Alicia Ault

WASHINGTON — The concept of a medical home is one step closer to reality for Medicare patients, after it received strong backing from the Medicare Payment Advisory Commission at its April meeting.

All 17 commissioners present at the meeting voted to urge Congress to instruct the Centers for Medicare and Medicaid Services to develop a large pilot study of medical homes for Medicare beneficiaries. The recommendation will be included in MedPAC's June report to Congress.

Most of the commissioners also voted to adjust the Medicare fee schedule to increase payment for primary care, which MedPAC has deemed as undervalued at previous meetings.

The medical home concept has been advanced by the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics. A demonstration project is authorized under the Medicare program, but the commissioners said that a larger pilot with clear thresholds could accelerate the evaluation process, and could easily be discontinued or expanded.

The commissioners compiled a wish list of criteria for a medical home, including the ability to provide primary care, use information technology for clinical decision support, conduct care management, offer 24-hour communication with patients, maintain up-to-date records of patients' advance directives, and operate a formal quality improvement program. Also, beneficiaries should agree to adhere to medical home principles by respecting the idea that someone is in charge of coordinating their care, and communicating with the physician when they seek care elsewhere.

There was some debate over whether patients should be allowed to access other providers without a referral, which is permitted under current fee-for-service Medicare. Most commissioners wanted some restrictions, or at least a way to track when patients see specialists, to facilitate assessment of the program's success or failure.

The medical home would not be limited to primary care physicians; specialists likely would be able to fulfill criteria for participation, according to the commission's vision.

The program would cost $50 million to $250 million in the first year, and cost less than $1 billion over the first 5 years, MedPAC staffers estimated. The estimate included monthly fees to medical homes, but not anticipated savings, said MedPAC staffer Christine Boccuti.

Dr. Francis Jay Crosson, a commissioner and senior medical director of Permanente Federation in Oakland, called the proposal a “significant evolution” from what had been presented to the panel in 2007. “And I think it's a good evolution,” he said.

“This is a very exciting recommendation,” said Commissioner Jack Ebeler, a health policy consultant in Reston, Va. Promotion of the medical home approach is a direct way to reform the health care delivery system, he added.

Commissioners also said that the medical home recommendation dovetailed with MedPAC's support of increased pay for primary care services.

An adjustment to the fee schedule is “long overdue,” said Dr. Ronald Castellanos, a commissioner and urologist in private practice in Ft. Myers, Fla. Increased pay might lure more residents into primary care, and help those currently practicing to stay in the workplace, he said.

The commissioners debated how the CMS could determine which physicians or other health providers—such as nurse practitioners—would receive the update. MedPAC staff presented the increase as budget neutral, which made some panelists uneasy.

Dr. Nicholas Wolter of the Billings (Mont.) Clinic, suggested that the increase be made without trying to maintain budget neutrality. Dr. Karen Borman, professor of surgery at the University of Mississippi, Jackson, expressed concern that rewarding primary care could end up hurting other physicians.

“I have some philosophical problems here,” said Dr. Borman, adding that primary care was not always linked with a traditional primary care physician. She said that she often provided what would be considered primary care to her breast cancer patients. Dr. Borman ended up voting against the recommendation for increased pay for primary care.

WASHINGTON — The concept of a medical home is one step closer to reality for Medicare patients, after it received strong backing from the Medicare Payment Advisory Commission at its April meeting.

All 17 commissioners present at the meeting voted to urge Congress to instruct the Centers for Medicare and Medicaid Services to develop a large pilot study of medical homes for Medicare beneficiaries. The recommendation will be included in MedPAC's June report to Congress.

Most of the commissioners also voted to adjust the Medicare fee schedule to increase payment for primary care, which MedPAC has deemed as undervalued at previous meetings.

The medical home concept has been advanced by the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics. A demonstration project is authorized under the Medicare program, but the commissioners said that a larger pilot with clear thresholds could accelerate the evaluation process, and could easily be discontinued or expanded.

The commissioners compiled a wish list of criteria for a medical home, including the ability to provide primary care, use information technology for clinical decision support, conduct care management, offer 24-hour communication with patients, maintain up-to-date records of patients' advance directives, and operate a formal quality improvement program. Also, beneficiaries should agree to adhere to medical home principles by respecting the idea that someone is in charge of coordinating their care, and communicating with the physician when they seek care elsewhere.

There was some debate over whether patients should be allowed to access other providers without a referral, which is permitted under current fee-for-service Medicare. Most commissioners wanted some restrictions, or at least a way to track when patients see specialists, to facilitate assessment of the program's success or failure.

The medical home would not be limited to primary care physicians; specialists likely would be able to fulfill criteria for participation, according to the commission's vision.

The program would cost $50 million to $250 million in the first year, and cost less than $1 billion over the first 5 years, MedPAC staffers estimated. The estimate included monthly fees to medical homes, but not anticipated savings, said MedPAC staffer Christine Boccuti.

Dr. Francis Jay Crosson, a commissioner and senior medical director of Permanente Federation in Oakland, called the proposal a “significant evolution” from what had been presented to the panel in 2007. “And I think it's a good evolution,” he said.

“This is a very exciting recommendation,” said Commissioner Jack Ebeler, a health policy consultant in Reston, Va. Promotion of the medical home approach is a direct way to reform the health care delivery system, he added.

Commissioners also said that the medical home recommendation dovetailed with MedPAC's support of increased pay for primary care services.

An adjustment to the fee schedule is “long overdue,” said Dr. Ronald Castellanos, a commissioner and urologist in private practice in Ft. Myers, Fla. Increased pay might lure more residents into primary care, and help those currently practicing to stay in the workplace, he said.

The commissioners debated how the CMS could determine which physicians or other health providers—such as nurse practitioners—would receive the update. MedPAC staff presented the increase as budget neutral, which made some panelists uneasy.

Dr. Nicholas Wolter of the Billings (Mont.) Clinic, suggested that the increase be made without trying to maintain budget neutrality. Dr. Karen Borman, professor of surgery at the University of Mississippi, Jackson, expressed concern that rewarding primary care could end up hurting other physicians.

“I have some philosophical problems here,” said Dr. Borman, adding that primary care was not always linked with a traditional primary care physician. She said that she often provided what would be considered primary care to her breast cancer patients. Dr. Borman ended up voting against the recommendation for increased pay for primary care.

WASHINGTON — The concept of a medical home is one step closer to reality for Medicare patients, after it received strong backing from the Medicare Payment Advisory Commission at its April meeting.

All 17 commissioners present at the meeting voted to urge Congress to instruct the Centers for Medicare and Medicaid Services to develop a large pilot study of medical homes for Medicare beneficiaries. The recommendation will be included in MedPAC's June report to Congress.

Most of the commissioners also voted to adjust the Medicare fee schedule to increase payment for primary care, which MedPAC has deemed as undervalued at previous meetings.

The medical home concept has been advanced by the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics. A demonstration project is authorized under the Medicare program, but the commissioners said that a larger pilot with clear thresholds could accelerate the evaluation process, and could easily be discontinued or expanded.

The commissioners compiled a wish list of criteria for a medical home, including the ability to provide primary care, use information technology for clinical decision support, conduct care management, offer 24-hour communication with patients, maintain up-to-date records of patients' advance directives, and operate a formal quality improvement program. Also, beneficiaries should agree to adhere to medical home principles by respecting the idea that someone is in charge of coordinating their care, and communicating with the physician when they seek care elsewhere.

There was some debate over whether patients should be allowed to access other providers without a referral, which is permitted under current fee-for-service Medicare. Most commissioners wanted some restrictions, or at least a way to track when patients see specialists, to facilitate assessment of the program's success or failure.

The medical home would not be limited to primary care physicians; specialists likely would be able to fulfill criteria for participation, according to the commission's vision.

The program would cost $50 million to $250 million in the first year, and cost less than $1 billion over the first 5 years, MedPAC staffers estimated. The estimate included monthly fees to medical homes, but not anticipated savings, said MedPAC staffer Christine Boccuti.

Dr. Francis Jay Crosson, a commissioner and senior medical director of Permanente Federation in Oakland, called the proposal a “significant evolution” from what had been presented to the panel in 2007. “And I think it's a good evolution,” he said.

“This is a very exciting recommendation,” said Commissioner Jack Ebeler, a health policy consultant in Reston, Va. Promotion of the medical home approach is a direct way to reform the health care delivery system, he added.

Commissioners also said that the medical home recommendation dovetailed with MedPAC's support of increased pay for primary care services.

An adjustment to the fee schedule is “long overdue,” said Dr. Ronald Castellanos, a commissioner and urologist in private practice in Ft. Myers, Fla. Increased pay might lure more residents into primary care, and help those currently practicing to stay in the workplace, he said.

The commissioners debated how the CMS could determine which physicians or other health providers—such as nurse practitioners—would receive the update. MedPAC staff presented the increase as budget neutral, which made some panelists uneasy.

Dr. Nicholas Wolter of the Billings (Mont.) Clinic, suggested that the increase be made without trying to maintain budget neutrality. Dr. Karen Borman, professor of surgery at the University of Mississippi, Jackson, expressed concern that rewarding primary care could end up hurting other physicians.

“I have some philosophical problems here,” said Dr. Borman, adding that primary care was not always linked with a traditional primary care physician. She said that she often provided what would be considered primary care to her breast cancer patients. Dr. Borman ended up voting against the recommendation for increased pay for primary care.

Ezetimibe Troubles Hit Home

Schering-Plough reported in its most recent quarterly filing with the Securities and Exchange Commission that its joint venture with Merck & Co. on ezetimibe (Zetia) and ezetimibe/simvastatin (Vytorin) is the subject of multiple lawsuits and legal inquiries. In a May 6 filing, Schering stated that it has received “several subpoenas from state officials, including state attorneys general, and requests for information from U.S. Attorneys,” all seeking information on the ENHANCE clinical trial, the sale and promotion of ezetimibe/simvastatin, and stock sales by corporate officer since April 2006, when ENHANCE was completed. Since mid-January, the company has been served with class action lawsuits alleging fraud in conjunction with the sale and marketing of the two products. The company is also looking at several securities-related class action suits, according to the filing.

CMS Covers Artificial Heart

Artificial hearts will be covered by Medicare when they are implanted as part of a study, according to a national coverage decision issued in May. The decision was not a surprise, as CMS telegraphed its intention to do so in a February proposal. According to a statement, the agency “believes there is now sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries in the carefully controlled clinical environment of an [Food and Drug Administration]-approved study.” The devices are for use in severe heart failure, where patients are at imminent risk of death.

Gainsharing Cuts Stent Costs

A study of gainsharing programs sanctioned by CMS at six cardiac catheterization labs has found that costs declined for coronary stent patients relative to nongainsharing hospitals. The gainsharing hospitals reduced costs by 7.4% per patient; 91% of the savings came from lower prices, and 9% from lower utilization, according to authors Jonathan Ketcham, Ph.D., and Michael Furukawa, Ph.D., of Arizona State University, Tempe. Under the programs, savings are shared equally by the hospital and the physician practice. From 2001 to 2006, the average cost per patient increased from $3,338 to $4,644, but the gainsharing hospitals were able to reduce that by $315 per patient, or 7.4%. The study appears in the May/June 2008 issue of Health Affairs.

Self-Referrals Drive Imaging Hike

Physicians who refer patients to their own facilities or machines for scans account for much of the increase in diagnostic imaging ordered for privately insured patients, according to a commentary in the journal Medical Care. The increases in imaging were seen mainly in privately insured patients with fee-for-service plans, according to by Dr. Vivian Ho, professor of medicine at Baylor College of Medicine, Houston. “Physicians seem to choose the self-referral option, meaning they do the imaging in their own office, because they are reimbursed by private insurance companies,” Dr. Ho wrote. If they don't have the equipment in their office, she said, they lease an imaging center's facilities and employees for a fixed period each week. This creates revenue for both parties involved, but raises questions about the necessity of the testing conducted, Dr. Ho wrote, adding, “The current reimbursement system lacks incentives to provide high quality imaging in a cost-effective manner.”

Ezetimibe Troubles Hit Home

Schering-Plough reported in its most recent quarterly filing with the Securities and Exchange Commission that its joint venture with Merck & Co. on ezetimibe (Zetia) and ezetimibe/simvastatin (Vytorin) is the subject of multiple lawsuits and legal inquiries. In a May 6 filing, Schering stated that it has received “several subpoenas from state officials, including state attorneys general, and requests for information from U.S. Attorneys,” all seeking information on the ENHANCE clinical trial, the sale and promotion of ezetimibe/simvastatin, and stock sales by corporate officer since April 2006, when ENHANCE was completed. Since mid-January, the company has been served with class action lawsuits alleging fraud in conjunction with the sale and marketing of the two products. The company is also looking at several securities-related class action suits, according to the filing.

CMS Covers Artificial Heart

Artificial hearts will be covered by Medicare when they are implanted as part of a study, according to a national coverage decision issued in May. The decision was not a surprise, as CMS telegraphed its intention to do so in a February proposal. According to a statement, the agency “believes there is now sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries in the carefully controlled clinical environment of an [Food and Drug Administration]-approved study.” The devices are for use in severe heart failure, where patients are at imminent risk of death.

Gainsharing Cuts Stent Costs

A study of gainsharing programs sanctioned by CMS at six cardiac catheterization labs has found that costs declined for coronary stent patients relative to nongainsharing hospitals. The gainsharing hospitals reduced costs by 7.4% per patient; 91% of the savings came from lower prices, and 9% from lower utilization, according to authors Jonathan Ketcham, Ph.D., and Michael Furukawa, Ph.D., of Arizona State University, Tempe. Under the programs, savings are shared equally by the hospital and the physician practice. From 2001 to 2006, the average cost per patient increased from $3,338 to $4,644, but the gainsharing hospitals were able to reduce that by $315 per patient, or 7.4%. The study appears in the May/June 2008 issue of Health Affairs.

Self-Referrals Drive Imaging Hike

Physicians who refer patients to their own facilities or machines for scans account for much of the increase in diagnostic imaging ordered for privately insured patients, according to a commentary in the journal Medical Care. The increases in imaging were seen mainly in privately insured patients with fee-for-service plans, according to by Dr. Vivian Ho, professor of medicine at Baylor College of Medicine, Houston. “Physicians seem to choose the self-referral option, meaning they do the imaging in their own office, because they are reimbursed by private insurance companies,” Dr. Ho wrote. If they don't have the equipment in their office, she said, they lease an imaging center's facilities and employees for a fixed period each week. This creates revenue for both parties involved, but raises questions about the necessity of the testing conducted, Dr. Ho wrote, adding, “The current reimbursement system lacks incentives to provide high quality imaging in a cost-effective manner.”

Ezetimibe Troubles Hit Home

Schering-Plough reported in its most recent quarterly filing with the Securities and Exchange Commission that its joint venture with Merck & Co. on ezetimibe (Zetia) and ezetimibe/simvastatin (Vytorin) is the subject of multiple lawsuits and legal inquiries. In a May 6 filing, Schering stated that it has received “several subpoenas from state officials, including state attorneys general, and requests for information from U.S. Attorneys,” all seeking information on the ENHANCE clinical trial, the sale and promotion of ezetimibe/simvastatin, and stock sales by corporate officer since April 2006, when ENHANCE was completed. Since mid-January, the company has been served with class action lawsuits alleging fraud in conjunction with the sale and marketing of the two products. The company is also looking at several securities-related class action suits, according to the filing.

CMS Covers Artificial Heart

Artificial hearts will be covered by Medicare when they are implanted as part of a study, according to a national coverage decision issued in May. The decision was not a surprise, as CMS telegraphed its intention to do so in a February proposal. According to a statement, the agency “believes there is now sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries in the carefully controlled clinical environment of an [Food and Drug Administration]-approved study.” The devices are for use in severe heart failure, where patients are at imminent risk of death.

Gainsharing Cuts Stent Costs

A study of gainsharing programs sanctioned by CMS at six cardiac catheterization labs has found that costs declined for coronary stent patients relative to nongainsharing hospitals. The gainsharing hospitals reduced costs by 7.4% per patient; 91% of the savings came from lower prices, and 9% from lower utilization, according to authors Jonathan Ketcham, Ph.D., and Michael Furukawa, Ph.D., of Arizona State University, Tempe. Under the programs, savings are shared equally by the hospital and the physician practice. From 2001 to 2006, the average cost per patient increased from $3,338 to $4,644, but the gainsharing hospitals were able to reduce that by $315 per patient, or 7.4%. The study appears in the May/June 2008 issue of Health Affairs.

Self-Referrals Drive Imaging Hike

Physicians who refer patients to their own facilities or machines for scans account for much of the increase in diagnostic imaging ordered for privately insured patients, according to a commentary in the journal Medical Care. The increases in imaging were seen mainly in privately insured patients with fee-for-service plans, according to by Dr. Vivian Ho, professor of medicine at Baylor College of Medicine, Houston. “Physicians seem to choose the self-referral option, meaning they do the imaging in their own office, because they are reimbursed by private insurance companies,” Dr. Ho wrote. If they don't have the equipment in their office, she said, they lease an imaging center's facilities and employees for a fixed period each week. This creates revenue for both parties involved, but raises questions about the necessity of the testing conducted, Dr. Ho wrote, adding, “The current reimbursement system lacks incentives to provide high quality imaging in a cost-effective manner.”

NEW ORLEANS — The American Society for Reproductive Medicine, in collaboration with the Society for Reproductive Endocrinology and Infertility, is revising its definition of infertility to encourage earlier evaluation of women aged over 35 years who are having difficulty conceiving.

The new definition, along with a new definition of recurrent pregnancy loss, will be published in the June issue of Fertility and Sterility, Dr. Marc Fritz said at the annual meeting of the American College of Obstetricians and Gynecologists.

ASRM members requested the new definitions, in part because insurers were adhering strictly to the existing guidelines, leading to a denial of access to appropriate treatment, Dr. Fritz said in an interview.

Infertility specialists say that the changes give credence to what's been standard practice in their field. The real impact should come from the word getting out to general ob.gyns., family physicians, and other physicians, Dr. Eric Surrey, medical director of the Colorado Center for Reproductive Medicine in Lonetree, said in an interview.

“This message is meant for the generalist, not the reproductive endocrinologist,” said Dr. Masood Khatamee of New York University and founder of the Society for the Prevention of Infertility in an interview. “And it's a very, very appropriate statement.”

Dr. Fritz agreed that the ASRM was aiming for a broader audience.

According to Dr. Fritz, the ASRM will urge early evaluation and treatment of all women based on natural history and physical findings after a failure to achieve pregnancy following at least 12 months of regular unprotected intercourse. Treatment and evaluation will be warranted after 6 months for women aged over 35 years.

The ASRM also for the first time is specifically defining recurrent pregnancy loss as a disease distinct from infertility, said Dr. Fritz, professor of obstetrics and gynecology and division chief of reproductive endocrinology and infertility at the University of North Carolina at Chapel Hill. It will be defined by two or more failed pregnancies; these pregnancies must be documented by ultrasound or pathologic examination. When the cause is unknown, each pregnancy loss merits careful review to determine whether specific evaluations may be appropriate, said Dr. Fritz. After three or more losses, a thorough evaluation is warranted, he said. Dr. Charles Miller, an infertility specialist in Chicago, said the ASRM “has thrown [its] weight behind what we in the field have done for awhile.”

The clear statements on both infertility and recurrent pregnancy loss may also help convince insurance companies to cover evaluation and treatment—in instances where they haven't in the past—Dr. Miller said in an interview.

Dr. Surrey agreed that the statements could be helpful for reimbursement. For instance, insurers often consider recurrent pregnancy loss to be a form of infertility, which is inappropriate and untrue, he said in an interview.

He said he was encouraged by the statement on infertility, noting that it will heighten patient and physician awareness that earlier evaluation is important. Women are often told they have plenty of time to conceive, but “that's not what they want to hear.”

The 6-month cut-off for women aged over 35 is a somewhat arbitrary figure, but is necessary to prompt quicker action, said Dr. Surrey. The earlier evaluations may result in more findings of no abnormalities, but at least women will be reassured that they aren't wasting their time if they are told to spend another 6 months trying to conceive, he said.

Dr. Khatamee agreed that the ASRM statement could promote more understanding. He tells other physicians and medical students that a woman's age is a key deciding factor when evaluating infertility. Women over age 35 should not be told to spend a year trying to conceive, he said.

For the first time, recurrent pregnancy loss is being defined as a disease distinct from infertility. DR. FRITZ

NEW ORLEANS — The American Society for Reproductive Medicine, in collaboration with the Society for Reproductive Endocrinology and Infertility, is revising its definition of infertility to encourage earlier evaluation of women aged over 35 years who are having difficulty conceiving.

The new definition, along with a new definition of recurrent pregnancy loss, will be published in the June issue of Fertility and Sterility, Dr. Marc Fritz said at the annual meeting of the American College of Obstetricians and Gynecologists.

ASRM members requested the new definitions, in part because insurers were adhering strictly to the existing guidelines, leading to a denial of access to appropriate treatment, Dr. Fritz said in an interview.

Infertility specialists say that the changes give credence to what's been standard practice in their field. The real impact should come from the word getting out to general ob.gyns., family physicians, and other physicians, Dr. Eric Surrey, medical director of the Colorado Center for Reproductive Medicine in Lonetree, said in an interview.

“This message is meant for the generalist, not the reproductive endocrinologist,” said Dr. Masood Khatamee of New York University and founder of the Society for the Prevention of Infertility in an interview. “And it's a very, very appropriate statement.”

Dr. Fritz agreed that the ASRM was aiming for a broader audience.

According to Dr. Fritz, the ASRM will urge early evaluation and treatment of all women based on natural history and physical findings after a failure to achieve pregnancy following at least 12 months of regular unprotected intercourse. Treatment and evaluation will be warranted after 6 months for women aged over 35 years.

The ASRM also for the first time is specifically defining recurrent pregnancy loss as a disease distinct from infertility, said Dr. Fritz, professor of obstetrics and gynecology and division chief of reproductive endocrinology and infertility at the University of North Carolina at Chapel Hill. It will be defined by two or more failed pregnancies; these pregnancies must be documented by ultrasound or pathologic examination. When the cause is unknown, each pregnancy loss merits careful review to determine whether specific evaluations may be appropriate, said Dr. Fritz. After three or more losses, a thorough evaluation is warranted, he said. Dr. Charles Miller, an infertility specialist in Chicago, said the ASRM “has thrown [its] weight behind what we in the field have done for awhile.”

The clear statements on both infertility and recurrent pregnancy loss may also help convince insurance companies to cover evaluation and treatment—in instances where they haven't in the past—Dr. Miller said in an interview.

Dr. Surrey agreed that the statements could be helpful for reimbursement. For instance, insurers often consider recurrent pregnancy loss to be a form of infertility, which is inappropriate and untrue, he said in an interview.

He said he was encouraged by the statement on infertility, noting that it will heighten patient and physician awareness that earlier evaluation is important. Women are often told they have plenty of time to conceive, but “that's not what they want to hear.”

The 6-month cut-off for women aged over 35 is a somewhat arbitrary figure, but is necessary to prompt quicker action, said Dr. Surrey. The earlier evaluations may result in more findings of no abnormalities, but at least women will be reassured that they aren't wasting their time if they are told to spend another 6 months trying to conceive, he said.

Dr. Khatamee agreed that the ASRM statement could promote more understanding. He tells other physicians and medical students that a woman's age is a key deciding factor when evaluating infertility. Women over age 35 should not be told to spend a year trying to conceive, he said.

For the first time, recurrent pregnancy loss is being defined as a disease distinct from infertility. DR. FRITZ

NEW ORLEANS — The American Society for Reproductive Medicine, in collaboration with the Society for Reproductive Endocrinology and Infertility, is revising its definition of infertility to encourage earlier evaluation of women aged over 35 years who are having difficulty conceiving.

The new definition, along with a new definition of recurrent pregnancy loss, will be published in the June issue of Fertility and Sterility, Dr. Marc Fritz said at the annual meeting of the American College of Obstetricians and Gynecologists.

ASRM members requested the new definitions, in part because insurers were adhering strictly to the existing guidelines, leading to a denial of access to appropriate treatment, Dr. Fritz said in an interview.

Infertility specialists say that the changes give credence to what's been standard practice in their field. The real impact should come from the word getting out to general ob.gyns., family physicians, and other physicians, Dr. Eric Surrey, medical director of the Colorado Center for Reproductive Medicine in Lonetree, said in an interview.

“This message is meant for the generalist, not the reproductive endocrinologist,” said Dr. Masood Khatamee of New York University and founder of the Society for the Prevention of Infertility in an interview. “And it's a very, very appropriate statement.”

Dr. Fritz agreed that the ASRM was aiming for a broader audience.

According to Dr. Fritz, the ASRM will urge early evaluation and treatment of all women based on natural history and physical findings after a failure to achieve pregnancy following at least 12 months of regular unprotected intercourse. Treatment and evaluation will be warranted after 6 months for women aged over 35 years.

The ASRM also for the first time is specifically defining recurrent pregnancy loss as a disease distinct from infertility, said Dr. Fritz, professor of obstetrics and gynecology and division chief of reproductive endocrinology and infertility at the University of North Carolina at Chapel Hill. It will be defined by two or more failed pregnancies; these pregnancies must be documented by ultrasound or pathologic examination. When the cause is unknown, each pregnancy loss merits careful review to determine whether specific evaluations may be appropriate, said Dr. Fritz. After three or more losses, a thorough evaluation is warranted, he said. Dr. Charles Miller, an infertility specialist in Chicago, said the ASRM “has thrown [its] weight behind what we in the field have done for awhile.”

The clear statements on both infertility and recurrent pregnancy loss may also help convince insurance companies to cover evaluation and treatment—in instances where they haven't in the past—Dr. Miller said in an interview.

Dr. Surrey agreed that the statements could be helpful for reimbursement. For instance, insurers often consider recurrent pregnancy loss to be a form of infertility, which is inappropriate and untrue, he said in an interview.

He said he was encouraged by the statement on infertility, noting that it will heighten patient and physician awareness that earlier evaluation is important. Women are often told they have plenty of time to conceive, but “that's not what they want to hear.”

The 6-month cut-off for women aged over 35 is a somewhat arbitrary figure, but is necessary to prompt quicker action, said Dr. Surrey. The earlier evaluations may result in more findings of no abnormalities, but at least women will be reassured that they aren't wasting their time if they are told to spend another 6 months trying to conceive, he said.

Dr. Khatamee agreed that the ASRM statement could promote more understanding. He tells other physicians and medical students that a woman's age is a key deciding factor when evaluating infertility. Women over age 35 should not be told to spend a year trying to conceive, he said.

For the first time, recurrent pregnancy loss is being defined as a disease distinct from infertility. DR. FRITZ

WASHINGTON – The concept of a medical home is one step closer to reality for Medicare patients, after it received strong backing from the Medicare Payment Advisory Commission.

All 17 commissioners present at the meeting in April voted to urge Congress to instruct the Centers for Medicare and Medicaid Services to develop a large pilot study of medical homes for Medicare beneficiaries. The recommendation will be included in MedPAC's June report to Congress.

Most of the commissioners also voted to adjust the Medicare fee schedule to increase payment for primary care, which MedPAC has deemed as undervalued at previous meetings.

The medical home concept has been advanced by the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics. A demonstration project is authorized under the Medicare program, but the commissioners said that a larger pilot with clear thresholds could accelerate the evaluation process, and could easily be discontinued or expanded.

The commissioners compiled a wish list of criteria for a medical home, including the ability to provide primary care, use information technology for clinical decision support, conduct care management, offer 24-hour communication with patients, maintain up-to-date records of patients' advance directives, and operate a formal quality improvement program. Also, beneficiaries should agree to adhere to medical home principles by respecting the idea that someone is in charge of coordinating their care, and communicating with the physician when they seek care elsewhere.

There was some debate over whether patients should be allowed to access other providers without a referral, which is permitted under current fee-for-service Medicare. Most commissioners wanted some restrictions, or at least a way to track when patients see specialists, to facilitate assessment of the program's success or failure.

The medical home would not be limited to primary care physicians; specialists likely would be able to fulfill criteria for participation, according to the commission's vision.

The program would cost $50–250 million in the first year, and cost less than $1 billion over the first 5 years, MedPAC staffers estimated. The estimate included monthly fees to medical homes, but not anticipated savings, said MedPAC staffer Christine Boccuti.

Dr. Francis Jay Crosson, a commissioner and senior medical director of Permanente Federation in Oakland, called the proposal a “significant evolution” from what had been presented to the panel in 2007. “And I think it's a good evolution,” he said.

“This is a very exciting recommendation,” said Commissioner Jack Ebeler, a health policy consultant in Reston, Va. Promotion of the medical home approach is a direct way to reform the health care delivery system, he added.

Commissioners also said that the medical home recommendation dovetailed with MedPAC's support of increased pay for primary care services.

An adjustment to the fee schedule is “long overdue,” said Dr. Ronald Castellanos, a commissioner and urologist in private practice in Ft. Myers, Fla. Increased pay might lure more residents into primary care, and help those currently practicing to stay in the workplace, he said.

The commissioners debated how the CMS could determine which physicians or other health providers–such as nurse practitioners–would receive the update. MedPAC staff presented the increase as budget neutral, which made some panelists uneasy.

Dr. Nicholas Wolter of the Billings (Mont.) Clinic, suggested that the increase be made without trying to maintain budget neutrality. Dr. Karen Borman, professor of surgery at the University of Mississippi, Jackson, expressed concern that rewarding primary care could end up hurting other physicians.

“I have some philosophical problems here,” said Dr. Borman, adding that primary care was not always linked with a traditional primary care physician. Dr. Borman ended up voting against the recommendation for increased pay for primary care.

WASHINGTON – The concept of a medical home is one step closer to reality for Medicare patients, after it received strong backing from the Medicare Payment Advisory Commission.

All 17 commissioners present at the meeting in April voted to urge Congress to instruct the Centers for Medicare and Medicaid Services to develop a large pilot study of medical homes for Medicare beneficiaries. The recommendation will be included in MedPAC's June report to Congress.

Most of the commissioners also voted to adjust the Medicare fee schedule to increase payment for primary care, which MedPAC has deemed as undervalued at previous meetings.

The medical home concept has been advanced by the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics. A demonstration project is authorized under the Medicare program, but the commissioners said that a larger pilot with clear thresholds could accelerate the evaluation process, and could easily be discontinued or expanded.

The commissioners compiled a wish list of criteria for a medical home, including the ability to provide primary care, use information technology for clinical decision support, conduct care management, offer 24-hour communication with patients, maintain up-to-date records of patients' advance directives, and operate a formal quality improvement program. Also, beneficiaries should agree to adhere to medical home principles by respecting the idea that someone is in charge of coordinating their care, and communicating with the physician when they seek care elsewhere.

There was some debate over whether patients should be allowed to access other providers without a referral, which is permitted under current fee-for-service Medicare. Most commissioners wanted some restrictions, or at least a way to track when patients see specialists, to facilitate assessment of the program's success or failure.

The medical home would not be limited to primary care physicians; specialists likely would be able to fulfill criteria for participation, according to the commission's vision.

The program would cost $50–250 million in the first year, and cost less than $1 billion over the first 5 years, MedPAC staffers estimated. The estimate included monthly fees to medical homes, but not anticipated savings, said MedPAC staffer Christine Boccuti.

Dr. Francis Jay Crosson, a commissioner and senior medical director of Permanente Federation in Oakland, called the proposal a “significant evolution” from what had been presented to the panel in 2007. “And I think it's a good evolution,” he said.

“This is a very exciting recommendation,” said Commissioner Jack Ebeler, a health policy consultant in Reston, Va. Promotion of the medical home approach is a direct way to reform the health care delivery system, he added.

Commissioners also said that the medical home recommendation dovetailed with MedPAC's support of increased pay for primary care services.

An adjustment to the fee schedule is “long overdue,” said Dr. Ronald Castellanos, a commissioner and urologist in private practice in Ft. Myers, Fla. Increased pay might lure more residents into primary care, and help those currently practicing to stay in the workplace, he said.

The commissioners debated how the CMS could determine which physicians or other health providers–such as nurse practitioners–would receive the update. MedPAC staff presented the increase as budget neutral, which made some panelists uneasy.

Dr. Nicholas Wolter of the Billings (Mont.) Clinic, suggested that the increase be made without trying to maintain budget neutrality. Dr. Karen Borman, professor of surgery at the University of Mississippi, Jackson, expressed concern that rewarding primary care could end up hurting other physicians.

“I have some philosophical problems here,” said Dr. Borman, adding that primary care was not always linked with a traditional primary care physician. Dr. Borman ended up voting against the recommendation for increased pay for primary care.

WASHINGTON – The concept of a medical home is one step closer to reality for Medicare patients, after it received strong backing from the Medicare Payment Advisory Commission.

All 17 commissioners present at the meeting in April voted to urge Congress to instruct the Centers for Medicare and Medicaid Services to develop a large pilot study of medical homes for Medicare beneficiaries. The recommendation will be included in MedPAC's June report to Congress.

Most of the commissioners also voted to adjust the Medicare fee schedule to increase payment for primary care, which MedPAC has deemed as undervalued at previous meetings.

The medical home concept has been advanced by the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics. A demonstration project is authorized under the Medicare program, but the commissioners said that a larger pilot with clear thresholds could accelerate the evaluation process, and could easily be discontinued or expanded.

The commissioners compiled a wish list of criteria for a medical home, including the ability to provide primary care, use information technology for clinical decision support, conduct care management, offer 24-hour communication with patients, maintain up-to-date records of patients' advance directives, and operate a formal quality improvement program. Also, beneficiaries should agree to adhere to medical home principles by respecting the idea that someone is in charge of coordinating their care, and communicating with the physician when they seek care elsewhere.

There was some debate over whether patients should be allowed to access other providers without a referral, which is permitted under current fee-for-service Medicare. Most commissioners wanted some restrictions, or at least a way to track when patients see specialists, to facilitate assessment of the program's success or failure.

The medical home would not be limited to primary care physicians; specialists likely would be able to fulfill criteria for participation, according to the commission's vision.

The program would cost $50–250 million in the first year, and cost less than $1 billion over the first 5 years, MedPAC staffers estimated. The estimate included monthly fees to medical homes, but not anticipated savings, said MedPAC staffer Christine Boccuti.

Dr. Francis Jay Crosson, a commissioner and senior medical director of Permanente Federation in Oakland, called the proposal a “significant evolution” from what had been presented to the panel in 2007. “And I think it's a good evolution,” he said.

“This is a very exciting recommendation,” said Commissioner Jack Ebeler, a health policy consultant in Reston, Va. Promotion of the medical home approach is a direct way to reform the health care delivery system, he added.

Commissioners also said that the medical home recommendation dovetailed with MedPAC's support of increased pay for primary care services.

An adjustment to the fee schedule is “long overdue,” said Dr. Ronald Castellanos, a commissioner and urologist in private practice in Ft. Myers, Fla. Increased pay might lure more residents into primary care, and help those currently practicing to stay in the workplace, he said.

The commissioners debated how the CMS could determine which physicians or other health providers–such as nurse practitioners–would receive the update. MedPAC staff presented the increase as budget neutral, which made some panelists uneasy.

Dr. Nicholas Wolter of the Billings (Mont.) Clinic, suggested that the increase be made without trying to maintain budget neutrality. Dr. Karen Borman, professor of surgery at the University of Mississippi, Jackson, expressed concern that rewarding primary care could end up hurting other physicians.

“I have some philosophical problems here,” said Dr. Borman, adding that primary care was not always linked with a traditional primary care physician. Dr. Borman ended up voting against the recommendation for increased pay for primary care.

WASHINGTON – Staggering growth in the popularity of hospice services–and in the rise of for-profit hospice providers–has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, but data have shown that some illnesses–such as Alzheimer's disease and ischemic heart disease–tend to result in longer stays, said Dr. Mathews.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, he said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market. From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a few more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

The analysis also determined that profit margins are much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000–mostly for-profit operations–had higher margins.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, said Dr. Mathews.

“Clearly, people see an opportunity–a financial opportunity–here,” commented MedPAC chairman Glenn Hackbarth. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested that Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care. “It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

WASHINGTON – Staggering growth in the popularity of hospice services–and in the rise of for-profit hospice providers–has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, but data have shown that some illnesses–such as Alzheimer's disease and ischemic heart disease–tend to result in longer stays, said Dr. Mathews.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, he said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market. From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a few more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

The analysis also determined that profit margins are much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000–mostly for-profit operations–had higher margins.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, said Dr. Mathews.

“Clearly, people see an opportunity–a financial opportunity–here,” commented MedPAC chairman Glenn Hackbarth. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested that Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care. “It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

WASHINGTON – Staggering growth in the popularity of hospice services–and in the rise of for-profit hospice providers–has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, but data have shown that some illnesses–such as Alzheimer's disease and ischemic heart disease–tend to result in longer stays, said Dr. Mathews.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, he said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market. From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a few more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

The analysis also determined that profit margins are much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000–mostly for-profit operations–had higher margins.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, said Dr. Mathews.

“Clearly, people see an opportunity–a financial opportunity–here,” commented MedPAC chairman Glenn Hackbarth. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested that Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care. “It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

WASHINGTON — Staggering growth in the popularity of hospice services—and in the rise of for-profit hospice providers—has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, although data have shown that some illnesses—such as Alzheimer's disease and ischemic heart disease—tend to result in longer stays, Dr. Mathews said.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, he said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market. From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a little more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

In addition, the analysis determined that profit margins are also much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000 had higher margins—and these were mostly for-profit operations.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, Dr. Mathews said.

“Clearly, people see an opportunity—a financial opportunity—here,” commented MedPAC chairman Glenn Hackbarth, a health care consultant based in Bend, Ore. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care.

“It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute in Washington.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

The commissioners and Dr. Schumacher agreed that a first step to a solution is getting more data on the hospice sector. CMS has already started down that path. In July, hospices will begin submitting data to CMS on the types of services they provide and which practitioners are delivering them.

WASHINGTON — Staggering growth in the popularity of hospice services—and in the rise of for-profit hospice providers—has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, although data have shown that some illnesses—such as Alzheimer's disease and ischemic heart disease—tend to result in longer stays, Dr. Mathews said.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, he said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market. From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a little more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

In addition, the analysis determined that profit margins are also much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000 had higher margins—and these were mostly for-profit operations.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, Dr. Mathews said.

“Clearly, people see an opportunity—a financial opportunity—here,” commented MedPAC chairman Glenn Hackbarth, a health care consultant based in Bend, Ore. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care.

“It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute in Washington.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

The commissioners and Dr. Schumacher agreed that a first step to a solution is getting more data on the hospice sector. CMS has already started down that path. In July, hospices will begin submitting data to CMS on the types of services they provide and which practitioners are delivering them.

WASHINGTON — Staggering growth in the popularity of hospice services—and in the rise of for-profit hospice providers—has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, although data have shown that some illnesses—such as Alzheimer's disease and ischemic heart disease—tend to result in longer stays, Dr. Mathews said.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, he said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market. From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a little more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

In addition, the analysis determined that profit margins are also much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000 had higher margins—and these were mostly for-profit operations.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, Dr. Mathews said.

“Clearly, people see an opportunity—a financial opportunity—here,” commented MedPAC chairman Glenn Hackbarth, a health care consultant based in Bend, Ore. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care.

“It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute in Washington.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

The commissioners and Dr. Schumacher agreed that a first step to a solution is getting more data on the hospice sector. CMS has already started down that path. In July, hospices will begin submitting data to CMS on the types of services they provide and which practitioners are delivering them.

AAD Fires Back on Indoor Tanning

The American Academy of Dermatology is launching a public service campaign to communicate the risks of indoor tanning. The target audience is 16- to 29-year-old women, according to the AAD. This group is being chosen because the data show that 70% of indoor tanners are women in that age group, and melanoma is increasing faster among women than men in that age range. The "Indoor Tanning Is Out" campaign includes print, television, and radio ads. The campaign comes on the heels of an ad blitz in New York, Boston, Washington, Chicago, San Francisco, Seattle, and Pittsburgh sponsored by the Indoor Tanning Association. That campaign claimed there is no compelling scientific evidence linking tanning to melanoma.

Tanning Industry Ties Cited

The Indoor Tanning Association also recently found its ties to a Boston University researcher, Dr. Michael F. Holick, scrutinized by the Wall Street Journal. Dr. Holick has published numerous articles on vitamin D deficiency, including a review in the New England Journal of Medicine in 2007 (N. Engl. J. Med. 2007;357:266–81), in which he suggested using tanning beds "in moderation" as a source of replenishment. The article was supported by grants from the National Institutes of Health and also the UV Foundation, which is a nonprofit arm of the Indoor Tanning Association. Dr. Holick and his research are prominently featured on the UV Foundation's Web site. In a video on the site, he again suggests the use of tanning beds in moderation. The Wall Street Journal reported that the New England Journal said that Dr. Holick properly disclosed his funding source and his potential conflicts.

Stiefel Buys Atlean Maker

Stiefel Laboratories Inc. has acquired ABR Invent and ABR Development, two French companies that developed Atlean, an injectable dermal filler. Atlean is made up of tricalcium phosphate particles suspended in a hyaluronic acid gel. The product was granted a CE marking in 2006, and is currently sold in France and Italy. The Coral Gables, Fla.-based Stiefel said it plans to launch Atlean in other European nations, Asia, Latin America, and the Caribbean in the next 18 months. The company will also eventually seek Food and Drug Administration approval, the company reported in a press release.

Generic Fluorouracil Cream Halted

Spear Pharmaceuticals Inc. has agreed to at least temporarily cease sales, marketing, and shipment of a generic fluorouracil cream 5%. Valeant Pharmaceuticals International, which makes the brand Efudex cream 5%, sued the FDA to challenge the agency's denial of Valeant's citizen's petition. The petition challenged the agency's approval of the generic. The company said that the FDA should not approve a generic that had not been tested head to head against Efudex in patients with superficial basal cell carcinoma. The agency said that generics needed to be tested only against actinic or solar keratoses. The FDA requested a 2-week stay of Valeant's lawsuit, which was granted.

Low Postmarketing FDACompliance

The FDA has issued its annual summary report of how pharmaceutical and biologic manufacturers are doing on meeting their commitments to conduct postmarketing studies. According to the agency, 76% of drug makers and 81% of biologic makers had met their commitment as of September 30, 2007. There were 136 drug makers and 54 biologic manufacturers with open postmarketing commitments as of that date. A closer look at the FDA data shows that only 12% of drug studies were completed or terminated with a final report submitted to the FDA that year. In all, 20% of biologics met that goal. Manufacturers are required to report annually on the status of safety, efficacy, pharmacology, and nonclinical toxicology studies required by the FDA, or to report that they have committed to conduct at the time of approval or after approval.

Disciplinary Actions Decline

The number and rate of serious disciplinary actions against physicians have decreased for the third consecutive year, according to Public Citizen's annual ranking of state medical boards. The advocacy group said the analysis indicates that many states are not living up to their obligations to protect patients from bad doctors. Since 2004, the number of serious disciplinary actions against doctors has decreased 17%, resulting in 553 fewer serious actions in 2007 than in 2004. Taking into account the increasing number of U.S. physicians since 2004, the rate of serious actions has fallen 22% since then, when calculated per 1,000 physicians, according to Public Citizen. The annual rankings are based on data from the Federation of State Medical Boards.

Half of Health Spending Wasted

Wasteful spending in the U.S. health system could amount to as much as $1.2 trillion of the $2.2 trillion spent annually, according to a report from the PricewaterhouseCoopers' Health Research Institute. Defensive medicine was identified as the biggest area of excess, followed by inefficient administration and the cost of care necessitated by preventable conditions, such as obesity, according to the report. The impact of issues such as nonadherence to medical advice and prescriptions, alcohol abuse, smoking, and obesity "are exponential," according to the report.

AAD Fires Back on Indoor Tanning

The American Academy of Dermatology is launching a public service campaign to communicate the risks of indoor tanning. The target audience is 16- to 29-year-old women, according to the AAD. This group is being chosen because the data show that 70% of indoor tanners are women in that age group, and melanoma is increasing faster among women than men in that age range. The "Indoor Tanning Is Out" campaign includes print, television, and radio ads. The campaign comes on the heels of an ad blitz in New York, Boston, Washington, Chicago, San Francisco, Seattle, and Pittsburgh sponsored by the Indoor Tanning Association. That campaign claimed there is no compelling scientific evidence linking tanning to melanoma.

Tanning Industry Ties Cited

The Indoor Tanning Association also recently found its ties to a Boston University researcher, Dr. Michael F. Holick, scrutinized by the Wall Street Journal. Dr. Holick has published numerous articles on vitamin D deficiency, including a review in the New England Journal of Medicine in 2007 (N. Engl. J. Med. 2007;357:266–81), in which he suggested using tanning beds "in moderation" as a source of replenishment. The article was supported by grants from the National Institutes of Health and also the UV Foundation, which is a nonprofit arm of the Indoor Tanning Association. Dr. Holick and his research are prominently featured on the UV Foundation's Web site. In a video on the site, he again suggests the use of tanning beds in moderation. The Wall Street Journal reported that the New England Journal said that Dr. Holick properly disclosed his funding source and his potential conflicts.

Stiefel Buys Atlean Maker

Stiefel Laboratories Inc. has acquired ABR Invent and ABR Development, two French companies that developed Atlean, an injectable dermal filler. Atlean is made up of tricalcium phosphate particles suspended in a hyaluronic acid gel. The product was granted a CE marking in 2006, and is currently sold in France and Italy. The Coral Gables, Fla.-based Stiefel said it plans to launch Atlean in other European nations, Asia, Latin America, and the Caribbean in the next 18 months. The company will also eventually seek Food and Drug Administration approval, the company reported in a press release.

Generic Fluorouracil Cream Halted

Spear Pharmaceuticals Inc. has agreed to at least temporarily cease sales, marketing, and shipment of a generic fluorouracil cream 5%. Valeant Pharmaceuticals International, which makes the brand Efudex cream 5%, sued the FDA to challenge the agency's denial of Valeant's citizen's petition. The petition challenged the agency's approval of the generic. The company said that the FDA should not approve a generic that had not been tested head to head against Efudex in patients with superficial basal cell carcinoma. The agency said that generics needed to be tested only against actinic or solar keratoses. The FDA requested a 2-week stay of Valeant's lawsuit, which was granted.

Low Postmarketing FDACompliance

The FDA has issued its annual summary report of how pharmaceutical and biologic manufacturers are doing on meeting their commitments to conduct postmarketing studies. According to the agency, 76% of drug makers and 81% of biologic makers had met their commitment as of September 30, 2007. There were 136 drug makers and 54 biologic manufacturers with open postmarketing commitments as of that date. A closer look at the FDA data shows that only 12% of drug studies were completed or terminated with a final report submitted to the FDA that year. In all, 20% of biologics met that goal. Manufacturers are required to report annually on the status of safety, efficacy, pharmacology, and nonclinical toxicology studies required by the FDA, or to report that they have committed to conduct at the time of approval or after approval.

Disciplinary Actions Decline

The number and rate of serious disciplinary actions against physicians have decreased for the third consecutive year, according to Public Citizen's annual ranking of state medical boards. The advocacy group said the analysis indicates that many states are not living up to their obligations to protect patients from bad doctors. Since 2004, the number of serious disciplinary actions against doctors has decreased 17%, resulting in 553 fewer serious actions in 2007 than in 2004. Taking into account the increasing number of U.S. physicians since 2004, the rate of serious actions has fallen 22% since then, when calculated per 1,000 physicians, according to Public Citizen. The annual rankings are based on data from the Federation of State Medical Boards.

Half of Health Spending Wasted

Wasteful spending in the U.S. health system could amount to as much as $1.2 trillion of the $2.2 trillion spent annually, according to a report from the PricewaterhouseCoopers' Health Research Institute. Defensive medicine was identified as the biggest area of excess, followed by inefficient administration and the cost of care necessitated by preventable conditions, such as obesity, according to the report. The impact of issues such as nonadherence to medical advice and prescriptions, alcohol abuse, smoking, and obesity "are exponential," according to the report.

AAD Fires Back on Indoor Tanning

The American Academy of Dermatology is launching a public service campaign to communicate the risks of indoor tanning. The target audience is 16- to 29-year-old women, according to the AAD. This group is being chosen because the data show that 70% of indoor tanners are women in that age group, and melanoma is increasing faster among women than men in that age range. The "Indoor Tanning Is Out" campaign includes print, television, and radio ads. The campaign comes on the heels of an ad blitz in New York, Boston, Washington, Chicago, San Francisco, Seattle, and Pittsburgh sponsored by the Indoor Tanning Association. That campaign claimed there is no compelling scientific evidence linking tanning to melanoma.

Tanning Industry Ties Cited

The Indoor Tanning Association also recently found its ties to a Boston University researcher, Dr. Michael F. Holick, scrutinized by the Wall Street Journal. Dr. Holick has published numerous articles on vitamin D deficiency, including a review in the New England Journal of Medicine in 2007 (N. Engl. J. Med. 2007;357:266–81), in which he suggested using tanning beds "in moderation" as a source of replenishment. The article was supported by grants from the National Institutes of Health and also the UV Foundation, which is a nonprofit arm of the Indoor Tanning Association. Dr. Holick and his research are prominently featured on the UV Foundation's Web site. In a video on the site, he again suggests the use of tanning beds in moderation. The Wall Street Journal reported that the New England Journal said that Dr. Holick properly disclosed his funding source and his potential conflicts.

Stiefel Buys Atlean Maker

Stiefel Laboratories Inc. has acquired ABR Invent and ABR Development, two French companies that developed Atlean, an injectable dermal filler. Atlean is made up of tricalcium phosphate particles suspended in a hyaluronic acid gel. The product was granted a CE marking in 2006, and is currently sold in France and Italy. The Coral Gables, Fla.-based Stiefel said it plans to launch Atlean in other European nations, Asia, Latin America, and the Caribbean in the next 18 months. The company will also eventually seek Food and Drug Administration approval, the company reported in a press release.

Generic Fluorouracil Cream Halted

Spear Pharmaceuticals Inc. has agreed to at least temporarily cease sales, marketing, and shipment of a generic fluorouracil cream 5%. Valeant Pharmaceuticals International, which makes the brand Efudex cream 5%, sued the FDA to challenge the agency's denial of Valeant's citizen's petition. The petition challenged the agency's approval of the generic. The company said that the FDA should not approve a generic that had not been tested head to head against Efudex in patients with superficial basal cell carcinoma. The agency said that generics needed to be tested only against actinic or solar keratoses. The FDA requested a 2-week stay of Valeant's lawsuit, which was granted.

Low Postmarketing FDACompliance

The FDA has issued its annual summary report of how pharmaceutical and biologic manufacturers are doing on meeting their commitments to conduct postmarketing studies. According to the agency, 76% of drug makers and 81% of biologic makers had met their commitment as of September 30, 2007. There were 136 drug makers and 54 biologic manufacturers with open postmarketing commitments as of that date. A closer look at the FDA data shows that only 12% of drug studies were completed or terminated with a final report submitted to the FDA that year. In all, 20% of biologics met that goal. Manufacturers are required to report annually on the status of safety, efficacy, pharmacology, and nonclinical toxicology studies required by the FDA, or to report that they have committed to conduct at the time of approval or after approval.

Disciplinary Actions Decline

The number and rate of serious disciplinary actions against physicians have decreased for the third consecutive year, according to Public Citizen's annual ranking of state medical boards. The advocacy group said the analysis indicates that many states are not living up to their obligations to protect patients from bad doctors. Since 2004, the number of serious disciplinary actions against doctors has decreased 17%, resulting in 553 fewer serious actions in 2007 than in 2004. Taking into account the increasing number of U.S. physicians since 2004, the rate of serious actions has fallen 22% since then, when calculated per 1,000 physicians, according to Public Citizen. The annual rankings are based on data from the Federation of State Medical Boards.

Half of Health Spending Wasted

Wasteful spending in the U.S. health system could amount to as much as $1.2 trillion of the $2.2 trillion spent annually, according to a report from the PricewaterhouseCoopers' Health Research Institute. Defensive medicine was identified as the biggest area of excess, followed by inefficient administration and the cost of care necessitated by preventable conditions, such as obesity, according to the report. The impact of issues such as nonadherence to medical advice and prescriptions, alcohol abuse, smoking, and obesity "are exponential," according to the report.

WASHINGTON — The Medicare Payment Advisory Commission has given its backing to bundling payment for hospitalization, which would essentially give hospitals and physicians an incentive to control costs and avoid readmissions.

At its April meeting, the commission (MedPAC) unanimously voted to include a bundling recommendation in its June report to Congress. As a first step, physicians and hospitals should be required to report to the Centers for Medicare and Medicaid Services (CMS) on resource use and readmissions during an “episode of care,” which is proposed to include the first 30 days post hospitalization. The data would be confidential initially, but should be made public by the third year, MedPAC commissioners recommended.

Once the resource and readmission data are in hand, CMS should start adjusting payment to hospitals, according to the recommendation. There would be the possibility for gainsharing among hospitals and physicians.

The commissioners also voted to direct CMS to study the feasibility of “virtual” bundling. With virtual bundling, the payment would be adjusted based on aggregate use of services over an entire episode of care.

Finally, MedPAC voted to recommend that CMS create a voluntary pilot to test actual bundled payment in selected disease conditions. The pilot could throw some light on how the hospital or accountable care organization receiving the payment decided to share funds, and how Medicare might share in any savings, according to MedPAC staff.

The pilot represents Medicare's ultimate goal—making bundled payments, said MedPAC chairman Glenn Hackbarth, a health care consultant in Bend, Ore.

The data collection and adjusting payment based on readmission are interim steps aimed at getting providers to collaborate to improve care and cut costs, said Mr. Hackbarth.

Commissioner Ronald Castellanos, a urologist in private practice in Fort Myers, Fla., said he thought it would take 5 or 10 years to make collaboration work, but that he agreed that it was the ultimate end point.

WASHINGTON — The Medicare Payment Advisory Commission has given its backing to bundling payment for hospitalization, which would essentially give hospitals and physicians an incentive to control costs and avoid readmissions.

At its April meeting, the commission (MedPAC) unanimously voted to include a bundling recommendation in its June report to Congress. As a first step, physicians and hospitals should be required to report to the Centers for Medicare and Medicaid Services (CMS) on resource use and readmissions during an “episode of care,” which is proposed to include the first 30 days post hospitalization. The data would be confidential initially, but should be made public by the third year, MedPAC commissioners recommended.

Once the resource and readmission data are in hand, CMS should start adjusting payment to hospitals, according to the recommendation. There would be the possibility for gainsharing among hospitals and physicians.

The commissioners also voted to direct CMS to study the feasibility of “virtual” bundling. With virtual bundling, the payment would be adjusted based on aggregate use of services over an entire episode of care.

Finally, MedPAC voted to recommend that CMS create a voluntary pilot to test actual bundled payment in selected disease conditions. The pilot could throw some light on how the hospital or accountable care organization receiving the payment decided to share funds, and how Medicare might share in any savings, according to MedPAC staff.

The pilot represents Medicare's ultimate goal—making bundled payments, said MedPAC chairman Glenn Hackbarth, a health care consultant in Bend, Ore.

The data collection and adjusting payment based on readmission are interim steps aimed at getting providers to collaborate to improve care and cut costs, said Mr. Hackbarth.

Commissioner Ronald Castellanos, a urologist in private practice in Fort Myers, Fla., said he thought it would take 5 or 10 years to make collaboration work, but that he agreed that it was the ultimate end point.

WASHINGTON — The Medicare Payment Advisory Commission has given its backing to bundling payment for hospitalization, which would essentially give hospitals and physicians an incentive to control costs and avoid readmissions.

At its April meeting, the commission (MedPAC) unanimously voted to include a bundling recommendation in its June report to Congress. As a first step, physicians and hospitals should be required to report to the Centers for Medicare and Medicaid Services (CMS) on resource use and readmissions during an “episode of care,” which is proposed to include the first 30 days post hospitalization. The data would be confidential initially, but should be made public by the third year, MedPAC commissioners recommended.

Once the resource and readmission data are in hand, CMS should start adjusting payment to hospitals, according to the recommendation. There would be the possibility for gainsharing among hospitals and physicians.

The commissioners also voted to direct CMS to study the feasibility of “virtual” bundling. With virtual bundling, the payment would be adjusted based on aggregate use of services over an entire episode of care.

Finally, MedPAC voted to recommend that CMS create a voluntary pilot to test actual bundled payment in selected disease conditions. The pilot could throw some light on how the hospital or accountable care organization receiving the payment decided to share funds, and how Medicare might share in any savings, according to MedPAC staff.

The pilot represents Medicare's ultimate goal—making bundled payments, said MedPAC chairman Glenn Hackbarth, a health care consultant in Bend, Ore.

The data collection and adjusting payment based on readmission are interim steps aimed at getting providers to collaborate to improve care and cut costs, said Mr. Hackbarth.

Commissioner Ronald Castellanos, a urologist in private practice in Fort Myers, Fla., said he thought it would take 5 or 10 years to make collaboration work, but that he agreed that it was the ultimate end point.

The federal government's portrayal of enrollment growth in the State Children's Health Insurance Program in 2007 is disingenuous and somewhat misleading, advocates for children's programs said.

According to the Centers for Medicare and Medicaid Services, 7.1 million children were enrolled in the program (SCHIP) in 2007, up from 6.7 million in 2006.

“While we are pleased that SCHIP continues to grow, we must do more to reach those at the lowest income levels who still need this coverage,” Mike Leavitt, Health and Human Services secretary, said in a statement.

“Toward that end, we will continue to work with Congress on the reauthorization of this vital program,” he added.

That comment is “disingenuous,” Dr. Steve Wegner, chairman of the child health funding committee at the American Academy of Pediatrics, said in an interview.

He noted that President Bush vetoed a compromise agreement to re-authorize SCHIP not once, but twice, in 2007.

“The administration did everything possible to stand in the way of the reauthorization,” Jenny Sullivan, a health policy analyst with Families USA, said in an interview.

SCHIP was finally given a reprieve, with Congress passing, and the president signing, a funding extension through March 2009.

But the program still has not been formally reauthorized.

And, said Ms. Sullivan and Dr. Wegner, many millions more children would have been covered in 2007 if the reauthorization had been approved when it was first taken up early in the year.

Centers for Medicare and Medicaid Services (CMS) spokeswoman Mary Kahn said that it was not accurate to imply that the Bush administration did not want to continue the SCHIP program. The administration did, however, want to fund SCHIP at a lower level, she said in an interview.

Also in the HHS statement, Kerry Weems, CMS acting administrator, said, “We continue to work with states to [ensure] that as many eligible, uninsured children as possible are enrolled in SCHIP and Medicaid.”

Dr. Wegner took exception to that statement as well, noting that a CMS directive issued in August 2007 has effectively prevented states from expanding eligibility. CMS said it would limit states' ability to expand coverage to children in families that had incomes at 250% of the poverty level or above.

Ms. Sullivan said that the directive had, in many cases, reversed expansion plans previously approved by CMS.

Twenty-three states are expected to be affected by the directive, according to the Kaiser Family Foundation. Nine states already cover children in families with incomes above 250%, and 13 states had received approval to expand eligibility at or above that level.

In addition, Washington was covering children at the 250% level and had gotten approval to raise that cap.

The directive is consistent with the administration's belief that every effort should be made to enroll 95% of children eligible at the lowest income levels before expanding it to those who are in higher-income families, Ms. Kahn said.

The increase in SCHIP enrollment was not unusually high for the program, Ms. Sullivan said.

And, she said, U.S. Census Bureau figures indicate that the overall number of uninsured children actually increased in the last 2 years.

There are approximately 9 million uninsured children in the United States, according to a Families USA analysis.

Both Ms. Sullivan and Dr. Wegner said they expect that number to grow in the current year, as states face harsh budget realities.

A much larger number of children are covered under traditional Medicaid programs—about 28 million in 2005, according to Kaiser—but their coverage is also being threatened because of a series of CMS regulations taking effect this year.

Rep. John Dingell (D-Mich.) and Rep. Tim Murphy (R-Penn.) introduced a bill in March (H.R. 5613) that would place a 1-year moratorium on seven of those regulations. According to estimates they cite from the Congressional Budget Office, the regulations could translate to $20 billion in cuts to Medicaid over the next 5 years.

The National Governors Association, the National Association of State Medicaid Directors, and the American Public Human Services Association have all expressed their opposition to the regulations in letters to HHS.

The picture grows even dimmer when next year considered.

For fiscal 2009, President Bush proposed increasing SCHIP funding by $19.7 billion (added to the current baseline of $25 billion) through 2013. That is a far cry from the $35 billion that was authorized in the two legislative packages vetoed by the President last year.

The budget also seeks to formalize the CMS directive that limited states' expansion plans by proposing to cap SCHIP eligibility at 250% of the poverty level.

'We must do more to reach those at the lowest income levels who still need this coverage.' MR. LEAVITT

The federal government's portrayal of enrollment growth in the State Children's Health Insurance Program in 2007 is disingenuous and somewhat misleading, advocates for children's programs said.

According to the Centers for Medicare and Medicaid Services, 7.1 million children were enrolled in the program (SCHIP) in 2007, up from 6.7 million in 2006.

“While we are pleased that SCHIP continues to grow, we must do more to reach those at the lowest income levels who still need this coverage,” Mike Leavitt, Health and Human Services secretary, said in a statement.

“Toward that end, we will continue to work with Congress on the reauthorization of this vital program,” he added.

That comment is “disingenuous,” Dr. Steve Wegner, chairman of the child health funding committee at the American Academy of Pediatrics, said in an interview.

He noted that President Bush vetoed a compromise agreement to re-authorize SCHIP not once, but twice, in 2007.

“The administration did everything possible to stand in the way of the reauthorization,” Jenny Sullivan, a health policy analyst with Families USA, said in an interview.

SCHIP was finally given a reprieve, with Congress passing, and the president signing, a funding extension through March 2009.

But the program still has not been formally reauthorized.

And, said Ms. Sullivan and Dr. Wegner, many millions more children would have been covered in 2007 if the reauthorization had been approved when it was first taken up early in the year.

Centers for Medicare and Medicaid Services (CMS) spokeswoman Mary Kahn said that it was not accurate to imply that the Bush administration did not want to continue the SCHIP program. The administration did, however, want to fund SCHIP at a lower level, she said in an interview.

Also in the HHS statement, Kerry Weems, CMS acting administrator, said, “We continue to work with states to [ensure] that as many eligible, uninsured children as possible are enrolled in SCHIP and Medicaid.”

Dr. Wegner took exception to that statement as well, noting that a CMS directive issued in August 2007 has effectively prevented states from expanding eligibility. CMS said it would limit states' ability to expand coverage to children in families that had incomes at 250% of the poverty level or above.

Ms. Sullivan said that the directive had, in many cases, reversed expansion plans previously approved by CMS.

Twenty-three states are expected to be affected by the directive, according to the Kaiser Family Foundation. Nine states already cover children in families with incomes above 250%, and 13 states had received approval to expand eligibility at or above that level.

In addition, Washington was covering children at the 250% level and had gotten approval to raise that cap.

The directive is consistent with the administration's belief that every effort should be made to enroll 95% of children eligible at the lowest income levels before expanding it to those who are in higher-income families, Ms. Kahn said.

The increase in SCHIP enrollment was not unusually high for the program, Ms. Sullivan said.

And, she said, U.S. Census Bureau figures indicate that the overall number of uninsured children actually increased in the last 2 years.

There are approximately 9 million uninsured children in the United States, according to a Families USA analysis.

Both Ms. Sullivan and Dr. Wegner said they expect that number to grow in the current year, as states face harsh budget realities.

A much larger number of children are covered under traditional Medicaid programs—about 28 million in 2005, according to Kaiser—but their coverage is also being threatened because of a series of CMS regulations taking effect this year.

Rep. John Dingell (D-Mich.) and Rep. Tim Murphy (R-Penn.) introduced a bill in March (H.R. 5613) that would place a 1-year moratorium on seven of those regulations. According to estimates they cite from the Congressional Budget Office, the regulations could translate to $20 billion in cuts to Medicaid over the next 5 years.

The National Governors Association, the National Association of State Medicaid Directors, and the American Public Human Services Association have all expressed their opposition to the regulations in letters to HHS.

The picture grows even dimmer when next year considered.

For fiscal 2009, President Bush proposed increasing SCHIP funding by $19.7 billion (added to the current baseline of $25 billion) through 2013. That is a far cry from the $35 billion that was authorized in the two legislative packages vetoed by the President last year.

The budget also seeks to formalize the CMS directive that limited states' expansion plans by proposing to cap SCHIP eligibility at 250% of the poverty level.

'We must do more to reach those at the lowest income levels who still need this coverage.' MR. LEAVITT

The federal government's portrayal of enrollment growth in the State Children's Health Insurance Program in 2007 is disingenuous and somewhat misleading, advocates for children's programs said.

According to the Centers for Medicare and Medicaid Services, 7.1 million children were enrolled in the program (SCHIP) in 2007, up from 6.7 million in 2006.

“While we are pleased that SCHIP continues to grow, we must do more to reach those at the lowest income levels who still need this coverage,” Mike Leavitt, Health and Human Services secretary, said in a statement.

“Toward that end, we will continue to work with Congress on the reauthorization of this vital program,” he added.

That comment is “disingenuous,” Dr. Steve Wegner, chairman of the child health funding committee at the American Academy of Pediatrics, said in an interview.

He noted that President Bush vetoed a compromise agreement to re-authorize SCHIP not once, but twice, in 2007.

“The administration did everything possible to stand in the way of the reauthorization,” Jenny Sullivan, a health policy analyst with Families USA, said in an interview.

SCHIP was finally given a reprieve, with Congress passing, and the president signing, a funding extension through March 2009.

But the program still has not been formally reauthorized.

And, said Ms. Sullivan and Dr. Wegner, many millions more children would have been covered in 2007 if the reauthorization had been approved when it was first taken up early in the year.

Centers for Medicare and Medicaid Services (CMS) spokeswoman Mary Kahn said that it was not accurate to imply that the Bush administration did not want to continue the SCHIP program. The administration did, however, want to fund SCHIP at a lower level, she said in an interview.

Also in the HHS statement, Kerry Weems, CMS acting administrator, said, “We continue to work with states to [ensure] that as many eligible, uninsured children as possible are enrolled in SCHIP and Medicaid.”

Dr. Wegner took exception to that statement as well, noting that a CMS directive issued in August 2007 has effectively prevented states from expanding eligibility. CMS said it would limit states' ability to expand coverage to children in families that had incomes at 250% of the poverty level or above.

Ms. Sullivan said that the directive had, in many cases, reversed expansion plans previously approved by CMS.

Twenty-three states are expected to be affected by the directive, according to the Kaiser Family Foundation. Nine states already cover children in families with incomes above 250%, and 13 states had received approval to expand eligibility at or above that level.

In addition, Washington was covering children at the 250% level and had gotten approval to raise that cap.

The directive is consistent with the administration's belief that every effort should be made to enroll 95% of children eligible at the lowest income levels before expanding it to those who are in higher-income families, Ms. Kahn said.

The increase in SCHIP enrollment was not unusually high for the program, Ms. Sullivan said.

And, she said, U.S. Census Bureau figures indicate that the overall number of uninsured children actually increased in the last 2 years.

There are approximately 9 million uninsured children in the United States, according to a Families USA analysis.

Both Ms. Sullivan and Dr. Wegner said they expect that number to grow in the current year, as states face harsh budget realities.

A much larger number of children are covered under traditional Medicaid programs—about 28 million in 2005, according to Kaiser—but their coverage is also being threatened because of a series of CMS regulations taking effect this year.

Rep. John Dingell (D-Mich.) and Rep. Tim Murphy (R-Penn.) introduced a bill in March (H.R. 5613) that would place a 1-year moratorium on seven of those regulations. According to estimates they cite from the Congressional Budget Office, the regulations could translate to $20 billion in cuts to Medicaid over the next 5 years.

The National Governors Association, the National Association of State Medicaid Directors, and the American Public Human Services Association have all expressed their opposition to the regulations in letters to HHS.

The picture grows even dimmer when next year considered.

For fiscal 2009, President Bush proposed increasing SCHIP funding by $19.7 billion (added to the current baseline of $25 billion) through 2013. That is a far cry from the $35 billion that was authorized in the two legislative packages vetoed by the President last year.

The budget also seeks to formalize the CMS directive that limited states' expansion plans by proposing to cap SCHIP eligibility at 250% of the poverty level.

'We must do more to reach those at the lowest income levels who still need this coverage.' MR. LEAVITT

WASHINGTON — Staggering growth in the popularity of hospice services—and in the rise of for-profit hospice providers—has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, although data have shown that some illnesses—such as Alzheimer's disease and ischemic heart disease—tend to result in longer stays, said Dr. Mathews.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, Dr. Mathews said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market.

From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a little more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

In addition, the analysis determined that profit margins are also much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000 had higher margins—and these were mostly for-profit operations.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, said Dr. Mathews.

“Clearly, people see an opportunity—a financial opportunity—here,” commented MedPAC chairman Glenn Hackbarth, a health care consultant based in Bend, Ore. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested that Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care.

“It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

The commissioners and Dr. Schumacher agreed that a first step to a solution is collecting more data on the hospice sector.

CMS has already started down that path. In July, hospices will begin submitting data to CMS on the types of services they provide and which practitioners are delivering them.

WASHINGTON — Staggering growth in the popularity of hospice services—and in the rise of for-profit hospice providers—has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, although data have shown that some illnesses—such as Alzheimer's disease and ischemic heart disease—tend to result in longer stays, said Dr. Mathews.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, Dr. Mathews said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market.

From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a little more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

In addition, the analysis determined that profit margins are also much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000 had higher margins—and these were mostly for-profit operations.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, said Dr. Mathews.

“Clearly, people see an opportunity—a financial opportunity—here,” commented MedPAC chairman Glenn Hackbarth, a health care consultant based in Bend, Ore. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested that Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care.

“It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

The commissioners and Dr. Schumacher agreed that a first step to a solution is collecting more data on the hospice sector.

CMS has already started down that path. In July, hospices will begin submitting data to CMS on the types of services they provide and which practitioners are delivering them.

WASHINGTON — Staggering growth in the popularity of hospice services—and in the rise of for-profit hospice providers—has caught the attention of the Medicare Payment Assessment Commission.

At their recent meeting, MedPAC commissioners debated the potential impact of rising hospice costs on the Medicare program. The hospice benefit began in 1983 with the idea that it would cost Medicare less to provide hospice than conventional end-of-life treatment, which is usually delivered in the hospital, said MedPAC staff member James Mathews, Ph.D.

But there is some evidence indicating that hospice use may actually result in higher spending, said Dr. Mathews.

According to MedPAC's analysis of Medicare claims data, hospice spending tripled from 2000 to 2007, when Medicare spent $10 billion on hospice services. The mean length of hospice stay increased 30% from 2000 to 2005. It's not clear why length of stay is increasing, although data have shown that some illnesses—such as Alzheimer's disease and ischemic heart disease—tend to result in longer stays, said Dr. Mathews.

One explanation may be that hospice care tends to be more expensive at the beginning and the end of the service; interim days are more profitable, so there is an incentive to lengthen stay, Dr. Mathews said.

But it appears that much of the growth in costs and length of stay is due to the huge increase in for-profit hospice facilities in the market.

From 2000 to 2007, very few nonprofit hospices entered the market, while the for-profit sector grew 12% a year, Dr. Mathews said. There were a little more than 1,600 for-profit hospices in 2007, compared with about 1,200 nonprofit and 400 government-run facilities, according to the MedPAC analysis.

In addition, the analysis determined that profit margins are also much higher at for-profit hospice facilities. In 2005, the last year in the analysis, for-profit margins were about 12%, while nonprofits had negative margins. MedPAC also found that hospices that entered the market since 2000 had higher margins—and these were mostly for-profit operations.

Some hospices, only about 9%, are subject to a cap that limits the length of stay, but even those facilities have found a way to profit from Medicare, said Dr. Mathews.

“Clearly, people see an opportunity—a financial opportunity—here,” commented MedPAC chairman Glenn Hackbarth, a health care consultant based in Bend, Ore. He said that the commission needed to find a way to keep the hospice program from spiraling out of control.

Commissioner Jack Ebeler suggested that Medicare “may need blunter instruments for slowing the growth,” but also added that the health program should not do anything to lose “an extraordinarily valuable benefit.”

MedPAC vice chairman Robert Reischauer, Ph.D., suggested that Medicare payment could be refined to buy more appropriate care.

“It strikes me that there's probably an easy way to do this,” said Dr. Reischauer, who is also president of the Urban Institute.

J. Donald Schumacher, Psy.D., president and CEO of the National Hospice and Palliative Care Association, acknowledged that there has been a “huge growth spurt” in the hospice field. Facilities are worried that the Centers for Medicare and Medicaid Services or Congress might clamp down, using a “blunt instrument,” Dr. Schumacher said at the meeting.

The commissioners and Dr. Schumacher agreed that a first step to a solution is collecting more data on the hospice sector.

CMS has already started down that path. In July, hospices will begin submitting data to CMS on the types of services they provide and which practitioners are delivering them.