet people every day where they're having successes in their life because opportunities and services were in place to serve as stepping stones to getting where they are today," she said. Dennis Winters isn't so sure. "If I stay here, I'll die," he said. "This state is going to kill me." - Arizona Republic Some states still prohibit hospitals from hiring doctors; physicians want to keep it that way August 19, 2009 Medical associations in California and Texas have been battling legislation that would allow rural hospitals to directly hire doctors -- a move some physicians say threatens to undermine their independent medical judgment and hinder patient care.Most states allow for direct hospital employment of physicians -- a growing trend in recent years as doctors increasingly seek more financial stability. California and Texas, however, are among only a handful of states that generally prohibit hospitals from employing doctors, under long-standing laws aimed at preventing corporate interference with the practice of medicine. Hospitals have sought the right to hire doctors in the Golden and Lone Star states, saying the changes are necessary to recruit doctors to underserved areas. The California and Texas medical associations don't dispute the need to address shortages. But they say there are other ways to recruit doctors without thwarting medical independence, such as reducing medical student debt and increasing residency slots. The employment legislation proposed in California would do nothing to alleviate physician shortages, said Brett Michelin, California Medical Assn. associate director of government affairs. "It just changes the economics." Instead, doctors on a hospital's payroll would be subject to administrators' rules on admissions, tests and referrals, rather than being free to make decisions based on patients' needs, he said. "Physicians' sole interest is ethically to their patients. They don't have a legal duty to make the hospital money, and that's what we want to avoid," Michelin said. If hired doctors are required to perform certain procedures at their respective hospitals, outside competition and patient choice may suffer, he added. And without adequate protections, hospitals may unfairly terminate nonemployed physicians' privileges to push a hired arrangement. The CMA successfully lobbied for provisions that would prevent privileged doctors from being supplanted under a bill to create a pilot project allowing certain rural hospitals to hire up to five physicians for 10 years. But the CMA remains opposed to the overall measure, which cleared a state Assembly committee in July after passing the Senate a month earlier. Two other bills would have annulled the ban and allowed various rural hospitals to hire physicians and surgeons, but those measures failed. In Texas, a hospital employment measure was defeated because it would have undermined the state's 2003 liability reforms, according to Gov. Rick Perry's veto of the bill in June. The legislation would have permitted publicly run hospitals in counties with fewer than 50,000 residents to hire physicians. An undebated, last-minute amendment, however, threatened to increase those doctors' liability risks beyond the state's damage caps. While generally opposed to the bill, the Texas Medical Assn. successfully lobbied for protections of employed doctors' clinical independence, as well as for due process safeguards for hired and nonhired physicians. Concerns lingered that broad language in the bill would allow hospitals to justify employment beyond underserved areas. The CMA expressed similar apprehension to the proposal in its state. Roughly 80% of Texas counties have fewer than 50,000 residents, said Dan K. McCoy, MD, chair of the TMA's legislation council. "We recognize that rural Texas is really hurting. But putting corporations in control of the doctor-patient relationship is not the right answer," he said. "The local community's medical staff should be involved in determining whether there's actually a need for this." But hospitals in Texas continue to lose physicians, particularly younger ones, to surrounding states that allow employment relationships, said Jennifer Banda, Texas Hospital Assn. senior director of government affairs. Because rural areas have fewer physicians, it's often difficult for them to meet the requirements to contract as a group. Exceptions to the California and Texas bans allow teaching hospitals and federally qualified health centers to hire doctors. Physician groups also may contract with hospitals for services in quasi-employment arrangements. The difference, said Dr. McCoy, is "doctors are still in control and there's a separation of that corporate power." Issues include patient access to care Hospitals and some physicians say allowing direct hospital employment not only would ease strains on access to care, it also would help relieve doctors of some of the financial and administrative burdens that keep them from focusing on patient care. California Hospital Assn. spokeswoman Jan Emerson called California's prohibition outdated. The proposed changes don't "force doctors to do anything. This just gives them an option if they want to have a sustainable income, pay their debt, have their medical malpractice insurance covered and not deal with insurance company billings." Emerson added that competition in rural areas is virtually nonexistent. "This is about access to care." California hematologist and oncologist John Rochat, MD, runs his clinic out of Mendocino Coast District Hospital, where he was hired under a smaller pilot project launched in 2003. Working for the hospital is the only way he can afford to stock the chemotherapy drugs his clinic patients need, as well as pay for his own family's health insurance coverage. He dismissed the notion his administrators dictate how he practices. If the proposed legislation fails, he will be out of a job next year, and the small rural hospital in northern California will lose its only cancer specialist. "I would have to send patients hours away, they would have to stay in a hotel overnight, and [their] drivers not going to work that day. So the cost of that health care is phenomenal," Dr. Rochat said. Financial pressures continue to drive more doctors to opt for hospital employment, said Medical Group Management Assn. President and CEO William F. Jessee, MD. But many still choose urban or suburban areas over rural regions. Elizabeth A. Snelson, a Minnesota-based lawyer who represents medical staffs around the country, said hospital employment continues to affect the role and dynamic of the medical staff. "There is a legitimate concern over the amount of influence the hospital can have over physicians, not just in the direct practice of medicine, but in the decision-making of the medical staff organization," she said. Staff bylaws should ensure that such authority is not limited to hospital employees and that hired doctors can exercise their votes without fear of getting fired, she said. James Bentley, a senior vice president at the American Hospital Assn., said employment contracts help clearly define both the hospital's and physician's goals and expectations. He acknowledged that "no matter what the arrangement, getting physicians and hospitals to work together can create tension. But clearly, we are all being pushed to be more efficient and more effective, and that collaboration, sometimes to the point of employment, is changing relationships." - American Medical News Senate health reformers work toward consensus bill during break August 19, 2009 As Congress broke for its August recess, a bipartisan group of six key Senate Finance Committee members were unable to hammer out a consensus health system reform proposal, despite some intense last-minute discussions and face time with President Obama.That leaves the Senate with just half of a comprehensive bill and breaks the Democratic leadership's original deadline for holding a floor vote on a measure. The Health, Education, Labor and Pensions Committee approved its version of a reform measure July 15 by a party-line vote, and leaders initially hoped to marry that bill with a bipartisan Finance product before the recess. But that doesn't mean the work stops until lawmakers return. "Senators have arranged to continue talking, and staff will continue their hard work," said Jennifer Donohue, a Finance Committee majority aide. "They will spend valuable time in their home states, listening to and learning from their constituents." Health policy experts said the core group of Finance members negotiating a potential consensus bill have their work cut out for them during the break and when they return. Some observers predicted that an agreement by the committee might not come until the end of the year. "Senate Democrats will have a difficult time this August as they return to their districts and work to convince their constituents to buy into the president's ambitious health reform agenda," said Erica Suares, Senate relations deputy director at the Heritage Foundation, a conservative think tank based in Washington, D.C. A lack of agreement on key reform issues keeps forcing Democratic leaders to push back their deadlines. When it became clear that the Senate would recess without the committee producing a bill, Finance Chair Max Baucus (D, Mont.) suggested a new deadline of Sept. 15 for agreeing on a proposal for committee consideration. But the mention of a new deadline received a cool reception from Republicans, who insisted that Congress cannot rush such a major undertaking. "I have not and will not agree to an artificial deadline, because I am committed to getting health care reform right, not finishing a bill by some arbitrary date," said Sen. Mike Enzi (R, Wyo.). Baucus and Enzi are two of the "gang of six" committee members who are working toward a bipartisan agreement. The other members of the group are the panel's ranking Republican, Charles Grassley (Iowa), and Sens. Olympia Snowe (R, Maine), Jeff Bingaman (D, N.M.) and Kent Conrad (D, N.D.). Members from both sides of the aisle report progress in their talks, but they acknowledge several major sticking points remain. Most Republicans, for example, are strongly opposed to a public insurance plan option. As a result, centrist Democrats have proposed replacing that option with private, consumer-owned insurance cooperatives. Both a public plan and co-ops are part of the HELP committee's bill. Other key issues Finance is debating include how to structure a Medicaid expansion, what level of savings to squeeze from Medicare and how to use tax provisions to raise revenue. The six senators had an opportunity to update President Obama on all of the outstanding issues during an Aug. 6 meeting at the White House just before the recess. While no agreements were reached at the meeting, congressional aides described it as a helpful listening session with the president in which he encouraged them to continue their efforts. A long haul Some observers said it was not a surprise that the gang of six was unable to cobble together an agreement before the August recess given the complexity of the unresolved issues. The Heritage Foundation's Suares said not having a bill introduced before the break will be a mixed bag for Democrats. "It is politically smart to not have a bill hanging out over the August recess for people to rip apart," she said. "In other ways, the public will think it weak that there is no product for them to see." Lawmakers may have more to discuss once they hear from the people they represent back home. Some town-hall meetings and other lawmaker events held early in the recess were disrupted by protesters opposing congressional reform plans. "I think you can say this is not a typical August," said Craig Orfield, minority communications director for the HELP committee, of which Enzi is the ranking member. Enzi is "always busy when he goes home, but he expects health care to be a top item on the agenda this time. There are a lot of concerns and comments coming from constituents." A quick turnaround by the Finance panel in the fall is looking unlikely, said Joseph Antos, a health care scholar at the conservative American Enterprise Institute in Washington, D.C. "Unless there is a real breakthrough in August, I can't see Finance coming back and washing away all of the problems right away. My guess is Sept. 15 will come and go." Antos said November is a more realistic target for Finance to unveil a consensus proposal, though it is "more likely to slide into December." The partisan way If Senate leaders decide that the gang of six cannot come to a bipartisan agreement fast enough, they may choose to pursue a Democratic bill and seek the 60 votes necessary to end debate on the legislation. If that is not possible, Senate Majority Leader Harry Reid (D, Nev.) might opt to use a controversial parliamentary tactic known as budget reconciliation to force a measure through with only 51 votes. Such a tactic is likely if Democrats decide to take the partisan route, Suares said. "Generally, people do not think Reid would have 60 votes for a more radical health reform bill to pass in the Senate." Republicans have been adamant in saying that the use of reconciliation would be the nuclear option for health reform, blasting a huge rift between the parties and exposing the Democrats to potentially disastrous political consequences. "It'll be a lost opportunity if Democratic leaders in Congress and the administration force action on health care legislation that's not ready because of the complexity of the issues and the high stakes in getting it right," Grassley said. "The public doesn't want a government takeover of the health care system, and we're working to stop it." Enzi insisted he "won't be moved by partisan threats to misuse the budget reconciliation process." At least for the time being, Baucus has dismissed talk of the Democrats going it alone and says he is committed to working closely with Grassley to ensure a bipartisan result. - American Medical News Chaotic working conditions wear down primary care physicians August 19, 2009 A chaotic work environment -- with insufficient time for proper patient care and lack of control over work -- takes a toll on primary care physicians.More than half of these physicians feel time pressure during office visits, while 48% said their work pace is chaotic and 78% said they have little control over their work. The analysis of 422 family physicians and general internists in 119 clinics was reported in the July 7 Annals of Internal Medicine (www.annals.org/cgi/content/abstract/151/1/28). These conditions were strongly associated with low physician satisfaction, high stress, burnout and intent to leave, the study's researchers said. Health system reform efforts to provide coverage to the uninsured make it especially important to attract and retain primary care physicians, say researchers and health policy experts. "A major issue in health reform is who is going to care for those [47] million uninsured people, so recruitment and retention in primary care is a major issue for the country," said study lead author Mark Linzer, MD, professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison. Working conditions speak volumes An annual Assn. of American Medical Colleges survey of graduating medical students found that the biggest factor in selecting a specialty is how well it matches student expectations of a satisfying career. "It's not just that primary care pays less, but it's also the fact that people don't like what they see when it comes to the daily practice of primary care right now," said Atul Grover, MD, PhD, chief advocacy officer of the AAMC. Students notice when teaching hospitals invest in facilities for lucrative specialties but not for primary care, according to a perspective written by Robert Steinbrook, MD, in the June 25 New England Journal of Medicine (content.nejm.org/cgi/content/full/360/26/2696/). "During specialty rotations, students may observe well-managed offices with spacious modern facilities, in contrast to crowded older primary care clinics with harried physicians," he wrote. The Annals study offers some solutions to easing a stressful work environment, including eliminating chaos and disorganization in the workplace, said co-author Linda Manwell, an epidemiologist at the University of Wisconsin medical school. Fixing the system won't be easy, but it is doable, Dr. Linzer said. - American Medical News Practices see slow progress in instant claims adjudication August 19, 2009 Real-time adjudication, which allows a claim to be submitted to an insurer and settled before a patient leaves the office, seems like something physicians, patients and insurers can support.Physicians who use it can shorten the revenue cycle and reduce bad debt. Patients like it because they don't get a surprise bill weeks after receiving care. Even insurers like it, because administrative costs of billing and handling inquiries about claims are reduced. But real-time claims adjudication has barely made an impact. By at least one insurer's reading, fewer than 2% of claims are settled this way. While real-time claims adjudication sounds simple, implementing it can be complicated and can require a physician's office to change how it handles billing and collections. Those submitting claims for real-time adjudication find that in almost half the cases, the claim cannot be processed immediately and is handled later by the insurer. Although this might not require additional work for office staff, the low yield is a factor discouraging physicians from participating. Meanwhile, without a standard adjudication system, physicians may have to customize their processes for each different insurer. "We're all sort of running into the same challenges," said Paul Kulpa, senior program manager of consumer-directed health plans for BlueCross BlueShield of Tennessee. Kulpa spoke at Healthcare Payments Solutions Expo 2009 in Chicago July 29-30. The conference examined ways to reduce money spent on the patient billing and payment cycle, which is believed to account for approximately 5% of all health care system costs. Real-time claims adjudication was presented as one possible solution to help cut administrative expenses, but even experts touting it said it is still a long way from common practice. Rates of use Insurance companies are making real-time adjudication possible, primarily in response to demands from employers that increasingly are purchasing high-deductible health plans for their employees. This is viewed as a solution to complaints that the billing associated with these plans is too confusing and leads to patients both under- and overpaying. Physicians who do use real-time claims adjudication appear to like it, said presenters at the conference. For example, a 10-physician practice in Texas participating in UnitedHealthcare's project saved $14,000 in billing costs in a year, said Gregory M. Fisher, UnitedHealthcare's electronic data interchange connectivity director. Another practice reduced accounts receivable by 13% and decreased the average time to collect insurer and patient payments from 45 days to six. According to Kulpa, a physician participating in the Tennessee Blues' program collected, on average, an additional $750 per day. Being able to print out the explanation of benefits on the spot can reassure patients that their payments were appropriate. But only approximately 650 of nearly 14,000 physicians in Tennessee and north Georgia who were signed on with the Tennessee Blues plan were using the insurer's real-time adjudication tools. Less than 1.5% of physicians linked to Humana were taking part in its program. Only 1.7%, about 4 million out of 240 million claims, were submitted to UnitedHealthcare's adjudication system. One barrier to use is how it changes the dynamic of the practice day. "The biggest problem that we have had is changing providers' work flow and adding another step when that patient is standing at the desk ready to leave," Kulpa said. Experts said too few insurers offer real-time claims adjudication to make physicians believe adopting it is essential. More plans need to make this available so it is worth it to a physician to change work flow, said Ken Willman, Humana's director of provider interface. Also, experts said making real-time claims software part of practice management systems would help, but adding it to the more than 1,400 different systems in operation is a slow process. Then there's one other problem: Real-time adjudication doesn't always mean claims are settled on the spot. In the UnitedHealthcare program, only 53.4% of claims submitted this way were processed immediately. This number was as high as 89% for gynecology, compared with 58% for family medicine, a difference experts attribute to the fact that certain specialties have less variance in coding. Claims that cannot be adjudicated immediately for various issues, such as needing clinical review by the insurer or the server timing out, do not have to be resubmitted. Rather, the claim drops to usual processing. But a low rate of success also discourages physicians. "You're not going to have 100% of claims real-time adjudicated, but certain claims are more appropriate," United's Fisher said. "Performance needs to be consistently over 50% to support a change in the work flow." In lieu of real-time claims adjudication, some plans offer tools that estimate a patient's share. Data suggest that these types of tools also lead to an increased chance of patients paying their bills. "The more people know in advance, the higher the likelihood they will pay. It's a very important thing to engage them early," said Bobbi Coluni, director of consumer innovations at information company Thomson Reuters, during her presentation on pre-care cost transparency tools. "Billing is more complex. Consumers and providers are very frustrated with not knowing what the consumers will owe in advance." A patient survey presented at the expo showed that 80% of patients using the Cigna Cost of Care Estimator, built by Thomson Reuters, found the estimates helpful. In addition, 74% said that knowing their financial obligations up front made it more likely they would pay their bills. With estimators, however, the claim is not actually adjudicated. So while patients and practices have an idea of the bill, and payment can be made, the terms can change when the claim is processed. - American Medical News Prescription Drug Sharing Among Teens Widespread August 19, 2009 A new survey reveals that 1 in 5 teenagers shares acne medications, antihistamines, birth control pills, and other prescription drugs, and most do not tell their physician about it.This trend is troubling in terms of its prevalence and because of its potential risks, which include abuse, addiction, antibiotic resistance, and birth defects, Richard Goldsworthy, PhD, director, Research and Development, The Academic Edge, Inc, Bloomington, Indiana, told Medscape Psychiatry. The findings suggest "a clear opportunity" for physicians and other healthcare providers, as a part of standardized care, to simply ask young patients whether they have shared a prescription medicine, said Dr. Goldsworthy, adding that there may be a future need for more a widespread public awareness campaign. The study was published online August 3 in the Journal of Adolescent Health. Allergy, Pain Medicines Top List At malls and parks and on public streets in 11 US urban and suburban centers, researchers interviewed 594 young people aged 12 to 17 years about their prescription drug sharing habits. The results revealed that 22.5% had loaned prescription medications, most commonly allergy medications and pain relievers. Only 47.5% of teens who loaned prescriptions provided printed instructions, and 55.7% offered verbal instructions. Borrowing habits were similar — 1 in 5 had borrowed a prescription medication, with only half receiving written and/or verbal instructions or warnings. The most common reason for borrowing (74%) was to avoid having to make an appointment with a healthcare provider, although 32.4% of these respondents ended up visiting a healthcare provider anyway. The authors point out that putting off seeking medical attention can lead to delayed diagnosis and treatment and potentially increased morbidity and mortality. Some teens reported having their own prescription but borrowed someone else's because they did not have theirs handy, said Dr. Goldsworthy. Another reason they cited, particularly in the case of pain relievers or allergy medications, was that they needed relief right away, he said. "There was an immediate need that they had to address and someone happened to have a medicine [at] hand." Of those teens who did finally seek medical attention, only 59.4% told their physician about sharing a prescription — a finding that suggests that providers need to be more proactive about inquiring about prescription borrowing, said Dr. Goldsworthy. More than one third (37.4%) of teens said they had experienced an allergic reaction or other adverse effect from a borrowed drug. However, the researchers did not ask whether this adverse effect may have been the reason for taking the drug. For example, some teens may have borrowed a pain reliever or a drug intended to treat attention deficit hyperactivity, such as Ritalin, simply to get "high," said Dr. Goldsworthy. "It would have been nice to parse that out, but we didn't have it in this data set." Sharing prescriptions among young people does not appear to be as widespread as in adults. A study Dr. Goldsworthy and his colleagues carried out about a year ago found that 1 in 3 adults reported sharing prescriptions. However, Dr. Goldsworthy suggested that this disparity may be because older people may have more opportunities to share drugs. Medication Labeling This current study arose out of research on labeling on acne medications, some of which carry risks for birth defects, said Dr. Goldsworthy. "We were interested in seeing if kids understood the labeling on some of that packaging, and it turned out they did, but there was no messaging about sharing. Since very little was known about prescription sharing among [teens], we needed to determine how frequently it occurs and what some of the consequences may be." Adding a warning on the label about sharing a drug "makes some sense," but it also might not get noticed, he said. "We have these ubiquitous messages that go on almost every prescription drug — things like 'take with food and water,' 'consult your doctor or pharmacist,' and 'do not take if pregnant' — so it may end up being visual noise to add 'do not share or borrow or loan' this medicine." For some medicines, sharing is a clear risk. Dr. Goldsworthy used the hypothetical example of a teen who borrows a friend's leftover antibiotic to treat a urinary tract infection. Her symptoms disappear and she resumes sexual relations with her boyfriend, only to learn that what she thought was a urinary tract infection was actually herpes when it recurs a year later. She not only delayed her own treatment but may very well have exposed others before being correctly diagnosed, he said. Sharing antibiotics can also contribute to the problem of resistance, as neither the borrower nor the lender is likely to have taken the entire course, said Dr. Goldsworthy. "If you take a partial dosage of an antibiotic, you are contributing in a small way to the likelihood that someone down the road won't be able to use that same antibiotic to cure something." Although sharing other medications — for example, antihistamines — carries a very low health risk, it's still illegal, pointed out Dr. Goldsworthy. "For some medicines, it's simply that you're not supposed to." The research has not yet reached a point that warrants spending money on public service announcements about the risks of sharing prescription drugs, said Dr. Goldsworthy. "We know that sharing is going on, and we know that it entails risks, but we don't know the extent to which those risks play into actual damages and/or costs to society, so I don't know whether or not you can make the case for large-scale cost-intensive media campaigns. I do know that steps taken by parents, providers, and others to reduce the frequency of sharing and increase awareness of potential problems associated with it are absolutely merited." Nip It in the Bud Asked by Medscape Psychiatry to comment on the findings, Jeff Bostic, MD, a child psychiatrist and director of school psychiatry at Massachusetts General Hospital, Boston, said the study highlights a behavior that, if not addressed right away, could become an even bigger health hazard in the future. "We should nip it in the bud, address it now," he said. Practitioners can address the problem of drug sharing by being mindful that they do not give children agents the children do not need, said Dr. Bostic. They can also get the conversation going on the topic by finding out from young patients whether their friends ever inquire about getting prescription drugs or whether they ever see or hear about this behavior at school. Dr. Bostic stressed that just warning young people about the dangers of sharing drugs does not work; physicians have to make it personal. They could ask a patient, for example, how he or she would feel if he or she shared a drug with a friend and that friend had an adverse reaction. "Kids really don't want to be responsible for their peers," he added. Physicians should also prepare beyond protecting young people, said Dr. Bostic. You have to kind of role play with adolescents about how they should react when asked to share medications. Physicians should also have a conversation with parents about where and how they store their prescription medications, he added. - Medscape Today New Review Endorses CV Benefits of Fish Oil August 19, 2009 A new review concludes that there is extensive evidence from three decades of research that fish oils, or more specifically the omega-3 polyunsaturated fatty acids (PUFAs) contained in them, are beneficial for everyone.This includes healthy people as well as those with heart disease — including postmyocardial infarction (MI) patients and those with heart failure, atherosclerosis, or atrial fibrillation — say Dr Carl J Lavie (Ochsner Medical Center, New Orleans, LA) and colleagues in their paper published online August 3, 2009, in the Journal of the American College of Cardiology. "We reviewed everything that was published on omega-3 that was clinically important, and the major finding is that there are a tremendous amount of data to support the benefits of omega-3, not just as a nutritional supplement — people have known that for years — but evidence that it prevents and treats many aspects of cardiovascular disease," Lavie told heartwire. Lavie said he believes physicians are not as familiar with the omega-3 studies as they should be: "Clinicians know the findings of many statin trials even if they do not know all the details — they know that there are a ton of statin data. The omega-3 data may not be as impressive or as plentiful as this, but it should be 'promoted' to clinicians." Omega-3 PUFA, says Lavie, "is a therapy that clinicians should be considering prescribing to their patients. Not just as something healthy but as something that may actually prevent the next event. In HF [heart failure], it may prevent death or hospitalization and the same thing post-MI." He and his colleagues reiterate the advice of the American Heart Association (AHA): that those with known coronary heart disease (CHD) or HF eat four or five oily-fish meals per week or take the equivalent in omega-3 supplements; healthy people should consume around two fatty-fish meals per week or the same in supplements. Most Data on EPA and DHA In their review, Lavie and colleagues explain that most of the data on omega-3 have been obtained in trials using docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), the long-chain fatty acids in this family. The most compelling evidence for cardiovascular benefits comes from four controlled trials of almost 40,000 participants randomized to receive EPA with or without DHA in studies of primary prevention, after MI, and most recently with HF, they note. They discuss the results for each specific cardiovascular condition in turn. For CHF, three large randomized trials — the Diet and Reinfarction Trial (DART), the Gruppo Italiano per lo Studio della Sopravvivenza nell' Infarto Miocardico (GISSI)-Prevenzione, and the Japan EPA Lipid Intervention Study (JELIS) — have indicated that omega-3 PUFAs lower CV risk in both the primary- and secondary-prevention settings, they note. Lavie elaborated to heartwire : "The benefit is different in different studies but can be as much as 30%." The effects are seen on total mortality, sudden death, CHD mortality, and cardiovascular mortality. But there are some studies that have not shown favorable results, although there are generally methodological reasons for this, they say. However, they do flag the most recent study of post-MI patients, OMEGA, which suggests there may not be additional short-term benefit of omega-3 PUFAs in low-risk patients already receiving optimal modern therapy. There is also evidence of benefit in atherosclerosis and in a wide range of arrhythmias, with the most significant effect and potential benefit seen in "the current epidemic" of atrial fibrillation (AF), note the researchers. But more studies are needed to explore the effects of various doses of omega-3 PUFAs on the primary and secondary reduction of AF and to determine whether the benefits are caused by antiarrhythmic effects, benefits on autonomic tone, or even anti-inflammatory effects, they observe. Benefit of Fish Oils Also Extend to HF Recently, the potential benefits of omega-3 PUFAs "have been extended to the prevention and treatment of HF," say Lavie et al. Although the reduction in events was "only 8% to 9% in the recent GISSI-HF trial, which is not huge," Lavie admits, "when you think of HF, it's a very serious disorder, and in GISSI-HF, those patients were treated vigorously for their HF, so they were on good therapy, and adding just one [omega-3 PUFA] pill a day reduced deaths by between 8% and 9%, which is a pretty nice additional benefit." But he and his colleagues say further studies are needed to determine the optimal dosing of omega-3 PUFA for different stages of HFand to investigate the underlying mechanisms for the benefits. However, in the meantime, omega-3 PUFA supplements "should join the short list of evidence-based life-prolonging therapies for HF." They also discuss the data on omega-3 PUFAs in hyperlipidemia, noting that the FDA has approved one such supplement for the treatment of very high triglyceride levels. And they note that more studies are needed to determine the optimal mix of DHA relative to EPA in various populations. Finally, they state that this review does not focus on the plant-based precursor of EPA, alpha-linolenic acid (ALA), which is found in abundance in flaxseed and to a lesser extent in other plants. But they observe "the overall evidence is much weaker for ALA than for EPA and DHA." Recommendations for Omega-3 Consumption Mirroring recommendations from the AHA, European Society of Cardiology, and the World Health Organization (WHO), Lavie and colleagues recommend that healthy people consume at least 500 mg per day of EPA/DHA — equal to around two fatty-fish meals per week — and that those with known CHD or HF get 800 to 1000 mg per day EPA/DHA. Asked by heartwire whether people should try to consume more fish or alternatively take supplements, Lavie says: "If somebody really were eating salmon and tuna and mackerel and sardines, and they were doing that several times a week, then they wouldn't need to be taking a supplement. But in the US, at least, very few people are going to eat the therapeutic doses of fatty fish." Other good reasons to take supplements include the fact that they have usually had impurities, such as mercury, removed, he notes. If people are trying to improve their consumption of oily fish, they could take supplements only on the days they were not eating such fish or every other day to try to get up to the recommended amount of omega-3 PUFAs, Lavie says. But he warns that regimens that are too complex might result in underconsumption: "I would tend to think that most people are getting very little omega-3 PUFAs in the diet. There's no harm in taking extra — the only negative of extra is the calories. I don't think anyone thinks now that fish oil is doing any harm." - Medscape Today ACIP updates recommendations for routine poliovirus vaccination August 19, 2009 The Advisory Committee on Immunization Practices (ACIP) has updated its recommendations for routine poliovirus vaccination and published them in the August 7 issue of the Morbidity and Mortality Weekly Report.The goals of the update are to highlight the importance of the booster dose in children older than 4 years, to extend the minimum interval between dose 3 and dose 4 from 4 weeks to 6 months, to include a new precaution regarding use of minimum intervals in the first 6 months of life, and to recommend schedules for poliovirus vaccination with specific combination vaccines. "On June 17, 1999, ACIP recommended that all poliovirus vaccine administered in the United States be an inactivated poliovirus vaccine (IPV) beginning January 1, 2000," the report states. "This policy was implemented to eliminate the risk for vaccine-associated paralytic poliomyelitis, a rare condition that has been associated with use of the live oral poliovirus vaccine.... Since 1999, no [oral poliovirus vaccine] has been distributed in the United States." The 1999 ACIP recommendations specified a routine IPV vaccination schedule of 4 doses given at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years, with 4 weeks being the minimum interval between all IPV doses. In the United States, 3 different combination vaccines containing IPV have been licensed for routine use since the 2000 ACIP recommendation was made in1999. The updated ACIP guidelines now include the following recommendations to avoid potential confusion related to using different vaccine products for routine and catch-up immunization: * The 4-dose IPV series should still be given at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years. * Regardless of the number of previous doses, the final dose in the IPV series should be given at age older than 4 years. * Between dose 3 and dose 4, the minimum interval is increased from 4 weeks to 6 months. * Between dose 1 and dose 2, and between dose 2 and dose 3, the minimum interval is still 4 weeks. * For dose 1, the minimum age is still 6 weeks. Another new ACIP recommendation is that use of the minimum age and minimum intervals for vaccination in the first 6 months of life are recommended only if the vaccine recipient is at risk for imminent exposure to circulating poliovirus; for example, during an outbreak or for travel to a polio-endemic region. The rationale for this new precaution is that shorter intervals and earlier start dates result in lower seroconversion rates. ACIP is also recommending a poliovirus vaccination schedule with specific combination vaccines, as follows: * When DTaP-IPV/Hib (Pentacel, Sanofi Pasteur) is given at ages 2, 4, 6, and 15 to 18 months (4 doses total), children should receive an additional booster dose of age-appropriate IPV-containing vaccine (IPV [Ipol, Sanofi Pasteur] or DTaP-IPV [Kinrix, GlaxoSmithKline]) at age 4 to 6 years, resulting in a 5-dose IPV vaccine series. * The booster dose at age 4 to 6 years should not be DTaP-IPV/Hib. * For optimal booster response, the minimum interval between dose 4 and dose 5 should be at least 6 months. * As per current recommendations, a booster dose should be given as soon as feasible to a child missing an IPV dose at age 4 to 6 years. - Medscape Medical News FTC Delays 'Red Flag' Rule July 31, 2009 The Federal Trade Commission has delayed enforcement of the "Red Flags" rule until Nov. 1, 2009. The rule requires many businesses, including health care organizations, to take specific steps to minimize identity theft. Following is the FTC's announcement on July 29, with a specific reference to health care in the last paragraph: To assist small businesses and other entities, the Federal Trade Commission staff will redouble its efforts to educate them about compliance with the "Red Flags" Rule and ease compliance by providing additional resources and guidance to clarify whether businesses are covered by the Rule and what they must do to comply. To give creditors and financial institutions more time to review this guidance and develop and implement written Identity Theft Prevention Programs, the FTC will further delay enforcement of the Rule until November 1, 2009. The Red Flags Rule is an anti-fraud regulation, requiring "creditors" and "financial institutions" with covered accounts to implement programs to identify, detect, and respond to the warning signs, or "red flags," that could indicate identity theft. The financial regulatory agencies, including the FTC, developed the Rule, which was mandated by the Fair and Accurate Credit Transactions Act of 2003 (FACTA). FACTA's definition of "creditor" includes any entity that regularly extends or renews credit - or arranges for others to do so - and includes all entities that regularly permit deferred payments for goods or services. Accepting credit cards as a form of payment does not, by itself, make an entity a creditor. "Financial institutions" include entities that offer accounts that enable consumers to write checks or make payments to third parties through other means, such as other negotiable instruments or telephone transfers. The FTC's Red Flags Web site, www.ftc.gov/redflagsrule, offers resources to help entities determine if they are covered and, if they are, how to comply with the Rule. It includes an online compliance template that enables companies to design their own Identity Theft Prevention Program through an easy-to-do form, as well as articles directed to specific businesses and industries, guidance manuals, and Frequently Asked Questions to help companies navigate the Rule. Although many covered entities have already developed and implemented appropriate, risk-based programs, some - particularly small businesses and entities with a low risk of identity theft - remain uncertain about their obligations. The additional compliance guidance that the Commission will make available shortly is designed to help them. Among other things, Commission staff will create a special link for small and low-risk entities on the Red Flags Rule Web site with materials that provide guidance and direction regarding the Rule. The Commission has already posted FAQs that address how the FTC intends to enforce the Rule and other topics - www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm. The enforcement FAQ states that Commission staff would be unlikely to recommend bringing a law enforcement action if entities know their customers or clients individually, or if they perform services in or around their customers' homes, or if they operate in sectors where identity theft is rare and they have not themselves been the target of identity theft. The three-month extension, coupled with this new guidance, should enable businesses to gain a better understanding of the Rule and any obligations that they may have under it. These steps are consistent with the House Appropriations Committee's recent request that the Commission defer enforcement in conjunction with additional efforts to minimize the burdens of the Rule on health care providers and small businesses with a low risk of identity theft problems. Today's announcement that the Commission will delay enforcement of the Rule until November 1, 2009, does not affect other federal agencies' enforcement of the original November 1, 2008, compliance deadline for institutions subject to their oversight. - Health Data Management New health idea puts emphasis on quality care July 31, 2009 Imagine a health-care system that rewards doctors for quality over quantity. Such an experiment is taking place in Arizona thanks to the efforts of IBM, which wants more bang for its health-care buck.The computer giant persuaded a health insurer, UnitedHealth Group, to test a new system in Arizona that pays doctors based on keeping patients healthy. That represents a departure from the fee-for-service model that pays doctors based on the number of patients they see and procedures they perform. Local participants say the "medical home" system merits attention because it coordinates the major stakeholders in health care - employers, insurers, doctors and patients. The idea is that if doctors and their patients are encouraged to better manage chronic health conditions such as diabetes or high cholesterol, patients are less likely to land in a hospital emergency room - the most expensive place to provide health care. Advocates say the approach, in which doctors become a person's medical home for all their health issues, can keep patients healthier and reduce costs. "Health care has gotten so expensive that people can't afford to get sick these days," said Dr. Danielle Sink, a Phoenix internal medicine doctor who is participating in the UnitedHealth pilot program. "Insurance companies are now motivated to pay up front." As Congress debates ways to reform the nation's health-care system, the medical-home concept has gained momentum. President Barack Obama has stressed preventative health measures similar to those outlined in pilot programs as the path to reducing health costs. The health-care reform bill in the House of Representatives calls for establishing medical-home pilots to better coordinate care. And there are already more than two dozen pilot projects now being tested in various forms across the nation, according to the Patient Centered Primary Care Collaborative, a Washington D.C.-based group that promotes the medical-home concept. Still, even advocates of the system acknowledge it's an early concept that must prove its worth over the long haul. That may be one reason why the medical home idea has not played a more prominent role in the health-care reform debate. "The data is not there yet," said Dr. W. Carl Cooley, medical director of the Concord, N.H.-based Center for Medical Home Improvement. "The train has left the station, and we're laying down the track one mile down the road." Even UnitedHealth's foray into medical home has not been without stumbles. The insurer could not convince physicians to stick with a medical-home project in Florida due to disagreements over funding and other requirements. IBM, a computing giant that employs several thousand people in Arizona, pushed UnitedHealth to launch the medical-home system this year because the company was fed up with the status quo. The company spends about $21 million each year on health care in this state, and it wasn't satisfied with the results. "We are pretty unhappy with the care we buy," said Dr. Paul Grundy, IBM's director of health care, technology and strategic initiatives. "What we would really like to see is increased value. Hopefully costs will go down, but at the end of the day, we would like to get more value for the dollars we spend." Grundy said IBM has ongoing medical-home pilot programs in Colorado, New Hampshire, New York, Pennsylvania and Vermont. But he said the Arizona pilot is the only one with a direct arrangement between the employer, a health insurer and physicians. In all, the UnitedHealth medical-home program in Arizona consists of seven physicians' offices in the Phoenix area and Tucson and about 14,000 patients. Although many IBM employees participate in the program, not all are required to do so. Doctors join Dr. Sink joined the three-year pilot because it jibes with her vision of giving patients sufficient attention. She wants to make sure patients have enough time to ask questions, and that both the doctor and the patient are comfortable with the care. Some physicians may be reluctant to spend extra time with patients because they are typically paid by the number of office visits and procedures. "The existing model encourages high volume and doesn't reward for counseling and coordination of care," said Dr. Robert Beauchamp, UnitedHealth's Western states medical director. "This model gives the physician some justification to slow things down a bit." Under the UnitedHealth program, doctors such as Sink could be paid 15 to 20 percent more than the insurer's conventional rates. Participating doctors will collect a monthly fee for each patient enrolled in the program to cover the costs of coordinating care. Doctors also can collect a performance bonus that will be based on clinical quality factors such as cholesterol and blood pressure levels as well as blood glucose measures for diabetic patients. UnitedHealth has agreed to hire a consultant to help the doctors establish the medical home. Among the features included are electronic health records that allow the primary-care doctors to coordinate services, prescribe drugs electronically and compile information such as lab tests and hospital visits. The insurer also keeps a weekly tally of patients who have used hospital emergency rooms. The insurer informs the doctors of these hospital visits and asks whether the visits were necessary. "There was good communication in some cases, and poor communication in others," between the doctor and patient, Beauchamp said. Saving primary care Doctors say the medical-home concept could rejuvenate the role of family doctor, a profession that has lost its luster among many medical school graduates who pursue more lucrative fields such as dermatology or plastic surgery. "We have to do something different, to preserve the role of family physicians," said Dr. Jim Dearing, a Phoenix doctor who also joined the medical pilot. "You are going to have a hard time creating health-care reform if you don't find ways" to reward family doctors. Dearing said he joined the medical-home pilot because it rewards him for keeping close tabs on his patients. He's also accessible - maintaining weekend and evening hours to ensure patients can see him at a moment's notice. While he is optimistic the pilot will prove beneficial, Dearing said it's too early to measure success. Because the three-year pilot program launched in February, Beauchamp agreed it's too early to tell whether the pilot program has improved care. IBM, however, is confident the program will create a healthier workforce. "The health-care costs are the tip of the iceberg," Grundy said. "What this is really about is IBM needs an innovative workforce." - azcentral.com Cardiothoracic Surgeon Shortage Likely By 2020, Study Predicts July 31, 2009 The United States faces a severe shortage of cardiothoracic surgeons within 10 years if entry into the profession keeps declining while the patient population ages, a study predicts.By 2025, even if CABG procedures are no longer performed--an extreme scenario--the US will lack at least 1500 cardiothoracic surgeons, the research estimates. The study highlights the need for more surgeons despite the drop in CABG procedures and the rise in interventions such as angioplasty, senior author Dr Irving Kron (University of Virginia, Charlottesville) told heartwire . "It turns out that even though angioplasty is a perfectly good therapy for a lot of people, many people have recurrence, and a significant number of patients still need coronary bypass and certainly other cardiac surgical operations," he said. "We need to start to do a better job of recruiting individuals into our specialty, or I think patients are going to suffer," Kron cautioned. The study is published online July 27 in Circulation. Unfilled Residency Spots In 2003, for the first time in 20 years, the number of practicing cardiothoracic surgeons dropped. Half of the currently active cardiothoracic surgeons are older than 55 years and expected to retire soon. Meanwhile, one third of new cardiothoracic residency spots remain vacant, Kron said. The shortage of applicants for residency spots began about eight years ago, when there was a lack of jobs for new surgeons, largely prompted by evolving cardiology technology, he noted. From 1997 to 2004, the rate of CABG operations, "a mainstay of the specialty," decreased by 28%, and the rate of coronary stent placement during angioplasty increased by 121%, the authors write. To determine future requirements for cardiothoracic surgeons in light of this decline in CABG surgery, the American Association for Thoracic Surgery and the Society of Thoracic Surgeons commissioned a study of projected supply and demand for these professionals through 2025. Decrease in CABG, Increase in Other Surgeries Based on the number of current active practitioners, anticipated retirements, and new recruits, the study's statistical model predicted that, by 2025, the supply of cardiothoracic surgeons would decrease by 21%. Meanwhile, based on current patterns of healthcare use and projections of a growing elderly population, demand for cardiothoracic surgery--including valve procedures, other open heart procedures, and lung operations--could rise by 46%. According to Kron, the job shortage for new cardiothoracic surgeons has reversed itself; there is an evolving need for surgeries other than CABG. Although some established surgeons are retraining in more leading-edge techniques, they are not dropping their surgical skills, he added. "The change in technology is a good thing," he said. His institution's training program is emphasizing some interventional skills for fixing aneurysms, and minimally invasive or transcatheter valve procedures are becoming part of a surgeon's repertoire. This study calls attention to the need for an immediate response to the looming expected shortage of cardiothoracic surgeons, Kron said. One potential response might be to reduce the training time after medical school from eight years to six years, he added. Alarming Specialist Shortage Predicted "The alarm that we feel is that, although there seems to be less interest in cardiac surgery today because of changes in the number of coronary bypass surgeries that are being done, this doesn’t portend well for the future when the number of patients requiring other types of cardiac surgery--valve replacement, repair of aneurysms, and other surgery for advanced heart failure--will be increasing," Dr Timothy J Gardner (Christiana Care Health System, Newark, DE), immediate past president of the American Heart Association, told heartwire . The drop-off in the number of surgeons reflects the growing number of procedures that are being done as interventional treatments, Gardner concurs. Some surgeons are training to perform catheter treatment of aortic aneurysms and aortic valve replacements--an area where there is some overlap between cardiologists and cardiac surgeons, he noted. The trend in surgery is to perform less-invasive procedures--such as off-pump coronary bypass grafting--and to use smaller incisions for valve replacement, which allows surgeons to deal with more challenging heart valve problems, he said. "You hear a lot of talk about the need to increase our workforce in primary care in the United States, but we better be very careful that we're not overemphasizing that and [ignoring] the projected need for specialists in cardiac surgery and even in cardiology," Gardner cautioned. "I think that this paper provides a bit of a warning or wakeup call in that regard," he said. - theheart.org New Insights Into Novel H1N1 July 31, 2009 This spring, a new influenza, or flu, virus began causing illness in people around the world. Originally called "swine flu" because it’s a descendant of viruses that have long infected pigs, the virus is now called "novel H1N1." Several new studies have revealed where the virus came from and given insight into how dangerous it might become.Influenza viruses have 8 genes, 2 of which—hemagglutinin (H) and neuraminidase (N)—code for proteins on the virus surface that allow the virus to enter and spread from cell to cell. There are 16 H subtypes and 9 N subtypes, making 144 possible HN combinations. Subtle variations in these 2 proteins affect how easily the viruses infect people and whether the immune system can recognize them. Several research groups funded by NIH’s National Institute of Allergy and Infectious Diseases (NIAID) and National Institute of General Medical Sciences (NIGMS) have recently put together a picture of where the novel H1N1 virus came from and how it evolved. They discovered that the novel H1N1 virus is a descendent not only of swine viruses but also of the H1N1 virus that caused the 1918 pandemic, which killed 40-50 million people worldwide. "The 1918-1919 influenza pandemic was a defining event in the history of public health," says NIAID Director Dr. Anthony S. Fauci. "The legacy of that pandemic lives on in many ways, including the fact that the descendents of the 1918 virus have continued to circulate for 9 decades." In other work, 2 research groups—an NIGMS-funded team at the Massachusetts Institute of Technology and researchers at the Centers for Disease Control and Prevention (CDC)—recently collaborated to test the ability of novel H1N1 to spread and cause disease. They isolated viruses from 3 patients and infected mice and ferrets. The results were published online ahead of print on July 2, 2009, in Science. The researchers found that, compared to seasonal H1N1 flu viruses, the novel H1N1 viruses replicated to higher levels in lung tissue and were also more deadly. The scientists also found the viruses in the intestinal tracts of the ferrets, which might explain reports of gastro-intestinal problems in some infected people. However, the novel H1N1 viruses transmitted less efficiently between ferrets in respiratory droplets than seasonal H1N1. The binding of influenza viruses to their target cells is mediated by hemagglutinin. The researchers found that the novel H1N1 hemagglutinin binds to receptors in the human respiratory tract much less effectively than other flu viruses that infect humans. However, flu viruses can mutate rapidly, so the virus could potentially improve its ability to bind. The researchers also found that novel H1N1 doesn’t have a version of another gene called PB2 that has been associated with efficient virus transmission. However, they point out that the virus could acquire another version of the gene through mutation or by exchanging genes with other influenza viruses. These recent insights into how novel H1N1 arose and how it spreads will be crucial for stopping a pandemic. "We need to pay careful attention to the evolution of this virus," says Dr. Ram Sasisekharan, who led the MIT research team. - National Institutes of Health Number of retail clinics shrinking; growth slows as partnerships sought with hospitals July 31, 2009 Projections that showed there would be 2,500 retail clinics operating by 2010 are coming up short as the industry has seen more clinic closings than openings in recent months.MinuteClinic, the first and largest retail clinic chain, now owned by CVS, closed 100 of its clinics for the summer, leaving 452. In two years, the number of clinics housed in Wal-Mart dropped from almost 80 to 30. The retail giant recently acknowledged it would not reach the goal it set in 2007: having 400 retail clinics in operation by 2010. Despite high satisfaction among patients who use retail clinics, investors have found the industry is slow to turn a profit. Many clinics were forced to close when they ran out of cash and were unable to shoulder the financial losses. Analysts say the current dip doesn't mean the demise of the industry. But it may indicate it's time to change strategy. Many analysts believe the key to sustainability will be clinics partnering with hospitals that are better prepared to shoulder the initial losses. Clinics also can build on hospital name recognition to attract more patients. But the downside is that hospitals move much more slowly than capital investment firms, leading to a drastic slowdown in opening new clinics. In addition, the recession has forced some hospitals to scale back plans for clinics, or choose between funding clinics or other capital projects. When Wal-Mart first entered the retail clinic market, its strategy was to partner with venture capital-backed chain operators for whom Wal-Mart served solely as the landlord. After RediClinic shut down 15 of its Wal-Mart clinics in 2008 and other independent chains followed suit, Wal-Mart shifted gears and said it would partner with hospital groups. Its plan was to have 400 hospital-affiliated clinics open by 2010. Half of the clinics were expected to open through a deal with RediClinic, which also cited the benefits of co-branding with hospital groups. Bruce Shepard, director of health business relationship development for Wal-Mart, said the company decided that hospital partnerships would lead to a more sustainable business model. He said more hospitals are willing to take on the initial financial loss as part of an overall marketing strategy focused on access to care. The clinics can serve as an entry point for new patients to eventually become connected to primary care physicians. But, Shepard said, the company underestimated the time it would take to get the clinics up and running. "As we learned more and more about the process and the time that it takes to get clinics to fruition with hospitals and health systems, generally, I think that's when we saw that [while] we're still committed to the [400] number, it's going to take a little bit longer." Partnerships moving slowly Paul Storey, vice president of physician services for Northwest (Arkansas) Health System, said the hospital system jumped at the chance to open clinics in two of the former RediClinic sites. But it is moving slowly on opening more clinics. "This is kind of a new business for us, so we are constantly tinkering with how to do things and what to do and how to refine it," he said. Northwest, which is part of Community Health Systems, has been analyzing locations for new clinics since March. Storey said it is looking at how to make the clinics a success before expanding in that area. Shepard said that's the case with many of Wal-Mart's potential hospital partners. But he is still getting calls from health systems interested in entering the market. "They see the value and they're wanting to move forward, but ... it's a calculated risk." Mary Kate Scott, principal of the Marina del Rey, Calif.-based consulting firm Scott & Co., authored a study in 2006 projecting 2,500 retail clinics by 2010. There are now about 1,100 nationwide. At the time of the study, venture capital firms were still driving much of the growth. These investors not only underestimated the time it would take to turn a profit, Scott said, but they also underestimated the value of marketing. "I am very surprised it's taken that long to market these clinics." It also takes time -- up to 36 months -- for hospitals to build a new clinic. Still, the partnering strategy makes sense, she said. Just as hospitals enter the market with the goal of a long-term relationship with that community, so does a retailer like Wal-Mart. "You're actually creating a relationship with someone that could last 30, 40 or 50 years. So why wouldn't you think it would take 18 to 36 months?" Scott said. Tom Charland, president and CEO of Merchant Medicine, a Shoreview, Minn.-based retail clinic consultancy firm, agreed the hospital-partnered model has the greatest chance of success. But he cautioned that it's not fail-proof. Hospitals hoping for success must have their physicians behind the idea, he said. If the clinics are to be an extension of the health care delivery strategy, physicians must be willing to work with clinic operators on coordinating care. But extending the delivery system too far can lead to failure. Aurora Health Care in Milwaukee, for example, had 19 clinics at one time. It's now down to 10. Aurora did not comment by this article's deadline. But Charland said there was too much saturation in the market, especially after Take Care Health Systems entered the Milwaukee area. "I think we'll see the slowdown last a couple of years," Charland said. "But I think once some of the things are sorted out with health care and the economy has turned around ... we'll see some shifting, and I think it'll be positive for this industry." - American Medical News Obama calls food safety bill a ‘major step’ July 31, 2009 The U.S. House of Representatives has passed a far-reaching food safety bill requiring more government inspections and imposing new penalties on those who violate the law, reacting strongly to an outbreak of salmonella in peanuts that killed at least nine people.The legislation would require greater oversight of food manufacturers and give the U.S. Food and Drug Administration new authority to order recalls. It also would require the FDA to develop a system for better tracing food-borne illnesses. Food companies would be required to create detailed food safety plans. President Barack Obama praised the bill soon after it was passed, calling it "a major step forward in modernizing our food safety system." Farm-state members had argued that the bill would be too invasive on farms, and had pushed colleagues to vote against it as it was considered under a special procedure that requires a two-thirds vote. It was rejected Wednesday by a few votes. Democrats scrambled to put the legislation back on the House floor Thursday under a rule that required a simple majority to pass. The vote was 283-142. Supporters said the legislation would help the FDA change its focus from a reactive to a more preventive approach in keeping the nation's food safe. "Americans are dying because the Food and Drug Administration doesn't have the authority to protect them," said Michigan Rep. John Dingell, the bill's sponsor and a long-serving Democrat who has been pushing for tougher standards for more than a decade. A similar bill sponsored by Sen. Richard Durbin, an Illinois Democrat, has not yet seen action in the Senate. Outbreaks give momentum The legislation gained new momentum in the wake of one of the largest product recalls in U.S. history, stemming from salmonella in peanuts that killed nine people, sickened hundreds of others and was linked to shoddy practices at a peanut company in Georgia. Other recent outbreaks include contaminated spinach in 2006 and salmonella in peppers last year. The government estimates that 76 million people each year are sickened by food-borne illness, hundreds of thousands are hospitalized and around 5,000 die. Those outbreaks have exposed a lack of resources and authority at the FDA as the embattled agency has struggled to contain and trace them. In the peanut outbreak, FDA inspectors quickly focused on the small Georgia processing plant but had to invoke bioterror laws to get lab reports that ultimately showed the company shipped tainted peanuts. Meanwhile, the agency had no authority to order a food recall. Connecticut Rep. Rosa DeLauro has said the bill is a solid first step but said she believes Congress needs to go even further and reorganize FDA to help it better focus on its "food" mission. She has introduced legislation that would divide the FDA in two, separating the agency's drug oversight and food safety duties. The FDA regulates most foods, though as many as 15 federal agencies have a hand in food safety. The Agriculture Department inspects meats, poultry and some eggs. The bill, which has support from the food industry as well as a wide range of consumer groups, would give the agency the authority to order recalls if a company fails to act on its own, and would increase the frequency of inspections to high-risk food processing facilities. It would charge food processors an annual $500 fee to help defray the cost of increased enforcement. Sponsors tweaked the legislation in recent days to appease the farm-state members who objected to it. Last-minute changes included modifying the way a trace-back system would work, clarifying that some hard-to-trace products, such as grains, would not be tracked to individual farms. It also lessened paperwork for some farms and clarified that some smaller operations would not have to register with the FDA or pay fees. Those changes appeased most farm-state Democrats, but many Republicans still voted against it, saying it would be invasive to farmers and not do enough to improve food safety. Oklahoma Rep. Frank Lucas, the top Republican on the House Agriculture Committee, led the charge against the legislation. "The bill still goes too far in the direction of trying to produce food from a bureaucrat's chair in Washington D.C.," Lucas said. - msnbc.com ER malpractice standard raised July 15, 2009 Patients who want to sue their emergency-room doctors due to medical errors now will have a higher hurdle to clear.A bill signed by Arizona Gov. Jan Brewer means emergency-room patients must prove there is "clear and convincing" evidence that medical errors by emergency health-care workers led to injury. The legislation raises the burden of proof patients must show when they sue an emergency-room physician, health-care worker or hospital. Doctors and hospital groups have been pushing for such legislation for several years, but a similar bill was vetoed by then-Gov. Janet Napolitano. They say existing law discouraged doctors from treating patients at emergency rooms over the fear of being sued. Hospitals say such jobs are a critical part of health care's safety net, and these doctors often see patients with little or no knowledge about the patient's medical history. "We've got to make some allowances for the fact that things can go wrong in these situations," said Chic Older, executive vice president of the Arizona Medical Association, which represents physicians. "You should not have to feel that anytime something goes wrong, you are going to get sued." Older added that the Senate Bill 1018, sponsored by Sen. Carolyn Allen, R-Scottsdale, and signed by Brewer on Friday, still allows patients to sue if they are injured during emergency treatment. They just need to prove a higher evidentiary standard to win such actions. A 2006 report by the Emergency Medical Services Access Task Force said such malpractice reform would make more physicians and specialists more willing to treat patients in emergency rooms. Arizona hospitals say there has been a shortage of such physicians willing to work "on-call" shifts for hospitals, especially among physicians who are trained in emergency and intensive care. A 1986 federal law requires all hospitals that participate in Medicare to screen, treat and stabilize patients who seek emergency care. Banner Health, Arizona's largest hospital group, favors the stricter malpractice standard. "It is right that people have recourse," said Bill Byron, Banner Health spokesman. "People have the right to bring a complaint. We think this brings some more balance." - azcentral.com Obama Nominates Regina Benjamin for Surgeon General July 15, 2009 President Barack Obama announced today that he would nominate Regina Benjamin, MD, a family physician in the fishing village of Bayou La Batre, Alabama, to be the next US surgeon general. The appointment requires confirmation by the US Senate.In one sense, the former community organizer in Chicago turned US senator and then US president chose someone very much in his mold. Dr. Benjamin's service in the poor Gulf Coast community of 2500 — devastated by Hurricane Katrina in 2005 and Hurricane Georges in 1998 — has been a springboard to medical leadership on a national scale. Dr. Benjamin has served on the board of trustees of the American Medical Association (AMA), for example. And she's the immediate past chair of the Federation of State Medical Boards of the United States. Appearing with President Obama when he announced the nomination, Dr. Benjamin said she wanted to ensure "that no one — no one — falls through the cracks as we improve our healthcare system." Fueling her motivation, she explained, was the medical history of her own family. "My father died with diabetes and hypertension," said Dr. Benjamin. "My older brother, and only sibling, died at age 44 of HIV-related illness. My mother died of lung cancer, because as a young girl, she wanted to smoke just like her twin brother could. My Uncle Buddy, my mother's twin, who's one of the few surviving black World War II prisoners of war, is at home right now, on oxygen, struggling for each breath because of the years of smoking." Voice for Improved Healthcare "My family is not here with me today, at least not in person, because of preventable diseases. While...I cannot change my family's past, I can be a voice in the movement to improve our nation's healthcare and our nation's health for the future." In 1990, Dr. Benjamin founded the Bayou La Batre Rural Health Clinic, which she has had to rebuild 3 times because of the 2 hurricanes as well as a fire. Patients have pitched in money to help the nonprofit clinic recover, but Dr. Benjamin received an even bigger boost in 2008, when the John T. and Catherine D. MacArthur Foundation awarded her a $500,000 "genius grant," one of numerous honors she has received. Many Bayou La Batre residents — a third of whom are immigrants from Vietnam, Cambodia, and Laos — lack health insurance. Doctoring in such a community makes her well-qualified for the post of surgeon general, said Georges Benjamin, MD, executive director of the American Public Health Association (no relation to Dr. Regina Benjamin). "She has Ivy League credentials, but she's not coming from an Ivy League practice," said the American Public Health Association's Dr. Benjamin, who has worked with her on health policy issues over the years. "She brings the experience of someone who's actually had to manage a person's blood pressure, and deal with people who can't afford healthcare." "True Understanding" Ted Epperly, MD, president of the American Academy of Family Physicians, also applauded her nomination, saying that Dr. Benjamin understands the need for both universal healthcare coverage and enough primary care physicians to deliver the care. "She has a true understanding of what it means to care for the underserved and address healthcare disparities," said Dr. Epperly. "She's very caring and empathetic, but tough. She won't give up. Look how many times she rebuilt her clinic. You've got to love that grit." Dr. Georges Benjamin said the nominee for the highest physician post in the land also comes well prepared to deal with the political challenges of the job, which will heat up as President Obama and Congress attempt to forge a path toward healthcare reform. "There's no more a political environment than the board of trustees of the AMA," noted Dr. Georges Benjamin. "She understands bureaucracies and the political environment. She's dealt with state legislators in Alabama. She's presented for the AMA on Capitol Hill. She's no rookie." Personal Understanding of Pitfalls Although Dr. Benjamin's nomination has received much praise, some online news sites have posted comments from readers who are dismayed that the surgeon general nominee is overweight. "An overweight surgeon general will not have the credibility to deal with the nation's most serious health problem, obesity," wrote one reader at the New York Times Web site. Dr. Epperly of the American Academy of Family Physicians, however, defended Dr. Benjamin's right to occupy the bully pulpit on this subject. "She more than anybody understands what it means to be overweight and for that to be a health issue," said Dr. Epperly. "She will help champion [this cause] even harder." Her situation, he added, "isn't dissimilar to President Obama being a smoker and signing the [US Food and Drug Administration] legislation" that authorizes the Food and Drug Administration to regulate tobacco. "As a smoker, he understands the pitfalls of smoking and addiction," said Dr. Epperly. "I think she understands the pitfalls of the obesity epidemic." Dr. Benjamin received her MD from the University of Alabama at Birmingham. She also holds an MBA from Tulane University. - Medscape Medical News Part B drug proposal would curtail Medicare pay cuts after 2010 July 15, 2009 The typically bleak outlook that marks the proposed Medicare fee schedule for the upcoming year was significantly brighter this time around for physicians looking for relief from impending pay cuts.In a major policy reversal from the previous administration, the Centers for Medicare & Medicaid Services has proposed removing physician-administered drugs from the calculation of the Medicare physician payment formula. Doctor pay is reduced across the board when spending on all physician services -- a category that includes Part B drugs -- exceeds annual targets. Removing the costs of the drugs would lessen the extent to which spending would exceed targets and trigger cuts. The CMS proposal, announced July 1, would not reduce next year's planned 21.5% across-the-board cut. But it would reduce the number of years after 2010 that physicians face reductions under the payment formula, and it also would decrease the size of the cuts that remain. Over the next five years, projected doctor pay updates of between -6.3% and -5.4% would be replaced with updates of between -3.1% and 1.4%, said Jonathan Blum, director of the CMS Center for Medicare Management. This means Medicare would pay physicians $45.4 billion more over those five years than it would if the physician-administered drugs remained part of the pay formula. The move also could make it more affordable for Congress to reverse the 21.5% cut and the additional future reductions mandated by the formula, because the five-year cost to lawmakers of legislating such a change would go down by the same amount. Unless Congress designates offsets for the $45.4 billion, however, that spending would be added to the federal deficit. The American Medical Association, which along with other physician organizations has been pushing for the removal of physician-administered drugs from the Medicare payment formula since 2002, called the proposed move a historic victory for doctors and their patients. "We are very pleased that the Obama administration agrees with the AMA that drugs do not belong in the physician payment formula," said AMA President J. James Rohack, MD. "Instead of yet another Band-Aid fix, today's action paves the way for Congress to ensure stable payment rates that reflect increasing medical practice costs and preserve seniors' access to care." A new legal outlook The AMA has maintained all along that CMS had the authority to take Part B drugs out of the equation retroactively at any time. But the Bush administration steadfastly refused to make the administrative change, saying it did not have the statutory authority under Medicare law to carry out the move. CMS under Obama came to a different conclusion. "Clearly, the fact that the Obama administration now thinks it can take it out shows you the legal interpretation could go either way," said Mark B. McClellan, MD, PhD, who made the decision against the policy change while serving as CMS administrator in the Bush administration from 2004 to 2006. "This is something that was reviewed every year, and there were legal arguments on both sides." Although the proposed formula change is retroactive to 1996, it would not revise any pay rates before 2011. "Keep in mind this is an accounting change going forward. It's a commitment to spend additional funds for physicians, and this is one step in acknowledging that overall physician spending in the future will be higher," said Dr. McClellan, now director of the Engelberg Center for Health Care Reform and a senior fellow at the Brookings Institution, a public policy organization based in Washington, D.C. He noted that Congress still has a long way to go in making Medicare physician spending more sustainable in the long run. The proposal is not a done deal unless CMS includes the provision in the final 2010 physician fee schedule rule, which typically comes out by Nov. 1. CMS included language in the proposal allowing for the plan to change between now and then "in light of new policy developments, new information or changed circumstances." Blum said CMS is mindful that this administrative change is occurring against the backdrop of health reform discussions on Capitol Hill. "So we want to make sure that our proposals are consistent with overall reform priorities." More help for primary care CMS' proposed fee schedule also would refine Medicare physician payments in ways that are expected to increase payment rates for primary care services by reducing some specialist pay. The most significant change would update the practice expense component of physician services starting in 2010. To value services more accurately, CMS is proposing to incorporate cost data from the AMA-conducted Physician Practice Information Survey. The agency also proposed stopping payment for consultation codes, which typically are billed by specialists and paid at higher rates than regular evaluation and management services. CMS said it would redirect more of the portion of Medicare's payment for professional liability insurance to physicians with the highest liability premium costs. Taken as a whole, these actions would increase average total payments to general practitioners, family physicians, internists and geriatricians by 6% to 8%, CMS said. Some primary care physician organizations praised the proposals. "We think it goes a long way toward helping improve payment for primary care," said James King, MD, chair of the board at the American Academy of Family Physicians. "We have a work force shortage of primary care physicians, so we need to help people choose the field." But organizations representing specialists whose services would sustain rate reductions because of the relative value revisions said the cuts go too deep. The American College of Cardiology questioned the validity of practice expense data from the AMA survey and was critical of the agency's process in adopting it. "We believe this is a significant departure from previous policy and may be a violation of statute," said Alfred Bove, MD, the ACC's president. "Given the extensive discussion of previous surveys in previous rules, the ACC is concerned about the very brief discussion of the new survey in this proposal." Additional proposed rate and policy changes in the rule would reduce payment for services that require the use of expensive imaging equipment. CMS says the reductions are necessary to control rapid imaging spending growth, but physicians who use the technology disagree. CMS is accepting comments on the proposed rule until Aug. 31. - American Medical News Reminder Program Boosts Mammography Rates July 15, 2009 A multimodal reminder system can be both effectively implemented and maintained in a large health system and increase mammography rates, according to the results of a study reported online July 14 in the American Journal of Preventive Medicine."We know mammograms are effective, but too many women put them off, even when they have health insurance," lead author Adrianne C. Feldstein, MD, from Kaiser Permanente's Center for Health Research in Portland, Oregon, said in a news release. "This study is the first to show that these reminder programs can be effective in such a large group of women. If we could improve the country's mammography rate by the same amount, we could detect as many as 25,000 additional cases of breast cancer each year." Using electronic medical record data, the investigators compared compliance with mammography during a prereminder phase (2004), a postreminder implementation phase (2006), and a postreminder maintenance phase (January 1 – July 1, 2007). The study sample consisted of 35,104 women aged 42 years or older who were 20 months past their last mammogram (index date) and who were members of the Kaiser Permanente Northwest health maintenance organization. The intervention, which targeted women aged 50 to 69 years, consisted of a "mammogram due soon" postcard mailed 20 months after the last mammogram, followed by up to 2 automated phone calls and 1 live call for nonresponders. The primary comparison group was women aged 42 to 49 years, for whom clinical guidelines also recommend mammography, who did not receive the reminder system intervention. The main study endpoint was the time until participants underwent mammography during the 10 months after the index date. In the prereminder phase, 63.4% of targeted women underwent mammography, compared with 75.4% in the postreminder implementation phase and 80.6% in the maintenance phases. During the same time, screening rates in the comparison group did not improve. In the postreminder implementation phase, women who received the intervention were 1.51 times more likely to undergo mammography than those in the comparison group (95% confidence interval [CI],1.40 – 1.62), after controlling for demographics and clinic visits. This effect was maintained in the postreminder maintenance phase (hazard ratio, 1.81; 95% CI, 1.65 – 1.99). "Our study shows that a reminder program can spark a big improvement in a short amount of time," said study coauthor Nancy Perrin, PhD, senior investigator at Kaiser Permanente's Center for Health Research. "Automated reminder programs make it more convenient for people to focus on staying healthy by getting the screenings they need." Limitations of this study include lack of randomization, age difference between women in the intervention and comparison groups, lack of generalizability beyond the single health maintenance organization studied, and possible unmeasured confounders. "The study found that this multimodal reminder system could be effectively implemented and maintained in a large health system," the study authors conclude. "If widely implemented, this intervention could substantially improve community mammography screening.... Future studies should address practice-based factors that assist patients in completing mammograms within the context of a reminder program, as well as other factors that affect the reach and cost effectiveness of delivering the intervention to diverse patient groups in multiple settings." - Medscape Medical News First draft of EHR "meaningful use" definition unveiled June 30, 2009 President Obama's point man on health care information technology has asked a key working group to revise its recommendations on what constitutes "meaningful use" of electronic health records, a pivotal term that will decide which physicians can obtain billions in federal EHR money.David Blumenthal, MD, national coordinator for health information technology, declined to specify why he asked the Health IT Policy Committee's meaningful use working group to amend the recommendations it released June 16. The panel is tasked with advising the government on a policy framework for the development and adoption of a nationwide health IT infrastructure. "We had a lively discussion, and it was decided after considerable input on the topic of meaningful use that we would take it back to discussion to work on it a little bit longer," Dr. Blumenthal said. He said the committee expects to unveil revised recommendations by July 16, the date of its next scheduled meeting. Dr. Blumenthal fielded questions during a June 16 conference call with Tony Trenkle, director of the Office of E-Health Standards and Services at the Centers for Medicare & Medicaid Services. CMS will rely heavily on the committee's recommendations in drafting a proposed rule on meaningful use, expected later this year, Trenkle said. The health care community is following the EHR meaningful use debate with much interest. The federal stimulus bill provides approximately $19 billion in net Medicare and Medicaid incentives for physicians, hospitals and others not only to adopt certified EHRs but also to use them in a meaningful way. The incentives start with bonuses for early adopters but turn into penalties for those who don't act fast enough. Incentive pay rules Physicians with approved EHRs in place before 2011 or 2012 will be eligible for the maximum Medicare incentive payments allowed by the stimulus package. Doctors who have not adopted an EHR before 2015 and who fail to obtain a hardship exemption will see a 1% cut to Medicare pay, a reduction that phases up to 3% for 2017 and remains each year after that. In a general sense, meaningful users have been defined as physicians who demonstrate to the government that they are using electronic prescribing, that their technology is connected in a manner that provides for electronic exchange of health data to improve quality of care, and that they submit information to the government on clinical quality measures. But for the past month, the meaningful user working group has been trying to detail exactly what objectives physicians would need to meet to earn the Medicare incentives. For example, the initial draft proposed that to be considered a meaningful user, practices should be able to maintain electronic medication and allergy lists, record vital signs, and incorporate lab results into their EHRs by 2011. The proposed list of mandates grows in 2013 and 2015. During the June 16 call, Dr. Blumenthal said the group would take comments over the next 10 days on the initial recommendations. He expected to hear concerns on how quickly EHRs could be adopted, on how well meaningful use criteria could be met and on how CMS eventually will certify approved records systems. "Our goal is to try to make it possible for as many physicians and hospitals as possible to be meaningful users by 2011," he said. Health policy experts note the importance of practices getting a jump on using an EHR system. "The requirements are weighted over time, but they're heavily loaded in the first couple of years," said Erica Drazen, a managing partner in the health care group at Computer Sciences Corp., a technology firm in Waltham, Mass. Drazen said it could prove particularly difficult for practices to adopt a computerized physician order entry component, one of the 2011 requirements in the first draft. Fewer than 20% of hospitals use CPOE, and the adoption rate for physicians is similarly low, she said. Becoming a meaningful EHR user The Health IT Policy Committee will revise its initial suggestions for defining "meaningful use" of electronic health records as a prerequisite for federal stimulus bonuses, but the first draft gives physicians an idea of what kind of requirements and deadlines to expect. By 2011: * Use computerized physician order entry for all order types, including medications. * Incorporate laboratory tests into EHRs and share results electronically with public health agencies. * Generate lists of patients by specific condition to use for quality improvement. * Provide clinical summaries for patients after each encounter. * Exchange key clinical information among health professionals (problems, medications, allergies, test results, etc.). By 2013: * Generate and transmit prescriptions electronically. * Manage chronic conditions using patient lists and decision support tools. * Use bar coding for medication administration. * Offer secure patient-physician messaging capability. * Record patient preferences in EHR. By 2015: * Achieve minimal levels of performance on quality, safety and efficiency measures. * Give patients access to self-management tools. * Access comprehensive patient data from all available sources. * Conduct automated real-time surveillance on occurrences such as adverse events, disease outbreaks and bioterrorism. * Incorporate clinical dashboards into EHR. - American Medical News New Guidelines Issued for Asthma Assessment June 30, 2009 The American Thoracic Society (ATS) and the European Respiratory Society (ERS) have released official standards regarding asthma evaluation for clinical trials and practice. The joint statement containing the new recommendations and underlying evidence base was approved by the ATS Board of Directors on March 13, 2009, and by the ERS Executive Committee on November 27, 2008, and it is published in the July 1 issue of the American Journal of Respiratory and Critical Care Medicine."In the past, there has been no standard way of assessing asthma," Helen K. Reddel, MB, PhD, from the Woolcock Institute of Medical Research in Camperdown, Australia, and cochair of the ATS/ERS Task Force on Asthma Control and Exacerbations, said in a news release. "This has led to a lot of confusion for doctors who are managing asthma, and in research, it was difficult to compare the results of different studies." Although evaluation and monitoring of asthma control are crucial to determining treatment response both in individual patients and in clinical trials, there have been a variety of definitions and assessments for asthma control, severity, and exacerbations. The ATS/ERS therefore convened a task force of 24 asthma experts from North America, Europe, South Africa, Australia, and New Zealand. Their objective was to issue guidelines applicable to adults and children 6 years or older regarding standardization of outcomes relating to asthma control, severity, and exacerbations in clinical trials and clinical practice. The task force performed a narrative review of the literature to assess the measurement properties and strengths and limitations of outcome measures pertinent to asthma control and exacerbations, including diary variables, physiologic measurements, composite scores, biomarkers, quality-of-life questionnaires, and indirect measures. New Definitions for Asthma Based on current therapeutic standards and relevance to clinical practice and research trials, the task force developed new definitions for asthma control, severity, and exacerbations. Asthma control was defined as the degree to which treatment can ameliorate or eradicate the features of asthma regarding both current clinical control and future risk. Specifically including future risk in the new definition of asthma control is a departure from earlier definitions, which primarily highlighted current clinical control. "The addition of future risk is important for three reasons: first, because some medications can improve symptoms while not treating the underlying disease; second, because some patients are at increased risk of asthma attacks despite having few symptoms; and third, because medication side-effects should be taken into account when deciding a patient's need for treatment," Dr. Reddel said. Frequency of asthma exacerbations, repeated measures of pulmonary function, and treatment-related adverse effects were the most robust predictors of future risk. "If a study is not long enough to measure these directly, the task force provided recommendations about surrogate markers such as sputum analysis or bronchial challenges which can predict the risk of these outcomes," Dr. Reddel said. Because the many facets of asthma and asthma control are widely recognized, no single outcome measure is sufficient to evaluate asthma control. Outcome measures should reflect both main objectives of asthma treatment, namely optimizing clinical control while minimizing future risk for adverse outcomes. However, the task force listed standardized endpoints for use in clinical trials, which were characterized as essential, desirable, and optional. All clinical trials attempting to study the effect of an intervention on asthma control should include and report the minimal or "essential" outcomes. Robust outcome measures for current clinical control were symptom-free days, use of symptom relievers, pulmonary function, quality of life, and a validated composite score. Additional endpoints that could be considered included a daily diary, preferably electronic, of symptoms and exacerbations and a record of clinician and emergency department visits. "In clinical practice, it is particularly important to measure lung function for the diagnosis of asthma, and also for assessment of patients whose asthma is troublesome either because they have a lot of symptoms despite treatment, or because they have few symptoms but a lot of severe attacks," Dr. Reddel said. Evaluation of Asthma Control The statement offers recommended strategies to evaluate asthma control in clinical trials and in clinical practice, both at baseline and in determining response to therapeutic interventions. These multicomponent evaluations can be used by clinicians, researchers, and others involved in designing, performing, and interpreting the findings of clinical trials, as well as by those in patient care settings. Detailed information is included regarding measurement and interpretation of each endpoint and the range of normal values. The task force redefined asthma severity as the intensity of treatment required to achieve good asthma control. Severe asthma requires high-intensity treatment, whereas mild asthma can be well controlled with low-intensity treatment. Pathologic and physiologic markers may describe the underlying disease activity and the patient's phenotype, both of which may affect asthma severity. "In the past, asthma severity was usually defined before a patient started asthma treatment, using measures which were almost identical to those used to assess asthma control," Dr. Reddel said. "This was very confusing, and it meant that asthma severity could not be re-assessed once treatment had started." The statement now defines asthma exacerbations as events in which symptoms become sufficiently severe to mandate a change in therapy. The definition of severe asthma exacerbations to be used in clinical trials was standardized to refer to events requiring urgent treatment, such as systemic corticosteroids (tablets, suspension, or injection), or an increase from a stable maintenance dose, for at least 3 days. In clinical practice, an exacerbation could also be defined as a hospitalization or emergency department visit because of asthma, requiring systemic corticosteroids. Advice for Clinicians The task force recommended that clinicians routinely ask every patient with asthma simple questions regarding short- and long-term symptoms and management. These should cover the number of days with symptoms in the past 1 to 4 weeks; the number of days per week with symptoms; use of medication for symptom relief; symptoms causing nocturnal awakening; and the number of severe attacks in the past year, which may identify patients at risk for future severe exacerbations. Future Research The statement included suggestions for future research in the different areas highlighted. An important goal is identifying appropriate biomarkers and evaluating their role in determining appropriate treatment for some patient subgroups. "More research is needed to understand more clearly how asthma control — and risks for asthma exacerbations — can be best assessed for the different types (ie, phenotypes) of asthma, which have different responses to therapy," said John Heffner, MD, past president of the ATS. "The task force identified that studies will need to characterize the clinical features of study patients during enrolment to 'type' their asthma and then note patterns of treatment responses for each type. With enough information, accurate type-specific measures to assess asthma control will emerge that will guide physicians in adjusting therapy for each phenotype." - Medscape Today FDA panel votes to eliminate Vicodin, Percocet June 30, 2009 Government experts say prescription drugs like Vicodin and Percocet that combine a popular painkiller with stronger narcotics should be eliminated because of their role in deadly overdoses.A Food and Drug Administration panel on Tuesday voted 20-17 that prescription drugs that combine acetaminophen with other painkilling ingredients should be pulled off the market. The FDA has assembled a group of experts to vote on ways to reduce liver damage associated with acetaminophen, one of the most widely used drugs in the U.S. Despite years of educational campaigns and other federal actions, acetaminophen remains the leading cause of liver failure in the U.S., according to the FDA. Panelists cited FDA data indicating 60 percent of acetaminophen-related deaths are related to prescription products. Acetaminophen is also found in popular over-the-counter medications like Tylenol and Excedrin. “We’re here because there are inadvertent overdoses with this drug that are fatal and this is the one opportunity we have to do something that will have a big impact,” said Dr. Judith Kramer of Duke University Medical Center. Many opposed to recommendation But many panelists opposed a sweeping withdraw of products that are so widely used to control severe, chronic pain. “To make this shift without very clear understanding of the implications on the management of pain would be a huge mistake,” said Dr. Robert Kerns of Yale University. In a separate vote, the panel voted overwhelmingly, 36-1, that if the drugs stay on the market they should carry a black box warning, the most serious safety label available. The FDA is not required to follow the advice of its panels, though it usually does. Prescription acetaminophen combination drugs were prescribed 200 million times last year, according to FDA data. Vicodin is marketed by Abbott Laboratories, while Percocet is marketed by Endo Pharmaceuticals. Both painkillers also are available in cheaper generic versions. The FDA convened the two-day meeting to ask experts to discuss and vote on a slew of proposals to reduce overdoses with acetaminophen. The drug has been on the market for about 50 years and many patients find it easier on the stomach than ibuprofen and aspirin, which can cause ulcers. Panel voted to lower maximum acetaminophen dose Earlier in the day, panelists took aim at safety problems with Tylenol and dozens of other over-the-counter painkillers. In a series of votes, the panel endorsed lowering the maximum dose of those products. FDA’s experts voted 21-16 to lower the current maximum daily dose of nonprescription acetaminophen, which is 4 grams, or eight pills of a medication like Extra Strength Tylenol. The group was not asked to recommend an alternative maximum daily dose. The panel also voted 24-13 to limit the maximum single dose of the drug to 650 milligrams. The current single dose of Johnson & Johnson’s Extra Strength Tylenol is 1,000 milligrams, or two tablets. In a third vote, a majority of panelists said the 1,000-milligram dose should only be available by prescription. However, panelists rejected a proposal to pull certain cold and cough medicines off the market because of their role in overdosing. The drugs in question, such as Procter & Gamble’s NyQuil or Novartis’ Theraflu, combine acetaminophen with other ingredients that treat cough and runny nose. The FDA says patients often pair the cold medications with pure acetaminophen drugs, like Tylenol, exposing themselves to unsafe levels of the drug. But panelists cited FDA data that said the medications play a minor role in acetaminophen overdoses, with only 10 percent of acetaminophen-related deaths involving a cold and cough product. “I don’t think we should be advocating a solution to a problem that really is not there,” said Dr. Osemwota Omoigui, of the Los Angeles pain clinic. The panel voted 24-13 to keep the products on the market. - msnbc Phoenix gets a new med-student program June 30, 2009 A new educational partnership at St. Joseph's Hospital and Medical Center could increase the number of medical students who ultimately decide to work as doctors in Arizona.A partnership with Creighton University School of Medicine, based in Omaha, Neb., will bring 42 Creighton students a year to St. Joseph's in Phoenix for their third and fourth years of training beginning in 2012. The new program adds another element to a growing central Phoenix presence for health care, research and training. In 2007, 24 students started classes at the University of Arizona's downtown Phoenix medical school. In 2008, 48 students started the four-year-program, and a third class of 48 will start soon. Creighton is a Catholic Jesuit institution with 4,000 undergraduate and 2,900 graduate students. Its medical school already sends about six students a month for rotations at St. Joseph's. When the medical school wanted to expand its enrollment, officials wanted to partner with a Catholic hospital for their training. St. Joseph's is Arizona's largest hospital and is owned by Catholic Healthcare West. Officials with both the hospital and university say they are a good match, with similar missions. While in Phoenix, the Creighton students will study surgery, family medicine, internal medicine, pediatrics, psychiatry, and obstetrics and gynecology. Creighton will admit 152 students to its program next year, and 42 of them will be eligible to come to St. Joseph's in 2012 for their third and fourth years of training. The new program will be known as Creighton University School of Medicine at St. Joseph's Hospital and Medical Center. Catholic Healthcare West has been working on the deal for four years, said Linda Hunt, service-area president for the company. "Another private medical school in downtown Phoenix adds excitement," she said. "It gives us the ability to educate more physicians for the Southwest." Dr. John Boyd, St. Joseph's chief medical officer, said, "We think it is a wonderful opportunity to continue our faith-based mission here with a partner that has a similar mission, values and core beliefs as us." Each year, the facility helps train about 240 third- and fourth-year medical students, Boyd said. The facility will continue its affiliations with other schools, including UA, and expand the number of positions for fourth-year students, but it won't significantly increase the number of students on site. The Creighton students will displace some of the students from other schools training at the facility, but the Creighton students will be more likely to stay in the area after graduation, Boyd said. Instead of having students from schools in New York, Pennsylvania or other states drop in for a month at a time, the Creighton students will live in Phoenix for their entire third year of school and parts of their fourth year. Many physicians choose to practice medicine where they get their hands-on experience. "This will be their education home," Boyd said. "Our hope would be that after their clerkships, they stay in the area to do their residency training, and then they have a much higher potential to stay in the area to practice medicine." That would benefit the region as the nation scrambles to find enough health-care workers to serve a growing and aging population. "Anytime you can bring in some residents or interns, it helps, and that is a big number of students to bring in," Tony Mitten, chief executive of the Maricopa County Medical Society, said of the Creighton plans. "The question is: 'Will these students and residents stay here?'" An October report from the Association of American Medical Colleges projects that demand for doctors will outpace supply through at least 2025, when the nation will have at least 124,000 fewer physicians than it needs. The new affiliation will allow Creighton to increase its enrollment to 152 entering medical students from the current 126, said Dr. Rowan Zetterman, Creighton's medical dean. "We believe there will be a number of students coming to us from the Southwest who will want to finish their education closer to their homes and parents," he said. The current class of students at Creighton has 12 from the Southwest, and Zetterman said the school will increase recruitment in the region because of the partnership. Danielle Potter, 28, from Hawaii, is one of the few Creighton students who was able to complete a clerkship at St. Joseph's, which she said she recommends because of the high volume of patients. "You get a good experience, and it's warmer (in Phoenix) than Nebraska," she said. She just began a four-year residency at the hospital but must return to Hawaii when finished to meet the obligations of a scholarship. "I went to Creighton because they have a lot of faculty that really care about the students, and you have that same feeling at St. Joseph's," she said. Other regional medical-school programs also are in growth mode. UA's goal is to grow classes so it can graduate 150 new doctors each year, more than three times the current class size of 48 students. Those plans hinge on funding that is being negotiated at the state Legislature. Midwestern University in Glendale also has expanded its osteopathic medical school. - azcentral.com Medical bills tied to 60 percent of bankruptcies June 15, 2009 Medical bills are involved in more than 60 percent of U.S. personal bankruptcies, an increase of 50 percent in just six years, U.S. researchers reported on Thursday.More than 75 percent of these bankrupt families had health insurance but still were overwhelmed by their medical debts, the team at Harvard Law School, Harvard Medical School and Ohio University reported in the American Journal of Medicine. "Using a conservative definition, 62.1 percent of all bankruptcies in 2007 were medical; 92 percent of these medical debtors had medical debts over $5,000, or 10 percent of pretax family income," the researchers wrote. "Most medical debtors were well-educated, owned homes and had middle-class occupations." The researchers, whose work was paid for by the Robert Wood Johnson Foundation, said the share of bankruptcies that could be blamed on medical problems rose by 50 percent from 2001 to 2007. "Unless you're Warren Buffett, your family is just one serious illness away from bankruptcy," Harvard's Dr. David Himmelstein, an advocate for a single-payer health insurance program for the United States, said in a statement. "For middle-class Americans, health insurance offers little protection," he added. The United States is embarking on an overhaul of its healthcare system, which is now a patchwork of public programs such as Medicare and employer-sponsored health insurance that leaves 15 percent of the population — 46 million people — with no coverage. About 170 million people get health insurance through an employer but President Barack Obama says soaring health care costs are hurting the economy and forcing businesses to drop medical insurance for their workers. "Nationally, a quarter of firms cancel coverage immediately when an employee suffers a disabling illness; another quarter do so within a year," the report reads. Obama told Congress on Wednesday he was open to making mandatory health insurance part of the overhaul but only with exemptions for the poor and for small businesses. Neither Congress nor Obama are considering the kind of single-payer plan advocated by Himmelstein and his colleague Dr. Steffie Woolhandler. "We need to rethink health reform," Woolhandler said. "Covering the uninsured isn't enough. "Only single-payer national health insurance can make universal, comprehensive coverage affordable by saving the hundreds of billions we now waste on insurance overhead and bureaucracy." The researchers surveyed 2,134 random families who filed for bankruptcy between January and April in 2007, before the current recession began. They used public bankruptcy court records and survey 1,032 respondents by telephone. While only 29 percent directly blamed medical bills for their bankruptcy, 62 percent had medical bills that totaled more than 10 percent of family income, said an illness was responsible, had lost income due to illness or some other medical factor. "Among common diagnoses, nonstroke neurologic illnesses such as multiple sclerosis were associated with the highest out-of-pocket expenditures (mean $34,167), followed by diabetes ($26,971), injuries ($25,096), stroke ($23,380), mental illnesses ($23,178), and heart disease ($21,955)," the researchers wrote. - msnbc.com Obama: Health care a 'ticking time-bomb' June 15, 2009 President Barack Obama is urging doctors gathered in Chicago to support wider insurance coverage and targeted federal spending cuts — calling health care "an escalating burden on our families and businesses."Obama spoke at the American Medical Association's annual meeting in his hometown Monday, tellings attendees that a system overhaul cannot wait. "Today, we are spending over $2 trillion a year on health care — almost 50 percent more per person than the next most costly nation," said the president. "And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren't any healthier." He continued, "Make no mistake — the cost of our health care is a threat to our economy ... It is a ticking time-bomb for the federal budget. And it is unsustainable for the United States of America." Obama added that the high cost of employee health care contributed to the financial woes of General Motors and Chrysler. "If we do not fix our health care system, America may go the way of GM — paying more, getting less, and going broke." The president told his audience he is open to requiring all Americans to have health insurance. But he emphasized that the plan he envisions would permit continuing help for those who cannot afford it on their own. Obama said a "health care exchange" would be set up for the uninsured to choose a plan. The nation's doctors, like many other groups, are divided over the president's proposals to reshape the health care delivery system. The White House anticipates heavy spending to cover the almost 50 million Americans who lack health insurance and has taken steps in recent days to outline just where that money could be found. For instance, Obama wants to cut federal payments to hospitals by about $200 billion and cut $313 billion from Medicare and Medicaid over 10 years. He also is proposing a $635 billion "down payment" in tax increases and spending cuts in the health care system. Persuading skeptics Obama's turn before the 250,000-physician group is his latest effort to persuade skeptics that providing health care to all Americans is worth the $1 trillion price tag it is expected to run during its first decade. Unified Republicans and some fiscally conservative Democrats on Capitol Hill have said they are nervous about how the administration plans to pay for Obama's ideas. There have been indications Obama has been quietly making a case for reducing malpractice lawsuits to help control costs, long a goal of the AMA and Republicans. Obama has not endorsed capping jury awards Former Senate Majority Leader Tom Daschle, D-S.D., said Monday that controlling the cost of malpractice insurance would have to be a part of the Obama administration's overhaul of the health care system. Daschle, whose nomination for secretary of health and human resources was derailed because of questions about his personal finances, said much of the unnecessary annual health care cost can be attributed to doctors ordering extra tests and taking extra precautions to make sure "they aren't sued." Obama has been speaking privately with lawmakers about his ideas and publicly with audiences, such as a town hall style meeting last week in Green Bay, Wis. Obama and his administration officials have blanketed the nation in support of his broad ideas, and Vice President Joe Biden on Sunday said it's up to Congress to pin down the details on how to pay for them. "They're either going to have to agree with us, come up with an alternative or we're not going to have health care," Biden told NBC's "Meet the Press." "And we're going to get health care." What it means for physicians Obama's proposed cuts in federal payments would hit hospitals more directly than doctors, but physicians will be affected by virtually every change that Congress eventually agrees to. Many medical professionals are not yet convinced Obama's overhaul is the best for their care or their pocketbooks. Broadly, the AMA supports a health care "reform" — a term that changes its definition based on who is speaking — although the specifics remain unclear. In a statement welcoming Obama, AMA president Dr. Nancy Nielsen said the medical profession wants to "reduce unnecessary costs by focusing on quality improvements, such as developing best practices for care and improving medication reconciliation." She also said doctors need greater protection from malpractice lawsuits and antitrust restrictions. Many congressional Republicans, insurance groups and others oppose Obama's bid for a government-run health insurance program that would compete with private companies. On Sunday, Senate Minority Leader Mitch McConnell, R-Ky., described a government plan as a "nonstarter." "There are a whole lot of other things we can agree to do on a bipartisan basis that will dramatically improve our system," he said. Considering a compromise To that end, lawmakers were considering a possible compromise that involved a cooperative program that would enjoy taxpayer support without direct governmental control. The concessions could be the smoothest way to deliver the bipartisan health care legislation the administration seeks by its self-imposed August deadline, officials said. "There is no one-size-fits-all idea," Health and Human Services Secretary Kathleen Sebelius told CNN's "State of the Union" on Sunday. "The president has said, 'These are the kinds of goals I'm after: lowering costs, covering all Americans, higherquality care.' And around those goals, there are lots of ways to get there." Momentum might be on Obama's side. Aaron Carroll, an Indiana University medical professor who has surveyed doctors' views on U.S. health care delivery, said 59 percent "favor government legislation to establish national health insurance," an increase over a previous poll's finding. He noted that many doctors are not AMA members, and therefore the association's views should not be overrated. - msnbc.com Practices feel financial pressure as patients ration their own care June 15, 2009 When administrative staff quit the nine-physician practice of Joseph Stubbs, MD, an internist in Albany, Ga., they are not replaced. To generate additional revenue, a room that contained paper charts before the practice switched to electronic medical records has been rented to a vascular surgeon.The group has had to take these actions because, although sick patients are coming in for care, they are not returning when they are well. They are foregoing check-ups and other preventive services. "I'm not kicking anybody out of the practice because they cannot pay me, but a lot of people just are not coming in," said Dr. Stubbs, who also is president of the American College of Physicians. The national unemployment rate hit 9.4% in May, and medical society surveys indicate Dr. Stubbs' experience is not unique. Patients are delaying or skipping all kinds of health care, and as a result physician practices are having to take steps to maintain financial viability. "Health care in general was protected from major changes in the economy. This [recession] has been a lot slower coming to health care, but ... clearly we are starting to catch up," said Cecil B. Wilson, MD, an internist in Winter Park, Fla., and a member of the American Medical Association's Board of Trustees. Practice patterns are changing The issue isn't just patients cancelling or failing to schedule appointments. Physicians also are noticing changes in who shows, and why, for routine care. For instance, Michael Barrow, MD, a Dayton, Ohio, family physician specializing in sports medicine, is caring for more people on Medicaid because long-standing patients have lost their employer-sponsored insurance. The effect on the bottom line for his practice at Samaritan North Family Physicians means no more overtime pay for hourly staff. In addition, Dr. Barrow is having trouble staying on schedule because patients are trying to get more issues cared for in a single visit. "They try to do a lot of things in one visit," said Dr. Barrow. "Sometimes it's overwhelming. It's harder and harder for me to keep on time." Data back up anecdotal stories An American Academy of Family Physicians survey released in May found 89% of its members were seeing more patients expressing concerns about their ability to pay for health care, and 58% were seeing an uptick in appointment cancellations. Patient coverage also has changed, with 73% of the family doctors reporting more patients without insurance, and 38% seeing an increase in patients on Medicaid. Overall, 54% of the doctors said they were seeing fewer patients, and 44% were cutting services and reducing staff, or considering doing so. "When it comes down to paying for gas or buying food, some people are putting off that health care visit until they feel like they are really dying," said Ted Epperly, MD, AAFP president. "I know of colleagues who have reduced services, cut staff and reduced hours. For the most part, nobody has just closed up shop, but [the recession] clearly has impacted them as well." About 35% of family physicians also reported that more of their pediatric patients were missing regular check-ups. The American Academy of Pediatrics is querying its own members on this subject. The first signs that health care would not go unscathed in this economic downturn emerged in data on elective procedures such as cosmetic surgeries. According to a report issued March 25 by the American Society of Plastic Surgeons, the amount of money spent on cosmetic procedures declined 9% from 2007 to 2008. A report from the American Hospital Assn., issued April 27, found 59% of hospital chief executive officers reported a moderate or significant decrease in elective procedures. Anecdotal evidence suggests this is not just because some patients have lost their jobs and private insurance. Most people -- physicians and patients -- have had some kind of financial loss in this recession. Patients who have insurance have higher co-pays. Some of those who still have jobs have seen their salaries reduced. They also may have been impacted economically if other household members have lost their livelihoods. "Most people have taken some sort of hit financially. They're feeling less secure or more vulnerable," said Dr. Epperly, program director and CEO of the Family Medicine Residency of Idaho in Boise. "I've lost 45% of my retirement savings. My job is secure. My retirement right now is kind of iffy. I don't know anybody who has not been impacted." Some insurance relief For those who have lost their jobs, the COBRA subsidy passed as part of the American Recovery and Reinvestment Act of 2009 has helped some, but by no means all. People who lose their health insurance as a result of being laid off between Sept. 1, 2008, and Dec. 31, 2009, will only have to pay 35% of the COBRA premium rate for up to nine months. But many physicians say it is still unaffordable for many who need it. "Even with the subsidy, for some it is out of the question," Dr. Stubbs said. Physicians say, however, that paying for services is not the only issue interfering with patient access to care. Time may become even tighter as patients take on multiple jobs to piece together a living. "Many patients are emotionally and financially hunkered down," said Iffath Hoskins, MD, a former vice president of the American College of Obstetricians and Gynecologists and chair of the ob-gyn department at Lutheran Medical Center in Brooklyn, N.Y. ACOG released a Gallup poll at its 57th annual clinical meeting in Chicago May 5 that found 14% of women ages 18 to 44 were postponing their annual ob-gyn checkup. In addition, 15% of women in this age group reported cutting back or stopping taking a medication because of cost. While physicians are taking steps toward their own economic survival, they also are taking steps to help their patients weather the crisis with their health intact. The AAFP survey found 71% of family physicians are providing more uncompensated care. Some physicians said they were downcoding visits to fit a patient's budget or working out no-interest payment plans. Free medication samples are being pursued more aggressively, and physicians and staff are gathering resources on free or low-cost health services to share with patients in need. The biggest concern, however, is about the patients who stop showing up completely. Medical society officials want physicians to encourage patients to make the appointments they need, then deal with any necessary financial arrangements. Physicians are being urged to ask patients about economic difficulties they may be experiencing. Patients "don't necessarily bring financial hardship to the attention of the physician," Dr. Epperly said. "But all of us should ask about this." - American Medical News WHO Increases Pandemic Alert Level to Phase 6 June 15, 2009 The World Health Organization (WHO) has increased the pandemic level to phase 6, the final alert phase, indicating that a global pandemic of influenza A (H1N1) is under way.According to the WHO, pandemic alert level phase 6 is characterized by "community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5." Phase 5 is characterized by human-to-human transmission of the virus into at least 2 countries in 1 WHO region. After holding an emergency meeting with its influenza experts, the WHO said it has raised the pandemic warning level from phase 5 to 6, according to a statement sent to health officials. WHO Director Dr. Margaret Chan made the announcement during a press conference today. Scientific Criteria Met "The world is now at the start of the 2009 influenza pandemic," she said. "The scientific criteria for a pandemic has been met." According to Dr. Chan, further spread is considered inevitable, "but no previous pandemic has been detected so early or watched real time right at the very beginning." "The virus is stable" and it looks very similar among countries, Dr. Chan said. "We need to continue to check this virus and monitor it. We should never forget...we still have H5N1 in phase 3 pandemic alert status, and this is the first time we have 2 viruses coexisting...it is an extremely unusual situation." She added that the virus can change the rules without rhyme or reason at any time, and it will be important to see how the virus changes as it returns to the Northern hemisphere in the fall. The H1N1 virus is of "moderate severity" with most people making a rapid and full recovery often in the absence of treatment, and the number of deaths is small. She pointed out that pregnant women are at increased risk for complications, and the virus preferentially infects younger age groups, under age 25 years. She added that it is unknown how this virus will behave under conditions in the developing world. The WHO says that it continues to put no restrictions on travel. Because of the susceptibility of the population, "influenza pandemics are remarkable events," she said, "but we are all in this together." As of today, the WHO is reporting nearly 30,000 confirmed cases from 74 countries. Pandemic Level Increase "Not a Surprise" At a press briefing immediately after the WHO announcement, Thomas R. Frieden, MD, MPH, who assumed the role of US Centers for Disease Control and Prevention (CDC) director on Monday, commented on the WHO's decision, stating that the increase to pandemic level phase 6 was "not a surprise" and that it was "expected based on the data." According to Dr. Frieden, the WHO waited until they were certain that they had documentation that on multiple continents that the virus was being transmitted from person to person in a sustained way and this "basically meets our definition of a pandemic." The key goals are to determine where the virus is spreading and to reduce its impact, "particularly on those who are most vulnerable — people with underlying health conditions and infants as well in this case," he said. Also at the briefing, Anne Schuchat, MD, the interim deputy director for science and public health program and director of the CDC's National Center for Immunization and Respiratory Diseases, noted that there are more than 13,000 confirmed cases reported in the United States. "There are over 1000 people who have been hospitalized that have been reported to us, and our last update on the counts of death are 27, but we'll be updating that soon and I do, unfortunately, expect that number to rise," she said. According to Dr. Schuchat, increases in influenza cases above normal levels for this time of year are still being observed in region 1 (New England) and region 2 (New York and New Jersey). CDC Was Responding as if to Pandemic Already "People think it is over, but we need to remain vigilant," she said. However, she pointed out that the CDC has been "reacting as though we were in a pandemic already in terms of our intensive efforts to prepare individuals and respond as a nation." According to Dr. Schuchat, 57% of the cases have occurred in people aged 5 to 24 years, and 41% of hospitalizations were also within that age range. The highest rates of hospitalizations are in children younger than 5 years. Of the hospitalizations, 71% have occurred in people with an underlying condition. "As we have noted, there's been a disproportionate amount of pregnant women among those who have had infection," she said. "What this declaration does do is remind the world that flu viruses like H1N1 need to be taken seriously," Health and Human Services Secretary Katherine Sebelius said in a news release today. "Although we have not seen large numbers of severe cases in this country so far, things could possibly be very different in the fall, especially if things change in the Southern hemisphere, and we need to start preparing now in order to be ready for a possible H1N1 immunization campaign starting in late September," she noted. - Medscape Today Medicaid Rules Linked to More Adverse Outcomes in Mentally Ill, Increased Mental Health Costs June 15, 2009 Some state Medicaid requirements meant to save money are associated with more adverse outcomes among mentally ill patients and might actually be increasing mental-health costs, new research suggests.Practices such as requiring a switch to generics, placing limits on the number or dosing of medication, requiring prior authorization, and requiring use of step therapy or fail-first protocols were associated with a greater number of adverse events in patients, the study authors, led by Joyce C. West, PhD, from the American Psychiatric Institute for Research and Education, in Arlington, Virginia, conclude. The investigators also conclude that states with more prescription-drug-management practices in place had significantly higher medication-access problems. After adjusting for patient case mix, the researchers found that patients with medication-access problems had a 3.6 times greater likelihood of experiencing a significant adverse event. “Medication-access problems were highly associated with utilization-management features and with adverse events. Medicaid prescription-drug-management policies that are based primarily on cost rather than clinical considerations may result in significant human, economic, and social costs," Dr. West, told Medscape Psychiatry. The study is published in the May issue of Psychiatric Services. Ten State Programs Examined The study looked at prescription-drug-management features in 10 state Medicaid programs, at medication-access problems among psychiatric patients in those 10 states, and at adverse events in those patients, including emergency-department visits, hospitalizations, homelessness, suicidal ideation or behavior, or incarceration. Data were collected from 857 psychiatrists in California, Florida, Georgia, Massachusetts, Michigan, New York, Ohio, Pennsylvania, Tennessee, and Texas. Psychiatrists in the study reported 5 common medication access problems: * 34% of patients could not access clinically indicated medication refills or new prescriptions because Medicaid would not cover or approve them. * 29% could not be prescribed the physician's preferred medication because of drug-coverage or -approval issues or because patient could not make copayments. * 26% of patients discontinued a drug as a result of prescription-drug-coverage or -management issues or problem with copayments. * 25% of patients were prescribed a medication not clinically preferred because clinically indicated or preferred medications were not covered or approved. * 14% of patients had problems accessing medications because of copayments. According to the study, patients who had problems with copayments had a nearly 8-fold greater likelihood of experiencing an adverse event. All of the access problems were associated with increased emergency visits and psychiatric hospitalizations. Access Problems, Adverse Events Of the 10 states studied, New York, Texas, and California had the lowest rates of access problems, while Ohio, Florida, Massachusetts, Pennsylvania, Tennessee, Georgia, and Michigan all had higher rates. "The bottom line in terms of implications and inferences from this study would be that those utilization-management features we were able to study — copays, prior authorizations, step therapy, etc — and the differences in the utilization-management features and the ways they were operating or functioning across the states appear to be associated with medication-access problems and adverse events," Dr. West said. Alyce S. Adams, PhD, who is a research scientist at Kaiser Permanente in Oakland, California, who recently completed a study showing prior-authorization policies for antidepressants had no adverse effect on patient outcomes, said the current study raises some questions about the researchers' classification of states' restrictive drug policies. "The authors have chosen an important topic and provide sobering data on persistent barriers to access among patients as reported by psychiatrists. However, the findings regarding the link between psychiatrist-reported patient outcomes and state Medicaid policies must be interpreted with caution." Drug Caps an Important Omission "As the authors acknowledge, cross-sectional studies cannot provide evidence of causality. Further, the inclusion of psychiatrists with varying exposure to the Medicaid program and reliance on self-reports of outcomes are additional threats to the internal validity of the study findings," Dr. Adams told Medscape Psychiatry. It is important to note, she added, that the investigators may have omitted 1 of the most powerful policy instruments available to states from their analysis — drug caps. "The authors describe limits on the number of medications, which I assume to mean restrictions on days' supply of medications (eg, 30 days). Drug caps, limits on the number of drugs that the state will reimburse per month (eg, 3 per month) are a less popular but more restrictive policy used by some state medication programs to control costs. Two of the states described as less restrictive by the authors have limits on the number of reimbursable prescriptions per month," she added. According to Dr. Adams, there is very strong evidence that caps on the number of reimbursable prescriptions per month and cost sharing reduce use of medications, even clinically essential medications, among the mentally ill. "Given that mental illness is generally undertreated, it may make sense for states to exclude these populations from such blunt policy instruments. The utility of other mechanisms such as prior authorization may vary, depending on the patient population and the implementation strategy," she said. Dr. Adams warned that states should consider the evidence from rigorous studies of patients with mental illness and implement monitoring policies to identify and address problems should they arise following implementation of restrictive prescription-drug policies. - Medscape Medical News Medicine decries nurse doctorate exam being touted as equal to physician testing June 15, 2009 Physician leaders say a new doctor of nursing practice certification exam is being wrongly compared with testing that physicians take. And they fear that patients may be misled into believing nurses who pass the exam share the same qualifications as physicians.Last fall, the National Board of Medical Examiners began offering the voluntary DNP test, based in part on Step 3 of the U.S. Medical Licensing Examination. Step 3 is the final stage in the physician testing series. In January, the Council for the Advancement of Comprehensive Care -- a nonprofit nursing group that contracted with the NBME to develop the exam -- announced the results of the first DNP certification test, with 50% of candidates receiving passing scores. In its announcement, the CACC said the exam "was comparable in content, similar in format and measured the same set of competencies and applied similar performance standards as Step 3 of the USMLE, which is administered to physicians as one component of qualifying for licensure." In past statements, the NBME stated that the scope of the DNP exam was "materially different" from physician testing, in addition to differences in underlying training. Physician leaders are chastising nursing organizations for what they say is a failure to portray the certification exam accurately. They also want the NBME to step in and further clarify that the DNP exam and physician tests are not equivalent. "Our concern prior to the first round of testing was that the meaning of this test would be deliberately misconstrued to imply there was equivalence between nurses and physicians. And indeed some of the first statements seem to go in the direction of making those comparisons, which we believe are totally invalid and misleading to the public," said American Medical Association Board of Trustees member William A. Hazel Jr., MD. The AMA and dozens of state and specialty medical organizations are asking the NBME to mandate that nursing groups clearly spell out the differences between the DNP and physician exams. At this article's deadline, the AMA House of Delegates was expected to consider, at its mid-June Annual Meeting, a resolution proposing to explore alternative physician licensing testing options. The resolution calls for the AMA to withdraw representation from the NBME if the testing organization fails to act to safeguard the integrity of the physician licensure process. Doctors said they support advances in nursing education, which can contribute to a physician-led care team. But there are significant differences in testing and training that should not be minimized, Dr. Hazel said. "For patients to make an informed decision, they need to know who is caring for them, what their level of training is and in what field. To the extent those lines are blurred, that [decision-making] becomes even harder," he said. A push for scope expansions The CACC in prior statements said the test was intended to set a uniform credentialing standard "to provide further evidence to the public that DNP certificants are qualified to provide comprehensive patient care" and help fill primary care shortages. The test comes at a time when DNP programs are growing. In 2008, more than 90 DNP programs were offered at nursing schools nationwide, up from 53 in 2007, according to the American Assn. of Colleges of Nursing. It wants more than 200 nursing schools to offer DNP programs by 2015. Physicians are concerned that nurses will leverage such DNP programs and the NBME test to seek scope-of-practice expansions. The AMA, the American Academy of Family Physicians and other physician organizations, in letters to the NBME, pointed to an article in the Jan. 16 Chronicle of Higher Education. Mary O'Neil Mundinger, DrPH, RN, dean of Columbia University School of Nursing in New York, was quoted as saying: "If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients." Mundinger, CACC president, declined comment for this article. Physician organizations say that a lack of response from the NBME will only add credibility to such statements as Mundinger's and compromise patient care. "It's very important the delineation between nursing degrees and physician degrees is not obscured and patients aren't misled," said Roger A. Moore, MD, president of the American Society of Anesthesiologists. He cited examples of DNPs referring to themselves as "doctor" in the clinical setting. Nursing schools also have adopted terms such as "residency" and "fellowship" as part of their doctoral programs. Use of the USMLE Step 3 "appeared to be one more step in that direction for nurses to be able to claim they have the same credentials as physicians ... and that's a misrepresentation," Dr. Moore said. American Assn. of Colleges of Nursing President C. Fay Raines, PhD, RN, said the DNP degree does not change nurses' scope of practice, which would be up to state legislatures. However, such programs "are similar [to obtaining a medical degree] in that they involve advanced preparation ... and certainly there are some things that are common across disciplines," said Raines, dean of the University of Alabama in Huntsville College of Nursing. Many states, for example, recognize advanced practice nurses' ability to independently treat and diagnose patients, as well as prescribe medications. Other health professions are moving toward practice doctorates to respond to primary care shortages and an aging population, Raines said. The NBME's certification exam for DNPs is an additional, voluntary credential, Raines added. "But it's always important for people to be recognized in areas in which they are experts." Transparency is important, but the term "doctor" is not exclusive to physicians, she said. NBME's role questioned The NBME declined comment for this article. In a position paper posted on its Web site, the organization said it had not received any substantiated reports that DNPs misrepresented their training abilities. AAFP President Ted Epperly, MD, questioned the NBME's endorsement of the test. "This is the National Board of Medical Examiners. These are nurses, not physicians ... and it only confuses the public." According to the NBME, the DNP certification exam draws on portions of the USMLE Step 3 that test skills and knowledge related to patient management. It does not include assessments of fundamental science, clinical diagnosis or clinical skills included in the other two portions of the physician test. Dr. Epperly said the DNP test uses defunct USMLE questions -- not current ones -- and applies a different performance standard, one set by a CACC-appointed committee. Delegates at the AMA's 2008 Annual Meeting voted to oppose the NBME's participation in the DNP test, and supported legislative and other efforts to ensure health professionals' clearly identify their qualifications to patients. The NBME defended its decision to offer the test as consistent with its mission. "Current and future patients of these nurse clinicians deserve a system that assures them that the clinician providing services meets appropriate quality standards. Our support for the DNP assessment process helps provide that assurance," stated the NBME position paper released, in part, in response to physicians' concerns. Now that the test is out there, however, the NBME has an obligation to clear up the confusion to protect patients and physicians, Dr. Epperly said. - American Medical News Vaccine Fights Melanoma June 15, 2009 For the first time, a vaccine that trains the immune system to seek out and attack cancer cells has been shown to shrink tumors in people with melanoma.In a study of 185 melanoma patients, the experimental vaccine also extended the time that people remained free of cancer. There are even indications that people given the vaccine live longer, but patients need to be followed longer before researchers can be sure, says Patrick Hwu, MD, head of melanoma medical oncology at the University of Texas M.D. Anderson Cancer Center in Houston. Hwu presented the results at the annual meeting of the American Society of Clinical Oncology. Melanoma Vaccine: How It Works Unlike the vaccine that helps prevent cervical cancer in healthy women, the melanoma vaccine is designed to help people who already have cancer. The vaccine is given along with interleukin-2, or IL-2, the standard treatment for melanoma. IL-2 stimulates the immune system to attack and kill cancer cells. Tumors shrink in one in four patients with advanced melanoma who get this treatment. The vaccine contains a substance, called gp100, that is on the surface of melanoma cells. The idea is that the immune system will see this as a threat and incite an even stronger attack against cancer cells. “The vaccine is capable of taking immune system soldiers to boot camp. Then, interleukin-2 multiplies them into an army,” Hwu tells WebMD. Melanoma is the deadliest form of skin cancer. This year in the U.S., there will be an estimated 68,720 new cases and 8,650 deaths from the disease, according to the American Cancer Society. Melanoma Vaccine Shrinks Tumors In the study, people with advanced melanoma were given the vaccine or a placebo injection, followed by four days of intravenous interleukin-2 treatment. This was repeated every three weeks until the tumor shrank or the cancer progressed. Tumors shrank in 22% of patients given the vaccine plus interleukin-2, compared with 10% of those given interleukin-2 alone. The vaccine also extended the time until the cancer started growing, from about one-and-a-half months for interleukin-2 alone to nearly three months for the one-two punch. That may not sound like much, but cancer advances are made in baby steps, says Len Lichtenfeld, MD, deputy medical director of the American Cancer Society. Lichtenfeld tells WebMD that there’s reason for “cautious optimism.” A lot of cancer vaccines that seemed promising in early studies haven’t panned out, he says. Louis M. Weiner, MD, head of the Lombardi Comprehensive Cancer Center in Washington, D.C., says the vaccine study is the latest in a series showing that the immune system can be mobilized to attack cancer. “Many of us believe that a combined approach that includes an immune system attack on cancer cells will ultimately prove to be most useful in controlling cancers such as melanoma,” he tells WebMD. Hwu says the next step is to try to reproduce the findings in a longer, larger study. Also, his team hopes to add yet another punch -- in the form of an agent that takes the brakes off the immune system. Then, the immune system soldiers can proliferate with impunity, hopefully killing even more cancer cells, he explains. - Medscape Today Some Doctors In Arizona Are Pulling The Plug On EMR June 01, 2009 Recently a friend of mine got rid of all his TV-related technology, reasoning that the once-simple act of sitting down in front of the boob tube had gotten bogged down with such technological “advances” as digital video recording, plasma display panels, Blu-Ray, HDTV and the like. Sure enough, after losing everything except for his remote-less television set and a converter box, he seems happy. Getting up to change the channel isn’t so bad, he says, when you’ve only got two channels to choose from.A little of that might be going on among physician groups in central Arizona. Dan Mitten, executive director of the Maricopa County Medical Society, said that, judging by conversations with physicians in the state, as well as a couple of internal studies, the rate of “deinstallation” among Arizona physician practices—wherein these practices opt out of their electronic medical record contracts due to affordability or adaptation issues—is around 20 percent. That’s kind of a shocking (if somewhat anecdotal) figure, seeing as Arizona is a self-proclaimed leader in the state health information technology movement. As mentioned in the 2009 Phoenix Market Overview, the market’s two top hospital systems, Banner Health and Catholic Healthcare West, have made the switch to electronic medical records, as has The Mayo Clinic and the Carl T. Hayden VA Medical Center. Part of the state’s ahead-of-the-curve position stems from a 2005 executive order by then-Gov. Janet Napolitano that called for all healthcare providers to have EMR systems up and running by 2010. Many of the benefits of EMR to physician practices should be apparent from the first day of installation. There are administrative benefits, such as improved inter-office communication, reduced copying expenses and fewer lost charts, and clinical benefits, such as better documentation of patient visits, automatic medication management and automatic allergy alerts. Long-term benefits of EMR include reduced transcription costs, lower chart and file storage expenses, and, in some cases, reduced premiums on malpractice insurance. So why are one in five practices pulling the plug? There are several reasons, physicians report. They say getting administrative staff to work with the new software is like pulling teeth; the expensive systems, which can cost as much as $30,000, need a host of expensive upgrades, and the simple act of writing a prescription can take five times as long on a computer as it does with pen and paper. It’s easy to see how a physician practice, especially a small one, might opt out of its EMR deals. Brad Tritle, executive director of Arizona Health-e Connection, a nonprofit private-public partnership created in 2005 to support successful health infrastructure in the state, chalks EMR deinstallation up to the “Wild West” climate going on in central Arizona right now, where competition among technology providers is so heated that EMR salespeople could be making promises that their products can’t deliver. Tritle predicts—and welcomes—another couple of years of competition and innovation before a clear winner emerges to provide the simple, affordable EMR solution sought after by physician practices big and small. In the meantime, there’s the Purchasing Assistance Collaborative for Electronic Health Records (PACeHR), a state-sponsored purchasing and assistance program designed to accelerate electronic health and medical record adoption among physician groups. Scheduled for June 2009 availability, PACeHR (pronounced “pacer”) will offer group purchase discounts and other incentives to make EMR software and training more affordable and more predictable. Perhaps most importantly, the program will “promote a community of information sharing,” so physicians won’t feel so all alone in the technology wilderness. - Chris Clancy Hot trend: Retail clinics fight for customers June 01, 2009 If you have been laid off and lost your health benefits, NextCare Urgent Care has a deal for you. Arizona's largest chain of urgent-care clinics wants to lure patients with an offer of discounted health services to the jobless. The Mesa-based company also has pitched its services to smallbusinesses that are struggling to afford skyrocketing health insurance premiums for employees. The reason: NextCare is attempting to drum up business in bad economic times. "We certainly have seen a decrease in our patient volume," said Dr. John Shufeldt, the founder and chief executive officer of NextCare. "People are putting off health care." Urgent-care clinics such as NextCare thrived during boom times, establishing sites in far-flung shopping centers. These retail clinics bill themselves as convenient care for busy families, the uninsured and those without a primary-care physician. Though these retail operations have proliferated in recent years, the facilities have discovered they are not immune to the tough economy. People are losing their jobs and insurance, and many have responded by skimping on health care, particularly medical procedures that are needed but not immediately necessary. But these urgent-care centers, which often take cash payments, see a niche opportunity to provide health care to the newly uninsured. "It is hitting everybody," said Cathy Torba, administrative manager for Maricopa Urgent Care. "We are seeing patients who say, 'I just lost my job and my insurance' . . . Money is tight." Maricopa Urgent Care opened in 2006 on the heels of the housing boom that transformed the small town into a fast-growing suburb. Today, the housing market's woes have churned through the community. One result is that more Maricopa Urgent Care customers arrive without health insurance and struggle to pay their bills. Other retail health clinics haven't been as lucky. MediMin, a Goodyear retail clinic, recently closed its locations inside two Bashas' stores and one Food City store. Health clinics located inside grocery stores typically offer less-comprehensive medical service than urgent-care centers such as NextCare and Maricopa Urgent Care. Urgent-care clinics are usually staffed by physicians, while in-store clinics such as MediMin and Minute Clinic hire nurse practitioners or physician's assistants to provide care. MediMin representatives say the chain was negotiating a deal that could yield new locations in the Phoenix area. The company did not say why its three stores closed. Cash customers NextCare, which has 17 clinics in the Phoenix area, has responded to the downturn with a series of moves aimed at reaching more patients. The clinic is marketing its ValueCare to patients who must pay cash because they no longer have health insurance. For a one-time fee of $35, patients can access health-care services for a flat fee of $80 for a standard office visit. If a patient needs a procedure such as a blood sample or an Xray, the visit costs $125. Since NextCare began promoting ValueCare, the chain has seen a spike in the number of patients choosing the option. Shufeldt, who also is an emergency-room physician at St. Joseph's Hospital and Medical Center, started the cash option to address what he believed was an unfair reality in health care: Those without health insurance typically pay much higher prices than insured patients for identical medical services. The reason: The insured patients are part of a larger group that has the ability to negotiate discounted prices. NextCare typically makes less money on patients who pay cash than those who have insurance. Still, it keeps patients coming who may otherwise skip health care. NextCare also has offered ValueCare to businesses that dropped out of Healthcare Group of Arizona, the state's health insurance plan for small businesses. The state capped enrollment in the government-backed plan for small businesses. Other businesses have found that the premiums for the state-backed plan are not affordable. "It is becoming more and more challenging for small businesses to provide insurance," said Laurel Spoimenoff, president of NextCare. "If we offer urgent care for these businesses at discounted prices, it is mutually beneficial." Doctors provide care Medical experts say it was not surprising to see retail health outlets resort to creative ways to appeal to customers in bad economic times. "It (urgent care) is an option for people who need the basic stuff," said Anthony Mitten, chief executive officer of Maricopa Medical Society. Mitten said urgent-care clinics may be an option for people who need an immunization or quick treatment for the flu. Still, he said, these retail clinics often cannot provide the same level of care as a doctor. "A (primary-care doctor) who has your complete medical history is going to treat you a lot more comprehensively," he said. Mitten added that most patients should talk to their own doctor if they lose their health coverage before assuming their doctor will not see them because they lost coverage. Many doctors will agree to work out payment plans, Mitten said. - AZ Republic Maricopa County to pay $1M to pro-choice doctor in settlement June 01, 2009 Dr. J. Christopher Carey, former chief of the obstetrics residency program at Maricopa Medical Center, won a $1.4 million settlement in a discrimination suit he filed against the hospital and Maricopa County officials.A pro-choice doctor and member of the United Methodist Church, Carey protested in 2003 when county officials tried to eliminate the abortion training program at MMC, according to the lawsuit filed in U.S. District Court of Arizona. Then, when county officials tried to transfer the training program to a Catholic institution that does not allow abortions, he protested further. He alleged in his lawsuit that the Maricopa County Board of Supervisors and other officials tried to force him out of his position, spread false statements to damage his reputation, attempted to block his reappointment to the medical staff and conducted investigations. In September 2004, the board voted to remove Carey from his position. While he said he is pleased with the settlement, Carey said it is crucial for medical residents to have abortion training so women would receive quality care when they needed it. Supervisor Don Stapley, who was a named defendant in the lawsuit, declined comment. Hospital officials deferred comment to county officials. Tim Casey, outside counsel for the Board of Supervisors, said the settlement was a mutual release, in which the board released Carey of claims and Carey released the county of claims. “The settlement was a pure business decision to save an enormous amount of money,” Casey said. “This allows all the parties to move on.” For more: www.reproductiverights.org. - Phoenix Business Journal AHCCCS ranks grow to 1.2 million June 01, 2009 The state’s version of Medicaid added close to 44,800 people to its roles since January as the area’s unemployment rate rises.The Arizona Health Care Cost Containment System provides health services to the state’s indigent, poor and uninsured. There are close to 1.2 million Arizona residents — about 18 percent of state’s population — enrolled in AHCCCS. In the Phoenix area, AHCCCS enrollment stands at more than 667,000 up nearly 30,000 since January, according state statistics. The program stands to gain funding via the federal stimulus plan, but faces potential budget cuts as Arizona tries to shore up a $3 billion deficit. - Phoenix Business Journal Can a surge in physicians' use of smartphones ripple to health IT adoption? June 01, 2009 For all the incentivizing, prompting and pleading to get physicians to adopt health IT, perhaps no one could have predicted 20 years ago that the cell phone would have the biggest impact on adoption rates.Evidence comes in a recent report, "Taking the Pulse v9.0," issued by Manhattan Research. It found that 64% of doctors, more than double the number eight years ago, are using smartphones -- iPhones, BlackBerrys, Treos and other hand-held devices with phone, wireless Internet access and robust applications that bring formerly desktop solutions to the palm. "You have to make it very easy for the average doctor," said Denis Harris, MD, a solo orthopedic surgeon from Washington, D.C., who runs most of his practice from his iPhone. Dr. Harris, 63, said that by having the technology mobile, many physicians who avoided IT adoption because they thought it would be obtrusive are now taking a second look. According to Manhattan's research, some of the most widely used mobile applications by physicians are drug and clinical references, as well as clinical tools such as dosage calculators. But many believe this is just the launching pad for a technology-driven health care system that will revolve around the smartphone. Monique Levy, senior director of research for Manhattan Research, said she is starting to see the line between the tasks done by physicians on desktop computers and on mobile devices "start to blur." "You prefer to do things where you need bigger visuals on your PC, but if it's useful to you because you are on the train or between patients, whatever it is, it seems to be good enough to do it on your mobile phone, which mirrors the consumer world," Levy said. Alex Kasten, a consulting analyst for The Diffusion Group who conducted a study two years ago on physician use of smartphone technology, said mobile devices and applications will never replace desktop systems entirely. They will, however, help physicians become more efficient by bringing those applications to the point of care, which may persuade more doctors to adopt health IT. "Primarily, the work flow you are going to enter into as a provider at the point of care, in front of the patient, will be done on a device like an iPhone. [A] desktop, laptop, keyboard is pretty much not going to work if you want to do things quickly and do things at the point of care," said Tom Giannulli, MD, an internist from Westlake Village, Calif., who |