Alicia Ault

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving β-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A_1c levels, according to the latest report card from the National Committee for Quality Assurance.

And, plans that report publicly on these measures deliver higher quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform anywhere from half a percent to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, said Ms. O'Kane. And, there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top-performers in the NCQA database, she said.

The report is based on data that is voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information (HEDIS) Set.

Much of the data comes from claims, but some also comes from chart reviews. None of it is adjusted for severity-of-illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, said Ms. O'Kane. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned, Medicaid plans notched increases in 34 of 43 “trendable” measures, and Medicare plans achieved increase only on 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial plans, 94% of Medicare, and 88% of Medicaid plans reported prescribing a β-blocker upon discharge after acute myocardial infarction. Over the last 6 years, β-blocker treatment has saved an estimated 4,400 to 5,600 lives, said Ms. O'Kane.

Given the high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive β-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates are also at all-time highs, about 80% for commercial plans and 73% for Medicaid plans for the recommended series of vaccinations.

There has been “stalling” in some of the older HEDIS measures, however, said Ms. O'Kane. Baseline screening for HbA_1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, said Ms. O'Kane.

Adherence to mental health measures has also been flat for almost a decade, virtually the same since 1998, and patients hospitalized for a mental illness are not getting quality care, said Ms. O'Kane.

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly. And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, said Ms. O'Kane.

Coupled with the HEDIS measures, the NCQA will eventually be able to rate which plans give the best quality care for the least money, said Ms. O'Kane.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving β-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A_1c levels, according to the latest report card from the National Committee for Quality Assurance.

And, plans that report publicly on these measures deliver higher quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform anywhere from half a percent to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, said Ms. O'Kane. And, there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top-performers in the NCQA database, she said.

The report is based on data that is voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information (HEDIS) Set.

Much of the data comes from claims, but some also comes from chart reviews. None of it is adjusted for severity-of-illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, said Ms. O'Kane. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned, Medicaid plans notched increases in 34 of 43 “trendable” measures, and Medicare plans achieved increase only on 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial plans, 94% of Medicare, and 88% of Medicaid plans reported prescribing a β-blocker upon discharge after acute myocardial infarction. Over the last 6 years, β-blocker treatment has saved an estimated 4,400 to 5,600 lives, said Ms. O'Kane.

Given the high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive β-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates are also at all-time highs, about 80% for commercial plans and 73% for Medicaid plans for the recommended series of vaccinations.

There has been “stalling” in some of the older HEDIS measures, however, said Ms. O'Kane. Baseline screening for HbA_1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, said Ms. O'Kane.

Adherence to mental health measures has also been flat for almost a decade, virtually the same since 1998, and patients hospitalized for a mental illness are not getting quality care, said Ms. O'Kane.

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly. And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, said Ms. O'Kane.

Coupled with the HEDIS measures, the NCQA will eventually be able to rate which plans give the best quality care for the least money, said Ms. O'Kane.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving β-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A_1c levels, according to the latest report card from the National Committee for Quality Assurance.

And, plans that report publicly on these measures deliver higher quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform anywhere from half a percent to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, said Ms. O'Kane. And, there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top-performers in the NCQA database, she said.

The report is based on data that is voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information (HEDIS) Set.

Much of the data comes from claims, but some also comes from chart reviews. None of it is adjusted for severity-of-illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, said Ms. O'Kane. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned, Medicaid plans notched increases in 34 of 43 “trendable” measures, and Medicare plans achieved increase only on 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial plans, 94% of Medicare, and 88% of Medicaid plans reported prescribing a β-blocker upon discharge after acute myocardial infarction. Over the last 6 years, β-blocker treatment has saved an estimated 4,400 to 5,600 lives, said Ms. O'Kane.

Given the high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive β-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates are also at all-time highs, about 80% for commercial plans and 73% for Medicaid plans for the recommended series of vaccinations.

There has been “stalling” in some of the older HEDIS measures, however, said Ms. O'Kane. Baseline screening for HbA_1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, said Ms. O'Kane.

Adherence to mental health measures has also been flat for almost a decade, virtually the same since 1998, and patients hospitalized for a mental illness are not getting quality care, said Ms. O'Kane.

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly. And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, said Ms. O'Kane.

Coupled with the HEDIS measures, the NCQA will eventually be able to rate which plans give the best quality care for the least money, said Ms. O'Kane.

The Centers for Medicare and Medicaid Services will increase payments for outpatient services by an average of 3.8% in 2008, with most of the rheumatologic, neurologic, cardiac, and gynecologic procedures covered under the payment system being slated for small to moderate increases.

Overall, hospitals will be paid about $36 billion in 2008, a 10% increase from 2007, and $1 billion more than was estimated in the proposed outpatient rule, according to CMS.

The 2008 Hospital Outpatient Prospective Payment System final rule also includes a revised method of paying for services in ambulatory surgical centers (ASCs). Starting in 2008, services performed in ASCs will be reimbursed at 65% of the rate paid for the same service in an outpatient hospital department. This rate is unchanged from the proposed rule.

Two of the rhematology-related procedures scheduled for an increase are infusions of Rituxan (rituximab) and Remicade (infliximab).

For 100 mg of Rituxan, the final rule stipulated a payment of $504.40 in 2008, a 4.7% increase over the 2007 rate. For Remicade, the payment per 10 mg will be $54.42, a 1.8% increase from 2007.

Dr. Sharad Lakhanpal, the newly elected chair of the government affairs committee at the American College of Rheumatology, said that although the increases are appreciated, the new payment is still unlikely to cover the cost of the procedure to the physician.

“You have to look at the cost of procurement of these drugs,” he said. And although he said he hasn't yet seen vendors' 2008 price list for these drugs, Dr. Lakhanpal guessed that infusions like these are “being done by rheumatologists more as a service to the patients and not something that they're making a lot of money on.”

In fact, in some cases, they may actually be losing money, he said.

Dr. Lakhanpal, who practices with nine other rheumatologists in Dallas, estimated that his practice conducts 10–20 infusions every day.

CMS Acting Administrator Kerry Weems said, “The revised system takes a major step toward eliminating financial incentives for choosing one care setting over another, thereby placing patients' needs first, increasing efficiencies, and leading to savings for both beneficiaries and the Medicare program.”

Hospitals will be required to report on seven quality measures, including five emergency department measures pertaining to transfer of acute myocardial infarction patients, and two surgical care improvement measures. Under the proposed rule, hospitals were going to be required to report on 10 measures. Three were dropped in the final rule: administration of an ACE inhibitor to heart failure patients, empiric antibiotics for community-acquired pneumonia, and hemoglobin A_1c control.

Now, if hospitals do not report on the seven measures, they will get an automatic 2% reduction in inpatient pay in 2009, according to CMS.

CMS also said it was issuing three new composite ambulatory payment classification (APC) groups. The APC bundles frequently performed procedures together into a single payment, thus creating an episode-of-care-based payment.

The new APCs in the final rule are for extended outpatient visits with observation, low dose rate prostate brachytherapy, and cardiac electrophysiologic evaluation and ablation.

The agency is continuing its policy of bundling payments for certain ancillary services, to create efficiencies and to give hospitals more flexibility to manage costs.

Among the services that will now be covered by a bundled payment: image processing services, intraoperative services, imaging supervision and interpretation services, diagnostic radiopharmaceuticals, contrast agents, and observation services.

Dr. Kim Allan Williams, nuclear cardiology director at the University of Chicago, said that bundled payments can often mean that a service is not properly reimbursed.

But under the outpatient payment system, CMS has found a way to make sure that every service is appropriately covered, said Dr. Williams in an interview.

Most cardiac procedures are slated for an increase—from a modest 1.9% for pacemaker insertion or replacement, to 5.2% for bare metal stents, to 13.3% for drug-eluting stents. Implantation of left ventricular pacing leads (add-on) will be cut by 12.4%, but that comes on the heels of 3 years of 80%-180% increases.

Some neurologic device implant procedures will also see a reimbursement increase. Neurostimulators, used primarily for lessening of symptoms of movement disorders such as Parkinson's disease and essential tremor, as well as control of epilepsy and pain, are slated for a 3.1% increase. The electrodes required with the devices will see a 3.4% rise in payment.

The changes aren't substantial enough to have any impact on the numbers of these procedures being done, said Dr. Rajesh Pahwa, director of the Parkinson's Disease and Movement Disorder Center at the University of Kansas, Kansas City.

For gynecologic procedures, endometrial ablation will get a 17.9% increase in pay, and surgical hysteroscopy a 4.2% increase.

The Centers for Medicare and Medicaid Services will increase payments for outpatient services by an average of 3.8% in 2008, with most of the rheumatologic, neurologic, cardiac, and gynecologic procedures covered under the payment system being slated for small to moderate increases.

Overall, hospitals will be paid about $36 billion in 2008, a 10% increase from 2007, and $1 billion more than was estimated in the proposed outpatient rule, according to CMS.

The 2008 Hospital Outpatient Prospective Payment System final rule also includes a revised method of paying for services in ambulatory surgical centers (ASCs). Starting in 2008, services performed in ASCs will be reimbursed at 65% of the rate paid for the same service in an outpatient hospital department. This rate is unchanged from the proposed rule.

Two of the rhematology-related procedures scheduled for an increase are infusions of Rituxan (rituximab) and Remicade (infliximab).

For 100 mg of Rituxan, the final rule stipulated a payment of $504.40 in 2008, a 4.7% increase over the 2007 rate. For Remicade, the payment per 10 mg will be $54.42, a 1.8% increase from 2007.

Dr. Sharad Lakhanpal, the newly elected chair of the government affairs committee at the American College of Rheumatology, said that although the increases are appreciated, the new payment is still unlikely to cover the cost of the procedure to the physician.

“You have to look at the cost of procurement of these drugs,” he said. And although he said he hasn't yet seen vendors' 2008 price list for these drugs, Dr. Lakhanpal guessed that infusions like these are “being done by rheumatologists more as a service to the patients and not something that they're making a lot of money on.”

In fact, in some cases, they may actually be losing money, he said.

Dr. Lakhanpal, who practices with nine other rheumatologists in Dallas, estimated that his practice conducts 10–20 infusions every day.

CMS Acting Administrator Kerry Weems said, “The revised system takes a major step toward eliminating financial incentives for choosing one care setting over another, thereby placing patients' needs first, increasing efficiencies, and leading to savings for both beneficiaries and the Medicare program.”

Hospitals will be required to report on seven quality measures, including five emergency department measures pertaining to transfer of acute myocardial infarction patients, and two surgical care improvement measures. Under the proposed rule, hospitals were going to be required to report on 10 measures. Three were dropped in the final rule: administration of an ACE inhibitor to heart failure patients, empiric antibiotics for community-acquired pneumonia, and hemoglobin A_1c control.

Now, if hospitals do not report on the seven measures, they will get an automatic 2% reduction in inpatient pay in 2009, according to CMS.

CMS also said it was issuing three new composite ambulatory payment classification (APC) groups. The APC bundles frequently performed procedures together into a single payment, thus creating an episode-of-care-based payment.

The new APCs in the final rule are for extended outpatient visits with observation, low dose rate prostate brachytherapy, and cardiac electrophysiologic evaluation and ablation.

The agency is continuing its policy of bundling payments for certain ancillary services, to create efficiencies and to give hospitals more flexibility to manage costs.

Among the services that will now be covered by a bundled payment: image processing services, intraoperative services, imaging supervision and interpretation services, diagnostic radiopharmaceuticals, contrast agents, and observation services.

Dr. Kim Allan Williams, nuclear cardiology director at the University of Chicago, said that bundled payments can often mean that a service is not properly reimbursed.

But under the outpatient payment system, CMS has found a way to make sure that every service is appropriately covered, said Dr. Williams in an interview.

Most cardiac procedures are slated for an increase—from a modest 1.9% for pacemaker insertion or replacement, to 5.2% for bare metal stents, to 13.3% for drug-eluting stents. Implantation of left ventricular pacing leads (add-on) will be cut by 12.4%, but that comes on the heels of 3 years of 80%-180% increases.

Some neurologic device implant procedures will also see a reimbursement increase. Neurostimulators, used primarily for lessening of symptoms of movement disorders such as Parkinson's disease and essential tremor, as well as control of epilepsy and pain, are slated for a 3.1% increase. The electrodes required with the devices will see a 3.4% rise in payment.

The changes aren't substantial enough to have any impact on the numbers of these procedures being done, said Dr. Rajesh Pahwa, director of the Parkinson's Disease and Movement Disorder Center at the University of Kansas, Kansas City.

For gynecologic procedures, endometrial ablation will get a 17.9% increase in pay, and surgical hysteroscopy a 4.2% increase.

The Centers for Medicare and Medicaid Services will increase payments for outpatient services by an average of 3.8% in 2008, with most of the rheumatologic, neurologic, cardiac, and gynecologic procedures covered under the payment system being slated for small to moderate increases.

Overall, hospitals will be paid about $36 billion in 2008, a 10% increase from 2007, and $1 billion more than was estimated in the proposed outpatient rule, according to CMS.

The 2008 Hospital Outpatient Prospective Payment System final rule also includes a revised method of paying for services in ambulatory surgical centers (ASCs). Starting in 2008, services performed in ASCs will be reimbursed at 65% of the rate paid for the same service in an outpatient hospital department. This rate is unchanged from the proposed rule.

Two of the rhematology-related procedures scheduled for an increase are infusions of Rituxan (rituximab) and Remicade (infliximab).

For 100 mg of Rituxan, the final rule stipulated a payment of $504.40 in 2008, a 4.7% increase over the 2007 rate. For Remicade, the payment per 10 mg will be $54.42, a 1.8% increase from 2007.

Dr. Sharad Lakhanpal, the newly elected chair of the government affairs committee at the American College of Rheumatology, said that although the increases are appreciated, the new payment is still unlikely to cover the cost of the procedure to the physician.

“You have to look at the cost of procurement of these drugs,” he said. And although he said he hasn't yet seen vendors' 2008 price list for these drugs, Dr. Lakhanpal guessed that infusions like these are “being done by rheumatologists more as a service to the patients and not something that they're making a lot of money on.”

In fact, in some cases, they may actually be losing money, he said.

Dr. Lakhanpal, who practices with nine other rheumatologists in Dallas, estimated that his practice conducts 10–20 infusions every day.

CMS Acting Administrator Kerry Weems said, “The revised system takes a major step toward eliminating financial incentives for choosing one care setting over another, thereby placing patients' needs first, increasing efficiencies, and leading to savings for both beneficiaries and the Medicare program.”

Hospitals will be required to report on seven quality measures, including five emergency department measures pertaining to transfer of acute myocardial infarction patients, and two surgical care improvement measures. Under the proposed rule, hospitals were going to be required to report on 10 measures. Three were dropped in the final rule: administration of an ACE inhibitor to heart failure patients, empiric antibiotics for community-acquired pneumonia, and hemoglobin A_1c control.

Now, if hospitals do not report on the seven measures, they will get an automatic 2% reduction in inpatient pay in 2009, according to CMS.

CMS also said it was issuing three new composite ambulatory payment classification (APC) groups. The APC bundles frequently performed procedures together into a single payment, thus creating an episode-of-care-based payment.

The new APCs in the final rule are for extended outpatient visits with observation, low dose rate prostate brachytherapy, and cardiac electrophysiologic evaluation and ablation.

The agency is continuing its policy of bundling payments for certain ancillary services, to create efficiencies and to give hospitals more flexibility to manage costs.

Among the services that will now be covered by a bundled payment: image processing services, intraoperative services, imaging supervision and interpretation services, diagnostic radiopharmaceuticals, contrast agents, and observation services.

Dr. Kim Allan Williams, nuclear cardiology director at the University of Chicago, said that bundled payments can often mean that a service is not properly reimbursed.

But under the outpatient payment system, CMS has found a way to make sure that every service is appropriately covered, said Dr. Williams in an interview.

Most cardiac procedures are slated for an increase—from a modest 1.9% for pacemaker insertion or replacement, to 5.2% for bare metal stents, to 13.3% for drug-eluting stents. Implantation of left ventricular pacing leads (add-on) will be cut by 12.4%, but that comes on the heels of 3 years of 80%-180% increases.

Some neurologic device implant procedures will also see a reimbursement increase. Neurostimulators, used primarily for lessening of symptoms of movement disorders such as Parkinson's disease and essential tremor, as well as control of epilepsy and pain, are slated for a 3.1% increase. The electrodes required with the devices will see a 3.4% rise in payment.

The changes aren't substantial enough to have any impact on the numbers of these procedures being done, said Dr. Rajesh Pahwa, director of the Parkinson's Disease and Movement Disorder Center at the University of Kansas, Kansas City.

For gynecologic procedures, endometrial ablation will get a 17.9% increase in pay, and surgical hysteroscopy a 4.2% increase.

In the third phase of the final regulations implementing the physician self-referral rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance.

The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, or other entities in which they may have ownership.

This is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office, in an interview. “The application of exceptions will be different going forward.”

Most physicians with referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association.

Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices. Exceptions were evaluated using an indirect compensation analysis, which was the subject of many complaints. In comments on Stark II, physician groups, hospitals, and other facilities urged CMS to revert to the old policy.

CMS came to see the indirect compensation analysis as a loophole that allowed potentially questionable arrangements to slip through, said Mr. Melvin.

In the Stark III rule, CMS wrote the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”

There were several other notable changes in Stark III.

In one clarification, physicians who administer pharmaceuticals under Medicare Part B (like chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to direct productivity credit for those orders, said Mr. Melvin.

The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.

CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far geographically that noncompete can extend, said Mr. Melvin.

Practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, he said.

“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.

The final Stark rule went into effect on Dec. 5, 2007.

In the third phase of the final regulations implementing the physician self-referral rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance.

The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, or other entities in which they may have ownership.

This is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office, in an interview. “The application of exceptions will be different going forward.”

Most physicians with referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association.

Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices. Exceptions were evaluated using an indirect compensation analysis, which was the subject of many complaints. In comments on Stark II, physician groups, hospitals, and other facilities urged CMS to revert to the old policy.

CMS came to see the indirect compensation analysis as a loophole that allowed potentially questionable arrangements to slip through, said Mr. Melvin.

In the Stark III rule, CMS wrote the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”

There were several other notable changes in Stark III.

In one clarification, physicians who administer pharmaceuticals under Medicare Part B (like chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to direct productivity credit for those orders, said Mr. Melvin.

The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.

CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far geographically that noncompete can extend, said Mr. Melvin.

Practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, he said.

“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.

The final Stark rule went into effect on Dec. 5, 2007.

In the third phase of the final regulations implementing the physician self-referral rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance.

The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, or other entities in which they may have ownership.

This is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office, in an interview. “The application of exceptions will be different going forward.”

Most physicians with referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association.

Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices. Exceptions were evaluated using an indirect compensation analysis, which was the subject of many complaints. In comments on Stark II, physician groups, hospitals, and other facilities urged CMS to revert to the old policy.

CMS came to see the indirect compensation analysis as a loophole that allowed potentially questionable arrangements to slip through, said Mr. Melvin.

In the Stark III rule, CMS wrote the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”

There were several other notable changes in Stark III.

In one clarification, physicians who administer pharmaceuticals under Medicare Part B (like chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to direct productivity credit for those orders, said Mr. Melvin.

The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.

CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far geographically that noncompete can extend, said Mr. Melvin.

Practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, he said.

“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.

The final Stark rule went into effect on Dec. 5, 2007.

The number of students entering medical school this fall—17,759—is the largest ever, according to the Association of American Medical Colleges.

While that number represents only a 2.3% increase from the previous year, there was an 8% increase in applicants, with 42,300 seeking to enter medical school in 2007. It was the fourth consecutive year in which the number of applicants was on the rise, after a 6-year decline.

In a briefing with reporters, AAMC President Darrell G. Kirch said that the continuing increase in applicants and enrollees shows “that the interest in medicine runs very strong in our country.”

Applicants and enrollees are more diverse than ever, according to the AAMC. While the number of applicants who identified themselves as white or white combined with another ethnicity—26,916—still dwarfs other races, there was an increase in the number of minority applicants. There were 2,999 applicants who identified themselves as Latino or Hispanic alone or in combination with another race, 3,471 African American/combination applicants, and 9,225 Asian/combination applicants.

There was an almost-even split between men and women. Men slightly edged out women, comprising 51% of applicants and 51.7% of enrollees.

Eleven of the 126 medical schools increased class size by more than 10%. Some of the increase in enrollment came through added capacity. Six universities are currently seeking accreditation for a medical school, said Dr. Kirch.

The rise in applicants and enrollment represents some light at the end of the tunnel, he said. The AAMC and other organizations have warned of looming physician shortages. Depending on the estimates used, there will be a shortfall of 55,000–90,000 physicians across all specialties by 2020.

The AAMC has pushed for a 30% increase in enrollment by 2015, said Dr. Kirch. He acknowledged that it can be difficult to accurately predict shortages.

Even so, despite the many current challenges of being a physician—including a patchwork health care system and unpredictable reimbursement picture—it's still seen as an attractive career choice, Dr. Kirch said. “What I think is most striking here is to see the draw that medicine still has despite those environmental forces,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

The number of students entering medical school this fall—17,759—is the largest ever, according to the Association of American Medical Colleges.

While that number represents only a 2.3% increase from the previous year, there was an 8% increase in applicants, with 42,300 seeking to enter medical school in 2007. It was the fourth consecutive year in which the number of applicants was on the rise, after a 6-year decline.

In a briefing with reporters, AAMC President Darrell G. Kirch said that the continuing increase in applicants and enrollees shows “that the interest in medicine runs very strong in our country.”

Applicants and enrollees are more diverse than ever, according to the AAMC. While the number of applicants who identified themselves as white or white combined with another ethnicity—26,916—still dwarfs other races, there was an increase in the number of minority applicants. There were 2,999 applicants who identified themselves as Latino or Hispanic alone or in combination with another race, 3,471 African American/combination applicants, and 9,225 Asian/combination applicants.

There was an almost-even split between men and women. Men slightly edged out women, comprising 51% of applicants and 51.7% of enrollees.

Eleven of the 126 medical schools increased class size by more than 10%. Some of the increase in enrollment came through added capacity. Six universities are currently seeking accreditation for a medical school, said Dr. Kirch.

The rise in applicants and enrollment represents some light at the end of the tunnel, he said. The AAMC and other organizations have warned of looming physician shortages. Depending on the estimates used, there will be a shortfall of 55,000–90,000 physicians across all specialties by 2020.

The AAMC has pushed for a 30% increase in enrollment by 2015, said Dr. Kirch. He acknowledged that it can be difficult to accurately predict shortages.

Even so, despite the many current challenges of being a physician—including a patchwork health care system and unpredictable reimbursement picture—it's still seen as an attractive career choice, Dr. Kirch said. “What I think is most striking here is to see the draw that medicine still has despite those environmental forces,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

The number of students entering medical school this fall—17,759—is the largest ever, according to the Association of American Medical Colleges.

While that number represents only a 2.3% increase from the previous year, there was an 8% increase in applicants, with 42,300 seeking to enter medical school in 2007. It was the fourth consecutive year in which the number of applicants was on the rise, after a 6-year decline.

In a briefing with reporters, AAMC President Darrell G. Kirch said that the continuing increase in applicants and enrollees shows “that the interest in medicine runs very strong in our country.”

Applicants and enrollees are more diverse than ever, according to the AAMC. While the number of applicants who identified themselves as white or white combined with another ethnicity—26,916—still dwarfs other races, there was an increase in the number of minority applicants. There were 2,999 applicants who identified themselves as Latino or Hispanic alone or in combination with another race, 3,471 African American/combination applicants, and 9,225 Asian/combination applicants.

There was an almost-even split between men and women. Men slightly edged out women, comprising 51% of applicants and 51.7% of enrollees.

Eleven of the 126 medical schools increased class size by more than 10%. Some of the increase in enrollment came through added capacity. Six universities are currently seeking accreditation for a medical school, said Dr. Kirch.

The rise in applicants and enrollment represents some light at the end of the tunnel, he said. The AAMC and other organizations have warned of looming physician shortages. Depending on the estimates used, there will be a shortfall of 55,000–90,000 physicians across all specialties by 2020.

The AAMC has pushed for a 30% increase in enrollment by 2015, said Dr. Kirch. He acknowledged that it can be difficult to accurately predict shortages.

Even so, despite the many current challenges of being a physician—including a patchwork health care system and unpredictable reimbursement picture—it's still seen as an attractive career choice, Dr. Kirch said. “What I think is most striking here is to see the draw that medicine still has despite those environmental forces,” he said.

ELSEVIER GLOBAL MEDICAL NEWS

Heart Drugs Skewing Younger

More people aged 20–44 years are taking prescription medications for cardiac conditions—and their ranks are growing faster than those age 45 or older who use the therapies, according to Medco Health Solutions. Extrapolating data from 2.5 million Medco drug benefit users, the company estimated that nationally, 4.2 million patients aged 20–44 years took lipid-lowering drugs in 2006—a 68% increase from 2001—and 8.5 million took antihypertensives, a 21% rise from 2001. The rate of increase for new users of lipid-lowering drugs was 37% higher for the under 45 group than for patients 45–64 years, and 31% higher than for those 65 and older. Medco chief medical officer Dr. Robert Epstein said in a statement that it's heartening that more young people are taking medications to control these conditions. “The bad news is that these conditions are showing up in patients at younger ages, which could be the result of the growing obesity epidemic and various lifestyle factors.”

SPECT Appropriateness Pilot

The American College of Cardiology, with the assistance of UnitedHealthcare, is starting a pilot program to help physicians implement appropriateness criteria for the use of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). The criteria were published jointly by the ACC and the American Society of Nuclear Cardiology in 2005. Physicians at 10 UnitedHealthcare practice sites will participate. The pilot will develop a Web-based tool for data collection, examine utilization patterns, give confidential feedback to physicians on their appropriateness patterns, and assess outliers and changes in patterns over time. “We are confident that cardiologists will use the insights from this initiative to help maximize their skills and effectiveness,” said Dr. Jack Lewin, CEO of the ACC, in a statement.

Grassley Seeks Device Prices

Are Medicare, Medicaid, and the State Children's Health Insurance Program paying too much for medical devices? Sen. Chuck Grassley (R-Iowa) wants to know. He and Sen. Arlen Specter (R-Penn.) have introduced the Transparency in Medical Device Pricing Act of 2007 (S. 2221), which would require device makers to submit to the government quarterly data on average and median sales prices for implantable devices used in outpatient and inpatient procedures. The price data would also be made public on the Centers for Medicare and Medicaid Services' Web site; penalties for failure to report would range from $10,000 to $100,000. Lack of price disclosure means some hospitals pay more than others for the same devices, and also means higher co-pays for Medicare recipients, said Sen. Grassley. “Taxpayers need confidence that they're getting the most bang for their buck,” said the Senator in a statement.

Wash. to Evaluate Off-Label Stent Use

The Washington State Health Care Authority is starting to collect data on the off-label use of cardiac stents with an eye toward a full systematic review. The agency will look at safety, efficacy, and cost, and whether or when stenting is appropriate instead of medical therapy. There is also some concern about stents being used in multiple vessels, according to WSHCA. The Society for Cardiovascular Angiography and Interventions has been providing information to WSHCA, and notes that the organization's effort may have broader implications, as Washington is part of a 12-state consortium that conducts technology assessments. The WSHCA is also looking at contrast-enhanced CT angiography as a screen for coronary artery disease.

Data on Elderly Glossed Over

Food and Drug Administration regulations for drug makers conducting clinical trials encourage the inclusion of elderly participants and the reporting of data by age, but the agency is not effective in getting its medical officers to include data on elderly patients in their new drug application (NDA) reviews, according to a report by the Government Accountability Office. The report, requested by Rep. Henry Waxman (D-Calif.) and Sen. Ted Kennedy (D-Mass.), was based on a review of 36 NDAs submitted by manufacturers from January 2001 to June 2004 for drugs to treat diseases that could affect patients aged 65 years and older. All of the NDAs had at least one trial that included elderly participants, but a third of the agency's NDA reviews had no documentation on safety or efficacy for that age group. In addition, the GAO noted that reviewers are not required to establish whether there was a sufficient number of elderly participants in a trial, and if they do address sufficiency, they do not have to document their methods. Sufficiency was addressed in about a quarter of the reviews, none of which detailed the methods used, the report found.

Heart Drugs Skewing Younger

More people aged 20–44 years are taking prescription medications for cardiac conditions—and their ranks are growing faster than those age 45 or older who use the therapies, according to Medco Health Solutions. Extrapolating data from 2.5 million Medco drug benefit users, the company estimated that nationally, 4.2 million patients aged 20–44 years took lipid-lowering drugs in 2006—a 68% increase from 2001—and 8.5 million took antihypertensives, a 21% rise from 2001. The rate of increase for new users of lipid-lowering drugs was 37% higher for the under 45 group than for patients 45–64 years, and 31% higher than for those 65 and older. Medco chief medical officer Dr. Robert Epstein said in a statement that it's heartening that more young people are taking medications to control these conditions. “The bad news is that these conditions are showing up in patients at younger ages, which could be the result of the growing obesity epidemic and various lifestyle factors.”

SPECT Appropriateness Pilot

The American College of Cardiology, with the assistance of UnitedHealthcare, is starting a pilot program to help physicians implement appropriateness criteria for the use of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). The criteria were published jointly by the ACC and the American Society of Nuclear Cardiology in 2005. Physicians at 10 UnitedHealthcare practice sites will participate. The pilot will develop a Web-based tool for data collection, examine utilization patterns, give confidential feedback to physicians on their appropriateness patterns, and assess outliers and changes in patterns over time. “We are confident that cardiologists will use the insights from this initiative to help maximize their skills and effectiveness,” said Dr. Jack Lewin, CEO of the ACC, in a statement.

Grassley Seeks Device Prices

Are Medicare, Medicaid, and the State Children's Health Insurance Program paying too much for medical devices? Sen. Chuck Grassley (R-Iowa) wants to know. He and Sen. Arlen Specter (R-Penn.) have introduced the Transparency in Medical Device Pricing Act of 2007 (S. 2221), which would require device makers to submit to the government quarterly data on average and median sales prices for implantable devices used in outpatient and inpatient procedures. The price data would also be made public on the Centers for Medicare and Medicaid Services' Web site; penalties for failure to report would range from $10,000 to $100,000. Lack of price disclosure means some hospitals pay more than others for the same devices, and also means higher co-pays for Medicare recipients, said Sen. Grassley. “Taxpayers need confidence that they're getting the most bang for their buck,” said the Senator in a statement.

Wash. to Evaluate Off-Label Stent Use

The Washington State Health Care Authority is starting to collect data on the off-label use of cardiac stents with an eye toward a full systematic review. The agency will look at safety, efficacy, and cost, and whether or when stenting is appropriate instead of medical therapy. There is also some concern about stents being used in multiple vessels, according to WSHCA. The Society for Cardiovascular Angiography and Interventions has been providing information to WSHCA, and notes that the organization's effort may have broader implications, as Washington is part of a 12-state consortium that conducts technology assessments. The WSHCA is also looking at contrast-enhanced CT angiography as a screen for coronary artery disease.

Data on Elderly Glossed Over

Food and Drug Administration regulations for drug makers conducting clinical trials encourage the inclusion of elderly participants and the reporting of data by age, but the agency is not effective in getting its medical officers to include data on elderly patients in their new drug application (NDA) reviews, according to a report by the Government Accountability Office. The report, requested by Rep. Henry Waxman (D-Calif.) and Sen. Ted Kennedy (D-Mass.), was based on a review of 36 NDAs submitted by manufacturers from January 2001 to June 2004 for drugs to treat diseases that could affect patients aged 65 years and older. All of the NDAs had at least one trial that included elderly participants, but a third of the agency's NDA reviews had no documentation on safety or efficacy for that age group. In addition, the GAO noted that reviewers are not required to establish whether there was a sufficient number of elderly participants in a trial, and if they do address sufficiency, they do not have to document their methods. Sufficiency was addressed in about a quarter of the reviews, none of which detailed the methods used, the report found.

Heart Drugs Skewing Younger

More people aged 20–44 years are taking prescription medications for cardiac conditions—and their ranks are growing faster than those age 45 or older who use the therapies, according to Medco Health Solutions. Extrapolating data from 2.5 million Medco drug benefit users, the company estimated that nationally, 4.2 million patients aged 20–44 years took lipid-lowering drugs in 2006—a 68% increase from 2001—and 8.5 million took antihypertensives, a 21% rise from 2001. The rate of increase for new users of lipid-lowering drugs was 37% higher for the under 45 group than for patients 45–64 years, and 31% higher than for those 65 and older. Medco chief medical officer Dr. Robert Epstein said in a statement that it's heartening that more young people are taking medications to control these conditions. “The bad news is that these conditions are showing up in patients at younger ages, which could be the result of the growing obesity epidemic and various lifestyle factors.”

SPECT Appropriateness Pilot

The American College of Cardiology, with the assistance of UnitedHealthcare, is starting a pilot program to help physicians implement appropriateness criteria for the use of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). The criteria were published jointly by the ACC and the American Society of Nuclear Cardiology in 2005. Physicians at 10 UnitedHealthcare practice sites will participate. The pilot will develop a Web-based tool for data collection, examine utilization patterns, give confidential feedback to physicians on their appropriateness patterns, and assess outliers and changes in patterns over time. “We are confident that cardiologists will use the insights from this initiative to help maximize their skills and effectiveness,” said Dr. Jack Lewin, CEO of the ACC, in a statement.

Grassley Seeks Device Prices

Are Medicare, Medicaid, and the State Children's Health Insurance Program paying too much for medical devices? Sen. Chuck Grassley (R-Iowa) wants to know. He and Sen. Arlen Specter (R-Penn.) have introduced the Transparency in Medical Device Pricing Act of 2007 (S. 2221), which would require device makers to submit to the government quarterly data on average and median sales prices for implantable devices used in outpatient and inpatient procedures. The price data would also be made public on the Centers for Medicare and Medicaid Services' Web site; penalties for failure to report would range from $10,000 to $100,000. Lack of price disclosure means some hospitals pay more than others for the same devices, and also means higher co-pays for Medicare recipients, said Sen. Grassley. “Taxpayers need confidence that they're getting the most bang for their buck,” said the Senator in a statement.

Wash. to Evaluate Off-Label Stent Use

The Washington State Health Care Authority is starting to collect data on the off-label use of cardiac stents with an eye toward a full systematic review. The agency will look at safety, efficacy, and cost, and whether or when stenting is appropriate instead of medical therapy. There is also some concern about stents being used in multiple vessels, according to WSHCA. The Society for Cardiovascular Angiography and Interventions has been providing information to WSHCA, and notes that the organization's effort may have broader implications, as Washington is part of a 12-state consortium that conducts technology assessments. The WSHCA is also looking at contrast-enhanced CT angiography as a screen for coronary artery disease.

Data on Elderly Glossed Over

Food and Drug Administration regulations for drug makers conducting clinical trials encourage the inclusion of elderly participants and the reporting of data by age, but the agency is not effective in getting its medical officers to include data on elderly patients in their new drug application (NDA) reviews, according to a report by the Government Accountability Office. The report, requested by Rep. Henry Waxman (D-Calif.) and Sen. Ted Kennedy (D-Mass.), was based on a review of 36 NDAs submitted by manufacturers from January 2001 to June 2004 for drugs to treat diseases that could affect patients aged 65 years and older. All of the NDAs had at least one trial that included elderly participants, but a third of the agency's NDA reviews had no documentation on safety or efficacy for that age group. In addition, the GAO noted that reviewers are not required to establish whether there was a sufficient number of elderly participants in a trial, and if they do address sufficiency, they do not have to document their methods. Sufficiency was addressed in about a quarter of the reviews, none of which detailed the methods used, the report found.

With the end of the year drawing near—and Congress past due to adjourn—the fate of the reauthorization of the State Children's Health Insurance Plan was unclear.

SCHIP received one reprieve last month when Congress approved a continuing resolution to keep the government operating through at least mid-November. The resolution kept funding at current levels for all government programs. As that November deadline approached at press time, the House had come up with another continuing resolution, which it attached to next year's defense spending bill, but the Senate had not taken up the legislation.

The continuing resolutions at least kept SCHIP operating. But without funding increases—as were promised under a reauthorization—many states were slated to start cutting enrollment as early as January.

About 6 million children are currently enrolled in SCHIP. The congressional proposal under consideration would increase funding by about $7 billion a year, adding as many as 4 million children to the SCHIP rolls.

What had seemed like a foregone conclusion early this year—that no one would question SCHIP's success, and that it would be easily refunded for another 5 years—was a distant memory by the time House and Senate negotiators sat down last month to discuss how to avert a second White House veto.

President Bush's first veto came in October. Soon thereafter, the House voted 273–156 to override the veto; that tally was 10 votes short of the needed two-thirds majority. The vote was split down party lines, with 229 Democrats and 44 Republicans voting in favor of override, and 154 Republicans and 2 Democrats voting against.

With that failure, the House took up a new SCHIP package on Oct. 25, voting 265–142 in favor. However, there were no new Republican converts, making it doubtful that the bill would survive another presidential veto. The Senate approved the same package by a vote of 64–30.

House and Senate leaders delayed sending the bill to the president, hoping to work out a compromise in conference that would withstand White House scrutiny.

Negotiators from the Bush administration were intent on making sure that at least 500,000 children who are currently eligible for SCHIP, but not receiving benefits, would be enrolled, according to a White House statement. “If enrolling these children requires more than the 20% funding increase proposed by the President, we will work with Congress to find the necessary money,” the statement noted.

House Republicans said they also would work to ensure that only low-income children would receive SCHIP benefits, and that the program would not extend benefits to illegal immigrants.

At press time, negotiators were deep in discussions over how to ensure that those requirements might be met, said Ron Pollack, executive director of the advocacy group Families USA, in an interview.

The goal of covering 10 million children and financing the program through an increase in the tobacco tax was not at issue among congressional negotiators, said Mr. Pollack. The Bush administration, however, has said it is adamantly opposed to a tobacco tax increase.

The American Medical Association said it was committed to expanding coverage. “The number of uninsured kids has increased by nearly 1 million over the past 2 years, and action must be taken to reverse this growing trend,” said Dr. Edward Langston, AMA board chair, in a statement.

With the end of the year drawing near—and Congress past due to adjourn—the fate of the reauthorization of the State Children's Health Insurance Plan was unclear.

SCHIP received one reprieve last month when Congress approved a continuing resolution to keep the government operating through at least mid-November. The resolution kept funding at current levels for all government programs. As that November deadline approached at press time, the House had come up with another continuing resolution, which it attached to next year's defense spending bill, but the Senate had not taken up the legislation.

The continuing resolutions at least kept SCHIP operating. But without funding increases—as were promised under a reauthorization—many states were slated to start cutting enrollment as early as January.

About 6 million children are currently enrolled in SCHIP. The congressional proposal under consideration would increase funding by about $7 billion a year, adding as many as 4 million children to the SCHIP rolls.

What had seemed like a foregone conclusion early this year—that no one would question SCHIP's success, and that it would be easily refunded for another 5 years—was a distant memory by the time House and Senate negotiators sat down last month to discuss how to avert a second White House veto.

President Bush's first veto came in October. Soon thereafter, the House voted 273–156 to override the veto; that tally was 10 votes short of the needed two-thirds majority. The vote was split down party lines, with 229 Democrats and 44 Republicans voting in favor of override, and 154 Republicans and 2 Democrats voting against.

With that failure, the House took up a new SCHIP package on Oct. 25, voting 265–142 in favor. However, there were no new Republican converts, making it doubtful that the bill would survive another presidential veto. The Senate approved the same package by a vote of 64–30.

House and Senate leaders delayed sending the bill to the president, hoping to work out a compromise in conference that would withstand White House scrutiny.

Negotiators from the Bush administration were intent on making sure that at least 500,000 children who are currently eligible for SCHIP, but not receiving benefits, would be enrolled, according to a White House statement. “If enrolling these children requires more than the 20% funding increase proposed by the President, we will work with Congress to find the necessary money,” the statement noted.

House Republicans said they also would work to ensure that only low-income children would receive SCHIP benefits, and that the program would not extend benefits to illegal immigrants.

At press time, negotiators were deep in discussions over how to ensure that those requirements might be met, said Ron Pollack, executive director of the advocacy group Families USA, in an interview.

The goal of covering 10 million children and financing the program through an increase in the tobacco tax was not at issue among congressional negotiators, said Mr. Pollack. The Bush administration, however, has said it is adamantly opposed to a tobacco tax increase.

The American Medical Association said it was committed to expanding coverage. “The number of uninsured kids has increased by nearly 1 million over the past 2 years, and action must be taken to reverse this growing trend,” said Dr. Edward Langston, AMA board chair, in a statement.

With the end of the year drawing near—and Congress past due to adjourn—the fate of the reauthorization of the State Children's Health Insurance Plan was unclear.

SCHIP received one reprieve last month when Congress approved a continuing resolution to keep the government operating through at least mid-November. The resolution kept funding at current levels for all government programs. As that November deadline approached at press time, the House had come up with another continuing resolution, which it attached to next year's defense spending bill, but the Senate had not taken up the legislation.

The continuing resolutions at least kept SCHIP operating. But without funding increases—as were promised under a reauthorization—many states were slated to start cutting enrollment as early as January.

About 6 million children are currently enrolled in SCHIP. The congressional proposal under consideration would increase funding by about $7 billion a year, adding as many as 4 million children to the SCHIP rolls.

What had seemed like a foregone conclusion early this year—that no one would question SCHIP's success, and that it would be easily refunded for another 5 years—was a distant memory by the time House and Senate negotiators sat down last month to discuss how to avert a second White House veto.

President Bush's first veto came in October. Soon thereafter, the House voted 273–156 to override the veto; that tally was 10 votes short of the needed two-thirds majority. The vote was split down party lines, with 229 Democrats and 44 Republicans voting in favor of override, and 154 Republicans and 2 Democrats voting against.

With that failure, the House took up a new SCHIP package on Oct. 25, voting 265–142 in favor. However, there were no new Republican converts, making it doubtful that the bill would survive another presidential veto. The Senate approved the same package by a vote of 64–30.

House and Senate leaders delayed sending the bill to the president, hoping to work out a compromise in conference that would withstand White House scrutiny.

Negotiators from the Bush administration were intent on making sure that at least 500,000 children who are currently eligible for SCHIP, but not receiving benefits, would be enrolled, according to a White House statement. “If enrolling these children requires more than the 20% funding increase proposed by the President, we will work with Congress to find the necessary money,” the statement noted.

House Republicans said they also would work to ensure that only low-income children would receive SCHIP benefits, and that the program would not extend benefits to illegal immigrants.

At press time, negotiators were deep in discussions over how to ensure that those requirements might be met, said Ron Pollack, executive director of the advocacy group Families USA, in an interview.

The goal of covering 10 million children and financing the program through an increase in the tobacco tax was not at issue among congressional negotiators, said Mr. Pollack. The Bush administration, however, has said it is adamantly opposed to a tobacco tax increase.

The American Medical Association said it was committed to expanding coverage. “The number of uninsured kids has increased by nearly 1 million over the past 2 years, and action must be taken to reverse this growing trend,” said Dr. Edward Langston, AMA board chair, in a statement.

The number of students who entered medical school this fall–17,759–was the largest ever, according to the Association of American Medical Colleges.

Although that number represents only a 2.3% increase from the previous year, there was an 8% increase in applicants, with 42,300 seeking to enter medical school in 2007. It was the fourth consecutive year in which the number of applicants was on the rise, after a 6-year decline.

In a briefing with reporters, Dr. Darrell G. Kirch, president of the AAMC, said the continuing increase in applicants and enrollees shows “that the interest in medicine runs very strong in our country.”

Applicants and enrollees are more diverse than ever, according to the AAMC. While the number of applicants who identified themselves as white or white combined with another ethnicity–26,916–still dwarfs other races, there was an increase in the number of minority applicants. There were 2,999 applicants who identified themselves as Latino or Hispanic alone or in combination with another race, 3,471 African American/combination applicants, and 9,225 Asian/combination applicants.

The number of black and Hispanic male applicants rose by 9.2%, which was larger than the growth of the overall applicant pool, according to the AAMC. Ultimately, black male acceptance and enrollment increased by 5.3%, and Hispanic male acceptance remained even with 2006 levels.

There was an almost even split among men and women applicants and enrollees. Men slightly edged out women, accounting for 51% of applicants and 51.7% of enrollees.

Eleven of the 126 medical schools increased their class size by more than 10%: Michigan State University (47% increase), Texas A&M University System (24%), University of Arizona (22%), Florida State University (19%), Emory University (14%), Mount Sinai School of Medicine (14%), University of California, Davis (13%), Joan C. Edwards School of Medicine at Marshall University (12%), and Drexel University, Howard University, and University of Minnesota (10% each). Some of the increase in enrollment came through added capacity–both Michigan State and Arizona opened additional campuses.

There are six universities currently seeking accreditation for a medical school, said Dr. Kirch.

The rise in applicants and enrollment represents some light at the end of the tunnel, he said. The AAMC and other organizations have warned of looming physician shortages. Depending on the estimates used, there will be a shortfall of 55,000–90,000 physicians across all specialties by 2020.

The AAMC has pushed for a 30% increase in enrollment by 2015, said Dr. Kirch. He acknowledged that it can be difficult to accurately predict shortages, noting that medical school enrollment has waxed and waned over the years.

Even so, despite the many current challenges of being a physician–including a patchwork health care system and unpredictable reimbursement picture–it's still seen as an attractive career choice, Dr. Kirch said.

“What I think is most striking here is to see the draw that medicine still has despite those environmental forces,” he said. “I personally view this as a reflection that there are few careers that can be as meaningful, as fulfilling as pursuing medicine,” he added.

ELSEVIER GLOBAL MEDICAL NEWS

The number of students who entered medical school this fall–17,759–was the largest ever, according to the Association of American Medical Colleges.

Although that number represents only a 2.3% increase from the previous year, there was an 8% increase in applicants, with 42,300 seeking to enter medical school in 2007. It was the fourth consecutive year in which the number of applicants was on the rise, after a 6-year decline.

In a briefing with reporters, Dr. Darrell G. Kirch, president of the AAMC, said the continuing increase in applicants and enrollees shows “that the interest in medicine runs very strong in our country.”

Applicants and enrollees are more diverse than ever, according to the AAMC. While the number of applicants who identified themselves as white or white combined with another ethnicity–26,916–still dwarfs other races, there was an increase in the number of minority applicants. There were 2,999 applicants who identified themselves as Latino or Hispanic alone or in combination with another race, 3,471 African American/combination applicants, and 9,225 Asian/combination applicants.

The number of black and Hispanic male applicants rose by 9.2%, which was larger than the growth of the overall applicant pool, according to the AAMC. Ultimately, black male acceptance and enrollment increased by 5.3%, and Hispanic male acceptance remained even with 2006 levels.

There was an almost even split among men and women applicants and enrollees. Men slightly edged out women, accounting for 51% of applicants and 51.7% of enrollees.

Eleven of the 126 medical schools increased their class size by more than 10%: Michigan State University (47% increase), Texas A&M University System (24%), University of Arizona (22%), Florida State University (19%), Emory University (14%), Mount Sinai School of Medicine (14%), University of California, Davis (13%), Joan C. Edwards School of Medicine at Marshall University (12%), and Drexel University, Howard University, and University of Minnesota (10% each). Some of the increase in enrollment came through added capacity–both Michigan State and Arizona opened additional campuses.

There are six universities currently seeking accreditation for a medical school, said Dr. Kirch.

The rise in applicants and enrollment represents some light at the end of the tunnel, he said. The AAMC and other organizations have warned of looming physician shortages. Depending on the estimates used, there will be a shortfall of 55,000–90,000 physicians across all specialties by 2020.

The AAMC has pushed for a 30% increase in enrollment by 2015, said Dr. Kirch. He acknowledged that it can be difficult to accurately predict shortages, noting that medical school enrollment has waxed and waned over the years.

Even so, despite the many current challenges of being a physician–including a patchwork health care system and unpredictable reimbursement picture–it's still seen as an attractive career choice, Dr. Kirch said.

“What I think is most striking here is to see the draw that medicine still has despite those environmental forces,” he said. “I personally view this as a reflection that there are few careers that can be as meaningful, as fulfilling as pursuing medicine,” he added.

ELSEVIER GLOBAL MEDICAL NEWS

The number of students who entered medical school this fall–17,759–was the largest ever, according to the Association of American Medical Colleges.

Although that number represents only a 2.3% increase from the previous year, there was an 8% increase in applicants, with 42,300 seeking to enter medical school in 2007. It was the fourth consecutive year in which the number of applicants was on the rise, after a 6-year decline.

In a briefing with reporters, Dr. Darrell G. Kirch, president of the AAMC, said the continuing increase in applicants and enrollees shows “that the interest in medicine runs very strong in our country.”

Applicants and enrollees are more diverse than ever, according to the AAMC. While the number of applicants who identified themselves as white or white combined with another ethnicity–26,916–still dwarfs other races, there was an increase in the number of minority applicants. There were 2,999 applicants who identified themselves as Latino or Hispanic alone or in combination with another race, 3,471 African American/combination applicants, and 9,225 Asian/combination applicants.

The number of black and Hispanic male applicants rose by 9.2%, which was larger than the growth of the overall applicant pool, according to the AAMC. Ultimately, black male acceptance and enrollment increased by 5.3%, and Hispanic male acceptance remained even with 2006 levels.

There was an almost even split among men and women applicants and enrollees. Men slightly edged out women, accounting for 51% of applicants and 51.7% of enrollees.

Eleven of the 126 medical schools increased their class size by more than 10%: Michigan State University (47% increase), Texas A&M University System (24%), University of Arizona (22%), Florida State University (19%), Emory University (14%), Mount Sinai School of Medicine (14%), University of California, Davis (13%), Joan C. Edwards School of Medicine at Marshall University (12%), and Drexel University, Howard University, and University of Minnesota (10% each). Some of the increase in enrollment came through added capacity–both Michigan State and Arizona opened additional campuses.

There are six universities currently seeking accreditation for a medical school, said Dr. Kirch.

The rise in applicants and enrollment represents some light at the end of the tunnel, he said. The AAMC and other organizations have warned of looming physician shortages. Depending on the estimates used, there will be a shortfall of 55,000–90,000 physicians across all specialties by 2020.

The AAMC has pushed for a 30% increase in enrollment by 2015, said Dr. Kirch. He acknowledged that it can be difficult to accurately predict shortages, noting that medical school enrollment has waxed and waned over the years.

Even so, despite the many current challenges of being a physician–including a patchwork health care system and unpredictable reimbursement picture–it's still seen as an attractive career choice, Dr. Kirch said.

“What I think is most striking here is to see the draw that medicine still has despite those environmental forces,” he said. “I personally view this as a reflection that there are few careers that can be as meaningful, as fulfilling as pursuing medicine,” he added.

ELSEVIER GLOBAL MEDICAL NEWS

Pregnant Women Eschew Meds

A minority of women believe it is safe to take depression medication while they are pregnant, according to a new survey by the Society for Women's Health Research. The survey of 1,000 women was conducted by telephone in October; 500 family and general practitioners and internal medicine specialists were also queried. Only 11% of women said they thought it was safe to take a depression therapy during pregnancy, compared with 68% of physicians. Less educated and lower income women and African American women were more likely to believe it was unsafe to take a medication. Half of women said it was safe post partum, compared with 97% of physicians. Women falsely believed that depression was a normal part of the postpartum experience and also underestimated their risk for depression at specific life stages involving hormonal transitions, according to the society. In a statement, Sherry Marts, vice president of scientific affairs for the society, said the survey shows a disconnect between physicians' beliefs about depression and women's perceptions. “The health care community needs to do a better job communicating with women about depression,” Ms. Marts said.

Secondary Depression Admits Up

In 10 years, the rate of admissions for depression as a secondary diagnosis approximately tripled, from 93 per 10,000 to 247 per 10,000, according to the Agency for Health Care Research and Quality. There were about 2.5 million hospitalizations with depression as a secondary diagnosis in 2005, compared with 930,000 in 1995. Meanwhile, hospitalizations with depression as the primary diagnosis stayed flat over that same period, at about 42 per 10,000. The numbers are from “Hospital Stays Related to Depression,” a report that draws its data from the Nationwide Inpatient Sample. That sample covers nonfederal, short-term hospitals, which account for 90% of discharges.

Katrina's Mental Health Cost

Contrary to what is observed after most disasters, mental distress seems to be on the rise on the Gulf Coast, not declining, according to results of an ongoing survey of 1,043 prehurricane residents of affected areas of Alabama, Louisiana, and Mississippi. The most recent results compare a baseline taken 5–8 months after the hurricane to a survey a year later. The project is being conducted by the Hurricane Katrina Community Advisory Group and directed by Ronald C. Kessler, Ph.D., a professor of health care policy at Harvard Medical School, Boston. Anxiety and mood disorder were reported by 31% at baseline and 34% a year later. Serious mental illness had increased from 11% to 14% of the sample; it was unchanged, however, in the New Orleans metro area. Suicidality was significantly higher at follow-up, and the incidence of posttraumatic stress syndrome doubled. “We would normally expect to find lower proportions of the population to have mental illness and suicidality this long after a disaster,” said Dr. Kessler at a Senate hearing in late October. “That we not only failed to find decreases of this sort, and actually found a number of increases, is an indication of the more severe adverse emotional effects of Hurricane Katrina than more typical disasters,” he said. The study is funded by the National Institute of Mental Health, the Federal Emergency Management Agency, and the Department of Health and Human Services.

… Hits Students Also

Schools in Alabama, Louisiana, Mississippi, and Texas that received an estimated 196,000 students displaced by Katrina have not been able to meet students' ongoing mental health needs, according to a RAND Corp. survey released in October. The researchers interviewed mental health professionals at 19 public and 11 private schools and school systems in the spring and in the fall of 2006 (Psych. Services 2007;58:1339–43). The targeted schools had student population increases of more than 10%. Though most mobilized large and effective assistance efforts early on, by the later survey, a majority of schools could not or did not continue services, according to the study. The schools cited pressure by administrators to focus again on academics, trouble reaching parents living in trailers or without reliable phone service or transportation, not enough resources, and staff burnout.

Data on Elderly Glossed Over

Food and Drug Administration regulations for drug makers conducting clinical trials encourage the inclusion of elderly participants and the reporting of data by age, but the agency is not effective in getting its medical officers to include data on elderly patients in their new drug application (NDA) reviews, according to a report by the Government Accountability Office. The report, requested by Rep. Henry Waxman (D-Calif.) and Sen. Ted Kennedy (D-Mass.), was based on a review of 36 NDAs submitted by manufacturers from January 2001 to June 2004 for drugs to treat diseases that could affect patients aged 65 years and older. All of the NDAs had at least one trial that included elderly participants, but a third of the agency's NDA reviews had no documentation on safety or efficacy for that age group. In addition, the GAO noted that reviewers are not required to establish whether there were a sufficient number of elderly participants in a trial, and if they do address sufficiency, they do not have to document their methods. Sufficiency was addressed in about a quarter of the reviews, none of which detailed the methods used, the report found.

Pregnant Women Eschew Meds

A minority of women believe it is safe to take depression medication while they are pregnant, according to a new survey by the Society for Women's Health Research. The survey of 1,000 women was conducted by telephone in October; 500 family and general practitioners and internal medicine specialists were also queried. Only 11% of women said they thought it was safe to take a depression therapy during pregnancy, compared with 68% of physicians. Less educated and lower income women and African American women were more likely to believe it was unsafe to take a medication. Half of women said it was safe post partum, compared with 97% of physicians. Women falsely believed that depression was a normal part of the postpartum experience and also underestimated their risk for depression at specific life stages involving hormonal transitions, according to the society. In a statement, Sherry Marts, vice president of scientific affairs for the society, said the survey shows a disconnect between physicians' beliefs about depression and women's perceptions. “The health care community needs to do a better job communicating with women about depression,” Ms. Marts said.

Secondary Depression Admits Up

In 10 years, the rate of admissions for depression as a secondary diagnosis approximately tripled, from 93 per 10,000 to 247 per 10,000, according to the Agency for Health Care Research and Quality. There were about 2.5 million hospitalizations with depression as a secondary diagnosis in 2005, compared with 930,000 in 1995. Meanwhile, hospitalizations with depression as the primary diagnosis stayed flat over that same period, at about 42 per 10,000. The numbers are from “Hospital Stays Related to Depression,” a report that draws its data from the Nationwide Inpatient Sample. That sample covers nonfederal, short-term hospitals, which account for 90% of discharges.

Katrina's Mental Health Cost

Contrary to what is observed after most disasters, mental distress seems to be on the rise on the Gulf Coast, not declining, according to results of an ongoing survey of 1,043 prehurricane residents of affected areas of Alabama, Louisiana, and Mississippi. The most recent results compare a baseline taken 5–8 months after the hurricane to a survey a year later. The project is being conducted by the Hurricane Katrina Community Advisory Group and directed by Ronald C. Kessler, Ph.D., a professor of health care policy at Harvard Medical School, Boston. Anxiety and mood disorder were reported by 31% at baseline and 34% a year later. Serious mental illness had increased from 11% to 14% of the sample; it was unchanged, however, in the New Orleans metro area. Suicidality was significantly higher at follow-up, and the incidence of posttraumatic stress syndrome doubled. “We would normally expect to find lower proportions of the population to have mental illness and suicidality this long after a disaster,” said Dr. Kessler at a Senate hearing in late October. “That we not only failed to find decreases of this sort, and actually found a number of increases, is an indication of the more severe adverse emotional effects of Hurricane Katrina than more typical disasters,” he said. The study is funded by the National Institute of Mental Health, the Federal Emergency Management Agency, and the Department of Health and Human Services.

… Hits Students Also

Schools in Alabama, Louisiana, Mississippi, and Texas that received an estimated 196,000 students displaced by Katrina have not been able to meet students' ongoing mental health needs, according to a RAND Corp. survey released in October. The researchers interviewed mental health professionals at 19 public and 11 private schools and school systems in the spring and in the fall of 2006 (Psych. Services 2007;58:1339–43). The targeted schools had student population increases of more than 10%. Though most mobilized large and effective assistance efforts early on, by the later survey, a majority of schools could not or did not continue services, according to the study. The schools cited pressure by administrators to focus again on academics, trouble reaching parents living in trailers or without reliable phone service or transportation, not enough resources, and staff burnout.

Data on Elderly Glossed Over

Food and Drug Administration regulations for drug makers conducting clinical trials encourage the inclusion of elderly participants and the reporting of data by age, but the agency is not effective in getting its medical officers to include data on elderly patients in their new drug application (NDA) reviews, according to a report by the Government Accountability Office. The report, requested by Rep. Henry Waxman (D-Calif.) and Sen. Ted Kennedy (D-Mass.), was based on a review of 36 NDAs submitted by manufacturers from January 2001 to June 2004 for drugs to treat diseases that could affect patients aged 65 years and older. All of the NDAs had at least one trial that included elderly participants, but a third of the agency's NDA reviews had no documentation on safety or efficacy for that age group. In addition, the GAO noted that reviewers are not required to establish whether there were a sufficient number of elderly participants in a trial, and if they do address sufficiency, they do not have to document their methods. Sufficiency was addressed in about a quarter of the reviews, none of which detailed the methods used, the report found.

Pregnant Women Eschew Meds

A minority of women believe it is safe to take depression medication while they are pregnant, according to a new survey by the Society for Women's Health Research. The survey of 1,000 women was conducted by telephone in October; 500 family and general practitioners and internal medicine specialists were also queried. Only 11% of women said they thought it was safe to take a depression therapy during pregnancy, compared with 68% of physicians. Less educated and lower income women and African American women were more likely to believe it was unsafe to take a medication. Half of women said it was safe post partum, compared with 97% of physicians. Women falsely believed that depression was a normal part of the postpartum experience and also underestimated their risk for depression at specific life stages involving hormonal transitions, according to the society. In a statement, Sherry Marts, vice president of scientific affairs for the society, said the survey shows a disconnect between physicians' beliefs about depression and women's perceptions. “The health care community needs to do a better job communicating with women about depression,” Ms. Marts said.

Secondary Depression Admits Up

In 10 years, the rate of admissions for depression as a secondary diagnosis approximately tripled, from 93 per 10,000 to 247 per 10,000, according to the Agency for Health Care Research and Quality. There were about 2.5 million hospitalizations with depression as a secondary diagnosis in 2005, compared with 930,000 in 1995. Meanwhile, hospitalizations with depression as the primary diagnosis stayed flat over that same period, at about 42 per 10,000. The numbers are from “Hospital Stays Related to Depression,” a report that draws its data from the Nationwide Inpatient Sample. That sample covers nonfederal, short-term hospitals, which account for 90% of discharges.

Katrina's Mental Health Cost

Contrary to what is observed after most disasters, mental distress seems to be on the rise on the Gulf Coast, not declining, according to results of an ongoing survey of 1,043 prehurricane residents of affected areas of Alabama, Louisiana, and Mississippi. The most recent results compare a baseline taken 5–8 months after the hurricane to a survey a year later. The project is being conducted by the Hurricane Katrina Community Advisory Group and directed by Ronald C. Kessler, Ph.D., a professor of health care policy at Harvard Medical School, Boston. Anxiety and mood disorder were reported by 31% at baseline and 34% a year later. Serious mental illness had increased from 11% to 14% of the sample; it was unchanged, however, in the New Orleans metro area. Suicidality was significantly higher at follow-up, and the incidence of posttraumatic stress syndrome doubled. “We would normally expect to find lower proportions of the population to have mental illness and suicidality this long after a disaster,” said Dr. Kessler at a Senate hearing in late October. “That we not only failed to find decreases of this sort, and actually found a number of increases, is an indication of the more severe adverse emotional effects of Hurricane Katrina than more typical disasters,” he said. The study is funded by the National Institute of Mental Health, the Federal Emergency Management Agency, and the Department of Health and Human Services.

… Hits Students Also

Schools in Alabama, Louisiana, Mississippi, and Texas that received an estimated 196,000 students displaced by Katrina have not been able to meet students' ongoing mental health needs, according to a RAND Corp. survey released in October. The researchers interviewed mental health professionals at 19 public and 11 private schools and school systems in the spring and in the fall of 2006 (Psych. Services 2007;58:1339–43). The targeted schools had student population increases of more than 10%. Though most mobilized large and effective assistance efforts early on, by the later survey, a majority of schools could not or did not continue services, according to the study. The schools cited pressure by administrators to focus again on academics, trouble reaching parents living in trailers or without reliable phone service or transportation, not enough resources, and staff burnout.

Data on Elderly Glossed Over

Food and Drug Administration regulations for drug makers conducting clinical trials encourage the inclusion of elderly participants and the reporting of data by age, but the agency is not effective in getting its medical officers to include data on elderly patients in their new drug application (NDA) reviews, according to a report by the Government Accountability Office. The report, requested by Rep. Henry Waxman (D-Calif.) and Sen. Ted Kennedy (D-Mass.), was based on a review of 36 NDAs submitted by manufacturers from January 2001 to June 2004 for drugs to treat diseases that could affect patients aged 65 years and older. All of the NDAs had at least one trial that included elderly participants, but a third of the agency's NDA reviews had no documentation on safety or efficacy for that age group. In addition, the GAO noted that reviewers are not required to establish whether there were a sufficient number of elderly participants in a trial, and if they do address sufficiency, they do not have to document their methods. Sufficiency was addressed in about a quarter of the reviews, none of which detailed the methods used, the report found.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving β-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A_1c levels, according to the latest report card issued by the National Committee for Quality Assurance.

And plans that report publicly on these measures deliver higher-quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform from 0.5% to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, Ms. O'Kane said. And there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top performers in the NCQA database, she said.

The report is based on data that are voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information Set (HEDIS).

Most of the data come from claims, but some also come from chart reviews. None of the data are adjusted for severity of illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, Ms. O'Kane said. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned. Medicaid plans notched increases in 34 of 43 “trendable” measures, while Medicare plans achieved increases on only 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial, 94% of Medicare, and 88% of Medicaid plans reported prescribing a β-blocker upon discharge after acute myocardial infarction. Over the last 6 years, treatment with a β-blocker has saved an estimated 4,400–5,600 lives, Ms. O'Kane explained.

Given the high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive β-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates are also at all-time highs, with the recommended series of vaccinations given by about 80% of commercial plans and 73% of Medicaid plans.

There has been “stalling” in some of the older HEDIS measures, however, Ms. O'Kane said. Baseline screening for HbA_1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, she said.

Adherence to mental health measures—which are already abysmally low—has also been flat for almost a decade. For instance, only 20% of commercial, 21% of Medicaid, and 11% of Medicare plans are meeting the benchmark of treating newly diagnosed depression patients with an antidepressant and following up with at least three visits within the 12-week acute treatment phase. These rates have stayed virtually the same since 1998.

Similarly, patients who have been hospitalized for a mental illness are not getting quality care, Ms. O'Kane said. Only 57% of patients in commercial plans, 37% of those in Medicare, and 39% of those in Medicaid had follow-up within a week of hospitalization. Rates improved somewhat a month out, to 75%, 55%, and 58%, respectively. Studies have shown that follow-up care decreases the risk of repeat hospitalizations and improves adherence, according to the NCQA.

The low follow-up rates are “a national disgrace,” said Ms. O'Kane, adding that for anyone to be “out 30 days with no one checking on you is unacceptable.”

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly.

And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, Ms. O'Kane said. The data will be used to determine the variations in resource use among health plans.

Coupled with the HEDIS quality measures, the NCQA will eventually be able to rate which plans give the best-quality care at the lowest cost, she said.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving β-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A_1c levels, according to the latest report card issued by the National Committee for Quality Assurance.

And plans that report publicly on these measures deliver higher-quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform from 0.5% to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, Ms. O'Kane said. And there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top performers in the NCQA database, she said.

The report is based on data that are voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information Set (HEDIS).

Most of the data come from claims, but some also come from chart reviews. None of the data are adjusted for severity of illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, Ms. O'Kane said. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned. Medicaid plans notched increases in 34 of 43 “trendable” measures, while Medicare plans achieved increases on only 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial, 94% of Medicare, and 88% of Medicaid plans reported prescribing a β-blocker upon discharge after acute myocardial infarction. Over the last 6 years, treatment with a β-blocker has saved an estimated 4,400–5,600 lives, Ms. O'Kane explained.

Given the high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive β-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates are also at all-time highs, with the recommended series of vaccinations given by about 80% of commercial plans and 73% of Medicaid plans.

There has been “stalling” in some of the older HEDIS measures, however, Ms. O'Kane said. Baseline screening for HbA_1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, she said.

Adherence to mental health measures—which are already abysmally low—has also been flat for almost a decade. For instance, only 20% of commercial, 21% of Medicaid, and 11% of Medicare plans are meeting the benchmark of treating newly diagnosed depression patients with an antidepressant and following up with at least three visits within the 12-week acute treatment phase. These rates have stayed virtually the same since 1998.

Similarly, patients who have been hospitalized for a mental illness are not getting quality care, Ms. O'Kane said. Only 57% of patients in commercial plans, 37% of those in Medicare, and 39% of those in Medicaid had follow-up within a week of hospitalization. Rates improved somewhat a month out, to 75%, 55%, and 58%, respectively. Studies have shown that follow-up care decreases the risk of repeat hospitalizations and improves adherence, according to the NCQA.

The low follow-up rates are “a national disgrace,” said Ms. O'Kane, adding that for anyone to be “out 30 days with no one checking on you is unacceptable.”

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly.

And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, Ms. O'Kane said. The data will be used to determine the variations in resource use among health plans.

Coupled with the HEDIS quality measures, the NCQA will eventually be able to rate which plans give the best-quality care at the lowest cost, she said.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving β-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A_1c levels, according to the latest report card issued by the National Committee for Quality Assurance.

And plans that report publicly on these measures deliver higher-quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform from 0.5% to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, Ms. O'Kane said. And there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top performers in the NCQA database, she said.

The report is based on data that are voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information Set (HEDIS).

Most of the data come from claims, but some also come from chart reviews. None of the data are adjusted for severity of illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, Ms. O'Kane said. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned. Medicaid plans notched increases in 34 of 43 “trendable” measures, while Medicare plans achieved increases on only 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial, 94% of Medicare, and 88% of Medicaid plans reported prescribing a β-blocker upon discharge after acute myocardial infarction. Over the last 6 years, treatment with a β-blocker has saved an estimated 4,400–5,600 lives, Ms. O'Kane explained.

Given the high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive β-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates are also at all-time highs, with the recommended series of vaccinations given by about 80% of commercial plans and 73% of Medicaid plans.

There has been “stalling” in some of the older HEDIS measures, however, Ms. O'Kane said. Baseline screening for HbA_1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, she said.

Adherence to mental health measures—which are already abysmally low—has also been flat for almost a decade. For instance, only 20% of commercial, 21% of Medicaid, and 11% of Medicare plans are meeting the benchmark of treating newly diagnosed depression patients with an antidepressant and following up with at least three visits within the 12-week acute treatment phase. These rates have stayed virtually the same since 1998.

Similarly, patients who have been hospitalized for a mental illness are not getting quality care, Ms. O'Kane said. Only 57% of patients in commercial plans, 37% of those in Medicare, and 39% of those in Medicaid had follow-up within a week of hospitalization. Rates improved somewhat a month out, to 75%, 55%, and 58%, respectively. Studies have shown that follow-up care decreases the risk of repeat hospitalizations and improves adherence, according to the NCQA.

The low follow-up rates are “a national disgrace,” said Ms. O'Kane, adding that for anyone to be “out 30 days with no one checking on you is unacceptable.”

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly.

And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, Ms. O'Kane said. The data will be used to determine the variations in resource use among health plans.

Coupled with the HEDIS quality measures, the NCQA will eventually be able to rate which plans give the best-quality care at the lowest cost, she said.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving ?-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A1c levels, according to the latest report card from the National Committee for Quality Assurance.

And, plans that report publicly on these measures deliver higher quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform anywhere from half a percent to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, said Ms. O'Kane. And, there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top performers in the NCQA database, she said.

The report is based on data that is voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information (HEDIS) Set.

Much of the data comes from claims, but some also comes from chart reviews. None of it is adjusted for severity-of-illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, said Ms. O'Kane. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned, Medicaid plans notched increases in 34 of 43 "trendable" measures, and Medicare plans achieved increase only on 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial plans, 94% of Medicare, and 88% of Medicaid plans reported prescribing a ?-blocker upon discharge after acute myocardial infarction. Over the last 6 years, ?-blocker treatment has saved an estimated 4,400 to 5,600 lives, said Ms. O'Kane.

Given these high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive ?-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates have also reached all-time highs, at about 80% for commercial plans and 73% for Medicaid plans for the recommended series of vaccinations.

There has been "stalling" in some of the older HEDIS measures, however, said Ms. O'Kane. Baseline screening for HbA1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, said Ms. O'Kane.

Adherence to mental health measures—which are already abysmally low—has also been flat for almost a decade. For instance, only 20% of commercial, 21% of Medicaid, and 11% of Medicare plans are meeting the benchmark of treating newly diagnosed depression patients with an antidepressant and following up with at least three visits within the 12-week acute treatment phase. These rates have stayed virtually the same since 1998.

Similarly, patients who have been hospitalized for a mental illness are not getting quality care, said Ms. O'Kane. Only 57% of patients in commercial, 37% of those in a Medicare, and 39% of those in a Medicaid plan had a follow-up within a week of hospitalization. Rates improved somewhat a month out, to 75%, 55%, and 58%. Studies have shown that follow-up care decreases the risk of repeat hospitalizations and improves adherence, according to the NCQA.

The low follow-up rates are "a national disgrace," said Ms. O'Kane, adding that for anyone to be "out 30 days with no one checking on you is unacceptable."

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly.

And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, said Ms. O'Kane.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving ?-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A1c levels, according to the latest report card from the National Committee for Quality Assurance.

And, plans that report publicly on these measures deliver higher quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform anywhere from half a percent to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, said Ms. O'Kane. And, there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top performers in the NCQA database, she said.

The report is based on data that is voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information (HEDIS) Set.

Much of the data comes from claims, but some also comes from chart reviews. None of it is adjusted for severity-of-illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, said Ms. O'Kane. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned, Medicaid plans notched increases in 34 of 43 "trendable" measures, and Medicare plans achieved increase only on 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial plans, 94% of Medicare, and 88% of Medicaid plans reported prescribing a ?-blocker upon discharge after acute myocardial infarction. Over the last 6 years, ?-blocker treatment has saved an estimated 4,400 to 5,600 lives, said Ms. O'Kane.

Given these high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive ?-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates have also reached all-time highs, at about 80% for commercial plans and 73% for Medicaid plans for the recommended series of vaccinations.

There has been "stalling" in some of the older HEDIS measures, however, said Ms. O'Kane. Baseline screening for HbA1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, said Ms. O'Kane.

Adherence to mental health measures—which are already abysmally low—has also been flat for almost a decade. For instance, only 20% of commercial, 21% of Medicaid, and 11% of Medicare plans are meeting the benchmark of treating newly diagnosed depression patients with an antidepressant and following up with at least three visits within the 12-week acute treatment phase. These rates have stayed virtually the same since 1998.

Similarly, patients who have been hospitalized for a mental illness are not getting quality care, said Ms. O'Kane. Only 57% of patients in commercial, 37% of those in a Medicare, and 39% of those in a Medicaid plan had a follow-up within a week of hospitalization. Rates improved somewhat a month out, to 75%, 55%, and 58%. Studies have shown that follow-up care decreases the risk of repeat hospitalizations and improves adherence, according to the NCQA.

The low follow-up rates are "a national disgrace," said Ms. O'Kane, adding that for anyone to be "out 30 days with no one checking on you is unacceptable."

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly.

And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, said Ms. O'Kane.

WASHINGTON — Thousands of lives are being saved each year as health plans and physicians more closely follow quality measures such as giving ?-blockers after a heart attack, managing hypertension and hypercholesterolemia, and controlling hemoglobin A1c levels, according to the latest report card from the National Committee for Quality Assurance.

And, plans that report publicly on these measures deliver higher quality care, said NCQA president Margaret O'Kane in a briefing.

The NCQA's recently released report card shows that commercial and Medicaid plans that publicly disclose NCQA-tracked quality measures perform anywhere from half a percent to 16% better than plans that do not disclose their data.

However, even with some notable successes, some of the gains—such as in controlling blood sugar—are starting to plateau, said Ms. O'Kane. And, there are still gaps in quality between top-performing and average health plans. Thousands more lives could be saved if the laggards did as well as the top performers in the NCQA database, she said.

The report is based on data that is voluntarily submitted to the NCQA, which also accredits health plans. In 2006, 767 organizations—626 managed care plans covering private patients and Medicare and Medicaid enrollees, and 83 commercial and 58 Medicare PPO plans—submitted data using the NCQA's Healthcare Effectiveness Data and Information (HEDIS) Set.

Much of the data comes from claims, but some also comes from chart reviews. None of it is adjusted for severity-of-illness, socioeconomic, or other factors.

Approximately 84 million Americans were enrolled in plans that used HEDIS measures to report to the NCQA in 2006. Although that is a big number, at least 100 million Americans are in health plans that do not report quality data, and some 47 million have no insurance, said Ms. O'Kane. The quality picture is completely dark for the uninsured, she said.

But for those plans that did report, the news was good. Overall, commercial plans improved performance in 30 of 44 HEDIS measures where a trend could be discerned, Medicaid plans notched increases in 34 of 43 "trendable" measures, and Medicare plans achieved increase only on 7 of 21 trendable measures.

Among the biggest successes was that 98% of commercial plans, 94% of Medicare, and 88% of Medicaid plans reported prescribing a ?-blocker upon discharge after acute myocardial infarction. Over the last 6 years, ?-blocker treatment has saved an estimated 4,400 to 5,600 lives, said Ms. O'Kane.

Given these high prescribing rates, the NCQA will no longer track this measure. Instead, the organization will collect data on how many patients still receive ?-blockers 6 months after discharge—currently, only about 74% in commercial plans and 70% for Medicare and Medicaid.

Childhood immunization rates have also reached all-time highs, at about 80% for commercial plans and 73% for Medicaid plans for the recommended series of vaccinations.

There has been "stalling" in some of the older HEDIS measures, however, said Ms. O'Kane. Baseline screening for HbA1c has plateaued at 88% in commercial plans and is down slightly for Medicare and Medicaid, at 87% and 78%, respectively. Cholesterol screening and control of total cholesterol is also trending flat or down. The NCQA has no explanation for the leveling off, said Ms. O'Kane.

Adherence to mental health measures—which are already abysmally low—has also been flat for almost a decade. For instance, only 20% of commercial, 21% of Medicaid, and 11% of Medicare plans are meeting the benchmark of treating newly diagnosed depression patients with an antidepressant and following up with at least three visits within the 12-week acute treatment phase. These rates have stayed virtually the same since 1998.

Similarly, patients who have been hospitalized for a mental illness are not getting quality care, said Ms. O'Kane. Only 57% of patients in commercial, 37% of those in a Medicare, and 39% of those in a Medicaid plan had a follow-up within a week of hospitalization. Rates improved somewhat a month out, to 75%, 55%, and 58%. Studies have shown that follow-up care decreases the risk of repeat hospitalizations and improves adherence, according to the NCQA.

The low follow-up rates are "a national disgrace," said Ms. O'Kane, adding that for anyone to be "out 30 days with no one checking on you is unacceptable."

Several new HEDIS measures are in place for 2007, including tracking of potentially harmful drug-disease interactions in the elderly.

And, for the first time, health plans are being asked to report on their use of resources in treating various conditions. In 2007, they are diabetes, asthma, and low back pain. In 2008, chronic obstructive pulmonary disease, hypertension, and cardiovascular disease will be added. These conditions account for 60% of health care spending, said Ms. O'Kane.