Alicia Ault

Psychologists OK Anti-Torture Policy

The American Psychological Association's membership has approved a resolution to prohibit psychologists from participating in interrogations. Once the policy becomes official at the APA's next annual meeting in August 2009, members will be restricted to working directly for detainees, for an independent third party to protect human rights, or to provide treatment to military personnel. The resolution was approved by 8,792 members; 6,157 voted against the measure. The American Civil Liberties Union and many psychologists had sought such a resolution for years. At the association's 2007 annual meeting, its membership adopted a weaker resolution that called on the U.S. government to ban 19 specific interrogation techniques. But it did not bar participation in those interrogations by psychologists.

Teva Loses Risperidone Exclusivity

Earlier this year, Teva Pharmaceutical Industries became the first company to sell generic risperidone, leading it to revise its sales and earnings estimates greatly upwards. But the U.S. Court of Appeals for the District of Columbia has vacated an April 2008 ruling that granted the company 6 months of marketing exclusivity for the generic, paving the way for other generic companies to release their versions. Mylan Inc., Par Pharmaceutical, Roxane, Ranbaxy Pharmaceuticals, Apotex Inc., and Pliva all have received tentative approval from the Food and Drug Administration for a generic formulation. Teva said it was seeking a stay of the decision, pending further appeals. The branded formation, Risperdal, had sales of just over $2 billion in 2007.

Media Influences Tobacco Use

Media communications–including movies, advertising, and news–play a key role in shaping tobacco use, according to a lengthy report from the National Cancer Institute. The report noted that cigarettes are among the most heavily marketed products in the United States, and that most of the cigarette industry's marketing budget is allocated to promotional activities, especially for price discounts, which accounted for 75% of the industry's $10 billion in total marketing expenditures in 2005. Depictions of cigarette smoking are pervasive in movies; they occur in three-quarters or more of contemporary box office hits, the NCI report said, adding that the weight of evidence indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. The report provides the government's strongest conclusion to date on the media's powerful and causal effect on tobacco use, Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, said in a statement.

Tobacco Control Support Drops

Budgets for tobacco control programs in most states are either staying level or declining despite increases in payments from the 1997 Tobacco Master Settlement Agreement, which was designed to compensate states for some of the cost of smoking-related illnesses, the American Lung Association reported. The passage of smoke-free air laws also has slowed down in most states, the ALA found. Only two states this year–Iowa and Nebraska–have approved legislation to strengthen existing laws. Activity on cigarette tax increases in 2008 also has been slower than in previous years, with only two states and the District of Columbia approving increases, according to the report. New York's increase in the cigarette tax is the highest, at $1.25 a pack, the ALA said.

CSPI Tries to Dampen Sparks

The Center for Science in the Public Interest has sued MillerCoors LLC to have its Sparks caffeinated alcoholic beverage taken off the market. In a suit filed in the Superior Court of the District of Columbia, the group said that at 6%-7% alcohol by volume, Sparks has more alcohol than beer (generally 4%-5% by volume) and that it contains unapproved additives such as caffeine and guarana, all wrapped in a sweet citrusy flavor that appeals to young people. “MillerCoors is trying to hook teens and tweens on a dangerous drink,” CSPI litigation director Steve Gardner in a statement. CSPI has won this battle before. In June, the group and 11 state attorneys general got Anheuser-Busch to agree to remove caffeine and other unapproved additives from its alcoholic energy drinks.

Pfizer Touts Its Drug Safety Site

Pfizer has launched a drug safety Web site for patients and physicians that is accessible through the company's home page,

www.pfizer.com

Grants to MDs in Hurricanes

The American Medical Association Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricanes Gustav and Ike, which hit parts of Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore medical practices in those locations, according to the AMA.

Psychologists OK Anti-Torture Policy

The American Psychological Association's membership has approved a resolution to prohibit psychologists from participating in interrogations. Once the policy becomes official at the APA's next annual meeting in August 2009, members will be restricted to working directly for detainees, for an independent third party to protect human rights, or to provide treatment to military personnel. The resolution was approved by 8,792 members; 6,157 voted against the measure. The American Civil Liberties Union and many psychologists had sought such a resolution for years. At the association's 2007 annual meeting, its membership adopted a weaker resolution that called on the U.S. government to ban 19 specific interrogation techniques. But it did not bar participation in those interrogations by psychologists.

Teva Loses Risperidone Exclusivity

Earlier this year, Teva Pharmaceutical Industries became the first company to sell generic risperidone, leading it to revise its sales and earnings estimates greatly upwards. But the U.S. Court of Appeals for the District of Columbia has vacated an April 2008 ruling that granted the company 6 months of marketing exclusivity for the generic, paving the way for other generic companies to release their versions. Mylan Inc., Par Pharmaceutical, Roxane, Ranbaxy Pharmaceuticals, Apotex Inc., and Pliva all have received tentative approval from the Food and Drug Administration for a generic formulation. Teva said it was seeking a stay of the decision, pending further appeals. The branded formation, Risperdal, had sales of just over $2 billion in 2007.

Media Influences Tobacco Use

Media communications–including movies, advertising, and news–play a key role in shaping tobacco use, according to a lengthy report from the National Cancer Institute. The report noted that cigarettes are among the most heavily marketed products in the United States, and that most of the cigarette industry's marketing budget is allocated to promotional activities, especially for price discounts, which accounted for 75% of the industry's $10 billion in total marketing expenditures in 2005. Depictions of cigarette smoking are pervasive in movies; they occur in three-quarters or more of contemporary box office hits, the NCI report said, adding that the weight of evidence indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. The report provides the government's strongest conclusion to date on the media's powerful and causal effect on tobacco use, Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, said in a statement.

Tobacco Control Support Drops

Budgets for tobacco control programs in most states are either staying level or declining despite increases in payments from the 1997 Tobacco Master Settlement Agreement, which was designed to compensate states for some of the cost of smoking-related illnesses, the American Lung Association reported. The passage of smoke-free air laws also has slowed down in most states, the ALA found. Only two states this year–Iowa and Nebraska–have approved legislation to strengthen existing laws. Activity on cigarette tax increases in 2008 also has been slower than in previous years, with only two states and the District of Columbia approving increases, according to the report. New York's increase in the cigarette tax is the highest, at $1.25 a pack, the ALA said.

CSPI Tries to Dampen Sparks

The Center for Science in the Public Interest has sued MillerCoors LLC to have its Sparks caffeinated alcoholic beverage taken off the market. In a suit filed in the Superior Court of the District of Columbia, the group said that at 6%-7% alcohol by volume, Sparks has more alcohol than beer (generally 4%-5% by volume) and that it contains unapproved additives such as caffeine and guarana, all wrapped in a sweet citrusy flavor that appeals to young people. “MillerCoors is trying to hook teens and tweens on a dangerous drink,” CSPI litigation director Steve Gardner in a statement. CSPI has won this battle before. In June, the group and 11 state attorneys general got Anheuser-Busch to agree to remove caffeine and other unapproved additives from its alcoholic energy drinks.

Pfizer Touts Its Drug Safety Site

Pfizer has launched a drug safety Web site for patients and physicians that is accessible through the company's home page,

www.pfizer.com

Grants to MDs in Hurricanes

The American Medical Association Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricanes Gustav and Ike, which hit parts of Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore medical practices in those locations, according to the AMA.

Psychologists OK Anti-Torture Policy

The American Psychological Association's membership has approved a resolution to prohibit psychologists from participating in interrogations. Once the policy becomes official at the APA's next annual meeting in August 2009, members will be restricted to working directly for detainees, for an independent third party to protect human rights, or to provide treatment to military personnel. The resolution was approved by 8,792 members; 6,157 voted against the measure. The American Civil Liberties Union and many psychologists had sought such a resolution for years. At the association's 2007 annual meeting, its membership adopted a weaker resolution that called on the U.S. government to ban 19 specific interrogation techniques. But it did not bar participation in those interrogations by psychologists.

Teva Loses Risperidone Exclusivity

Earlier this year, Teva Pharmaceutical Industries became the first company to sell generic risperidone, leading it to revise its sales and earnings estimates greatly upwards. But the U.S. Court of Appeals for the District of Columbia has vacated an April 2008 ruling that granted the company 6 months of marketing exclusivity for the generic, paving the way for other generic companies to release their versions. Mylan Inc., Par Pharmaceutical, Roxane, Ranbaxy Pharmaceuticals, Apotex Inc., and Pliva all have received tentative approval from the Food and Drug Administration for a generic formulation. Teva said it was seeking a stay of the decision, pending further appeals. The branded formation, Risperdal, had sales of just over $2 billion in 2007.

Media Influences Tobacco Use

Media communications–including movies, advertising, and news–play a key role in shaping tobacco use, according to a lengthy report from the National Cancer Institute. The report noted that cigarettes are among the most heavily marketed products in the United States, and that most of the cigarette industry's marketing budget is allocated to promotional activities, especially for price discounts, which accounted for 75% of the industry's $10 billion in total marketing expenditures in 2005. Depictions of cigarette smoking are pervasive in movies; they occur in three-quarters or more of contemporary box office hits, the NCI report said, adding that the weight of evidence indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. The report provides the government's strongest conclusion to date on the media's powerful and causal effect on tobacco use, Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, said in a statement.

Tobacco Control Support Drops

Budgets for tobacco control programs in most states are either staying level or declining despite increases in payments from the 1997 Tobacco Master Settlement Agreement, which was designed to compensate states for some of the cost of smoking-related illnesses, the American Lung Association reported. The passage of smoke-free air laws also has slowed down in most states, the ALA found. Only two states this year–Iowa and Nebraska–have approved legislation to strengthen existing laws. Activity on cigarette tax increases in 2008 also has been slower than in previous years, with only two states and the District of Columbia approving increases, according to the report. New York's increase in the cigarette tax is the highest, at $1.25 a pack, the ALA said.

CSPI Tries to Dampen Sparks

The Center for Science in the Public Interest has sued MillerCoors LLC to have its Sparks caffeinated alcoholic beverage taken off the market. In a suit filed in the Superior Court of the District of Columbia, the group said that at 6%-7% alcohol by volume, Sparks has more alcohol than beer (generally 4%-5% by volume) and that it contains unapproved additives such as caffeine and guarana, all wrapped in a sweet citrusy flavor that appeals to young people. “MillerCoors is trying to hook teens and tweens on a dangerous drink,” CSPI litigation director Steve Gardner in a statement. CSPI has won this battle before. In June, the group and 11 state attorneys general got Anheuser-Busch to agree to remove caffeine and other unapproved additives from its alcoholic energy drinks.

Pfizer Touts Its Drug Safety Site

Pfizer has launched a drug safety Web site for patients and physicians that is accessible through the company's home page,

www.pfizer.com

Grants to MDs in Hurricanes

The American Medical Association Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricanes Gustav and Ike, which hit parts of Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore medical practices in those locations, according to the AMA.

Standardizing criteria across hospitals could help reduce the practice of ambulance diversion, as could reductions in emergency department boarding and increased coverage of uninsured patients, a new report suggests.

Currently, hospitals in most areas decide on their own when and how often to go on diversion, which leads to a chaotic system and poses health risks to patients who may be delayed in getting needed care, said Dr. Guy Clifton, professor of neurosurgery at the University of Texas, Houston.

Dr. Clifton coauthored the report, “Ambulance Diversions: What They Are, Why We Care, and What to Do,” for the New America Foundation, a Washington, D.C.-based public policy institute.

Covering uninsured patients also would help curb diversion, because it would reduce the number of nonurgent cases contributing to emergency department crowding, he said in an interview.

Before joining the foundation, Dr. Clifton was a Robert Wood Johnson Foundation Health Policy Fellow in the office of Sen. Orrin Hatch (R-Utah). He also wrote the forthcoming book “Flatlined: Resuscitating American Medicine” (Piscataway, N.J.: Rutgers University Press, 2009), which takes on the issues raised by the huge number of uninsured Americans.

According to the report, about half of hospitals and 70% of urban hospitals reported at least some time on diversion in 2004. The diversion picture is a bit fuzzy, he said.

Dr. Clifton said that because there is a shortage of primary care providers, many people, even those with insurance, are receiving less preventive care. When they come to the emergency department, they are not seeking nonurgent help, and are often sick enough that they require admission.

Diversion standards, data collection, and public reporting should be instituted nationally, he said.

For a copy of the report, visit www.newamerica.net/files/Ambulance%20Diversions.pdf

Standardizing criteria across hospitals could help reduce the practice of ambulance diversion, as could reductions in emergency department boarding and increased coverage of uninsured patients, a new report suggests.

Currently, hospitals in most areas decide on their own when and how often to go on diversion, which leads to a chaotic system and poses health risks to patients who may be delayed in getting needed care, said Dr. Guy Clifton, professor of neurosurgery at the University of Texas, Houston.

Dr. Clifton coauthored the report, “Ambulance Diversions: What They Are, Why We Care, and What to Do,” for the New America Foundation, a Washington, D.C.-based public policy institute.

Covering uninsured patients also would help curb diversion, because it would reduce the number of nonurgent cases contributing to emergency department crowding, he said in an interview.

Before joining the foundation, Dr. Clifton was a Robert Wood Johnson Foundation Health Policy Fellow in the office of Sen. Orrin Hatch (R-Utah). He also wrote the forthcoming book “Flatlined: Resuscitating American Medicine” (Piscataway, N.J.: Rutgers University Press, 2009), which takes on the issues raised by the huge number of uninsured Americans.

According to the report, about half of hospitals and 70% of urban hospitals reported at least some time on diversion in 2004. The diversion picture is a bit fuzzy, he said.

Dr. Clifton said that because there is a shortage of primary care providers, many people, even those with insurance, are receiving less preventive care. When they come to the emergency department, they are not seeking nonurgent help, and are often sick enough that they require admission.

Diversion standards, data collection, and public reporting should be instituted nationally, he said.

For a copy of the report, visit www.newamerica.net/files/Ambulance%20Diversions.pdf

Standardizing criteria across hospitals could help reduce the practice of ambulance diversion, as could reductions in emergency department boarding and increased coverage of uninsured patients, a new report suggests.

Currently, hospitals in most areas decide on their own when and how often to go on diversion, which leads to a chaotic system and poses health risks to patients who may be delayed in getting needed care, said Dr. Guy Clifton, professor of neurosurgery at the University of Texas, Houston.

Dr. Clifton coauthored the report, “Ambulance Diversions: What They Are, Why We Care, and What to Do,” for the New America Foundation, a Washington, D.C.-based public policy institute.

Covering uninsured patients also would help curb diversion, because it would reduce the number of nonurgent cases contributing to emergency department crowding, he said in an interview.

Before joining the foundation, Dr. Clifton was a Robert Wood Johnson Foundation Health Policy Fellow in the office of Sen. Orrin Hatch (R-Utah). He also wrote the forthcoming book “Flatlined: Resuscitating American Medicine” (Piscataway, N.J.: Rutgers University Press, 2009), which takes on the issues raised by the huge number of uninsured Americans.

According to the report, about half of hospitals and 70% of urban hospitals reported at least some time on diversion in 2004. The diversion picture is a bit fuzzy, he said.

Dr. Clifton said that because there is a shortage of primary care providers, many people, even those with insurance, are receiving less preventive care. When they come to the emergency department, they are not seeking nonurgent help, and are often sick enough that they require admission.

Diversion standards, data collection, and public reporting should be instituted nationally, he said.

For a copy of the report, visit www.newamerica.net/files/Ambulance%20Diversions.pdf

SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.

A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.

In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.

Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.

At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.

“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.

Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.

Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.

Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.

With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.

The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.

Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.

The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.

The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.

The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.

In either case, going without sedation appears to be acceptable for an increasing number of patients, he said.

Dr. Sidney J. Winawer noted after Dr. Leung spoke that the United States is unusual in its preference for sedated colonoscopy. This can be attributed largely to deep-rooted fears that go back to the old days of rigid sigmoidoscopy and poor sedation practices with colonoscopy, both of which increased discomfort, said Dr. Winawer, Paul Sherlock Chair of the gastroenterology and nutrition service at Memorial Sloan-Kettering Cancer Center in New York.

“We have to overcome this old fear that people have had,” he said. “It's very hard to try to reeducate the public that colonoscopy can be a very comfortable procedure, usually with adequate sedation, and they should not be afraid of it,” Dr. Winawer said.

Dr. Leung and Dr. Winawer disclosed no conflicts of interest.

SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.

A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.

In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.

Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.

At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.

“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.

Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.

Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.

Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.

With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.

The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.

Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.

The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.

The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.

The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.

In either case, going without sedation appears to be acceptable for an increasing number of patients, he said.

Dr. Sidney J. Winawer noted after Dr. Leung spoke that the United States is unusual in its preference for sedated colonoscopy. This can be attributed largely to deep-rooted fears that go back to the old days of rigid sigmoidoscopy and poor sedation practices with colonoscopy, both of which increased discomfort, said Dr. Winawer, Paul Sherlock Chair of the gastroenterology and nutrition service at Memorial Sloan-Kettering Cancer Center in New York.

“We have to overcome this old fear that people have had,” he said. “It's very hard to try to reeducate the public that colonoscopy can be a very comfortable procedure, usually with adequate sedation, and they should not be afraid of it,” Dr. Winawer said.

Dr. Leung and Dr. Winawer disclosed no conflicts of interest.

SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.

A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.

In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.

Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.

At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.

“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.

Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.

Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.

Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.

With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.

The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.

Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.

The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.

The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.

The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.

In either case, going without sedation appears to be acceptable for an increasing number of patients, he said.

Dr. Sidney J. Winawer noted after Dr. Leung spoke that the United States is unusual in its preference for sedated colonoscopy. This can be attributed largely to deep-rooted fears that go back to the old days of rigid sigmoidoscopy and poor sedation practices with colonoscopy, both of which increased discomfort, said Dr. Winawer, Paul Sherlock Chair of the gastroenterology and nutrition service at Memorial Sloan-Kettering Cancer Center in New York.

“We have to overcome this old fear that people have had,” he said. “It's very hard to try to reeducate the public that colonoscopy can be a very comfortable procedure, usually with adequate sedation, and they should not be afraid of it,” Dr. Winawer said.

Dr. Leung and Dr. Winawer disclosed no conflicts of interest.

MedSpa Bill Fails in California

A bill that could have shuttered a huge number of medical spas in California essentially expired after a failed floor vote in the state Senate and protracted negotiations over a competing bill in the Assembly. Introduced in February, AB 2398 made its way through the legislature with the support of the American Society for Dermatologic Surgery Association, the California Society of Dermatology and Dermatologic Surgery, and other groups. The bill would have revoked the licenses of any physician who practiced for a "business organization" that provided outpatient cosmetic procedures, because it would be considered a violation of the prohibition against the corporate practice of medicine. The California Medspa Management Association, the International Medical Spa Association (IMSA), and the Manufacturers of Equipment for Light-Based Aesthetics said the law would amount to restraint of trade and would "undermine a physician's right to make a living," according to a letter sent to Gov. Arnold Schwarzenegger by IMSA.

FDA Warns on Laser Brush

The Food and Drug Administration has warned Sunetics International Corp. of Las Vegas that it is illegally marketing its Laser Hair Brush and Laser Skin Brush. The company advertises the products as laser devices that can grow hair and treat skin conditions such as acne and dyspigmentation, according to the FDA. The devices have not received premarket approval, which is required for any product making a claim to affect a structure or function in the body, according to the agency's warning letter. Sunetics did submit an approval application in January of this year, but it is still being reviewed, the agency said.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

Genomics Collaboration

Pharmacy benefit manager Medco Health Solutions Inc. and the FDA have partnered to study genetic testing and the effect of genetics on prescription drug efficacy, according to Medco. The agreement extends to Aug. 31, 2010. Over the next 2 years, Medco will deliver a series of reports to the FDA that will address the safety of prescription drugs, physician participation in pharmacogenomics testing, the usefulness of the tests in prescribing, and the quantifying of prescription information that contains genetic information. Medco said its reports will be derived from clinical settings, including one that will examine whether physicians are willing to change the dose of a prescription based on a genetic test result. "Studying this field can advance pharmacy care to remove some of the trial and error in how medications are prescribed," Dr. Robert Epstein, Medco chief medical officer, said in a statement.

Uninsured Spend $30B on Care

Americans who lack health insurance for any part of 2008 will spend $30 billion out of pocket for health services, and also will receive $56 billion in uncompensated care while uninsured, according to a study in the journal Health Affairs. Government programs will pay about $43 billion for the uncompensated care, the researchers reported. Compared with people who have full-year private health care coverage, people who are uninsured for a full year receive less than half as much care but pay a larger share out of pocket, the authors reported. Someone who is uninsured all year would pay 35% (or $583 on average) out of pocket toward average annual medical costs of $1,686, the study said. In contrast, the annual medical costs of the privately insured average $3,915, with 17% (or $681 on average) paid out of pocket, according to the study.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people (66% of all adults and 81% of those who have online access) said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, as opposed to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the pollsters called "cybercondriacs"—which indicates that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

MedSpa Bill Fails in California

A bill that could have shuttered a huge number of medical spas in California essentially expired after a failed floor vote in the state Senate and protracted negotiations over a competing bill in the Assembly. Introduced in February, AB 2398 made its way through the legislature with the support of the American Society for Dermatologic Surgery Association, the California Society of Dermatology and Dermatologic Surgery, and other groups. The bill would have revoked the licenses of any physician who practiced for a "business organization" that provided outpatient cosmetic procedures, because it would be considered a violation of the prohibition against the corporate practice of medicine. The California Medspa Management Association, the International Medical Spa Association (IMSA), and the Manufacturers of Equipment for Light-Based Aesthetics said the law would amount to restraint of trade and would "undermine a physician's right to make a living," according to a letter sent to Gov. Arnold Schwarzenegger by IMSA.

FDA Warns on Laser Brush

The Food and Drug Administration has warned Sunetics International Corp. of Las Vegas that it is illegally marketing its Laser Hair Brush and Laser Skin Brush. The company advertises the products as laser devices that can grow hair and treat skin conditions such as acne and dyspigmentation, according to the FDA. The devices have not received premarket approval, which is required for any product making a claim to affect a structure or function in the body, according to the agency's warning letter. Sunetics did submit an approval application in January of this year, but it is still being reviewed, the agency said.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

Genomics Collaboration

Pharmacy benefit manager Medco Health Solutions Inc. and the FDA have partnered to study genetic testing and the effect of genetics on prescription drug efficacy, according to Medco. The agreement extends to Aug. 31, 2010. Over the next 2 years, Medco will deliver a series of reports to the FDA that will address the safety of prescription drugs, physician participation in pharmacogenomics testing, the usefulness of the tests in prescribing, and the quantifying of prescription information that contains genetic information. Medco said its reports will be derived from clinical settings, including one that will examine whether physicians are willing to change the dose of a prescription based on a genetic test result. "Studying this field can advance pharmacy care to remove some of the trial and error in how medications are prescribed," Dr. Robert Epstein, Medco chief medical officer, said in a statement.

Uninsured Spend $30B on Care

Americans who lack health insurance for any part of 2008 will spend $30 billion out of pocket for health services, and also will receive $56 billion in uncompensated care while uninsured, according to a study in the journal Health Affairs. Government programs will pay about $43 billion for the uncompensated care, the researchers reported. Compared with people who have full-year private health care coverage, people who are uninsured for a full year receive less than half as much care but pay a larger share out of pocket, the authors reported. Someone who is uninsured all year would pay 35% (or $583 on average) out of pocket toward average annual medical costs of $1,686, the study said. In contrast, the annual medical costs of the privately insured average $3,915, with 17% (or $681 on average) paid out of pocket, according to the study.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people (66% of all adults and 81% of those who have online access) said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, as opposed to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the pollsters called "cybercondriacs"—which indicates that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

MedSpa Bill Fails in California

A bill that could have shuttered a huge number of medical spas in California essentially expired after a failed floor vote in the state Senate and protracted negotiations over a competing bill in the Assembly. Introduced in February, AB 2398 made its way through the legislature with the support of the American Society for Dermatologic Surgery Association, the California Society of Dermatology and Dermatologic Surgery, and other groups. The bill would have revoked the licenses of any physician who practiced for a "business organization" that provided outpatient cosmetic procedures, because it would be considered a violation of the prohibition against the corporate practice of medicine. The California Medspa Management Association, the International Medical Spa Association (IMSA), and the Manufacturers of Equipment for Light-Based Aesthetics said the law would amount to restraint of trade and would "undermine a physician's right to make a living," according to a letter sent to Gov. Arnold Schwarzenegger by IMSA.

FDA Warns on Laser Brush

The Food and Drug Administration has warned Sunetics International Corp. of Las Vegas that it is illegally marketing its Laser Hair Brush and Laser Skin Brush. The company advertises the products as laser devices that can grow hair and treat skin conditions such as acne and dyspigmentation, according to the FDA. The devices have not received premarket approval, which is required for any product making a claim to affect a structure or function in the body, according to the agency's warning letter. Sunetics did submit an approval application in January of this year, but it is still being reviewed, the agency said.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

Genomics Collaboration

Pharmacy benefit manager Medco Health Solutions Inc. and the FDA have partnered to study genetic testing and the effect of genetics on prescription drug efficacy, according to Medco. The agreement extends to Aug. 31, 2010. Over the next 2 years, Medco will deliver a series of reports to the FDA that will address the safety of prescription drugs, physician participation in pharmacogenomics testing, the usefulness of the tests in prescribing, and the quantifying of prescription information that contains genetic information. Medco said its reports will be derived from clinical settings, including one that will examine whether physicians are willing to change the dose of a prescription based on a genetic test result. "Studying this field can advance pharmacy care to remove some of the trial and error in how medications are prescribed," Dr. Robert Epstein, Medco chief medical officer, said in a statement.

Uninsured Spend $30B on Care

Americans who lack health insurance for any part of 2008 will spend $30 billion out of pocket for health services, and also will receive $56 billion in uncompensated care while uninsured, according to a study in the journal Health Affairs. Government programs will pay about $43 billion for the uncompensated care, the researchers reported. Compared with people who have full-year private health care coverage, people who are uninsured for a full year receive less than half as much care but pay a larger share out of pocket, the authors reported. Someone who is uninsured all year would pay 35% (or $583 on average) out of pocket toward average annual medical costs of $1,686, the study said. In contrast, the annual medical costs of the privately insured average $3,915, with 17% (or $681 on average) paid out of pocket, according to the study.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people (66% of all adults and 81% of those who have online access) said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, as opposed to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the pollsters called "cybercondriacs"—which indicates that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

Leaders at the American Academy of Family Physicians and the American College of Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.

ACEP issued eight principles that it says should guide the development of a medical home, a concept that was developed by the American Academy of Pediatrics, and has been championed by ACP, AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.

The approach is the subject of demonstration projects around the country, with sponsorship by a variety of payers, from Medicare and Medicaid to big employers such as IBM.

But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department (ED), including caring for the uninsured.

“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper, but it went on to describe several concerns.

“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But the hurdles to making it work are high, she said.

First, there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week.

And, there are no studies showing that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.

Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted.

“This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”

Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is how ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed, and yet still face the same daily struggles, the professional group maintains.

ACEP says that enhanced access should be demonstrated and that once a medical home is established, patients should be able to continue to be a part of that home, whether or not they change or lose their insurance.

Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.

More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.

ACEP also states that the value of the medical home concept should be proven before it is widely adopted.

Dr. Michael Barr, vice president for practice advocacy and improvement at ACP, agreed, noting his commentary in JAMA in late August.

“Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834–5). “However, it is imperative to test the model in a credible and transparent way in different environments,” he added.

In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, ACP has advocated for universal health coverage, he added.

But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.

Dr. James King, president of the AAFP, said in an interview that he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.

“The entire health care system needs reforming, but if we wait we're going to be even farther behind,” he said. The medical home concept will not solve the problem of the uninsured, but it can help more people get good quality health care, Dr. King said.

Leaders at the American Academy of Family Physicians and the American College of Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.

ACEP issued eight principles that it says should guide the development of a medical home, a concept that was developed by the American Academy of Pediatrics, and has been championed by ACP, AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.

The approach is the subject of demonstration projects around the country, with sponsorship by a variety of payers, from Medicare and Medicaid to big employers such as IBM.

But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department (ED), including caring for the uninsured.

“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper, but it went on to describe several concerns.

“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But the hurdles to making it work are high, she said.

First, there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week.

And, there are no studies showing that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.

Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted.

“This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”

Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is how ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed, and yet still face the same daily struggles, the professional group maintains.

ACEP says that enhanced access should be demonstrated and that once a medical home is established, patients should be able to continue to be a part of that home, whether or not they change or lose their insurance.

Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.

More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.

ACEP also states that the value of the medical home concept should be proven before it is widely adopted.

Dr. Michael Barr, vice president for practice advocacy and improvement at ACP, agreed, noting his commentary in JAMA in late August.

“Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834–5). “However, it is imperative to test the model in a credible and transparent way in different environments,” he added.

In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, ACP has advocated for universal health coverage, he added.

But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.

Dr. James King, president of the AAFP, said in an interview that he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.

“The entire health care system needs reforming, but if we wait we're going to be even farther behind,” he said. The medical home concept will not solve the problem of the uninsured, but it can help more people get good quality health care, Dr. King said.

Leaders at the American Academy of Family Physicians and the American College of Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.

ACEP issued eight principles that it says should guide the development of a medical home, a concept that was developed by the American Academy of Pediatrics, and has been championed by ACP, AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.

The approach is the subject of demonstration projects around the country, with sponsorship by a variety of payers, from Medicare and Medicaid to big employers such as IBM.

But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department (ED), including caring for the uninsured.

“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper, but it went on to describe several concerns.

“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But the hurdles to making it work are high, she said.

First, there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week.

And, there are no studies showing that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.

Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted.

“This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”

Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is how ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed, and yet still face the same daily struggles, the professional group maintains.

ACEP says that enhanced access should be demonstrated and that once a medical home is established, patients should be able to continue to be a part of that home, whether or not they change or lose their insurance.

Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.

More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.

ACEP also states that the value of the medical home concept should be proven before it is widely adopted.

Dr. Michael Barr, vice president for practice advocacy and improvement at ACP, agreed, noting his commentary in JAMA in late August.

“Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834–5). “However, it is imperative to test the model in a credible and transparent way in different environments,” he added.

In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, ACP has advocated for universal health coverage, he added.

But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.

Dr. James King, president of the AAFP, said in an interview that he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.

“The entire health care system needs reforming, but if we wait we're going to be even farther behind,” he said. The medical home concept will not solve the problem of the uninsured, but it can help more people get good quality health care, Dr. King said.

Leaders at the American College of Physicians and the American Academy of Family Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.

ACEP issued eight principles it says should guide the development of a medical home, a concept developed by the American Academy of Pediatrics and championed by the ACP, the AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.

The approach is the subject of demonstration projects around the country, with sponsorship by Medicare, Medicaid, and big employers such as IBM.

“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper. But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department, including caring for the uninsured.

“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week. And no studies show that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.

Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted. “This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”

Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is what ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed and yet still face the same daily struggles, the professional group maintains.

ACEP says enhanced access should be demonstrated and that once a medical home is established, patients should be able to remain a part of that home, whether or not they change or lose their insurance. Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.

More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.

ACEP also said the value of the medical home should be proved before it is widely adopted.

Dr. Michael Barr, vice president for practice advocacy and improvement at the ACP, agreed, noting his commentary in JAMA in late August. “Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834-5). “However, it is imperative to test the model in a credible and transparent way in different environments.”

In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, the ACP has advocated for universal health coverage, he added.

But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.

Dr. James King, AAFP president, said he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.

Leaders at the American College of Physicians and the American Academy of Family Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.

ACEP issued eight principles it says should guide the development of a medical home, a concept developed by the American Academy of Pediatrics and championed by the ACP, the AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.

The approach is the subject of demonstration projects around the country, with sponsorship by Medicare, Medicaid, and big employers such as IBM.

“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper. But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department, including caring for the uninsured.

“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week. And no studies show that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.

Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted. “This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”

Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is what ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed and yet still face the same daily struggles, the professional group maintains.

ACEP says enhanced access should be demonstrated and that once a medical home is established, patients should be able to remain a part of that home, whether or not they change or lose their insurance. Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.

More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.

ACEP also said the value of the medical home should be proved before it is widely adopted.

Dr. Michael Barr, vice president for practice advocacy and improvement at the ACP, agreed, noting his commentary in JAMA in late August. “Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834-5). “However, it is imperative to test the model in a credible and transparent way in different environments.”

In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, the ACP has advocated for universal health coverage, he added.

But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.

Dr. James King, AAFP president, said he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.

Leaders at the American College of Physicians and the American Academy of Family Physicians say they welcome the American College of Emergency Physicians' recent statement supporting the concept of a patient-centered medical home, and hope to work with the group to address its concerns.

ACEP issued eight principles it says should guide the development of a medical home, a concept developed by the American Academy of Pediatrics and championed by the ACP, the AAFP, and the American Osteopathic Association. The idea of a medical home, where patients could receive consistent, coordinated care aided by electronic medical records, has been gaining attention from health policy makers.

The approach is the subject of demonstration projects around the country, with sponsorship by Medicare, Medicaid, and big employers such as IBM.

“ACEP agrees with the basic tenets of the patient-centered medical home model,” the organization said in its position paper. But ACEP says it is concerned that widespread implementation could exacerbate challenges in the emergency department, including caring for the uninsured.

“In an ideal world, the concepts in a patient-centered medical home are laudable,” Dr. Linda Lawrence, ACEP president, said in an interview. But there is a shortage of primary care physicians, and access to them cannot be guaranteed 24 hours a day, 7 days a week. And no studies show that a medical home will increase access to basic care or reduce the number of unnecessary visits to the ED, according to ACEP.

Many Americans continue to lack health insurance or have less-than-adequate coverage, Dr. Lawrence noted. “This could drive a greater divide in access to health care in America,” she said. “We have to be a bit skeptical that without overall change in the system, you're going to have more boutique medicine, and the rest are going to fall by the wayside.”

Inevitably, ACEP said, patients will still rely on the ED as their “medical home away from home,” which is what ACEP has dubbed the nation's emergency departments. If health care dollars are shifted to the medical home, EDs might end up being short-changed and yet still face the same daily struggles, the professional group maintains.

ACEP says enhanced access should be demonstrated and that once a medical home is established, patients should be able to remain a part of that home, whether or not they change or lose their insurance. Patients also should be able to switch medical homes when necessary, choose their own specialists, and access the emergency department when they determine it is appropriate.

More than a decade ago, emergency physicians fought to codify the notion that a “prudent layperson” could determine when it is necessary to seek emergency care. This came in the wake of frequent payment denials for emergency services by cost-conscious managed care organizations, Dr. Lawrence said. No one wants to repeat that battle, she said.

ACEP also said the value of the medical home should be proved before it is widely adopted.

Dr. Michael Barr, vice president for practice advocacy and improvement at the ACP, agreed, noting his commentary in JAMA in late August. “Data suggest that the model will deliver improved quality and reduced costs and prove attractive to patients and their families,” Dr. Barr wrote (JAMA 2008;300:834-5). “However, it is imperative to test the model in a credible and transparent way in different environments.”

In an interview, Dr. Barr agreed with Dr. Lawrence and her ACEP colleagues that the “medical home is not the answer to all the ills of the American health care system right now.” Like ACEP, the ACP has advocated for universal health coverage, he added.

But medical home supporters are not trying to limit patient choice, or to prevent patients from choosing the emergency department when necessary. “What the medical home would do if it works is hopefully reduce unnecessary or avoidable ED visits and at same time not limit appropriate ED referrals and use by patients,” Dr. Barr said.

Dr. James King, AAFP president, said he's “pleased [ACEP] has thought about and evaluated the medical home.” Emergency physicians are seeing the 47 million uninsured, and “they need to get paid for that,” he said.

Democrats and Republicans are so confident about the chances of some type of health reform in the next administration that staff meetings and hearings geared toward crafting legislation have been going on in earnest in both the House and the Senate, with the goal of being ready to go in January, according to advocates and policy watchers.

Many health policy analysts have compared and contrasted this election cycle with that of 1992, which sent Bill Clinton to the White House and launched the Clintons' health care reform efforts.

Both elections—1992 and 2008—feature a high level of public concern about access to health care and its costs, said Len Nichols, an analyst at the New America Foundation, a nonpartisan public policy institute.

For instance, a Harris Interactive survey conducted for the Commonwealth Fund in May found that 82% of Americans think the health care system should be fundamentally changed or completely rebuilt.

But the differences between the two elections are striking in a positive way, Mr. Nichols said in an interview.

First, the two major candidates themselves have acknowledged that cost is an overriding concern, he said. Also, a common theme is the use of private markets, which he called “evidence, I would say, of moderation” and, perhaps, the proposals' better legislative traction.

Both candidates—Sen. Barack Obama (D-Ill.) and Sen. John McCain (R-Ariz.)—have also learned that “no president is going to send [to Congress] a 1,400-page health bill written in a hotel room by 300 wonks,” Mr. Nichols said.

Instead, “Congress is going to own this [effort] far earlier and deeper than before,” he said, adding, “It's still going to require a lot of presidential leadership. But the Congress has to be an equal, more than it has before.”

Several proposals are likely starting points for congressional negotiations with the new administration, he said. First is the Healthy Americans Act, introduced in January 2007 by Sen. Ron Wyden (D-Ore.) and Sen. Bob Bennett (R-Utah). It has 16 cosponsors from both parties, including Sen. Chuck Grassley (R-Iowa), the Finance Committee's ranking minority member.

The bill is being championed in the House by Rep. Debbie Wasserman Schultz (D-Fla.) and Rep. Jo Ann Emerson (R-Mo.). Rep. Wasserman Schultz is important “because she's a rising star and has impeccable liberal credentials,” Mr. Nichols said.

In a paper published in the policy journal Health Affairs, Sen. Wyden and Sen. Bennett said they saw “signs of an ideological truce” on the Hill, with agreement that there is a need for the Democratic-backed universal coverage and the Republican-supported desire for market forces to promote competition and innovation. “The Healthy Americans Act strikes a balance between these ideals,” they wrote (Health Affairs 2008;27:689-92).

The bill would require individuals to purchase insurance for themselves and their dependent children, and would require insurers to offer a prescribed package of benefits.

It would subsidize coverage for Americans with incomes up to 400% of the federal poverty level. Employers would convert benefit dollars into salary; such compensation would be tax free, with the goal that the money would be used to purchase coverage.

Sen. Wyden is likely to be front and center in crafting a bill, as he is a member of two of the committees of jurisdiction: finance and budget, said Mr. Nichols, adding that those committees, along with the Health, Education, Labor and Pensions (HELP) Committee, “will play very important roles.”

Ron Pollack, executive director of the advocacy group Families USA, said that although Sen. Wyden may play a part, “I have little doubt that Sen. Baucus is going to be as instrumental in the process as anyone.”

Sen. Max Baucus (D-Mont.), chairman of the Finance Committee, held a health care summit in mid-June. Staff from the Finance Committee and the HELP Committee, led by Sen. Edward M. Kennedy (D-Mass.), have been coordinating meetings with those two panels and the Budget Committee, Mr. Pollack said in an interview.

Committee chairs have the greatest influence on the legislative process, he said. Both Mr. Pollack and Mr. Nichols also expect Sen. Kennedy to play a very significant part in creating the legislation, as much as his cancer will allow.

Even so, “to pass anything of significance will require bipartisanship,” said Mr. Pollack, noting that Sen. Baucus and Sen. Grassley have worked closely on many bills.

The House is not as far along in preparing for health reform, but staffers on the four relevant committees with jurisdiction over health care have been meeting, Mr. Pollack said.

“I think there's significant movement underway in anticipation of health care reform being a top domestic priority,” he said. But, “I don't think any of the proposals that have come out so far are going to be the proposals,” Mr. Pollack added.

Instead, the expectation is that a health reform bill will be developed during the transition period between November and January, “and that's what we should look at most seriously,” he said.

Still Concerned About Health Care After All These Years

Harry and Louise, who became infamous in a 1993-1994 television ad lambasting the Clinton administration's health care reform plan, were dragged briefly out of mothballs to appear in a new commercial that urged Congress and the next president to make such reform the top domestic policy priority.

The effort was bankrolled by five groups that by their own admission have “historically divergent views about health care reform”: the American Cancer Society's Cancer Action Network, the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).

“We intend to transcend ideology and partisan politics,” said Families USA Executive Director Ron Pollack at a press conference. The multimillion-dollar campaign aired nationally for 2 weeks during the Republican and Democratic conventions.

The new ad featured Harry and Louise, back at their kitchen table. The characters were portrayed by the same two actors, now 14 years older. Harry noted that health care costs are going up again and that small businesses are being forced to drop their plans. Louise said that a friend just found out he has cancer and can't afford a plan. Harry remarked that “too many people are falling through the cracks.” Finally, Louise said that “whoever the next president is,” health care should be “at the top of his agenda,” and that he should bring everyone to the table and “make it happen.”

The campaign did not advocate any specific solution. The sponsors said their goal was to create momentum for change, and that they believed that, unlike 14 years ago, there is a consensus that reform is inevitable and necessary.

“The status quo is no longer acceptable,” said Rich Umbdenstock, AHA president and CEO.

“We simply can't be having this conversation 14 years from now,” added Sister Carol Keehan, CHA president and CEO.

The NFIB joined the effort because its membership said that “health care costs are their No. 1 concern,” said Todd Stottlemyer, president and CEO.

The five groups were joined at the briefing by Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP (back when it was known as the Health Insurance Association of America) launched Harry and Louise the first time, helping to defeat the Clinton reform plan.

But Ms. Ignani said times are different now: “Our commitment is to make sure no one falls through the cracks,” she said.

Harry and Louise were back at their kitchen table in a new ad promoting health care reform. Health Care First

Democrats and Republicans are so confident about the chances of some type of health reform in the next administration that staff meetings and hearings geared toward crafting legislation have been going on in earnest in both the House and the Senate, with the goal of being ready to go in January, according to advocates and policy watchers.

Many health policy analysts have compared and contrasted this election cycle with that of 1992, which sent Bill Clinton to the White House and launched the Clintons' health care reform efforts.

Both elections—1992 and 2008—feature a high level of public concern about access to health care and its costs, said Len Nichols, an analyst at the New America Foundation, a nonpartisan public policy institute.

For instance, a Harris Interactive survey conducted for the Commonwealth Fund in May found that 82% of Americans think the health care system should be fundamentally changed or completely rebuilt.

But the differences between the two elections are striking in a positive way, Mr. Nichols said in an interview.

First, the two major candidates themselves have acknowledged that cost is an overriding concern, he said. Also, a common theme is the use of private markets, which he called “evidence, I would say, of moderation” and, perhaps, the proposals' better legislative traction.

Both candidates—Sen. Barack Obama (D-Ill.) and Sen. John McCain (R-Ariz.)—have also learned that “no president is going to send [to Congress] a 1,400-page health bill written in a hotel room by 300 wonks,” Mr. Nichols said.

Instead, “Congress is going to own this [effort] far earlier and deeper than before,” he said, adding, “It's still going to require a lot of presidential leadership. But the Congress has to be an equal, more than it has before.”

Several proposals are likely starting points for congressional negotiations with the new administration, he said. First is the Healthy Americans Act, introduced in January 2007 by Sen. Ron Wyden (D-Ore.) and Sen. Bob Bennett (R-Utah). It has 16 cosponsors from both parties, including Sen. Chuck Grassley (R-Iowa), the Finance Committee's ranking minority member.

The bill is being championed in the House by Rep. Debbie Wasserman Schultz (D-Fla.) and Rep. Jo Ann Emerson (R-Mo.). Rep. Wasserman Schultz is important “because she's a rising star and has impeccable liberal credentials,” Mr. Nichols said.

In a paper published in the policy journal Health Affairs, Sen. Wyden and Sen. Bennett said they saw “signs of an ideological truce” on the Hill, with agreement that there is a need for the Democratic-backed universal coverage and the Republican-supported desire for market forces to promote competition and innovation. “The Healthy Americans Act strikes a balance between these ideals,” they wrote (Health Affairs 2008;27:689-92).

The bill would require individuals to purchase insurance for themselves and their dependent children, and would require insurers to offer a prescribed package of benefits.

It would subsidize coverage for Americans with incomes up to 400% of the federal poverty level. Employers would convert benefit dollars into salary; such compensation would be tax free, with the goal that the money would be used to purchase coverage.

Sen. Wyden is likely to be front and center in crafting a bill, as he is a member of two of the committees of jurisdiction: finance and budget, said Mr. Nichols, adding that those committees, along with the Health, Education, Labor and Pensions (HELP) Committee, “will play very important roles.”

Ron Pollack, executive director of the advocacy group Families USA, said that although Sen. Wyden may play a part, “I have little doubt that Sen. Baucus is going to be as instrumental in the process as anyone.”

Sen. Max Baucus (D-Mont.), chairman of the Finance Committee, held a health care summit in mid-June. Staff from the Finance Committee and the HELP Committee, led by Sen. Edward M. Kennedy (D-Mass.), have been coordinating meetings with those two panels and the Budget Committee, Mr. Pollack said in an interview.

Committee chairs have the greatest influence on the legislative process, he said. Both Mr. Pollack and Mr. Nichols also expect Sen. Kennedy to play a very significant part in creating the legislation, as much as his cancer will allow.

Even so, “to pass anything of significance will require bipartisanship,” said Mr. Pollack, noting that Sen. Baucus and Sen. Grassley have worked closely on many bills.

The House is not as far along in preparing for health reform, but staffers on the four relevant committees with jurisdiction over health care have been meeting, Mr. Pollack said.

“I think there's significant movement underway in anticipation of health care reform being a top domestic priority,” he said. But, “I don't think any of the proposals that have come out so far are going to be the proposals,” Mr. Pollack added.

Instead, the expectation is that a health reform bill will be developed during the transition period between November and January, “and that's what we should look at most seriously,” he said.

Still Concerned About Health Care After All These Years

Harry and Louise, who became infamous in a 1993-1994 television ad lambasting the Clinton administration's health care reform plan, were dragged briefly out of mothballs to appear in a new commercial that urged Congress and the next president to make such reform the top domestic policy priority.

The effort was bankrolled by five groups that by their own admission have “historically divergent views about health care reform”: the American Cancer Society's Cancer Action Network, the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).

“We intend to transcend ideology and partisan politics,” said Families USA Executive Director Ron Pollack at a press conference. The multimillion-dollar campaign aired nationally for 2 weeks during the Republican and Democratic conventions.

The new ad featured Harry and Louise, back at their kitchen table. The characters were portrayed by the same two actors, now 14 years older. Harry noted that health care costs are going up again and that small businesses are being forced to drop their plans. Louise said that a friend just found out he has cancer and can't afford a plan. Harry remarked that “too many people are falling through the cracks.” Finally, Louise said that “whoever the next president is,” health care should be “at the top of his agenda,” and that he should bring everyone to the table and “make it happen.”

The campaign did not advocate any specific solution. The sponsors said their goal was to create momentum for change, and that they believed that, unlike 14 years ago, there is a consensus that reform is inevitable and necessary.

“The status quo is no longer acceptable,” said Rich Umbdenstock, AHA president and CEO.

“We simply can't be having this conversation 14 years from now,” added Sister Carol Keehan, CHA president and CEO.

The NFIB joined the effort because its membership said that “health care costs are their No. 1 concern,” said Todd Stottlemyer, president and CEO.

The five groups were joined at the briefing by Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP (back when it was known as the Health Insurance Association of America) launched Harry and Louise the first time, helping to defeat the Clinton reform plan.

But Ms. Ignani said times are different now: “Our commitment is to make sure no one falls through the cracks,” she said.

Harry and Louise were back at their kitchen table in a new ad promoting health care reform. Health Care First

Democrats and Republicans are so confident about the chances of some type of health reform in the next administration that staff meetings and hearings geared toward crafting legislation have been going on in earnest in both the House and the Senate, with the goal of being ready to go in January, according to advocates and policy watchers.

Many health policy analysts have compared and contrasted this election cycle with that of 1992, which sent Bill Clinton to the White House and launched the Clintons' health care reform efforts.

Both elections—1992 and 2008—feature a high level of public concern about access to health care and its costs, said Len Nichols, an analyst at the New America Foundation, a nonpartisan public policy institute.

For instance, a Harris Interactive survey conducted for the Commonwealth Fund in May found that 82% of Americans think the health care system should be fundamentally changed or completely rebuilt.

But the differences between the two elections are striking in a positive way, Mr. Nichols said in an interview.

First, the two major candidates themselves have acknowledged that cost is an overriding concern, he said. Also, a common theme is the use of private markets, which he called “evidence, I would say, of moderation” and, perhaps, the proposals' better legislative traction.

Both candidates—Sen. Barack Obama (D-Ill.) and Sen. John McCain (R-Ariz.)—have also learned that “no president is going to send [to Congress] a 1,400-page health bill written in a hotel room by 300 wonks,” Mr. Nichols said.

Instead, “Congress is going to own this [effort] far earlier and deeper than before,” he said, adding, “It's still going to require a lot of presidential leadership. But the Congress has to be an equal, more than it has before.”

Several proposals are likely starting points for congressional negotiations with the new administration, he said. First is the Healthy Americans Act, introduced in January 2007 by Sen. Ron Wyden (D-Ore.) and Sen. Bob Bennett (R-Utah). It has 16 cosponsors from both parties, including Sen. Chuck Grassley (R-Iowa), the Finance Committee's ranking minority member.

The bill is being championed in the House by Rep. Debbie Wasserman Schultz (D-Fla.) and Rep. Jo Ann Emerson (R-Mo.). Rep. Wasserman Schultz is important “because she's a rising star and has impeccable liberal credentials,” Mr. Nichols said.

In a paper published in the policy journal Health Affairs, Sen. Wyden and Sen. Bennett said they saw “signs of an ideological truce” on the Hill, with agreement that there is a need for the Democratic-backed universal coverage and the Republican-supported desire for market forces to promote competition and innovation. “The Healthy Americans Act strikes a balance between these ideals,” they wrote (Health Affairs 2008;27:689-92).

The bill would require individuals to purchase insurance for themselves and their dependent children, and would require insurers to offer a prescribed package of benefits.

It would subsidize coverage for Americans with incomes up to 400% of the federal poverty level. Employers would convert benefit dollars into salary; such compensation would be tax free, with the goal that the money would be used to purchase coverage.

Sen. Wyden is likely to be front and center in crafting a bill, as he is a member of two of the committees of jurisdiction: finance and budget, said Mr. Nichols, adding that those committees, along with the Health, Education, Labor and Pensions (HELP) Committee, “will play very important roles.”

Ron Pollack, executive director of the advocacy group Families USA, said that although Sen. Wyden may play a part, “I have little doubt that Sen. Baucus is going to be as instrumental in the process as anyone.”

Sen. Max Baucus (D-Mont.), chairman of the Finance Committee, held a health care summit in mid-June. Staff from the Finance Committee and the HELP Committee, led by Sen. Edward M. Kennedy (D-Mass.), have been coordinating meetings with those two panels and the Budget Committee, Mr. Pollack said in an interview.

Committee chairs have the greatest influence on the legislative process, he said. Both Mr. Pollack and Mr. Nichols also expect Sen. Kennedy to play a very significant part in creating the legislation, as much as his cancer will allow.

Even so, “to pass anything of significance will require bipartisanship,” said Mr. Pollack, noting that Sen. Baucus and Sen. Grassley have worked closely on many bills.

The House is not as far along in preparing for health reform, but staffers on the four relevant committees with jurisdiction over health care have been meeting, Mr. Pollack said.

“I think there's significant movement underway in anticipation of health care reform being a top domestic priority,” he said. But, “I don't think any of the proposals that have come out so far are going to be the proposals,” Mr. Pollack added.

Instead, the expectation is that a health reform bill will be developed during the transition period between November and January, “and that's what we should look at most seriously,” he said.

Still Concerned About Health Care After All These Years

Harry and Louise, who became infamous in a 1993-1994 television ad lambasting the Clinton administration's health care reform plan, were dragged briefly out of mothballs to appear in a new commercial that urged Congress and the next president to make such reform the top domestic policy priority.

The effort was bankrolled by five groups that by their own admission have “historically divergent views about health care reform”: the American Cancer Society's Cancer Action Network, the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).

“We intend to transcend ideology and partisan politics,” said Families USA Executive Director Ron Pollack at a press conference. The multimillion-dollar campaign aired nationally for 2 weeks during the Republican and Democratic conventions.

The new ad featured Harry and Louise, back at their kitchen table. The characters were portrayed by the same two actors, now 14 years older. Harry noted that health care costs are going up again and that small businesses are being forced to drop their plans. Louise said that a friend just found out he has cancer and can't afford a plan. Harry remarked that “too many people are falling through the cracks.” Finally, Louise said that “whoever the next president is,” health care should be “at the top of his agenda,” and that he should bring everyone to the table and “make it happen.”

The campaign did not advocate any specific solution. The sponsors said their goal was to create momentum for change, and that they believed that, unlike 14 years ago, there is a consensus that reform is inevitable and necessary.

“The status quo is no longer acceptable,” said Rich Umbdenstock, AHA president and CEO.

“We simply can't be having this conversation 14 years from now,” added Sister Carol Keehan, CHA president and CEO.

The NFIB joined the effort because its membership said that “health care costs are their No. 1 concern,” said Todd Stottlemyer, president and CEO.

The five groups were joined at the briefing by Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP (back when it was known as the Health Insurance Association of America) launched Harry and Louise the first time, helping to defeat the Clinton reform plan.

But Ms. Ignani said times are different now: “Our commitment is to make sure no one falls through the cracks,” she said.

Harry and Louise were back at their kitchen table in a new ad promoting health care reform. Health Care First

Democrats and Republicans are so confident about the chances of some type of health reform in the next administration that staff meetings and hearings geared toward crafting legislation have been going on in earnest in both the House and the Senate, with the goal of being ready to go in January, according to advocates and policy watchers.

Many health policy analysts have compared and contrasted this election cycle with that of 1992, which sent Bill Clinton to the White House and launched the Clintons' health care reform efforts.

Both elections—1992 and 2008—feature a high level of public concern about access to health care and its costs, said Len Nichols, an analyst at the New America Foundation, a nonpartisan public policy institute.

For instance, a Harris Interactive survey conducted for the Commonwealth Fund in May found that 82% of Americans think the health care system should be fundamentally changed or completely rebuilt.

But the differences between the two elections are striking in a positive way, said Mr. Nichols, in an interview.

First, the two major candidates themselves have acknowledged that cost is an overriding concern, he said. Also, a common theme is the use of private markets, which he called “evidence, I would say, of moderation” and, perhaps, the proposals' better legislative traction.

Both candidates—Sen. Barack Obama (D-Ill.) and Sen. John McCain (R-Ariz.)—have also learned that “no president is going to send [to Congress] a 1,400-page health bill written in a hotel room by 300 wonks,” Mr. Nichols said.

Instead, “Congress is going to own this [effort] far earlier and deeper than before,” he said, adding, “It's still going to require a lot of presidential leadership. But the Congress has to be an equal, more than it has before.”

Several proposals are likely starting points for congressional negotiations with the new administration, he said. First is the Healthy Americans Act, introduced in January 2007 by Sen. Ron Wyden (D-Ore.) and Sen. Bob Bennett (R-Utah). It has 16 cosponsors from both parties, including Sen. Chuck Grassley (R-Iowa), the Finance Committee's ranking minority member.

The bill is being championed in the House by Rep. Debbie Wasserman Schultz (D-Fla.) and Rep. Jo Ann Emerson (R-Mo.). Rep. Wasserman Schultz is important “because she's a rising star and has impeccable liberal credentials,” said Mr. Nichols.

In a paper published in the May/June 2008 issue of the policy journal Health Affairs, Sen. Wyden and Sen. Bennett said they saw “signs of an ideological truce” on the Hill, with agreement that there is a need for the Democratic-backed universal coverage and the Republican-supported desire for market forces to promote competition and innovation. “The Healthy Americans Act strikes a balance between these ideals,” they wrote (Health Affairs 2008;27:689–92).

The bill would require individuals to purchase insurance for themselves and their dependent children, and would require insurers to offer a prescribed package of benefits. It would subsidize coverage for Americans with incomes up to 400% of the federal poverty level. Employers would convert benefit dollars into salary; such compensation would be tax free, with the goal that the money would be used to purchase coverage.

Sen. Wyden is likely to be front and center in crafting a bill, as he is a member of two of the committees of jurisdiction: finance and budget, said Mr. Nichols, adding that those committees, along with the Health, Education, Labor and Pensions (HELP) Committee “will play very important roles.”

Ron Pollack, executive director of the advocacy group Families USA, said that although Sen. Wyden may play a part, “I have little doubt that Sen. Baucus is going to be as instrumental in the process as anyone.”

Sen. Max Baucus (D-Mont.), chairman of the Finance Committee, held a health care summit in mid-June. Staff from the Finance Committee and the HELP Committee, led by Sen. Edward M. Kennedy (D-Mass.), have been coordinating meetings with those two panels and the Budget Committee, Mr. Pollack said in an interview.

Committee chairs have the greatest influence on the legislative process, he said. Both Mr. Pollack and Mr. Nichols also expect Sen. Kennedy to play a very significant part in creating the legislation, as much as his cancer will allow.

The Brief Return of Harry and Louise

Harry and Louise, who became infamous in a 1993–1994 television ad lambasting the Clinton administration's health care reform plan, were dragged briefly out of mothballs to appear in a new commercial that urged Congress and the next president to make such reform the top domestic policy priority.

The effort was being bankrolled by five groups that by their own admission have “historically divergent views about health care reform”: the American Cancer Society's Cancer Action Network, the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).

“We intend to transcend ideology and partisan politics,” said Families USA Executive Director Ron Pollack at a press conference. The multimillion dollar campaign aired nationally for 2 weeks during the Republican and Democratic conventions.

The ad featured Harry and Louise, back at their kitchen table. The characters were portrayed by the same two actors, now 14 years older. Harry noted that health care costs are going up again and that small businesses are being forced to drop their plans. Louise said that a friend just found out he has cancer and can't afford a plan. Harry remarked that “too many people are falling through the cracks.” Finally, Louise said that “whoever the next president is,” health care should be “at the top of his agenda,” and that he should bring everyone to the table and “make it happen.”

The campaign did not advocate any specific solution. The sponsors said their goal was to create momentum for change, and that they believed that, unlike 14 years ago, there is a consensus that reform is inevitable and necessary.

“The status quo is no longer acceptable,” said Rich Umbdenstock, AHA president and CEO.

“We simply can't be having this conversation 14 years from now,” added Sister Carol Keehan, CHA president and CEO.

The NFIB joined the effort because its membership said that “health care costs are their No. 1 concern,” said Todd Stottlemyer, president and CEO.

The five groups were joined at the briefing by Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP (back when it was known as the Health Insurance Association of America) launched Harry and Louise the first time, helping to defeat the Clinton reform plan.

But Ms. Ignani said times are different now: “Our commitment is to make sure no one falls through the cracks,” she said.

Democrats and Republicans are so confident about the chances of some type of health reform in the next administration that staff meetings and hearings geared toward crafting legislation have been going on in earnest in both the House and the Senate, with the goal of being ready to go in January, according to advocates and policy watchers.

Many health policy analysts have compared and contrasted this election cycle with that of 1992, which sent Bill Clinton to the White House and launched the Clintons' health care reform efforts.

Both elections—1992 and 2008—feature a high level of public concern about access to health care and its costs, said Len Nichols, an analyst at the New America Foundation, a nonpartisan public policy institute.

For instance, a Harris Interactive survey conducted for the Commonwealth Fund in May found that 82% of Americans think the health care system should be fundamentally changed or completely rebuilt.

But the differences between the two elections are striking in a positive way, said Mr. Nichols, in an interview.

First, the two major candidates themselves have acknowledged that cost is an overriding concern, he said. Also, a common theme is the use of private markets, which he called “evidence, I would say, of moderation” and, perhaps, the proposals' better legislative traction.

Both candidates—Sen. Barack Obama (D-Ill.) and Sen. John McCain (R-Ariz.)—have also learned that “no president is going to send [to Congress] a 1,400-page health bill written in a hotel room by 300 wonks,” Mr. Nichols said.

Instead, “Congress is going to own this [effort] far earlier and deeper than before,” he said, adding, “It's still going to require a lot of presidential leadership. But the Congress has to be an equal, more than it has before.”

Several proposals are likely starting points for congressional negotiations with the new administration, he said. First is the Healthy Americans Act, introduced in January 2007 by Sen. Ron Wyden (D-Ore.) and Sen. Bob Bennett (R-Utah). It has 16 cosponsors from both parties, including Sen. Chuck Grassley (R-Iowa), the Finance Committee's ranking minority member.

The bill is being championed in the House by Rep. Debbie Wasserman Schultz (D-Fla.) and Rep. Jo Ann Emerson (R-Mo.). Rep. Wasserman Schultz is important “because she's a rising star and has impeccable liberal credentials,” said Mr. Nichols.

In a paper published in the May/June 2008 issue of the policy journal Health Affairs, Sen. Wyden and Sen. Bennett said they saw “signs of an ideological truce” on the Hill, with agreement that there is a need for the Democratic-backed universal coverage and the Republican-supported desire for market forces to promote competition and innovation. “The Healthy Americans Act strikes a balance between these ideals,” they wrote (Health Affairs 2008;27:689–92).

The bill would require individuals to purchase insurance for themselves and their dependent children, and would require insurers to offer a prescribed package of benefits. It would subsidize coverage for Americans with incomes up to 400% of the federal poverty level. Employers would convert benefit dollars into salary; such compensation would be tax free, with the goal that the money would be used to purchase coverage.

Sen. Wyden is likely to be front and center in crafting a bill, as he is a member of two of the committees of jurisdiction: finance and budget, said Mr. Nichols, adding that those committees, along with the Health, Education, Labor and Pensions (HELP) Committee “will play very important roles.”

Ron Pollack, executive director of the advocacy group Families USA, said that although Sen. Wyden may play a part, “I have little doubt that Sen. Baucus is going to be as instrumental in the process as anyone.”

Sen. Max Baucus (D-Mont.), chairman of the Finance Committee, held a health care summit in mid-June. Staff from the Finance Committee and the HELP Committee, led by Sen. Edward M. Kennedy (D-Mass.), have been coordinating meetings with those two panels and the Budget Committee, Mr. Pollack said in an interview.

Committee chairs have the greatest influence on the legislative process, he said. Both Mr. Pollack and Mr. Nichols also expect Sen. Kennedy to play a very significant part in creating the legislation, as much as his cancer will allow.

The Brief Return of Harry and Louise

Harry and Louise, who became infamous in a 1993–1994 television ad lambasting the Clinton administration's health care reform plan, were dragged briefly out of mothballs to appear in a new commercial that urged Congress and the next president to make such reform the top domestic policy priority.

The effort was being bankrolled by five groups that by their own admission have “historically divergent views about health care reform”: the American Cancer Society's Cancer Action Network, the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).

“We intend to transcend ideology and partisan politics,” said Families USA Executive Director Ron Pollack at a press conference. The multimillion dollar campaign aired nationally for 2 weeks during the Republican and Democratic conventions.

The ad featured Harry and Louise, back at their kitchen table. The characters were portrayed by the same two actors, now 14 years older. Harry noted that health care costs are going up again and that small businesses are being forced to drop their plans. Louise said that a friend just found out he has cancer and can't afford a plan. Harry remarked that “too many people are falling through the cracks.” Finally, Louise said that “whoever the next president is,” health care should be “at the top of his agenda,” and that he should bring everyone to the table and “make it happen.”

The campaign did not advocate any specific solution. The sponsors said their goal was to create momentum for change, and that they believed that, unlike 14 years ago, there is a consensus that reform is inevitable and necessary.

“The status quo is no longer acceptable,” said Rich Umbdenstock, AHA president and CEO.

“We simply can't be having this conversation 14 years from now,” added Sister Carol Keehan, CHA president and CEO.

The NFIB joined the effort because its membership said that “health care costs are their No. 1 concern,” said Todd Stottlemyer, president and CEO.

The five groups were joined at the briefing by Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP (back when it was known as the Health Insurance Association of America) launched Harry and Louise the first time, helping to defeat the Clinton reform plan.

But Ms. Ignani said times are different now: “Our commitment is to make sure no one falls through the cracks,” she said.

Democrats and Republicans are so confident about the chances of some type of health reform in the next administration that staff meetings and hearings geared toward crafting legislation have been going on in earnest in both the House and the Senate, with the goal of being ready to go in January, according to advocates and policy watchers.

Many health policy analysts have compared and contrasted this election cycle with that of 1992, which sent Bill Clinton to the White House and launched the Clintons' health care reform efforts.

Both elections—1992 and 2008—feature a high level of public concern about access to health care and its costs, said Len Nichols, an analyst at the New America Foundation, a nonpartisan public policy institute.

For instance, a Harris Interactive survey conducted for the Commonwealth Fund in May found that 82% of Americans think the health care system should be fundamentally changed or completely rebuilt.

But the differences between the two elections are striking in a positive way, said Mr. Nichols, in an interview.

First, the two major candidates themselves have acknowledged that cost is an overriding concern, he said. Also, a common theme is the use of private markets, which he called “evidence, I would say, of moderation” and, perhaps, the proposals' better legislative traction.

Both candidates—Sen. Barack Obama (D-Ill.) and Sen. John McCain (R-Ariz.)—have also learned that “no president is going to send [to Congress] a 1,400-page health bill written in a hotel room by 300 wonks,” Mr. Nichols said.

Instead, “Congress is going to own this [effort] far earlier and deeper than before,” he said, adding, “It's still going to require a lot of presidential leadership. But the Congress has to be an equal, more than it has before.”

Several proposals are likely starting points for congressional negotiations with the new administration, he said. First is the Healthy Americans Act, introduced in January 2007 by Sen. Ron Wyden (D-Ore.) and Sen. Bob Bennett (R-Utah). It has 16 cosponsors from both parties, including Sen. Chuck Grassley (R-Iowa), the Finance Committee's ranking minority member.

The bill is being championed in the House by Rep. Debbie Wasserman Schultz (D-Fla.) and Rep. Jo Ann Emerson (R-Mo.). Rep. Wasserman Schultz is important “because she's a rising star and has impeccable liberal credentials,” said Mr. Nichols.

In a paper published in the May/June 2008 issue of the policy journal Health Affairs, Sen. Wyden and Sen. Bennett said they saw “signs of an ideological truce” on the Hill, with agreement that there is a need for the Democratic-backed universal coverage and the Republican-supported desire for market forces to promote competition and innovation. “The Healthy Americans Act strikes a balance between these ideals,” they wrote (Health Affairs 2008;27:689–92).

The bill would require individuals to purchase insurance for themselves and their dependent children, and would require insurers to offer a prescribed package of benefits. It would subsidize coverage for Americans with incomes up to 400% of the federal poverty level. Employers would convert benefit dollars into salary; such compensation would be tax free, with the goal that the money would be used to purchase coverage.

Sen. Wyden is likely to be front and center in crafting a bill, as he is a member of two of the committees of jurisdiction: finance and budget, said Mr. Nichols, adding that those committees, along with the Health, Education, Labor and Pensions (HELP) Committee “will play very important roles.”

Ron Pollack, executive director of the advocacy group Families USA, said that although Sen. Wyden may play a part, “I have little doubt that Sen. Baucus is going to be as instrumental in the process as anyone.”

Sen. Max Baucus (D-Mont.), chairman of the Finance Committee, held a health care summit in mid-June. Staff from the Finance Committee and the HELP Committee, led by Sen. Edward M. Kennedy (D-Mass.), have been coordinating meetings with those two panels and the Budget Committee, Mr. Pollack said in an interview.

Committee chairs have the greatest influence on the legislative process, he said. Both Mr. Pollack and Mr. Nichols also expect Sen. Kennedy to play a very significant part in creating the legislation, as much as his cancer will allow.

The Brief Return of Harry and Louise

Harry and Louise, who became infamous in a 1993–1994 television ad lambasting the Clinton administration's health care reform plan, were dragged briefly out of mothballs to appear in a new commercial that urged Congress and the next president to make such reform the top domestic policy priority.

The effort was being bankrolled by five groups that by their own admission have “historically divergent views about health care reform”: the American Cancer Society's Cancer Action Network, the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).

“We intend to transcend ideology and partisan politics,” said Families USA Executive Director Ron Pollack at a press conference. The multimillion dollar campaign aired nationally for 2 weeks during the Republican and Democratic conventions.

The ad featured Harry and Louise, back at their kitchen table. The characters were portrayed by the same two actors, now 14 years older. Harry noted that health care costs are going up again and that small businesses are being forced to drop their plans. Louise said that a friend just found out he has cancer and can't afford a plan. Harry remarked that “too many people are falling through the cracks.” Finally, Louise said that “whoever the next president is,” health care should be “at the top of his agenda,” and that he should bring everyone to the table and “make it happen.”

The campaign did not advocate any specific solution. The sponsors said their goal was to create momentum for change, and that they believed that, unlike 14 years ago, there is a consensus that reform is inevitable and necessary.

“The status quo is no longer acceptable,” said Rich Umbdenstock, AHA president and CEO.

“We simply can't be having this conversation 14 years from now,” added Sister Carol Keehan, CHA president and CEO.

The NFIB joined the effort because its membership said that “health care costs are their No. 1 concern,” said Todd Stottlemyer, president and CEO.

The five groups were joined at the briefing by Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP (back when it was known as the Health Insurance Association of America) launched Harry and Louise the first time, helping to defeat the Clinton reform plan.

But Ms. Ignani said times are different now: “Our commitment is to make sure no one falls through the cracks,” she said.

SAN FRANCISCO — Speaking at the insurance industry's annual meeting, an Aetna executive defended the company's performance-based physician networks, saying that they were a way to keep costs down and to let patients know which physicians offered the best and most cost-effective care.

Dr. Gerald Bishop, senior medical director for Aetna's West division, spoke at the AHIP Institute, at a conference sponsored by America's Health Insurance Plans.

Preferred provider networks have been the subject of legal challenges around the country, most recently in Massachusetts and Connecticut.

Physicians have claimed that the networks use inappropriate methodology to rate their performance.

In 2007, New York Attorney General Andrew Cuomo struck a settlement with several insurers in which they agreed to publicly disclose rating methods and how much of the ratings is based on cost, and to retain an independent monitoring board to report on compliance. Aetna was one of the first insurers to sign on to that settlement, and has continued to comply, said Dr. Bishop.

He noted, for instance, that Aetna reviews and updates its provider list every 2 years and notifies each physician in writing if there has been any change in his or her status. Physicians have the opportunity to appeal if there is an error—before any data are made public, he said.

The company also encourages physicians to submit any relevant information from medical records if they have a question about the rating.

Aetna first began developing its Aexcel network in 2002, said Dr. Bishop. The goal was to mitigate rising costs, ensure patient access to specialists, and find a way to recognize the variations in costs and practices in each individual market, he said. The company found that 12 specialties represented 70% of spending on specialists and 50% of the overall spending: cardiology, cardiothoracic surgery, gastroenterology, general surgery, neurology, neurosurgery, obstetrics/gynecology, orthopedics, otolaryngology, plastic surgery, urology, and vascular surgery.

When considering which physicians were eligible for the network, Aetna looked at the number of Aetna cases managed over a 3-year period; there was a 20-case minimum.

The company also uses nationally recognized performance measures to gauge clinical performance. Physicians who score statistically significantly below their peers are excluded.

The company also uses the Episode Treatment Group methodology to evaluate 3 years of claims for cost and utilization patterns. A physician is considered efficient if his or her score is greater than the mean for that specialty and that market, said Dr. Bishop.

The Aexcel network now exists in 35 markets, covering 670,000 members. Aetna members in most, though not all, those areas can log onto a secure patient Web site and see costs for various procedures and information on why his or her physician has been designated a preferred provider in the network.

Dr. Bishop said that Aetna has determined that physicians in the Aexcel network typically perform 1%–8% more efficiently than their peers. Each client could save up to 4% of annual claim costs if all its covered workers used the network, he said.

Although some physicians have been unhappy with the designations, “amazingly few physicians balk at this,” said Dr. Bishop.

SAN FRANCISCO — Speaking at the insurance industry's annual meeting, an Aetna executive defended the company's performance-based physician networks, saying that they were a way to keep costs down and to let patients know which physicians offered the best and most cost-effective care.

Dr. Gerald Bishop, senior medical director for Aetna's West division, spoke at the AHIP Institute, at a conference sponsored by America's Health Insurance Plans.

Preferred provider networks have been the subject of legal challenges around the country, most recently in Massachusetts and Connecticut.

Physicians have claimed that the networks use inappropriate methodology to rate their performance.

In 2007, New York Attorney General Andrew Cuomo struck a settlement with several insurers in which they agreed to publicly disclose rating methods and how much of the ratings is based on cost, and to retain an independent monitoring board to report on compliance. Aetna was one of the first insurers to sign on to that settlement, and has continued to comply, said Dr. Bishop.

He noted, for instance, that Aetna reviews and updates its provider list every 2 years and notifies each physician in writing if there has been any change in his or her status. Physicians have the opportunity to appeal if there is an error—before any data are made public, he said.

The company also encourages physicians to submit any relevant information from medical records if they have a question about the rating.

Aetna first began developing its Aexcel network in 2002, said Dr. Bishop. The goal was to mitigate rising costs, ensure patient access to specialists, and find a way to recognize the variations in costs and practices in each individual market, he said. The company found that 12 specialties represented 70% of spending on specialists and 50% of the overall spending: cardiology, cardiothoracic surgery, gastroenterology, general surgery, neurology, neurosurgery, obstetrics/gynecology, orthopedics, otolaryngology, plastic surgery, urology, and vascular surgery.

When considering which physicians were eligible for the network, Aetna looked at the number of Aetna cases managed over a 3-year period; there was a 20-case minimum.

The company also uses nationally recognized performance measures to gauge clinical performance. Physicians who score statistically significantly below their peers are excluded.

The company also uses the Episode Treatment Group methodology to evaluate 3 years of claims for cost and utilization patterns. A physician is considered efficient if his or her score is greater than the mean for that specialty and that market, said Dr. Bishop.

The Aexcel network now exists in 35 markets, covering 670,000 members. Aetna members in most, though not all, those areas can log onto a secure patient Web site and see costs for various procedures and information on why his or her physician has been designated a preferred provider in the network.

Dr. Bishop said that Aetna has determined that physicians in the Aexcel network typically perform 1%–8% more efficiently than their peers. Each client could save up to 4% of annual claim costs if all its covered workers used the network, he said.

Although some physicians have been unhappy with the designations, “amazingly few physicians balk at this,” said Dr. Bishop.

SAN FRANCISCO — Speaking at the insurance industry's annual meeting, an Aetna executive defended the company's performance-based physician networks, saying that they were a way to keep costs down and to let patients know which physicians offered the best and most cost-effective care.

Dr. Gerald Bishop, senior medical director for Aetna's West division, spoke at the AHIP Institute, at a conference sponsored by America's Health Insurance Plans.

Preferred provider networks have been the subject of legal challenges around the country, most recently in Massachusetts and Connecticut.

Physicians have claimed that the networks use inappropriate methodology to rate their performance.

In 2007, New York Attorney General Andrew Cuomo struck a settlement with several insurers in which they agreed to publicly disclose rating methods and how much of the ratings is based on cost, and to retain an independent monitoring board to report on compliance. Aetna was one of the first insurers to sign on to that settlement, and has continued to comply, said Dr. Bishop.

He noted, for instance, that Aetna reviews and updates its provider list every 2 years and notifies each physician in writing if there has been any change in his or her status. Physicians have the opportunity to appeal if there is an error—before any data are made public, he said.

The company also encourages physicians to submit any relevant information from medical records if they have a question about the rating.

Aetna first began developing its Aexcel network in 2002, said Dr. Bishop. The goal was to mitigate rising costs, ensure patient access to specialists, and find a way to recognize the variations in costs and practices in each individual market, he said. The company found that 12 specialties represented 70% of spending on specialists and 50% of the overall spending: cardiology, cardiothoracic surgery, gastroenterology, general surgery, neurology, neurosurgery, obstetrics/gynecology, orthopedics, otolaryngology, plastic surgery, urology, and vascular surgery.

When considering which physicians were eligible for the network, Aetna looked at the number of Aetna cases managed over a 3-year period; there was a 20-case minimum.

The company also uses nationally recognized performance measures to gauge clinical performance. Physicians who score statistically significantly below their peers are excluded.

The company also uses the Episode Treatment Group methodology to evaluate 3 years of claims for cost and utilization patterns. A physician is considered efficient if his or her score is greater than the mean for that specialty and that market, said Dr. Bishop.

The Aexcel network now exists in 35 markets, covering 670,000 members. Aetna members in most, though not all, those areas can log onto a secure patient Web site and see costs for various procedures and information on why his or her physician has been designated a preferred provider in the network.

Dr. Bishop said that Aetna has determined that physicians in the Aexcel network typically perform 1%–8% more efficiently than their peers. Each client could save up to 4% of annual claim costs if all its covered workers used the network, he said.

Although some physicians have been unhappy with the designations, “amazingly few physicians balk at this,” said Dr. Bishop.

The rankings are posted at www.athenapayerview.com

Aetna has taken over from Cigna as the fastest and most accurate national insurer when it comes to paying physicians, according to the third annual ranking of payer performance by one of the nation's largest physician management companies.

Cigna achieved the top rank in 2006, and Aetna was No. 2, having moved up from the fourth spot in the 2005 survey by AthenaHealth.

The 2007 data are based on 30 million charge lines collected by AthenaHealth, and cover 137 national, regional, and government payers and 12,000 medical providers. The company, which is based in Watertown, Mass., collected almost $3 billion for its 980 physician clients in 2007.

According to the company, several trends were apparent in the data. Payers have moved to make Web portals more available to physicians, and they've become more proactive about contacting physicians with guideline changes. This has resulted in an almost 3% drop in the number of days that claims are in accounts receivable, at least for regional payers.

Claims denial and resubmission rates increased, however, partly due to problems implementing the new National Provider Identifier number required by Medicare. The full impact of that transition may not be felt until this year, according to AthenaHealth.

After Aetna and Cigna, the top performers were Humana, Medicare Part B, UnitedHealth Group, WellPoint, Coventry Health Care, and Champus Tricare. Humana and Medicare were the top two payers in 2005; United, Wellpoint, Coventry, and Champus have more or less held steady.

“We commend Aetna for their progress in improving what should be any insurer's core competency: paying insurance claims accurately and promptly,” said Dr. William F. Jessee, president and CEO of the Medical Group Management Association, in a statement.

Aetna CEO Ronald A. Williams said in a statement, “While we are pleased that the progress we have made has been recognized, we are committed to continuous improvement in this area.”

Rankings are calculated by scores given to performance in seven areas. If a payer paid quickly and fully, it tended to receive a higher ranking overall. Fifty-eight percent of the score came from days in accounts receivable (DAR), first pass resolve rate, and percentage of billed charges deemed the patient's responsibility.

Physicians have a greater collections burden when payers ask patients to foot more of the bill. There was a 19% increase in patient liability in 2006, but it only rose 0.4% in 2007. Increased availability of real-time claims adjudication has helped cut the physician collection burden, according to AthenaHealth.

Aetna's DAR was 26.9 days, compared with 32.6 for Cigna, and 35.7 for Coventry, which holds the No. 8 overall position. Blue Cross Blue Shield of Rhode Island had the lowest DAR for the second year in a row, at 15.8 days. Denial rate is also an important metric used in the ranking. Aetna had the lowest denial rate among national payers, at about 6%. The highest denial rate—38%—was at Health Choice Arizona. The lowest denial rate overall was 3.17%, at Blue Cross Blue Shield of Rhode Island.

The New York State Medicaid program came in for special criticism. It lagged in most of the key measures. The program had the highest DAR of any payer—for the second year running—coming in at 137.3 days in 2007, compared with the national median of 35.4. New York Medicaid also had the lowest first pass resolve rate, at 57%, compared with 97% for Blue Cross Blue Shield of Ohio, the top performer in that category. According to AthenaHealth, the New York program “ranked at the bottom on the clarity of why the program rejects a medical claim.”

The rankings are posted at www.athenapayerview.com

Aetna has taken over from Cigna as the fastest and most accurate national insurer when it comes to paying physicians, according to the third annual ranking of payer performance by one of the nation's largest physician management companies.

Cigna achieved the top rank in 2006, and Aetna was No. 2, having moved up from the fourth spot in the 2005 survey by AthenaHealth.

The 2007 data are based on 30 million charge lines collected by AthenaHealth, and cover 137 national, regional, and government payers and 12,000 medical providers. The company, which is based in Watertown, Mass., collected almost $3 billion for its 980 physician clients in 2007.

According to the company, several trends were apparent in the data. Payers have moved to make Web portals more available to physicians, and they've become more proactive about contacting physicians with guideline changes. This has resulted in an almost 3% drop in the number of days that claims are in accounts receivable, at least for regional payers.

Claims denial and resubmission rates increased, however, partly due to problems implementing the new National Provider Identifier number required by Medicare. The full impact of that transition may not be felt until this year, according to AthenaHealth.

After Aetna and Cigna, the top performers were Humana, Medicare Part B, UnitedHealth Group, WellPoint, Coventry Health Care, and Champus Tricare. Humana and Medicare were the top two payers in 2005; United, Wellpoint, Coventry, and Champus have more or less held steady.

“We commend Aetna for their progress in improving what should be any insurer's core competency: paying insurance claims accurately and promptly,” said Dr. William F. Jessee, president and CEO of the Medical Group Management Association, in a statement.

Aetna CEO Ronald A. Williams said in a statement, “While we are pleased that the progress we have made has been recognized, we are committed to continuous improvement in this area.”

Rankings are calculated by scores given to performance in seven areas. If a payer paid quickly and fully, it tended to receive a higher ranking overall. Fifty-eight percent of the score came from days in accounts receivable (DAR), first pass resolve rate, and percentage of billed charges deemed the patient's responsibility.

Physicians have a greater collections burden when payers ask patients to foot more of the bill. There was a 19% increase in patient liability in 2006, but it only rose 0.4% in 2007. Increased availability of real-time claims adjudication has helped cut the physician collection burden, according to AthenaHealth.

Aetna's DAR was 26.9 days, compared with 32.6 for Cigna, and 35.7 for Coventry, which holds the No. 8 overall position. Blue Cross Blue Shield of Rhode Island had the lowest DAR for the second year in a row, at 15.8 days. Denial rate is also an important metric used in the ranking. Aetna had the lowest denial rate among national payers, at about 6%. The highest denial rate—38%—was at Health Choice Arizona. The lowest denial rate overall was 3.17%, at Blue Cross Blue Shield of Rhode Island.

The New York State Medicaid program came in for special criticism. It lagged in most of the key measures. The program had the highest DAR of any payer—for the second year running—coming in at 137.3 days in 2007, compared with the national median of 35.4. New York Medicaid also had the lowest first pass resolve rate, at 57%, compared with 97% for Blue Cross Blue Shield of Ohio, the top performer in that category. According to AthenaHealth, the New York program “ranked at the bottom on the clarity of why the program rejects a medical claim.”

The rankings are posted at www.athenapayerview.com

Aetna has taken over from Cigna as the fastest and most accurate national insurer when it comes to paying physicians, according to the third annual ranking of payer performance by one of the nation's largest physician management companies.

Cigna achieved the top rank in 2006, and Aetna was No. 2, having moved up from the fourth spot in the 2005 survey by AthenaHealth.

The 2007 data are based on 30 million charge lines collected by AthenaHealth, and cover 137 national, regional, and government payers and 12,000 medical providers. The company, which is based in Watertown, Mass., collected almost $3 billion for its 980 physician clients in 2007.

According to the company, several trends were apparent in the data. Payers have moved to make Web portals more available to physicians, and they've become more proactive about contacting physicians with guideline changes. This has resulted in an almost 3% drop in the number of days that claims are in accounts receivable, at least for regional payers.

Claims denial and resubmission rates increased, however, partly due to problems implementing the new National Provider Identifier number required by Medicare. The full impact of that transition may not be felt until this year, according to AthenaHealth.

After Aetna and Cigna, the top performers were Humana, Medicare Part B, UnitedHealth Group, WellPoint, Coventry Health Care, and Champus Tricare. Humana and Medicare were the top two payers in 2005; United, Wellpoint, Coventry, and Champus have more or less held steady.

“We commend Aetna for their progress in improving what should be any insurer's core competency: paying insurance claims accurately and promptly,” said Dr. William F. Jessee, president and CEO of the Medical Group Management Association, in a statement.

Aetna CEO Ronald A. Williams said in a statement, “While we are pleased that the progress we have made has been recognized, we are committed to continuous improvement in this area.”

Rankings are calculated by scores given to performance in seven areas. If a payer paid quickly and fully, it tended to receive a higher ranking overall. Fifty-eight percent of the score came from days in accounts receivable (DAR), first pass resolve rate, and percentage of billed charges deemed the patient's responsibility.

Physicians have a greater collections burden when payers ask patients to foot more of the bill. There was a 19% increase in patient liability in 2006, but it only rose 0.4% in 2007. Increased availability of real-time claims adjudication has helped cut the physician collection burden, according to AthenaHealth.

Aetna's DAR was 26.9 days, compared with 32.6 for Cigna, and 35.7 for Coventry, which holds the No. 8 overall position. Blue Cross Blue Shield of Rhode Island had the lowest DAR for the second year in a row, at 15.8 days. Denial rate is also an important metric used in the ranking. Aetna had the lowest denial rate among national payers, at about 6%. The highest denial rate—38%—was at Health Choice Arizona. The lowest denial rate overall was 3.17%, at Blue Cross Blue Shield of Rhode Island.

The New York State Medicaid program came in for special criticism. It lagged in most of the key measures. The program had the highest DAR of any payer—for the second year running—coming in at 137.3 days in 2007, compared with the national median of 35.4. New York Medicaid also had the lowest first pass resolve rate, at 57%, compared with 97% for Blue Cross Blue Shield of Ohio, the top performer in that category. According to AthenaHealth, the New York program “ranked at the bottom on the clarity of why the program rejects a medical claim.”