Alicia Ault

Men Heavier Alcohol Users

As has been previously shown, males are more likely than females to report heavy alcohol use and binge alcohol use, the National Survey on Drug Use and Health found. In 2004–2005, 57% of males aged 12 years or older reported past-month alcohol use, compared with 45% of females. Binge alcohol use was reported by 31% of males, compared with only 15% of females. Similarly, 10% of males, compared with only 3% of females, reported heavy alcohol use (defined as five or more drinks on the same occasion on 5 or more days in the past month). Alcohol dependence or abuse was highest in 18- to 25-year-old men (22%), and in American Indian or Alaskan Native men (19%). Men living in households with incomes less than $20,000 also had higher levels of dependence or abuse. The survey is published by the Substance Abuse and Mental Health Services Administration.

Torture Resolution Criticized

At its annual meeting, the American Psychological Association resolved that although psychologists can attend or participate in interrogations, they should not plan, design, assist, or participate in sessions that involve 19 techniques that group deemed “unethical,” including waterboarding, sexual humiliation, sleep deprivation, hooding, the use of dogs, the exploitation of phobias, the use of psychotropic drugs, and threats of harm or death. Some members have been fighting for years to get the organization to completely bar participation in abusive interrogations. The American Civil Liberties Union called on the group to do so before the meeting, which was heavily protested. The group's ethics director, Stephen Behnke, Ph.D., said in a statement that the organization had a “long-standing position that torture and other forms of inhuman and degrading treatment are unethical,” and that the new resolution “adds specificity to that prohibition.” The psychologists called on the U.S. government to prohibit the 19 techniques. After the meeting, popular author and association member Mary Pipher, Ph.D., returned a presidential citation she earned in 2006, saying that the resolution was a “terrible mistake.”

Beefing Up School Mental Health

Lawmakers in the House and Senate have introduced legislation to funnel grants to schools to increase their ability to respond to students' mental health needs. Rep. Grace Napolitano's (D-Calif.) Mental Health in Schools Act of 2007 (H.R. 3430) is the companion to S. 1332, introduced in May by Senators Ted Kennedy (D-Mass.), Michael Enzi (R-Wyo.), Pete Domenici (R-N.M.), and Christopher Dodd (D-Conn.). Rep. Napolitano's bill has 65 cosponsors. Neither the House nor Senate version has advanced to committee yet. Both bills would direct the Department of Health and Human Services to award grants to establish comprehensive mental health programs in schools.

Drug Premium About $25 in 2008

The Centers for Medicare and Medicaid Services said Medicare beneficiaries will pay about $25 a month for their Part D prescription drug coverage in 2008. This is an approximate $3 per month increase over the average premium in 2007, but is still 40% lower than what had been projected when the program was established in 2003, according to CMS. The premiums for those who get their benefits through private Medicare Advantage plans will be about $14, according to CMS. The agency said that almost 10 million low-income beneficiaries are having their premiums subsidized by the federal government. Because Part D is sketching out to cost 30% less in the first 10 years than had been estimated, President Bush's 2009 budget will be retooled to reflect the decline, according to CMS.

Small Practices Decline

Physicians are shying away from solo and two-physician practices, according to a new report from the Center for Studying Health System Change. Although these small practices are still the most common practice arrangements, between 1996–1997 and 2004–2005 researchers saw a shift from solo and two-person practices to midsized, single-specialty groups of 6–50 physicians. The percentage of physicians who practiced in solo and two-person practices fell from 41% in 1996–1997 to 33% in 2004–2005. During the same period, the percentage of physicians practicing in midsized groups rose from 13% to 18%. The biggest declines in physicians choosing small practices have come from medical specialists and surgical specialists, whereas the proportion of primary care physicians in small practices has remained steady at about 36%. The report's findings are based on the Center for Studying Health System Change's nationally representative Community Tracking Study Physician Survey.

GAO Finds Medicaid Decline

A law requiring most U.S. citizens applying for Medicaid coverage to document their citizenship has caused eligible citizens to lose Medicaid coverage, and the law costs far more to administer than it saves, according to two government analyses. The law went into effect on July 1, 2006, and affects 30 million children and 16 million parents currently enrolled in Medicaid, as well as millions of new applicants. The first analysis, from the Government Accountability Office, found that half the states are reporting declines in Medicaid coverage because of the requirement, and many of those losing coverage appear to be U.S. citizens. The second analysis, produced by the House Committee on Oversight and Government Reform, found that for every $100 spent by federal taxpayers to implement the documentation requirements in six states, only 14 cents in Medicaid savings can be documented.

Men Heavier Alcohol Users

As has been previously shown, males are more likely than females to report heavy alcohol use and binge alcohol use, the National Survey on Drug Use and Health found. In 2004–2005, 57% of males aged 12 years or older reported past-month alcohol use, compared with 45% of females. Binge alcohol use was reported by 31% of males, compared with only 15% of females. Similarly, 10% of males, compared with only 3% of females, reported heavy alcohol use (defined as five or more drinks on the same occasion on 5 or more days in the past month). Alcohol dependence or abuse was highest in 18- to 25-year-old men (22%), and in American Indian or Alaskan Native men (19%). Men living in households with incomes less than $20,000 also had higher levels of dependence or abuse. The survey is published by the Substance Abuse and Mental Health Services Administration.

Torture Resolution Criticized

At its annual meeting, the American Psychological Association resolved that although psychologists can attend or participate in interrogations, they should not plan, design, assist, or participate in sessions that involve 19 techniques that group deemed “unethical,” including waterboarding, sexual humiliation, sleep deprivation, hooding, the use of dogs, the exploitation of phobias, the use of psychotropic drugs, and threats of harm or death. Some members have been fighting for years to get the organization to completely bar participation in abusive interrogations. The American Civil Liberties Union called on the group to do so before the meeting, which was heavily protested. The group's ethics director, Stephen Behnke, Ph.D., said in a statement that the organization had a “long-standing position that torture and other forms of inhuman and degrading treatment are unethical,” and that the new resolution “adds specificity to that prohibition.” The psychologists called on the U.S. government to prohibit the 19 techniques. After the meeting, popular author and association member Mary Pipher, Ph.D., returned a presidential citation she earned in 2006, saying that the resolution was a “terrible mistake.”

Beefing Up School Mental Health

Lawmakers in the House and Senate have introduced legislation to funnel grants to schools to increase their ability to respond to students' mental health needs. Rep. Grace Napolitano's (D-Calif.) Mental Health in Schools Act of 2007 (H.R. 3430) is the companion to S. 1332, introduced in May by Senators Ted Kennedy (D-Mass.), Michael Enzi (R-Wyo.), Pete Domenici (R-N.M.), and Christopher Dodd (D-Conn.). Rep. Napolitano's bill has 65 cosponsors. Neither the House nor Senate version has advanced to committee yet. Both bills would direct the Department of Health and Human Services to award grants to establish comprehensive mental health programs in schools.

Drug Premium About $25 in 2008

The Centers for Medicare and Medicaid Services said Medicare beneficiaries will pay about $25 a month for their Part D prescription drug coverage in 2008. This is an approximate $3 per month increase over the average premium in 2007, but is still 40% lower than what had been projected when the program was established in 2003, according to CMS. The premiums for those who get their benefits through private Medicare Advantage plans will be about $14, according to CMS. The agency said that almost 10 million low-income beneficiaries are having their premiums subsidized by the federal government. Because Part D is sketching out to cost 30% less in the first 10 years than had been estimated, President Bush's 2009 budget will be retooled to reflect the decline, according to CMS.

Small Practices Decline

Physicians are shying away from solo and two-physician practices, according to a new report from the Center for Studying Health System Change. Although these small practices are still the most common practice arrangements, between 1996–1997 and 2004–2005 researchers saw a shift from solo and two-person practices to midsized, single-specialty groups of 6–50 physicians. The percentage of physicians who practiced in solo and two-person practices fell from 41% in 1996–1997 to 33% in 2004–2005. During the same period, the percentage of physicians practicing in midsized groups rose from 13% to 18%. The biggest declines in physicians choosing small practices have come from medical specialists and surgical specialists, whereas the proportion of primary care physicians in small practices has remained steady at about 36%. The report's findings are based on the Center for Studying Health System Change's nationally representative Community Tracking Study Physician Survey.

GAO Finds Medicaid Decline

A law requiring most U.S. citizens applying for Medicaid coverage to document their citizenship has caused eligible citizens to lose Medicaid coverage, and the law costs far more to administer than it saves, according to two government analyses. The law went into effect on July 1, 2006, and affects 30 million children and 16 million parents currently enrolled in Medicaid, as well as millions of new applicants. The first analysis, from the Government Accountability Office, found that half the states are reporting declines in Medicaid coverage because of the requirement, and many of those losing coverage appear to be U.S. citizens. The second analysis, produced by the House Committee on Oversight and Government Reform, found that for every $100 spent by federal taxpayers to implement the documentation requirements in six states, only 14 cents in Medicaid savings can be documented.

Men Heavier Alcohol Users

As has been previously shown, males are more likely than females to report heavy alcohol use and binge alcohol use, the National Survey on Drug Use and Health found. In 2004–2005, 57% of males aged 12 years or older reported past-month alcohol use, compared with 45% of females. Binge alcohol use was reported by 31% of males, compared with only 15% of females. Similarly, 10% of males, compared with only 3% of females, reported heavy alcohol use (defined as five or more drinks on the same occasion on 5 or more days in the past month). Alcohol dependence or abuse was highest in 18- to 25-year-old men (22%), and in American Indian or Alaskan Native men (19%). Men living in households with incomes less than $20,000 also had higher levels of dependence or abuse. The survey is published by the Substance Abuse and Mental Health Services Administration.

Torture Resolution Criticized

At its annual meeting, the American Psychological Association resolved that although psychologists can attend or participate in interrogations, they should not plan, design, assist, or participate in sessions that involve 19 techniques that group deemed “unethical,” including waterboarding, sexual humiliation, sleep deprivation, hooding, the use of dogs, the exploitation of phobias, the use of psychotropic drugs, and threats of harm or death. Some members have been fighting for years to get the organization to completely bar participation in abusive interrogations. The American Civil Liberties Union called on the group to do so before the meeting, which was heavily protested. The group's ethics director, Stephen Behnke, Ph.D., said in a statement that the organization had a “long-standing position that torture and other forms of inhuman and degrading treatment are unethical,” and that the new resolution “adds specificity to that prohibition.” The psychologists called on the U.S. government to prohibit the 19 techniques. After the meeting, popular author and association member Mary Pipher, Ph.D., returned a presidential citation she earned in 2006, saying that the resolution was a “terrible mistake.”

Beefing Up School Mental Health

Lawmakers in the House and Senate have introduced legislation to funnel grants to schools to increase their ability to respond to students' mental health needs. Rep. Grace Napolitano's (D-Calif.) Mental Health in Schools Act of 2007 (H.R. 3430) is the companion to S. 1332, introduced in May by Senators Ted Kennedy (D-Mass.), Michael Enzi (R-Wyo.), Pete Domenici (R-N.M.), and Christopher Dodd (D-Conn.). Rep. Napolitano's bill has 65 cosponsors. Neither the House nor Senate version has advanced to committee yet. Both bills would direct the Department of Health and Human Services to award grants to establish comprehensive mental health programs in schools.

Drug Premium About $25 in 2008

The Centers for Medicare and Medicaid Services said Medicare beneficiaries will pay about $25 a month for their Part D prescription drug coverage in 2008. This is an approximate $3 per month increase over the average premium in 2007, but is still 40% lower than what had been projected when the program was established in 2003, according to CMS. The premiums for those who get their benefits through private Medicare Advantage plans will be about $14, according to CMS. The agency said that almost 10 million low-income beneficiaries are having their premiums subsidized by the federal government. Because Part D is sketching out to cost 30% less in the first 10 years than had been estimated, President Bush's 2009 budget will be retooled to reflect the decline, according to CMS.

Small Practices Decline

Physicians are shying away from solo and two-physician practices, according to a new report from the Center for Studying Health System Change. Although these small practices are still the most common practice arrangements, between 1996–1997 and 2004–2005 researchers saw a shift from solo and two-person practices to midsized, single-specialty groups of 6–50 physicians. The percentage of physicians who practiced in solo and two-person practices fell from 41% in 1996–1997 to 33% in 2004–2005. During the same period, the percentage of physicians practicing in midsized groups rose from 13% to 18%. The biggest declines in physicians choosing small practices have come from medical specialists and surgical specialists, whereas the proportion of primary care physicians in small practices has remained steady at about 36%. The report's findings are based on the Center for Studying Health System Change's nationally representative Community Tracking Study Physician Survey.

GAO Finds Medicaid Decline

A law requiring most U.S. citizens applying for Medicaid coverage to document their citizenship has caused eligible citizens to lose Medicaid coverage, and the law costs far more to administer than it saves, according to two government analyses. The law went into effect on July 1, 2006, and affects 30 million children and 16 million parents currently enrolled in Medicaid, as well as millions of new applicants. The first analysis, from the Government Accountability Office, found that half the states are reporting declines in Medicaid coverage because of the requirement, and many of those losing coverage appear to be U.S. citizens. The second analysis, produced by the House Committee on Oversight and Government Reform, found that for every $100 spent by federal taxpayers to implement the documentation requirements in six states, only 14 cents in Medicaid savings can be documented.

CHICAGO – A proposed definition and diagnostic criteria aim to help physicians deal with the growing number of patients presenting with refractory migraine, Dr. Elliott A. Schulman said at the annual meeting of the American Headache Society.

“[Refractory migraine] is out there, we just haven't defined it,” said Dr. Schulman, noting that the incidence is probably 10%–50% of cases seen in practice. By setting a definition, he said, patients who need greater care can be identified early, a standard of care can be established, the epidemiology can be further studied and clarified, and candidates for novel treatment approaches can be identified for clinical trials.

To address the problem, the society's Refractory Headache Special Interest Section was formed in 2000. In April 2006, the section surveyed all AHS members on a proposed definition of refractory migraine, whether it should be added to the International Classification of Headache Disorders, and for information on some of the best practices used.

Two hundred-twenty members responded, for a response rate of 18%, said Dr. Schulman, a neurologist at Lankenau Hospital, Wynnewood, Pa. More than half the respondents believed that refractory migraine should be defined as occurring more than 15 days a month, that it should be associated with disability, and that a definition should include inadequate response to multiple abortive and preventive medications. Almost 60% said a refractory migraine definition should be added to the ICHD.

The criteria proposed for refractory migraine and refractory chronic migraine, which were unveiled at the AHS meeting, were based on the survey results, a literature review, and collaborative discussions, Dr. Schulman said.

The section proposed the following criteria:

▸ The primary diagnosis is ICHD-II migraine or chronic migraine.

▸ The headaches cause significant interference with function of quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. This would include failed adequate trials of preventive medicines, alone or in combination, from two of four drug classes: β-blockers, anticonvulsants, tricyclic antidepressants, and calcium channel blockers, as well as failed adequate trials of abortive medicines, including both a triptan and an intranasal or injectable dihydroergotamine (DHE); and either nonsteroidal anti-inflammatory drugs or combination analgesics.

▸ An adequate trial is defined as an appropriate dose administered typically for at least 2 months or the maximum-tolerated dose.

▸ The following modifiers would be included: with or without medication overuse, as defined by ICHD-II; with significant disability, as defined by a Migraine Disability Assessment Questionnaire score of 11 or higher.

The criteria “are intended to stimulate discussion leading to a consensus on the definition of refractory migraine and refractory chronic migraine for research and clinical purposes,” said Dr. Schulman.

Dr. Morris Levin of Dartmouth University, Hanover, N.H., discussed at least four different options for how refractory migraine could be added to the ICHD classification system: as a new diagnostic chapter; as a subdivision to each current headache chapter; as a modifier to the primary diagnosis, as is done with the DSM-IV used for psychiatric disorders; or as an “axis II” diagnosis, again, as is used in the DSM-IV.

In weighing the pros and cons, Dr. Levin noted that the first option would make for a huge new chapter, which might be impractical. Adding subsections to the primary headache diagnosis is logical but would create new language and many new diagnoses, he said.

The addition of a modifier would least affect the rest of the ICHD, but would add another layer to each patient's diagnosis, said Dr. Levin.

Finally, adding another axis would change the overall ICHD format.

Even so, he said, it is worth trying at least one approach and then field testing it, as that would help provide data and validity to the ICHD classification committee.

Dr. Schulman disclosed that he has received grants, honoraria, advisory board and consultation fees from Merck & Co. and Pfizer Inc., and his institution receives direct pharmaceutical industry support. Dr. Levin has received grants, honoraria, and other fees for consultation and advisory board participation from Elan Pharmaceuticals Inc., Allergan Inc., AstraZeneca, Merck, Pfizer, and Ortho-McNeil Inc. His institution also receives direct pharmaceutical industry support.

CHICAGO – A proposed definition and diagnostic criteria aim to help physicians deal with the growing number of patients presenting with refractory migraine, Dr. Elliott A. Schulman said at the annual meeting of the American Headache Society.

“[Refractory migraine] is out there, we just haven't defined it,” said Dr. Schulman, noting that the incidence is probably 10%–50% of cases seen in practice. By setting a definition, he said, patients who need greater care can be identified early, a standard of care can be established, the epidemiology can be further studied and clarified, and candidates for novel treatment approaches can be identified for clinical trials.

To address the problem, the society's Refractory Headache Special Interest Section was formed in 2000. In April 2006, the section surveyed all AHS members on a proposed definition of refractory migraine, whether it should be added to the International Classification of Headache Disorders, and for information on some of the best practices used.

Two hundred-twenty members responded, for a response rate of 18%, said Dr. Schulman, a neurologist at Lankenau Hospital, Wynnewood, Pa. More than half the respondents believed that refractory migraine should be defined as occurring more than 15 days a month, that it should be associated with disability, and that a definition should include inadequate response to multiple abortive and preventive medications. Almost 60% said a refractory migraine definition should be added to the ICHD.

The criteria proposed for refractory migraine and refractory chronic migraine, which were unveiled at the AHS meeting, were based on the survey results, a literature review, and collaborative discussions, Dr. Schulman said.

The section proposed the following criteria:

▸ The primary diagnosis is ICHD-II migraine or chronic migraine.

▸ The headaches cause significant interference with function of quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. This would include failed adequate trials of preventive medicines, alone or in combination, from two of four drug classes: β-blockers, anticonvulsants, tricyclic antidepressants, and calcium channel blockers, as well as failed adequate trials of abortive medicines, including both a triptan and an intranasal or injectable dihydroergotamine (DHE); and either nonsteroidal anti-inflammatory drugs or combination analgesics.

▸ An adequate trial is defined as an appropriate dose administered typically for at least 2 months or the maximum-tolerated dose.

▸ The following modifiers would be included: with or without medication overuse, as defined by ICHD-II; with significant disability, as defined by a Migraine Disability Assessment Questionnaire score of 11 or higher.

The criteria “are intended to stimulate discussion leading to a consensus on the definition of refractory migraine and refractory chronic migraine for research and clinical purposes,” said Dr. Schulman.

Dr. Morris Levin of Dartmouth University, Hanover, N.H., discussed at least four different options for how refractory migraine could be added to the ICHD classification system: as a new diagnostic chapter; as a subdivision to each current headache chapter; as a modifier to the primary diagnosis, as is done with the DSM-IV used for psychiatric disorders; or as an “axis II” diagnosis, again, as is used in the DSM-IV.

In weighing the pros and cons, Dr. Levin noted that the first option would make for a huge new chapter, which might be impractical. Adding subsections to the primary headache diagnosis is logical but would create new language and many new diagnoses, he said.

The addition of a modifier would least affect the rest of the ICHD, but would add another layer to each patient's diagnosis, said Dr. Levin.

Finally, adding another axis would change the overall ICHD format.

Even so, he said, it is worth trying at least one approach and then field testing it, as that would help provide data and validity to the ICHD classification committee.

Dr. Schulman disclosed that he has received grants, honoraria, advisory board and consultation fees from Merck & Co. and Pfizer Inc., and his institution receives direct pharmaceutical industry support. Dr. Levin has received grants, honoraria, and other fees for consultation and advisory board participation from Elan Pharmaceuticals Inc., Allergan Inc., AstraZeneca, Merck, Pfizer, and Ortho-McNeil Inc. His institution also receives direct pharmaceutical industry support.

CHICAGO – A proposed definition and diagnostic criteria aim to help physicians deal with the growing number of patients presenting with refractory migraine, Dr. Elliott A. Schulman said at the annual meeting of the American Headache Society.

“[Refractory migraine] is out there, we just haven't defined it,” said Dr. Schulman, noting that the incidence is probably 10%–50% of cases seen in practice. By setting a definition, he said, patients who need greater care can be identified early, a standard of care can be established, the epidemiology can be further studied and clarified, and candidates for novel treatment approaches can be identified for clinical trials.

To address the problem, the society's Refractory Headache Special Interest Section was formed in 2000. In April 2006, the section surveyed all AHS members on a proposed definition of refractory migraine, whether it should be added to the International Classification of Headache Disorders, and for information on some of the best practices used.

Two hundred-twenty members responded, for a response rate of 18%, said Dr. Schulman, a neurologist at Lankenau Hospital, Wynnewood, Pa. More than half the respondents believed that refractory migraine should be defined as occurring more than 15 days a month, that it should be associated with disability, and that a definition should include inadequate response to multiple abortive and preventive medications. Almost 60% said a refractory migraine definition should be added to the ICHD.

The criteria proposed for refractory migraine and refractory chronic migraine, which were unveiled at the AHS meeting, were based on the survey results, a literature review, and collaborative discussions, Dr. Schulman said.

The section proposed the following criteria:

▸ The primary diagnosis is ICHD-II migraine or chronic migraine.

▸ The headaches cause significant interference with function of quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. This would include failed adequate trials of preventive medicines, alone or in combination, from two of four drug classes: β-blockers, anticonvulsants, tricyclic antidepressants, and calcium channel blockers, as well as failed adequate trials of abortive medicines, including both a triptan and an intranasal or injectable dihydroergotamine (DHE); and either nonsteroidal anti-inflammatory drugs or combination analgesics.

▸ An adequate trial is defined as an appropriate dose administered typically for at least 2 months or the maximum-tolerated dose.

▸ The following modifiers would be included: with or without medication overuse, as defined by ICHD-II; with significant disability, as defined by a Migraine Disability Assessment Questionnaire score of 11 or higher.

The criteria “are intended to stimulate discussion leading to a consensus on the definition of refractory migraine and refractory chronic migraine for research and clinical purposes,” said Dr. Schulman.

Dr. Morris Levin of Dartmouth University, Hanover, N.H., discussed at least four different options for how refractory migraine could be added to the ICHD classification system: as a new diagnostic chapter; as a subdivision to each current headache chapter; as a modifier to the primary diagnosis, as is done with the DSM-IV used for psychiatric disorders; or as an “axis II” diagnosis, again, as is used in the DSM-IV.

In weighing the pros and cons, Dr. Levin noted that the first option would make for a huge new chapter, which might be impractical. Adding subsections to the primary headache diagnosis is logical but would create new language and many new diagnoses, he said.

The addition of a modifier would least affect the rest of the ICHD, but would add another layer to each patient's diagnosis, said Dr. Levin.

Finally, adding another axis would change the overall ICHD format.

Even so, he said, it is worth trying at least one approach and then field testing it, as that would help provide data and validity to the ICHD classification committee.

Dr. Schulman disclosed that he has received grants, honoraria, advisory board and consultation fees from Merck & Co. and Pfizer Inc., and his institution receives direct pharmaceutical industry support. Dr. Levin has received grants, honoraria, and other fees for consultation and advisory board participation from Elan Pharmaceuticals Inc., Allergan Inc., AstraZeneca, Merck, Pfizer, and Ortho-McNeil Inc. His institution also receives direct pharmaceutical industry support.

Starting next year, federal health programs will cover any procedure performed at an ambulatory surgery center, with few but defined exclusions, according to final regulations released by the Centers for Medicare and Medicaid Services.

The payment formula for such procedures, to be phased in over 4 years, was also set by the regulations.

Previously, CMS covered approximately 2,600 procedures when they were performed at an ASC; now, an additional 790 procedures will be eligible in 2008. According to Dr. Charles Mabry, chairman of the American College of Surgeons' health policy steering committee and a member of the general surgery coding and reimbursement committee, as new procedures receive CPT codes, they, too will be covered, unless they are specifically excluded.

CMS will not pay for a procedure if it falls within these exclusion criteria:

▸ It poses a significant safety risk to the beneficiary.

▸ It would result in the patient's requiring active monitoring or an overnight stay.

▸ It directly involves major blood vessels.

▸ It requires major or prolonged invasion of body cavities.

▸ It results in extensive blood loss.

▸ It is emergent or life threatening.

▸ It requires systemic thrombolysis.

▸ It can be reported only with an unlisted code.

The change means that more patients will likely be able to have procedures done in an ASC, said Dr. Mabry, who is also a shareholder in an ambulatory surgery center in Pine Bluff, Ark.

The question now: “Is the payment rate the right rate?” he said. (See box.)

CMS also decided to limit payment for procedures performed in an ASC that are done in a physician's office more than half the time. “CMS does not want to create inappropriate payment incentives for procedures to be performed in ASCs if the physician's office is the most efficient setting for providing high quality care,” according to the agency.

FASA, the advocacy arm of the Foundation for Ambulatory Surgery in America, objected to this proposal and also to CMS's list of exclusions, arguing that the agency should pay for any procedure that is not covered under the inpatient system.

Under the new rule, Medicare will make separate payments for ancillary services, such as radiology, and for some drugs and biologicals considered integral to a surgical procedure.

The agency will also make adjustments for procedures that have high device costs—that is, when the cost of the device accounts for more than half the median cost of the procedure.

Those high device-cost procedures include placement of neurostimulators, pulse generators, or pacemakers.

The adjustment is already in effect under CMS's hospital outpatient payment system.

Payment Proposals for 2008: More Increases Than Cuts

CMS is accepting comments on the 2008 proposals until mid-September. The final regulations will be published in November.

In addition to setting the formula for how ambulatory surgery centers will be paid going forward, CMS has also issued proposals on how the formula will guide payments to ASCs in 2008, and on how much hospital outpatient departments will receive in 2008.

In 2008, the federal health agency has proposed that ASCs would be paid at 65% of hospital outpatient rates, a slight increase over an earlier proposal of 62%.

Medicare and Medicaid expect to pay $3 billion in 2008 to about 4,600 participating ASCs, according to CMS.

In the proposed pay rates, orthopedic procedures would receive the greatest increases, whereas gastrointestinal procedures would be cut. An upper GI endoscopy with biopsy (CPT code 43239) would be cut by 13%, from $446 in 2007 to $387 in 2008. A small-bowel endoscopy with biopsy (CPT code 44361) would be cut by about 11%.

The American Gastroenterological Association said in a statement that it “intends to aggressively fight the [proposed] rule's implementation, through congressional action, if necessary.”

The group argued that by setting a uniform rate of 65%, an ASC will not be able to cover the costs of many procedures, including luminal stents for gastrointestinal cancers and endoscopic ultrasound. ASC payments should be tied to the hospital outpatient market basket factor, not the consumer price index, as CMS is proposing, according to the AGA.

The agency also issued its proposal for hospital outpatient payments, which is partially driven by the desire to keep beneficiary copays at 20%. In 2008, the overall copay will be about 26%, but for most procedures, beneficiaries will be liable for only 20%.

Hospitals will receive $35 billion under the proposed rule in 2008, about a 10% increase over 2007. CMS said “the current rate of growth of expenditures is of great concern,” because of its effect on taxpayers and beneficiaries whose premiums fund 25% of Medicare Part B expenses.

Procedures involving the implantation of cardiac devices are mostly slated for increases: from 5% for bare-metal stents to 14% for drug-eluting stents, and 3%–20% for defibrillators.

Payment for the implantation of neurologic devices would also increase under the proposal. For instance, implantation of a neurostimulator would rise from $11,500 in 2007 to $12,500 in 2008.

Hospitals will get an automatic 2% cut in fees in 2009 if they don't report on 10 quality measures in 2008, including five measures on how well emergency departments handle MI; two surgical care measures (the selection and timing of antibiotic prophylaxis); one heart failure measure (ACE inhibitor or angiotensin receptor blocker given); one on community-acquired pneumonia (empiric antibiotic); and a diabetes measure (poor hemoglobin A_1c control).

Starting next year, federal health programs will cover any procedure performed at an ambulatory surgery center, with few but defined exclusions, according to final regulations released by the Centers for Medicare and Medicaid Services.

The payment formula for such procedures, to be phased in over 4 years, was also set by the regulations.

Previously, CMS covered approximately 2,600 procedures when they were performed at an ASC; now, an additional 790 procedures will be eligible in 2008. According to Dr. Charles Mabry, chairman of the American College of Surgeons' health policy steering committee and a member of the general surgery coding and reimbursement committee, as new procedures receive CPT codes, they, too will be covered, unless they are specifically excluded.

CMS will not pay for a procedure if it falls within these exclusion criteria:

▸ It poses a significant safety risk to the beneficiary.

▸ It would result in the patient's requiring active monitoring or an overnight stay.

▸ It directly involves major blood vessels.

▸ It requires major or prolonged invasion of body cavities.

▸ It results in extensive blood loss.

▸ It is emergent or life threatening.

▸ It requires systemic thrombolysis.

▸ It can be reported only with an unlisted code.

The change means that more patients will likely be able to have procedures done in an ASC, said Dr. Mabry, who is also a shareholder in an ambulatory surgery center in Pine Bluff, Ark.

The question now: “Is the payment rate the right rate?” he said. (See box.)

CMS also decided to limit payment for procedures performed in an ASC that are done in a physician's office more than half the time. “CMS does not want to create inappropriate payment incentives for procedures to be performed in ASCs if the physician's office is the most efficient setting for providing high quality care,” according to the agency.

FASA, the advocacy arm of the Foundation for Ambulatory Surgery in America, objected to this proposal and also to CMS's list of exclusions, arguing that the agency should pay for any procedure that is not covered under the inpatient system.

Under the new rule, Medicare will make separate payments for ancillary services, such as radiology, and for some drugs and biologicals considered integral to a surgical procedure.

The agency will also make adjustments for procedures that have high device costs—that is, when the cost of the device accounts for more than half the median cost of the procedure.

Those high device-cost procedures include placement of neurostimulators, pulse generators, or pacemakers.

The adjustment is already in effect under CMS's hospital outpatient payment system.

Payment Proposals for 2008: More Increases Than Cuts

CMS is accepting comments on the 2008 proposals until mid-September. The final regulations will be published in November.

In addition to setting the formula for how ambulatory surgery centers will be paid going forward, CMS has also issued proposals on how the formula will guide payments to ASCs in 2008, and on how much hospital outpatient departments will receive in 2008.

In 2008, the federal health agency has proposed that ASCs would be paid at 65% of hospital outpatient rates, a slight increase over an earlier proposal of 62%.

Medicare and Medicaid expect to pay $3 billion in 2008 to about 4,600 participating ASCs, according to CMS.

In the proposed pay rates, orthopedic procedures would receive the greatest increases, whereas gastrointestinal procedures would be cut. An upper GI endoscopy with biopsy (CPT code 43239) would be cut by 13%, from $446 in 2007 to $387 in 2008. A small-bowel endoscopy with biopsy (CPT code 44361) would be cut by about 11%.

The American Gastroenterological Association said in a statement that it “intends to aggressively fight the [proposed] rule's implementation, through congressional action, if necessary.”

The group argued that by setting a uniform rate of 65%, an ASC will not be able to cover the costs of many procedures, including luminal stents for gastrointestinal cancers and endoscopic ultrasound. ASC payments should be tied to the hospital outpatient market basket factor, not the consumer price index, as CMS is proposing, according to the AGA.

The agency also issued its proposal for hospital outpatient payments, which is partially driven by the desire to keep beneficiary copays at 20%. In 2008, the overall copay will be about 26%, but for most procedures, beneficiaries will be liable for only 20%.

Hospitals will receive $35 billion under the proposed rule in 2008, about a 10% increase over 2007. CMS said “the current rate of growth of expenditures is of great concern,” because of its effect on taxpayers and beneficiaries whose premiums fund 25% of Medicare Part B expenses.

Procedures involving the implantation of cardiac devices are mostly slated for increases: from 5% for bare-metal stents to 14% for drug-eluting stents, and 3%–20% for defibrillators.

Payment for the implantation of neurologic devices would also increase under the proposal. For instance, implantation of a neurostimulator would rise from $11,500 in 2007 to $12,500 in 2008.

Hospitals will get an automatic 2% cut in fees in 2009 if they don't report on 10 quality measures in 2008, including five measures on how well emergency departments handle MI; two surgical care measures (the selection and timing of antibiotic prophylaxis); one heart failure measure (ACE inhibitor or angiotensin receptor blocker given); one on community-acquired pneumonia (empiric antibiotic); and a diabetes measure (poor hemoglobin A_1c control).

Starting next year, federal health programs will cover any procedure performed at an ambulatory surgery center, with few but defined exclusions, according to final regulations released by the Centers for Medicare and Medicaid Services.

The payment formula for such procedures, to be phased in over 4 years, was also set by the regulations.

Previously, CMS covered approximately 2,600 procedures when they were performed at an ASC; now, an additional 790 procedures will be eligible in 2008. According to Dr. Charles Mabry, chairman of the American College of Surgeons' health policy steering committee and a member of the general surgery coding and reimbursement committee, as new procedures receive CPT codes, they, too will be covered, unless they are specifically excluded.

CMS will not pay for a procedure if it falls within these exclusion criteria:

▸ It poses a significant safety risk to the beneficiary.

▸ It would result in the patient's requiring active monitoring or an overnight stay.

▸ It directly involves major blood vessels.

▸ It requires major or prolonged invasion of body cavities.

▸ It results in extensive blood loss.

▸ It is emergent or life threatening.

▸ It requires systemic thrombolysis.

▸ It can be reported only with an unlisted code.

The change means that more patients will likely be able to have procedures done in an ASC, said Dr. Mabry, who is also a shareholder in an ambulatory surgery center in Pine Bluff, Ark.

The question now: “Is the payment rate the right rate?” he said. (See box.)

CMS also decided to limit payment for procedures performed in an ASC that are done in a physician's office more than half the time. “CMS does not want to create inappropriate payment incentives for procedures to be performed in ASCs if the physician's office is the most efficient setting for providing high quality care,” according to the agency.

FASA, the advocacy arm of the Foundation for Ambulatory Surgery in America, objected to this proposal and also to CMS's list of exclusions, arguing that the agency should pay for any procedure that is not covered under the inpatient system.

Under the new rule, Medicare will make separate payments for ancillary services, such as radiology, and for some drugs and biologicals considered integral to a surgical procedure.

The agency will also make adjustments for procedures that have high device costs—that is, when the cost of the device accounts for more than half the median cost of the procedure.

Those high device-cost procedures include placement of neurostimulators, pulse generators, or pacemakers.

The adjustment is already in effect under CMS's hospital outpatient payment system.

Payment Proposals for 2008: More Increases Than Cuts

CMS is accepting comments on the 2008 proposals until mid-September. The final regulations will be published in November.

In addition to setting the formula for how ambulatory surgery centers will be paid going forward, CMS has also issued proposals on how the formula will guide payments to ASCs in 2008, and on how much hospital outpatient departments will receive in 2008.

In 2008, the federal health agency has proposed that ASCs would be paid at 65% of hospital outpatient rates, a slight increase over an earlier proposal of 62%.

Medicare and Medicaid expect to pay $3 billion in 2008 to about 4,600 participating ASCs, according to CMS.

In the proposed pay rates, orthopedic procedures would receive the greatest increases, whereas gastrointestinal procedures would be cut. An upper GI endoscopy with biopsy (CPT code 43239) would be cut by 13%, from $446 in 2007 to $387 in 2008. A small-bowel endoscopy with biopsy (CPT code 44361) would be cut by about 11%.

The American Gastroenterological Association said in a statement that it “intends to aggressively fight the [proposed] rule's implementation, through congressional action, if necessary.”

The group argued that by setting a uniform rate of 65%, an ASC will not be able to cover the costs of many procedures, including luminal stents for gastrointestinal cancers and endoscopic ultrasound. ASC payments should be tied to the hospital outpatient market basket factor, not the consumer price index, as CMS is proposing, according to the AGA.

The agency also issued its proposal for hospital outpatient payments, which is partially driven by the desire to keep beneficiary copays at 20%. In 2008, the overall copay will be about 26%, but for most procedures, beneficiaries will be liable for only 20%.

Hospitals will receive $35 billion under the proposed rule in 2008, about a 10% increase over 2007. CMS said “the current rate of growth of expenditures is of great concern,” because of its effect on taxpayers and beneficiaries whose premiums fund 25% of Medicare Part B expenses.

Procedures involving the implantation of cardiac devices are mostly slated for increases: from 5% for bare-metal stents to 14% for drug-eluting stents, and 3%–20% for defibrillators.

Payment for the implantation of neurologic devices would also increase under the proposal. For instance, implantation of a neurostimulator would rise from $11,500 in 2007 to $12,500 in 2008.

Hospitals will get an automatic 2% cut in fees in 2009 if they don't report on 10 quality measures in 2008, including five measures on how well emergency departments handle MI; two surgical care measures (the selection and timing of antibiotic prophylaxis); one heart failure measure (ACE inhibitor or angiotensin receptor blocker given); one on community-acquired pneumonia (empiric antibiotic); and a diabetes measure (poor hemoglobin A_1c control).

WASHINGTON — Patients who are sicker, who are taking warfarin, and whose polyps are removed by snare with cautery are at higher risk for complications following screening or surveillance colonoscopy, according to an analysis presented at the annual Digestive Disease Week.

Overall, the incidence of serious complications after screening was 2.2 of every 1,000 exams, and it was 1.7/1,000 for potential related events, according to Dr. Cynthia Ko of the University of Washington, Seattle.

Dr. Ko and her colleagues prospectively assessed colonoscopies performed on 18,271 patients aged 40 years and older who were referred for average risk screening, surveillance of prior polyps or cancer, a family history of polyps or cancer, or follow-up after another diagnostic procedure, such as a positive result on a fecal occult blood test.

Patients were excluded if they had a history of recent gastrointestinal bleeding or of inflammatory bowel disease, or had an incomplete colonoscopy because of poor bowel preparation.

The researchers identified the study patients through the Clinical Outcomes Research Initiative, a database maintained by the Oregon Health and Science University, Portland. Participating practices include academic, Veterans Affairs, and community endoscopy practices that agree to generate electronic medical record reports for endoscopic procedures.

Currently, complication rates for surveillance and screening aren't well defined, Dr. Ko said. Perforation rates vary from 0.01% to 0.2%, and postpolypectomy syndrome incidence varies from 0.4% to 1%, she said.

In the Washington study, patients were queried at 7 and 30 days after colonoscopy about new symptoms, physician visits, hospitalizations, and unplanned surgeries.

Related events included colon perforation, GI bleeding, diverticulitis, and postpolypectomy syndrome. Potentially related complications included cardiac and neurologic events.

The 18,271 patients came from 19 sites and received colonoscopies from 89 endoscopists. The patients were referred because they were at risk (42%), they needed surveillance (27%), they had a family history (17%), or they had to have follow-up on a previous diagnostic test (14%).

Related complication rates were 1.3/1,000 for GI bleeding requiring hospitalization, 0.8/1,000 for GI bleeding requiring transfusion, 0.9/1,000 for diverticulitis, 0.3/1,000 for diverticulitis requiring hospitalization, 0.1/1,000 for postpolypectomy syndrome, and 0.2/1,000 for perforation.

The authors also calculated an overall complication rate of 2.2/1,000, which included GI bleeding with transfusion, diverticulitis with hospitalization, perforation, or postpolypectomy syndrome. The serious complication rate was 1.4/1,000; serious complications included GI bleeding with hospitalization, diverticulitis with hospitalization, perforation, or postpolypectomy syndrome.

Potentially related events included angina or myocardial infarction (0.6/1,000), stroke or transient ischemic attack (0.4/1,000), and other events, including hospitalization for intravenous catheter site infections, abdominal pain, arrythmia, gallstones, kidney stones, and drug reactions (0.7/1,000).

Complications were more common in patients undergoing a surveillance or follow-up exam, and for those who were older. There were no complications among the 40- to 49-year-olds, compared with 4.4/1,000 among patients aged 80 and older.

Using a multivariate analysis, the authors determined that there was a threefold increase in complications in patients who were American Society of Anesthesiologists class III, compared with class I or II patients; a fivefold increase in patients who took warfarin, compared with those who used aspirin or NSAIDs; and a fivefold increase for a polyp removed with cautery. If more than one polyp was removed, there was a 13-fold increase in complications, Dr. Ko said. There was no difference among the sites, and the endoscopist's case volume did not influence the findings, she said.

She cautioned against applying the results to all physicians because the study included only gastroenterologists.

The study was supported by the National Institutes of Health and the Centers for Disease Control and Prevention, said Dr. Ko, who had no disclosures.

WASHINGTON — Patients who are sicker, who are taking warfarin, and whose polyps are removed by snare with cautery are at higher risk for complications following screening or surveillance colonoscopy, according to an analysis presented at the annual Digestive Disease Week.

Overall, the incidence of serious complications after screening was 2.2 of every 1,000 exams, and it was 1.7/1,000 for potential related events, according to Dr. Cynthia Ko of the University of Washington, Seattle.

Dr. Ko and her colleagues prospectively assessed colonoscopies performed on 18,271 patients aged 40 years and older who were referred for average risk screening, surveillance of prior polyps or cancer, a family history of polyps or cancer, or follow-up after another diagnostic procedure, such as a positive result on a fecal occult blood test.

Patients were excluded if they had a history of recent gastrointestinal bleeding or of inflammatory bowel disease, or had an incomplete colonoscopy because of poor bowel preparation.

The researchers identified the study patients through the Clinical Outcomes Research Initiative, a database maintained by the Oregon Health and Science University, Portland. Participating practices include academic, Veterans Affairs, and community endoscopy practices that agree to generate electronic medical record reports for endoscopic procedures.

Currently, complication rates for surveillance and screening aren't well defined, Dr. Ko said. Perforation rates vary from 0.01% to 0.2%, and postpolypectomy syndrome incidence varies from 0.4% to 1%, she said.

In the Washington study, patients were queried at 7 and 30 days after colonoscopy about new symptoms, physician visits, hospitalizations, and unplanned surgeries.

Related events included colon perforation, GI bleeding, diverticulitis, and postpolypectomy syndrome. Potentially related complications included cardiac and neurologic events.

The 18,271 patients came from 19 sites and received colonoscopies from 89 endoscopists. The patients were referred because they were at risk (42%), they needed surveillance (27%), they had a family history (17%), or they had to have follow-up on a previous diagnostic test (14%).

Related complication rates were 1.3/1,000 for GI bleeding requiring hospitalization, 0.8/1,000 for GI bleeding requiring transfusion, 0.9/1,000 for diverticulitis, 0.3/1,000 for diverticulitis requiring hospitalization, 0.1/1,000 for postpolypectomy syndrome, and 0.2/1,000 for perforation.

The authors also calculated an overall complication rate of 2.2/1,000, which included GI bleeding with transfusion, diverticulitis with hospitalization, perforation, or postpolypectomy syndrome. The serious complication rate was 1.4/1,000; serious complications included GI bleeding with hospitalization, diverticulitis with hospitalization, perforation, or postpolypectomy syndrome.

Potentially related events included angina or myocardial infarction (0.6/1,000), stroke or transient ischemic attack (0.4/1,000), and other events, including hospitalization for intravenous catheter site infections, abdominal pain, arrythmia, gallstones, kidney stones, and drug reactions (0.7/1,000).

Complications were more common in patients undergoing a surveillance or follow-up exam, and for those who were older. There were no complications among the 40- to 49-year-olds, compared with 4.4/1,000 among patients aged 80 and older.

Using a multivariate analysis, the authors determined that there was a threefold increase in complications in patients who were American Society of Anesthesiologists class III, compared with class I or II patients; a fivefold increase in patients who took warfarin, compared with those who used aspirin or NSAIDs; and a fivefold increase for a polyp removed with cautery. If more than one polyp was removed, there was a 13-fold increase in complications, Dr. Ko said. There was no difference among the sites, and the endoscopist's case volume did not influence the findings, she said.

She cautioned against applying the results to all physicians because the study included only gastroenterologists.

The study was supported by the National Institutes of Health and the Centers for Disease Control and Prevention, said Dr. Ko, who had no disclosures.

WASHINGTON — Patients who are sicker, who are taking warfarin, and whose polyps are removed by snare with cautery are at higher risk for complications following screening or surveillance colonoscopy, according to an analysis presented at the annual Digestive Disease Week.

Overall, the incidence of serious complications after screening was 2.2 of every 1,000 exams, and it was 1.7/1,000 for potential related events, according to Dr. Cynthia Ko of the University of Washington, Seattle.

Dr. Ko and her colleagues prospectively assessed colonoscopies performed on 18,271 patients aged 40 years and older who were referred for average risk screening, surveillance of prior polyps or cancer, a family history of polyps or cancer, or follow-up after another diagnostic procedure, such as a positive result on a fecal occult blood test.

Patients were excluded if they had a history of recent gastrointestinal bleeding or of inflammatory bowel disease, or had an incomplete colonoscopy because of poor bowel preparation.

The researchers identified the study patients through the Clinical Outcomes Research Initiative, a database maintained by the Oregon Health and Science University, Portland. Participating practices include academic, Veterans Affairs, and community endoscopy practices that agree to generate electronic medical record reports for endoscopic procedures.

Currently, complication rates for surveillance and screening aren't well defined, Dr. Ko said. Perforation rates vary from 0.01% to 0.2%, and postpolypectomy syndrome incidence varies from 0.4% to 1%, she said.

In the Washington study, patients were queried at 7 and 30 days after colonoscopy about new symptoms, physician visits, hospitalizations, and unplanned surgeries.

Related events included colon perforation, GI bleeding, diverticulitis, and postpolypectomy syndrome. Potentially related complications included cardiac and neurologic events.

The 18,271 patients came from 19 sites and received colonoscopies from 89 endoscopists. The patients were referred because they were at risk (42%), they needed surveillance (27%), they had a family history (17%), or they had to have follow-up on a previous diagnostic test (14%).

Related complication rates were 1.3/1,000 for GI bleeding requiring hospitalization, 0.8/1,000 for GI bleeding requiring transfusion, 0.9/1,000 for diverticulitis, 0.3/1,000 for diverticulitis requiring hospitalization, 0.1/1,000 for postpolypectomy syndrome, and 0.2/1,000 for perforation.

The authors also calculated an overall complication rate of 2.2/1,000, which included GI bleeding with transfusion, diverticulitis with hospitalization, perforation, or postpolypectomy syndrome. The serious complication rate was 1.4/1,000; serious complications included GI bleeding with hospitalization, diverticulitis with hospitalization, perforation, or postpolypectomy syndrome.

Potentially related events included angina or myocardial infarction (0.6/1,000), stroke or transient ischemic attack (0.4/1,000), and other events, including hospitalization for intravenous catheter site infections, abdominal pain, arrythmia, gallstones, kidney stones, and drug reactions (0.7/1,000).

Complications were more common in patients undergoing a surveillance or follow-up exam, and for those who were older. There were no complications among the 40- to 49-year-olds, compared with 4.4/1,000 among patients aged 80 and older.

Using a multivariate analysis, the authors determined that there was a threefold increase in complications in patients who were American Society of Anesthesiologists class III, compared with class I or II patients; a fivefold increase in patients who took warfarin, compared with those who used aspirin or NSAIDs; and a fivefold increase for a polyp removed with cautery. If more than one polyp was removed, there was a 13-fold increase in complications, Dr. Ko said. There was no difference among the sites, and the endoscopist's case volume did not influence the findings, she said.

She cautioned against applying the results to all physicians because the study included only gastroenterologists.

The study was supported by the National Institutes of Health and the Centers for Disease Control and Prevention, said Dr. Ko, who had no disclosures.

Starting next year, federal health programs will cover any procedure performed at an ambulatory surgery center, with few but defined exclusions, according to final regulations released by the Centers for Medicare and Medicaid Services.

The payment formula for such procedures, to be phased in over 4 years, was also set by the regulations.

Previously, CMS covered approximately 2,600 procedures when they were performed at an ASC; now, an additional 790 procedures will be eligible in 2008. According to Dr. Charles Mabry, chairman of the American College of Surgeons' health policy steering committee and a member of the general surgery coding and reimbursement committee, as new procedures receive CPT codes, they too will be covered, unless they are specifically excluded.

CMS will not pay for a procedure if it falls within the following exclusion criteria:

▸ It poses a significant safety risk to the beneficiary.

▸ It would result in the patient's requiring active monitoring or an overnight stay.

▸ It directly involves major blood vessels.

▸ It requires major or prolonged invasion of body cavities.

▸ It results in extensive blood loss.

▸ It is emergent or life threatening.

▸ It requires systemic thrombolysis.

▸ It can be reported only with an unlisted code.

The change means that more patients will likely be able to have procedures done in an ASC, said Dr. Mabry, who is also a shareholder in an ambulatory surgery center in Pine Bluff, Ark.

CMS also decided to limit payment for procedures performed in an ASC that are done in a physician's office more than half the time. "CMS does not want to create inappropriate payment incentives for procedures to be performed in ASCs if the physician's office is the most efficient setting for providing high quality care," according to the agency.

FASA, the advocacy arm of the Foundation for Ambulatory Surgery in America, objected to this proposal and also to CMS's list of exclusions, arguing that the agency should pay for any procedure that is not covered under the inpatient system.

Medicare will make separate payments for ancillary services, such as radiology, and for some drugs and biologicals considered integral to a procedure. The agency will also make adjustments for procedures that have high device costs (that is, when the cost of the device accounts for more than half the median cost of the procedure). Those high device-cost procedures include placement of neurostimulators, pulse generators, or pacemakers.

The adjustment is already in effect under CMS's hospital outpatient payment system.

Starting next year, federal health programs will cover any procedure performed at an ambulatory surgery center, with few but defined exclusions, according to final regulations released by the Centers for Medicare and Medicaid Services.

The payment formula for such procedures, to be phased in over 4 years, was also set by the regulations.

Previously, CMS covered approximately 2,600 procedures when they were performed at an ASC; now, an additional 790 procedures will be eligible in 2008. According to Dr. Charles Mabry, chairman of the American College of Surgeons' health policy steering committee and a member of the general surgery coding and reimbursement committee, as new procedures receive CPT codes, they too will be covered, unless they are specifically excluded.

CMS will not pay for a procedure if it falls within the following exclusion criteria:

▸ It poses a significant safety risk to the beneficiary.

▸ It would result in the patient's requiring active monitoring or an overnight stay.

▸ It directly involves major blood vessels.

▸ It requires major or prolonged invasion of body cavities.

▸ It results in extensive blood loss.

▸ It is emergent or life threatening.

▸ It requires systemic thrombolysis.

▸ It can be reported only with an unlisted code.

The change means that more patients will likely be able to have procedures done in an ASC, said Dr. Mabry, who is also a shareholder in an ambulatory surgery center in Pine Bluff, Ark.

CMS also decided to limit payment for procedures performed in an ASC that are done in a physician's office more than half the time. "CMS does not want to create inappropriate payment incentives for procedures to be performed in ASCs if the physician's office is the most efficient setting for providing high quality care," according to the agency.

FASA, the advocacy arm of the Foundation for Ambulatory Surgery in America, objected to this proposal and also to CMS's list of exclusions, arguing that the agency should pay for any procedure that is not covered under the inpatient system.

Medicare will make separate payments for ancillary services, such as radiology, and for some drugs and biologicals considered integral to a procedure. The agency will also make adjustments for procedures that have high device costs (that is, when the cost of the device accounts for more than half the median cost of the procedure). Those high device-cost procedures include placement of neurostimulators, pulse generators, or pacemakers.

The adjustment is already in effect under CMS's hospital outpatient payment system.

Starting next year, federal health programs will cover any procedure performed at an ambulatory surgery center, with few but defined exclusions, according to final regulations released by the Centers for Medicare and Medicaid Services.

The payment formula for such procedures, to be phased in over 4 years, was also set by the regulations.

Previously, CMS covered approximately 2,600 procedures when they were performed at an ASC; now, an additional 790 procedures will be eligible in 2008. According to Dr. Charles Mabry, chairman of the American College of Surgeons' health policy steering committee and a member of the general surgery coding and reimbursement committee, as new procedures receive CPT codes, they too will be covered, unless they are specifically excluded.

CMS will not pay for a procedure if it falls within the following exclusion criteria:

▸ It poses a significant safety risk to the beneficiary.

▸ It would result in the patient's requiring active monitoring or an overnight stay.

▸ It directly involves major blood vessels.

▸ It requires major or prolonged invasion of body cavities.

▸ It results in extensive blood loss.

▸ It is emergent or life threatening.

▸ It requires systemic thrombolysis.

▸ It can be reported only with an unlisted code.

The change means that more patients will likely be able to have procedures done in an ASC, said Dr. Mabry, who is also a shareholder in an ambulatory surgery center in Pine Bluff, Ark.

CMS also decided to limit payment for procedures performed in an ASC that are done in a physician's office more than half the time. "CMS does not want to create inappropriate payment incentives for procedures to be performed in ASCs if the physician's office is the most efficient setting for providing high quality care," according to the agency.

FASA, the advocacy arm of the Foundation for Ambulatory Surgery in America, objected to this proposal and also to CMS's list of exclusions, arguing that the agency should pay for any procedure that is not covered under the inpatient system.

Medicare will make separate payments for ancillary services, such as radiology, and for some drugs and biologicals considered integral to a procedure. The agency will also make adjustments for procedures that have high device costs (that is, when the cost of the device accounts for more than half the median cost of the procedure). Those high device-cost procedures include placement of neurostimulators, pulse generators, or pacemakers.

The adjustment is already in effect under CMS's hospital outpatient payment system.

Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but very needy, population.

It's a picture that's changed some—but not much—since a year ago.

Emergency departments, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. In mid-2006, according to claims information from Blue Cross and Blue Shield, only half had come back. The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by the Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006—to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care in the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is "going to give us a chance to expand upon what's been developing—multiple neighborhood clinics that are turning into medical homes," said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said. The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments. "We're trying to find those patients in the ER and get them into our system," she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take.

According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site. The city—along with LSU and Tulane—is trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing that—before Katrina—the VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing. Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish. At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site "is above sea level and not located in a floodplain."

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

Mayor C. Ray Nagin is supporting a plan for a new medical center on a 37-acre parcel a few blocks from Charity Hospital. Jay Westcott/Elsevier Global Medical News

Federal Incentive Grants Offered to Draw Physicians to Louisiana

The state of Louisiana and city of New Orleans are struggling to lure physicians, dentists, mental health professionals, and nurses back to the city, or at least to convince those who did return to stay in the face of an onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area a health professional shortage area, eligible for federal grants to retain or recruit health professionals. This gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention; the money was originally earmarked at 70% for recruitment and 30% for retention.

Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds in mid-2006, there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients. The DHH determined that—based on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)–there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan. The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009 when the grant cycle ends. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialist—the applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, "that's a dire need," said Ms. Strahan. Applicants—and there had been 300 as of press time—have to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their packages of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology. Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

For more information on the program and to download an application, visit

www.pcrh.dhh.louisiana.gov

Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but very needy, population.

It's a picture that's changed some—but not much—since a year ago.

Emergency departments, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. In mid-2006, according to claims information from Blue Cross and Blue Shield, only half had come back. The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by the Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006—to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care in the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is "going to give us a chance to expand upon what's been developing—multiple neighborhood clinics that are turning into medical homes," said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said. The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments. "We're trying to find those patients in the ER and get them into our system," she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take.

According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site. The city—along with LSU and Tulane—is trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing that—before Katrina—the VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing. Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish. At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site "is above sea level and not located in a floodplain."

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

Mayor C. Ray Nagin is supporting a plan for a new medical center on a 37-acre parcel a few blocks from Charity Hospital. Jay Westcott/Elsevier Global Medical News

Federal Incentive Grants Offered to Draw Physicians to Louisiana

The state of Louisiana and city of New Orleans are struggling to lure physicians, dentists, mental health professionals, and nurses back to the city, or at least to convince those who did return to stay in the face of an onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area a health professional shortage area, eligible for federal grants to retain or recruit health professionals. This gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention; the money was originally earmarked at 70% for recruitment and 30% for retention.

Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds in mid-2006, there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients. The DHH determined that—based on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)–there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan. The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009 when the grant cycle ends. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialist—the applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, "that's a dire need," said Ms. Strahan. Applicants—and there had been 300 as of press time—have to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their packages of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology. Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

For more information on the program and to download an application, visit

www.pcrh.dhh.louisiana.gov

Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but very needy, population.

It's a picture that's changed some—but not much—since a year ago.

Emergency departments, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. In mid-2006, according to claims information from Blue Cross and Blue Shield, only half had come back. The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by the Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006—to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care in the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is "going to give us a chance to expand upon what's been developing—multiple neighborhood clinics that are turning into medical homes," said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said. The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments. "We're trying to find those patients in the ER and get them into our system," she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take.

According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site. The city—along with LSU and Tulane—is trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing that—before Katrina—the VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing. Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish. At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site "is above sea level and not located in a floodplain."

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

Mayor C. Ray Nagin is supporting a plan for a new medical center on a 37-acre parcel a few blocks from Charity Hospital. Jay Westcott/Elsevier Global Medical News

Federal Incentive Grants Offered to Draw Physicians to Louisiana

The state of Louisiana and city of New Orleans are struggling to lure physicians, dentists, mental health professionals, and nurses back to the city, or at least to convince those who did return to stay in the face of an onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area a health professional shortage area, eligible for federal grants to retain or recruit health professionals. This gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention; the money was originally earmarked at 70% for recruitment and 30% for retention.

Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds in mid-2006, there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients. The DHH determined that—based on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)–there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan. The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009 when the grant cycle ends. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialist—the applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, "that's a dire need," said Ms. Strahan. Applicants—and there had been 300 as of press time—have to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their packages of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology. Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

For more information on the program and to download an application, visit

www.pcrh.dhh.louisiana.gov

Solaraze Ads Run Afoul of FDA

The Food and Drug Administration has warned Doak Dermatologics that materials used by sales representatives and a journal ad for its Solaraze gel (diclofenac sodium) are promoting off-label and unapproved uses. In a letter sent to the company, the FDA's Division of Drug Marketing, Advertising, and Communications said that the materials are misleading because they "suggest that Solaraze Gel is approved for use in the treatment of AK (actinic keratoses) when used in combination with cryotherapy." The materials include a bar graph with data on patients treated with cryotherapy alone or cryotherapy followed by Solaraze; the sales aid included before and after pictures of patients treated with both therapies. Solaraze is approved only as a monotherapy. Doak also failed to submit the journal ad to the FDA when it was published, as is required.

AAD Alert on Mall Cosmetic Surgery

In response to the growing trend of cosmetic procedures' being performed in malls, at spas, and walk-in clinics, the American Academy of Dermatology has issued a consumer alert urging patients to use only board-certified physicians for cosmetic surgery. The growing availability of procedures that are being offered, both by nonphysicians and in more locations, may provide convenience, but "the limited training and supervision of the person performing the procedure, and the equipment available to handle complications or medical emergencies, can jeopardize the health and appearance of the patient," said Dr. Arielle N.B. Kauvar, of the department of dermatology at New York University, New York, in a statement issued by the academy. Dermatologists are seeing more patients who've had botched procedures, according to the AAD. A 2007 survey by the American Society for Dermatologic Surgery found that 56% of members who responded said they were seeing more patients with complications, such as burns, scarring, and skin discoloration, from procedures conducted by nonphysicians.

FDA, Defense Dept. to Share Data

The Department of Defense will share data and expertise with the FDA related to the review and use of FDA-regulated drugs, biologics, and medical devices in an effort to identify potential concerns and to recognize the benefits of products, the two agencies said. The DoD will share general patient data such as prescriptions, laboratory results, and patient weight from military health system records with the FDA, although the agencies will protect all personal health information exchanged under the agreement. Among the DoD programs involved in the agreement is TRICARE, which serves 9.1 million members of the uniformed services, military retirees, and their families. TRICARE prescription data likely will be the first information shared as part of the project. The partnership between the DoD and FDA is part of the FDA's Sentinel Network, a project intended to explore linking private sector and public sector information to create an integrated electronic network.

Survey Shows Poor Sunscreen Use

Forty percent of people who responded to a recent survey said they never wear sunscreen. The lack of use was highest among men, 47% of whom said they never use sunscreen, compared with 34% of women. The mid-May telephone survey of 521 women and 483 men was conducted for iVillage and the Skin Cancer Foundation by GfK Roper Public Affairs and Media. Sixty percent of respondents said they at least occasionally use sunscreen, but only 11% use one with an SPF of 15 or higher every day. Reapplication of sunscreen is skimpy; 74% said they reapply every 4-6 hours and 28% said they reapply at least every 2 hours, as recommended.

FDA Updates Tanning Info

The Food and Drug Administration has updated its online information on tanning. The Web page, which formerly focused on indoor tanning, now contains information about ultraviolet radiation; the risks of both indoor and outdoor tanning; tanning pills and sunless tanning lotions; tips on sun protection; and how to choose a sunscreen. The site also has links to tanning information at the Centers for Disease Control and Prevention, the American Cancer Society, the American Academy of Dermatology, and other organizations. The site is at

www.fda.gov/cdrh/tanning

Publix to Offer Free Antibiotics

Publix Super Markets Inc. will offer seven oral antibiotics free of charge at its 684 pharmacy locations in Florida, Georgia, South Carolina, Alabama, and Tennessee, the Lakeland, Fla.-based chain said. The antibiotics included in the program—amoxicillin, sulfamethoxazole/trimethoprim (SMZ-TMP), cephalexin, ciprofloxacin penicillin VK, (excluding extended-release ciprofloxacin), ampicillin, and erythromycin (excluding Ery-Tab)–account for almost 50% of the generic pediatric prescriptions filled at Publix, the company said. New or current customers simply need a prescription, which will be filled regardless of the customer's insurance coverage. The chain will cover up to a 14-day supply, and there is no limit on the number of free prescriptions. However, Publix will no longer match the $4 price on generic prescriptions offered by rival chain Wal-Mart. A company spokesman told the St. Petersburg Times that Publix never had an official match, but that it did fill generics for $4 when asked to do so by customers.

Solaraze Ads Run Afoul of FDA

The Food and Drug Administration has warned Doak Dermatologics that materials used by sales representatives and a journal ad for its Solaraze gel (diclofenac sodium) are promoting off-label and unapproved uses. In a letter sent to the company, the FDA's Division of Drug Marketing, Advertising, and Communications said that the materials are misleading because they "suggest that Solaraze Gel is approved for use in the treatment of AK (actinic keratoses) when used in combination with cryotherapy." The materials include a bar graph with data on patients treated with cryotherapy alone or cryotherapy followed by Solaraze; the sales aid included before and after pictures of patients treated with both therapies. Solaraze is approved only as a monotherapy. Doak also failed to submit the journal ad to the FDA when it was published, as is required.

AAD Alert on Mall Cosmetic Surgery

In response to the growing trend of cosmetic procedures' being performed in malls, at spas, and walk-in clinics, the American Academy of Dermatology has issued a consumer alert urging patients to use only board-certified physicians for cosmetic surgery. The growing availability of procedures that are being offered, both by nonphysicians and in more locations, may provide convenience, but "the limited training and supervision of the person performing the procedure, and the equipment available to handle complications or medical emergencies, can jeopardize the health and appearance of the patient," said Dr. Arielle N.B. Kauvar, of the department of dermatology at New York University, New York, in a statement issued by the academy. Dermatologists are seeing more patients who've had botched procedures, according to the AAD. A 2007 survey by the American Society for Dermatologic Surgery found that 56% of members who responded said they were seeing more patients with complications, such as burns, scarring, and skin discoloration, from procedures conducted by nonphysicians.

FDA, Defense Dept. to Share Data

The Department of Defense will share data and expertise with the FDA related to the review and use of FDA-regulated drugs, biologics, and medical devices in an effort to identify potential concerns and to recognize the benefits of products, the two agencies said. The DoD will share general patient data such as prescriptions, laboratory results, and patient weight from military health system records with the FDA, although the agencies will protect all personal health information exchanged under the agreement. Among the DoD programs involved in the agreement is TRICARE, which serves 9.1 million members of the uniformed services, military retirees, and their families. TRICARE prescription data likely will be the first information shared as part of the project. The partnership between the DoD and FDA is part of the FDA's Sentinel Network, a project intended to explore linking private sector and public sector information to create an integrated electronic network.

Survey Shows Poor Sunscreen Use

Forty percent of people who responded to a recent survey said they never wear sunscreen. The lack of use was highest among men, 47% of whom said they never use sunscreen, compared with 34% of women. The mid-May telephone survey of 521 women and 483 men was conducted for iVillage and the Skin Cancer Foundation by GfK Roper Public Affairs and Media. Sixty percent of respondents said they at least occasionally use sunscreen, but only 11% use one with an SPF of 15 or higher every day. Reapplication of sunscreen is skimpy; 74% said they reapply every 4-6 hours and 28% said they reapply at least every 2 hours, as recommended.

FDA Updates Tanning Info

The Food and Drug Administration has updated its online information on tanning. The Web page, which formerly focused on indoor tanning, now contains information about ultraviolet radiation; the risks of both indoor and outdoor tanning; tanning pills and sunless tanning lotions; tips on sun protection; and how to choose a sunscreen. The site also has links to tanning information at the Centers for Disease Control and Prevention, the American Cancer Society, the American Academy of Dermatology, and other organizations. The site is at

www.fda.gov/cdrh/tanning

Publix to Offer Free Antibiotics

Publix Super Markets Inc. will offer seven oral antibiotics free of charge at its 684 pharmacy locations in Florida, Georgia, South Carolina, Alabama, and Tennessee, the Lakeland, Fla.-based chain said. The antibiotics included in the program—amoxicillin, sulfamethoxazole/trimethoprim (SMZ-TMP), cephalexin, ciprofloxacin penicillin VK, (excluding extended-release ciprofloxacin), ampicillin, and erythromycin (excluding Ery-Tab)–account for almost 50% of the generic pediatric prescriptions filled at Publix, the company said. New or current customers simply need a prescription, which will be filled regardless of the customer's insurance coverage. The chain will cover up to a 14-day supply, and there is no limit on the number of free prescriptions. However, Publix will no longer match the $4 price on generic prescriptions offered by rival chain Wal-Mart. A company spokesman told the St. Petersburg Times that Publix never had an official match, but that it did fill generics for $4 when asked to do so by customers.

Solaraze Ads Run Afoul of FDA

The Food and Drug Administration has warned Doak Dermatologics that materials used by sales representatives and a journal ad for its Solaraze gel (diclofenac sodium) are promoting off-label and unapproved uses. In a letter sent to the company, the FDA's Division of Drug Marketing, Advertising, and Communications said that the materials are misleading because they "suggest that Solaraze Gel is approved for use in the treatment of AK (actinic keratoses) when used in combination with cryotherapy." The materials include a bar graph with data on patients treated with cryotherapy alone or cryotherapy followed by Solaraze; the sales aid included before and after pictures of patients treated with both therapies. Solaraze is approved only as a monotherapy. Doak also failed to submit the journal ad to the FDA when it was published, as is required.

AAD Alert on Mall Cosmetic Surgery

In response to the growing trend of cosmetic procedures' being performed in malls, at spas, and walk-in clinics, the American Academy of Dermatology has issued a consumer alert urging patients to use only board-certified physicians for cosmetic surgery. The growing availability of procedures that are being offered, both by nonphysicians and in more locations, may provide convenience, but "the limited training and supervision of the person performing the procedure, and the equipment available to handle complications or medical emergencies, can jeopardize the health and appearance of the patient," said Dr. Arielle N.B. Kauvar, of the department of dermatology at New York University, New York, in a statement issued by the academy. Dermatologists are seeing more patients who've had botched procedures, according to the AAD. A 2007 survey by the American Society for Dermatologic Surgery found that 56% of members who responded said they were seeing more patients with complications, such as burns, scarring, and skin discoloration, from procedures conducted by nonphysicians.

FDA, Defense Dept. to Share Data

The Department of Defense will share data and expertise with the FDA related to the review and use of FDA-regulated drugs, biologics, and medical devices in an effort to identify potential concerns and to recognize the benefits of products, the two agencies said. The DoD will share general patient data such as prescriptions, laboratory results, and patient weight from military health system records with the FDA, although the agencies will protect all personal health information exchanged under the agreement. Among the DoD programs involved in the agreement is TRICARE, which serves 9.1 million members of the uniformed services, military retirees, and their families. TRICARE prescription data likely will be the first information shared as part of the project. The partnership between the DoD and FDA is part of the FDA's Sentinel Network, a project intended to explore linking private sector and public sector information to create an integrated electronic network.

Survey Shows Poor Sunscreen Use

Forty percent of people who responded to a recent survey said they never wear sunscreen. The lack of use was highest among men, 47% of whom said they never use sunscreen, compared with 34% of women. The mid-May telephone survey of 521 women and 483 men was conducted for iVillage and the Skin Cancer Foundation by GfK Roper Public Affairs and Media. Sixty percent of respondents said they at least occasionally use sunscreen, but only 11% use one with an SPF of 15 or higher every day. Reapplication of sunscreen is skimpy; 74% said they reapply every 4-6 hours and 28% said they reapply at least every 2 hours, as recommended.

FDA Updates Tanning Info

The Food and Drug Administration has updated its online information on tanning. The Web page, which formerly focused on indoor tanning, now contains information about ultraviolet radiation; the risks of both indoor and outdoor tanning; tanning pills and sunless tanning lotions; tips on sun protection; and how to choose a sunscreen. The site also has links to tanning information at the Centers for Disease Control and Prevention, the American Cancer Society, the American Academy of Dermatology, and other organizations. The site is at

www.fda.gov/cdrh/tanning

Publix to Offer Free Antibiotics

Publix Super Markets Inc. will offer seven oral antibiotics free of charge at its 684 pharmacy locations in Florida, Georgia, South Carolina, Alabama, and Tennessee, the Lakeland, Fla.-based chain said. The antibiotics included in the program—amoxicillin, sulfamethoxazole/trimethoprim (SMZ-TMP), cephalexin, ciprofloxacin penicillin VK, (excluding extended-release ciprofloxacin), ampicillin, and erythromycin (excluding Ery-Tab)–account for almost 50% of the generic pediatric prescriptions filled at Publix, the company said. New or current customers simply need a prescription, which will be filled regardless of the customer's insurance coverage. The chain will cover up to a 14-day supply, and there is no limit on the number of free prescriptions. However, Publix will no longer match the $4 price on generic prescriptions offered by rival chain Wal-Mart. A company spokesman told the St. Petersburg Times that Publix never had an official match, but that it did fill generics for $4 when asked to do so by customers.

Building on the success of its Hospital Quality Improvement Demonstration, Premier Inc. is launching a new initiative to pay hospitals that perform at the top of a scale measuring improvements in mortality, the percentage of patients receiving appropriate care, efficiency, harm avoidance, and patient satisfaction.

Premier introduced the QUEST (Quality, Efficiency, Safety, and Transparency) initiative in late July and said it was recruiting hospitals to participate through the end of September. In a briefing with reporters, Premier president and CEO Richard A. Norling said that 60 hospitals had expressed interest so far, but he declined to name them.

Premier is an alliance owned by 1,700 nonprofit hospitals. Premier's purchasing network also serves 46,500 health care entities. The alliance's previous project–HQID–was a joint effort with the Centers for Medicare & Medicaid Services that began in 2003 and concludes in November.

QUEST will initially focus on hospitals' risk-adjusted mortality ratio, and on how well they deliver appropriate care, measured by the percentage of patients who receive perfect care according to evidence-based guidelines. Hospitals will also be measured on the severity adjusted cost per discharge, a reflection of efficiency.

In the second year, QUEST hospitals will have to show how well they prevent health care-related infections and adverse drug events, and how well they serve patients, measured through CMS Hospital Consumer Assessment of Healthcare Providers and Systems. QUEST participants are also expected to share best practices.

The hospitals that show the most improvement from baseline will receive an incentive payment, most likely in year 3. Premier has provided seed money for the incentives, said Susan DeVore, the alliance's chief operating officer. The company is in discussions with the Blue Cross Blue Shield Association to provide more funds.

QUEST results will be made public at some point, though in aggregate only.

“Transparency has arrived and should be considered a good thing for providers,” said Dr. Ken Davis, chief medical officer of North Mississippi Health Services, at the briefing. The Tupelo, Miss.-based hospital is a member of Premier and will be a QUEST participant, he said.

Building on the success of its Hospital Quality Improvement Demonstration, Premier Inc. is launching a new initiative to pay hospitals that perform at the top of a scale measuring improvements in mortality, the percentage of patients receiving appropriate care, efficiency, harm avoidance, and patient satisfaction.

Premier introduced the QUEST (Quality, Efficiency, Safety, and Transparency) initiative in late July and said it was recruiting hospitals to participate through the end of September. In a briefing with reporters, Premier president and CEO Richard A. Norling said that 60 hospitals had expressed interest so far, but he declined to name them.

Premier is an alliance owned by 1,700 nonprofit hospitals. Premier's purchasing network also serves 46,500 health care entities. The alliance's previous project–HQID–was a joint effort with the Centers for Medicare & Medicaid Services that began in 2003 and concludes in November.

QUEST will initially focus on hospitals' risk-adjusted mortality ratio, and on how well they deliver appropriate care, measured by the percentage of patients who receive perfect care according to evidence-based guidelines. Hospitals will also be measured on the severity adjusted cost per discharge, a reflection of efficiency.

In the second year, QUEST hospitals will have to show how well they prevent health care-related infections and adverse drug events, and how well they serve patients, measured through CMS Hospital Consumer Assessment of Healthcare Providers and Systems. QUEST participants are also expected to share best practices.

The hospitals that show the most improvement from baseline will receive an incentive payment, most likely in year 3. Premier has provided seed money for the incentives, said Susan DeVore, the alliance's chief operating officer. The company is in discussions with the Blue Cross Blue Shield Association to provide more funds.

QUEST results will be made public at some point, though in aggregate only.

“Transparency has arrived and should be considered a good thing for providers,” said Dr. Ken Davis, chief medical officer of North Mississippi Health Services, at the briefing. The Tupelo, Miss.-based hospital is a member of Premier and will be a QUEST participant, he said.

Building on the success of its Hospital Quality Improvement Demonstration, Premier Inc. is launching a new initiative to pay hospitals that perform at the top of a scale measuring improvements in mortality, the percentage of patients receiving appropriate care, efficiency, harm avoidance, and patient satisfaction.

Premier introduced the QUEST (Quality, Efficiency, Safety, and Transparency) initiative in late July and said it was recruiting hospitals to participate through the end of September. In a briefing with reporters, Premier president and CEO Richard A. Norling said that 60 hospitals had expressed interest so far, but he declined to name them.

Premier is an alliance owned by 1,700 nonprofit hospitals. Premier's purchasing network also serves 46,500 health care entities. The alliance's previous project–HQID–was a joint effort with the Centers for Medicare & Medicaid Services that began in 2003 and concludes in November.

QUEST will initially focus on hospitals' risk-adjusted mortality ratio, and on how well they deliver appropriate care, measured by the percentage of patients who receive perfect care according to evidence-based guidelines. Hospitals will also be measured on the severity adjusted cost per discharge, a reflection of efficiency.

In the second year, QUEST hospitals will have to show how well they prevent health care-related infections and adverse drug events, and how well they serve patients, measured through CMS Hospital Consumer Assessment of Healthcare Providers and Systems. QUEST participants are also expected to share best practices.

The hospitals that show the most improvement from baseline will receive an incentive payment, most likely in year 3. Premier has provided seed money for the incentives, said Susan DeVore, the alliance's chief operating officer. The company is in discussions with the Blue Cross Blue Shield Association to provide more funds.

QUEST results will be made public at some point, though in aggregate only.

“Transparency has arrived and should be considered a good thing for providers,” said Dr. Ken Davis, chief medical officer of North Mississippi Health Services, at the briefing. The Tupelo, Miss.-based hospital is a member of Premier and will be a QUEST participant, he said.

www.pcrh.dhh.louisiana.gov

Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but just as medically needy, population.

It's a picture that's changed some–but not much–since a year ago.

Emergency rooms, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. By mid-2006, according to claims information from Blue Cross and Blue Shield, only half of them had come back.

The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006–to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive about $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care around the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House, in an interview. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is “going to give us a chance to expand upon what's been developing–multiple neighborhood clinics that are turning into medical homes,” said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said.

The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments.

“We're trying to find those patients in the ER and get them into our system,” she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take. According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site.

The city–along with LSU and Tulane–is trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing that–before Katrina–the VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing.

Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish.

At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site “is above sea level and not located in a flood plain.”

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

And some stalwarts have not given up on reopening Charity. Last year, the state legislature approved a study by an independent team of investigators to see if the first three floors could be refurbished while a new medical campus is put together.

EDs Feel Ripple Effect

The lack of inpatient beds and mental health care, and the shortage of primary care sites are felt most acutely in the area's emergency departments.

Two years ago, the now-shuttered Charity Hospital received 120,000 to 200,000 ED visits a year. Granted, there are fewer people in the city now, but there are more now who come in the door sicker or in need of basic care, said Dr. Jim Aiken of the emergency medicine department at LSU.

“We do a lot of renewing prescriptions and checking blood pressures,” and other primary care types of interventions, he said in an interview.

The Interim Hospital sees about 3,500 patients a month. Although things have improved in the last year, the ED is admitting more patients than before the storm, and “we struggle every day with surge capacity,” said Dr. Aiken.

Diversion is not uncommon, but the hospitals in the area now at least have a new communications module that lets them track online what's happening at other facilities in the area.

The lack of adequate mental health care, combined with poststorm stress and anxiety, is having the biggest impact on the ED, said Dr. Aiken. It is not unusual for the hospital to be holding 15 psychiatric patients at its 31-bed ED, he said.

Charity also housed a crisis intervention unit where the police could take the mentally ill. With that unit gone, those with psychiatric needs have been spread out around the city.

Before Katrina, there were 578 psychiatric and detox beds in and around New Orleans; that number is now at 236, with only a small portion of them actually in downtown New Orleans, according to Dr. Cerise.

The deteriorated mental health system is “probably in my mind the most critical health care issue in this state since the storm,” said Dr. Aiken.

Even the LSU system in Baton Rouge has been affected, said Dr. William “Beau” Clark, president of the Louisiana chapter of the American College of Emergency Physicians.

Emergency rooms in that city have absorbed some of New Orleans' outflow, including psychiatric patients who end up boarding in Baton Rouge, he said.

A new medical center is planned on a 37-acre parcel a few blocks from Charity Hospital, said Mayor C. Ray Nagin. Jay Westcott/Elsevier Global Medical News

Grants Offered for Primary Care Help

The state of Louisiana and city of New Orleans are struggling to lure physicians–especially primary care doctors–dentists, mental health professionals, and nurses back to the city or at least to convince those who did come back to stay in the face of a new and bigger onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area–encompassing Orleans, Jefferson, Plaquemines, and St. Bernard parishes–a health-professional shortage area.

The region became eligible for federal grants to offer incentives to retain or recruit health professionals and gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention. The first chunk, $15 million, was received in March 2007; 70% of the funds were earmarked for recruitment and 30% for retention.

In mid-June, the state agency received another $35 million. Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds–in mid-2006–there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients.

The DHH determined that–based on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)–there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan.

The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009, when the grant cycle ends, she said. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialist–the applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, “that's a dire need,” said Ms. Strahan.

Applicants–and there were 300 as of press time–have to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their own package of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology.

Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

So far, there have been at least 125 awards, including 62 primary care positions (including mid-level providers), 16 dentists, 42 mental health professionals, and 5 pharmacists.

www.pcrh.dhh.louisiana.gov

Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but just as medically needy, population.

It's a picture that's changed some–but not much–since a year ago.

Emergency rooms, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. By mid-2006, according to claims information from Blue Cross and Blue Shield, only half of them had come back.

The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006–to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive about $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care around the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House, in an interview. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is “going to give us a chance to expand upon what's been developing–multiple neighborhood clinics that are turning into medical homes,” said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said.

The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments.

“We're trying to find those patients in the ER and get them into our system,” she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take. According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site.

The city–along with LSU and Tulane–is trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing that–before Katrina–the VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing.

Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish.

At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site “is above sea level and not located in a flood plain.”

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

And some stalwarts have not given up on reopening Charity. Last year, the state legislature approved a study by an independent team of investigators to see if the first three floors could be refurbished while a new medical campus is put together.

EDs Feel Ripple Effect

The lack of inpatient beds and mental health care, and the shortage of primary care sites are felt most acutely in the area's emergency departments.

Two years ago, the now-shuttered Charity Hospital received 120,000 to 200,000 ED visits a year. Granted, there are fewer people in the city now, but there are more now who come in the door sicker or in need of basic care, said Dr. Jim Aiken of the emergency medicine department at LSU.

“We do a lot of renewing prescriptions and checking blood pressures,” and other primary care types of interventions, he said in an interview.

The Interim Hospital sees about 3,500 patients a month. Although things have improved in the last year, the ED is admitting more patients than before the storm, and “we struggle every day with surge capacity,” said Dr. Aiken.

Diversion is not uncommon, but the hospitals in the area now at least have a new communications module that lets them track online what's happening at other facilities in the area.

The lack of adequate mental health care, combined with poststorm stress and anxiety, is having the biggest impact on the ED, said Dr. Aiken. It is not unusual for the hospital to be holding 15 psychiatric patients at its 31-bed ED, he said.

Charity also housed a crisis intervention unit where the police could take the mentally ill. With that unit gone, those with psychiatric needs have been spread out around the city.

Before Katrina, there were 578 psychiatric and detox beds in and around New Orleans; that number is now at 236, with only a small portion of them actually in downtown New Orleans, according to Dr. Cerise.

The deteriorated mental health system is “probably in my mind the most critical health care issue in this state since the storm,” said Dr. Aiken.

Even the LSU system in Baton Rouge has been affected, said Dr. William “Beau” Clark, president of the Louisiana chapter of the American College of Emergency Physicians.

Emergency rooms in that city have absorbed some of New Orleans' outflow, including psychiatric patients who end up boarding in Baton Rouge, he said.

A new medical center is planned on a 37-acre parcel a few blocks from Charity Hospital, said Mayor C. Ray Nagin. Jay Westcott/Elsevier Global Medical News

Grants Offered for Primary Care Help

The state of Louisiana and city of New Orleans are struggling to lure physicians–especially primary care doctors–dentists, mental health professionals, and nurses back to the city or at least to convince those who did come back to stay in the face of a new and bigger onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area–encompassing Orleans, Jefferson, Plaquemines, and St. Bernard parishes–a health-professional shortage area.

The region became eligible for federal grants to offer incentives to retain or recruit health professionals and gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention. The first chunk, $15 million, was received in March 2007; 70% of the funds were earmarked for recruitment and 30% for retention.

In mid-June, the state agency received another $35 million. Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds–in mid-2006–there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients.

The DHH determined that–based on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)–there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan.

The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009, when the grant cycle ends, she said. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialist–the applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, “that's a dire need,” said Ms. Strahan.

Applicants–and there were 300 as of press time–have to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their own package of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology.

Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

So far, there have been at least 125 awards, including 62 primary care positions (including mid-level providers), 16 dentists, 42 mental health professionals, and 5 pharmacists.

www.pcrh.dhh.louisiana.gov

Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but just as medically needy, population.

It's a picture that's changed some–but not much–since a year ago.

Emergency rooms, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. By mid-2006, according to claims information from Blue Cross and Blue Shield, only half of them had come back.

The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006–to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive about $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care around the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House, in an interview. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is “going to give us a chance to expand upon what's been developing–multiple neighborhood clinics that are turning into medical homes,” said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said.

The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments.

“We're trying to find those patients in the ER and get them into our system,” she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take. According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site.

The city–along with LSU and Tulane–is trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing that–before Katrina–the VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing.

Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish.

At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site “is above sea level and not located in a flood plain.”

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

And some stalwarts have not given up on reopening Charity. Last year, the state legislature approved a study by an independent team of investigators to see if the first three floors could be refurbished while a new medical campus is put together.

EDs Feel Ripple Effect

The lack of inpatient beds and mental health care, and the shortage of primary care sites are felt most acutely in the area's emergency departments.

Two years ago, the now-shuttered Charity Hospital received 120,000 to 200,000 ED visits a year. Granted, there are fewer people in the city now, but there are more now who come in the door sicker or in need of basic care, said Dr. Jim Aiken of the emergency medicine department at LSU.

“We do a lot of renewing prescriptions and checking blood pressures,” and other primary care types of interventions, he said in an interview.

The Interim Hospital sees about 3,500 patients a month. Although things have improved in the last year, the ED is admitting more patients than before the storm, and “we struggle every day with surge capacity,” said Dr. Aiken.

Diversion is not uncommon, but the hospitals in the area now at least have a new communications module that lets them track online what's happening at other facilities in the area.

The lack of adequate mental health care, combined with poststorm stress and anxiety, is having the biggest impact on the ED, said Dr. Aiken. It is not unusual for the hospital to be holding 15 psychiatric patients at its 31-bed ED, he said.

Charity also housed a crisis intervention unit where the police could take the mentally ill. With that unit gone, those with psychiatric needs have been spread out around the city.

Before Katrina, there were 578 psychiatric and detox beds in and around New Orleans; that number is now at 236, with only a small portion of them actually in downtown New Orleans, according to Dr. Cerise.

The deteriorated mental health system is “probably in my mind the most critical health care issue in this state since the storm,” said Dr. Aiken.

Even the LSU system in Baton Rouge has been affected, said Dr. William “Beau” Clark, president of the Louisiana chapter of the American College of Emergency Physicians.

Emergency rooms in that city have absorbed some of New Orleans' outflow, including psychiatric patients who end up boarding in Baton Rouge, he said.

A new medical center is planned on a 37-acre parcel a few blocks from Charity Hospital, said Mayor C. Ray Nagin. Jay Westcott/Elsevier Global Medical News

Grants Offered for Primary Care Help

The state of Louisiana and city of New Orleans are struggling to lure physicians–especially primary care doctors–dentists, mental health professionals, and nurses back to the city or at least to convince those who did come back to stay in the face of a new and bigger onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area–encompassing Orleans, Jefferson, Plaquemines, and St. Bernard parishes–a health-professional shortage area.

The region became eligible for federal grants to offer incentives to retain or recruit health professionals and gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention. The first chunk, $15 million, was received in March 2007; 70% of the funds were earmarked for recruitment and 30% for retention.

In mid-June, the state agency received another $35 million. Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds–in mid-2006–there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients.

The DHH determined that–based on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)–there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan.

The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009, when the grant cycle ends, she said. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialist–the applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, “that's a dire need,” said Ms. Strahan.

Applicants–and there were 300 as of press time–have to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their own package of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology.

Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

So far, there have been at least 125 awards, including 62 primary care positions (including mid-level providers), 16 dentists, 42 mental health professionals, and 5 pharmacists.

WASHINGTON — People who are overweight or obese appear to take advantage of colorectal cancer screening opportunities at the same rate as normal-weight Americans.

Several studies have indicated that people with a higher body mass index (BMI) do not seek out screening for breast and colon cancer. But Dr. Deborah A. Fisher, of Duke University, Durham, N.C., and Durham Veterans Affairs Medical Center, and her colleagues determined that overweight and obese residents of North Carolina access fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy at the same rate as those who are normal weight.

At the annual Digestive Disease Week, she presented an analysis of the North Carolina Colon Cancer Study, a case-control population-based study. The study used height and weight measurements to calculate BMI, but information about colon cancer screening was self-reported by patients.

The primary outcome was whether the patient was current for any colon cancer screening test, which included a fecal occult blood test in the past year, a colonoscopy within the past 10 years, a flexible sigmoidoscopy within the past 5 years, or a barium enema within the past 5 years.

Among the 928 patients, the average age was 67 years; half were male, 59% were white, and 41% were African American. Of these patients, 29% were normal weight (BMI of 18–24.9 kg/m

Across all the BMI categories, the percentage of those who had undergone screening ranged from 54% to 67%. There was no difference in screening behavior in any of the overweight or obese patients, compared with normal-weight patients. Gender also had no impact on screening behavior. Dr. Fisher reported no disclosures. The study was supported by a National Institutes of Health grant.

WASHINGTON — People who are overweight or obese appear to take advantage of colorectal cancer screening opportunities at the same rate as normal-weight Americans.

Several studies have indicated that people with a higher body mass index (BMI) do not seek out screening for breast and colon cancer. But Dr. Deborah A. Fisher, of Duke University, Durham, N.C., and Durham Veterans Affairs Medical Center, and her colleagues determined that overweight and obese residents of North Carolina access fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy at the same rate as those who are normal weight.

At the annual Digestive Disease Week, she presented an analysis of the North Carolina Colon Cancer Study, a case-control population-based study. The study used height and weight measurements to calculate BMI, but information about colon cancer screening was self-reported by patients.

The primary outcome was whether the patient was current for any colon cancer screening test, which included a fecal occult blood test in the past year, a colonoscopy within the past 10 years, a flexible sigmoidoscopy within the past 5 years, or a barium enema within the past 5 years.

Among the 928 patients, the average age was 67 years; half were male, 59% were white, and 41% were African American. Of these patients, 29% were normal weight (BMI of 18–24.9 kg/m

Across all the BMI categories, the percentage of those who had undergone screening ranged from 54% to 67%. There was no difference in screening behavior in any of the overweight or obese patients, compared with normal-weight patients. Gender also had no impact on screening behavior. Dr. Fisher reported no disclosures. The study was supported by a National Institutes of Health grant.

WASHINGTON — People who are overweight or obese appear to take advantage of colorectal cancer screening opportunities at the same rate as normal-weight Americans.

Several studies have indicated that people with a higher body mass index (BMI) do not seek out screening for breast and colon cancer. But Dr. Deborah A. Fisher, of Duke University, Durham, N.C., and Durham Veterans Affairs Medical Center, and her colleagues determined that overweight and obese residents of North Carolina access fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy at the same rate as those who are normal weight.

At the annual Digestive Disease Week, she presented an analysis of the North Carolina Colon Cancer Study, a case-control population-based study. The study used height and weight measurements to calculate BMI, but information about colon cancer screening was self-reported by patients.

The primary outcome was whether the patient was current for any colon cancer screening test, which included a fecal occult blood test in the past year, a colonoscopy within the past 10 years, a flexible sigmoidoscopy within the past 5 years, or a barium enema within the past 5 years.

Among the 928 patients, the average age was 67 years; half were male, 59% were white, and 41% were African American. Of these patients, 29% were normal weight (BMI of 18–24.9 kg/m

Across all the BMI categories, the percentage of those who had undergone screening ranged from 54% to 67%. There was no difference in screening behavior in any of the overweight or obese patients, compared with normal-weight patients. Gender also had no impact on screening behavior. Dr. Fisher reported no disclosures. The study was supported by a National Institutes of Health grant.