Alicia Ault

WASHINGTON — As one of the biggest and most influential payers in medicine, Medicare should use its clout to help reduce and eliminate the disparities in care for racial and ethnic minorities, according to a report from an independent panel of the National Academy of Social Insurance.

The report, along with an updated survey on health plans' progress in identifying disparities, was released at a press briefing sponsored by the journal Health Affairs. NASI, a Washington-based nonprofit organization of experts in Social Security, Medicare and social insurance, made 17 recommendations on how Medicare can improve quality of, and access to care for minorities, educate health care providers in cultural competence, and hold them accountable for reducing disparities.

About 9 million of Medicare's 42 million beneficiaries are minorities. Those minority beneficiaries generally are in poorer health, according to NASI. For example, more black Medicare beneficiaries than white beneficiaries have diabetes, 30% and 18%, respectively.

Medicare is uniquely positioned to influence practice patterns, and has a duty to ensure that its recipients get care on a fair and equitable basis, said Bruce C. Vladeck, Ph.D., chairman of the NASI panel and Interim President of the University of Medicine and Dentistry of New Jersey, Newark.

NASI's report was funded by the Robert Wood Johnson Foundation, the California Endowment, and the Joint Center for Political and Economic Studies.

The panel recommended that the federal government start addressing gaps in care by creating incentives to improve quality. Incentives should be carefully structured to avoid exacerbating disparities, however, said Mr. Vladeck.

To increase access, Medicare should ensure that minorities are enrolled in Medicare supplemental insurance—or Medigap—plans, said the report. Health systems should increase the number of minority providers and staff, and enhance cultural competence training. Providers should collect data that will help identify minorities and assess their special needs, according to the panel.

Health plans already collect such data, according to Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP, with funding from the Robert Wood Johnson Foundation, queried 260 plans on how and why they collect data on minority enrollees. According to the responses—from 156 plans, covering 87 million people—there has been a 500% increase in data collection since a previous query in 2001, said Ms. Ignani.

Overall, 58.2 million of the 87 million enrollees are in plans that collect race and ethnicity data. Medicare and Medicaid plans were most likely to collect that data. Race and ethnicity data were collected on 94% of enrollees in Medicare and Medicaide plans, compared with 63% of enrollees in commercial plans.

WASHINGTON — As one of the biggest and most influential payers in medicine, Medicare should use its clout to help reduce and eliminate the disparities in care for racial and ethnic minorities, according to a report from an independent panel of the National Academy of Social Insurance.

The report, along with an updated survey on health plans' progress in identifying disparities, was released at a press briefing sponsored by the journal Health Affairs. NASI, a Washington-based nonprofit organization of experts in Social Security, Medicare and social insurance, made 17 recommendations on how Medicare can improve quality of, and access to care for minorities, educate health care providers in cultural competence, and hold them accountable for reducing disparities.

About 9 million of Medicare's 42 million beneficiaries are minorities. Those minority beneficiaries generally are in poorer health, according to NASI. For example, more black Medicare beneficiaries than white beneficiaries have diabetes, 30% and 18%, respectively.

Medicare is uniquely positioned to influence practice patterns, and has a duty to ensure that its recipients get care on a fair and equitable basis, said Bruce C. Vladeck, Ph.D., chairman of the NASI panel and Interim President of the University of Medicine and Dentistry of New Jersey, Newark.

NASI's report was funded by the Robert Wood Johnson Foundation, the California Endowment, and the Joint Center for Political and Economic Studies.

The panel recommended that the federal government start addressing gaps in care by creating incentives to improve quality. Incentives should be carefully structured to avoid exacerbating disparities, however, said Mr. Vladeck.

To increase access, Medicare should ensure that minorities are enrolled in Medicare supplemental insurance—or Medigap—plans, said the report. Health systems should increase the number of minority providers and staff, and enhance cultural competence training. Providers should collect data that will help identify minorities and assess their special needs, according to the panel.

Health plans already collect such data, according to Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP, with funding from the Robert Wood Johnson Foundation, queried 260 plans on how and why they collect data on minority enrollees. According to the responses—from 156 plans, covering 87 million people—there has been a 500% increase in data collection since a previous query in 2001, said Ms. Ignani.

Overall, 58.2 million of the 87 million enrollees are in plans that collect race and ethnicity data. Medicare and Medicaid plans were most likely to collect that data. Race and ethnicity data were collected on 94% of enrollees in Medicare and Medicaide plans, compared with 63% of enrollees in commercial plans.

WASHINGTON — As one of the biggest and most influential payers in medicine, Medicare should use its clout to help reduce and eliminate the disparities in care for racial and ethnic minorities, according to a report from an independent panel of the National Academy of Social Insurance.

The report, along with an updated survey on health plans' progress in identifying disparities, was released at a press briefing sponsored by the journal Health Affairs. NASI, a Washington-based nonprofit organization of experts in Social Security, Medicare and social insurance, made 17 recommendations on how Medicare can improve quality of, and access to care for minorities, educate health care providers in cultural competence, and hold them accountable for reducing disparities.

About 9 million of Medicare's 42 million beneficiaries are minorities. Those minority beneficiaries generally are in poorer health, according to NASI. For example, more black Medicare beneficiaries than white beneficiaries have diabetes, 30% and 18%, respectively.

Medicare is uniquely positioned to influence practice patterns, and has a duty to ensure that its recipients get care on a fair and equitable basis, said Bruce C. Vladeck, Ph.D., chairman of the NASI panel and Interim President of the University of Medicine and Dentistry of New Jersey, Newark.

NASI's report was funded by the Robert Wood Johnson Foundation, the California Endowment, and the Joint Center for Political and Economic Studies.

The panel recommended that the federal government start addressing gaps in care by creating incentives to improve quality. Incentives should be carefully structured to avoid exacerbating disparities, however, said Mr. Vladeck.

To increase access, Medicare should ensure that minorities are enrolled in Medicare supplemental insurance—or Medigap—plans, said the report. Health systems should increase the number of minority providers and staff, and enhance cultural competence training. Providers should collect data that will help identify minorities and assess their special needs, according to the panel.

Health plans already collect such data, according to Karen Ignani, president and CEO of America's Health Insurance Plans. AHIP, with funding from the Robert Wood Johnson Foundation, queried 260 plans on how and why they collect data on minority enrollees. According to the responses—from 156 plans, covering 87 million people—there has been a 500% increase in data collection since a previous query in 2001, said Ms. Ignani.

Overall, 58.2 million of the 87 million enrollees are in plans that collect race and ethnicity data. Medicare and Medicaid plans were most likely to collect that data. Race and ethnicity data were collected on 94% of enrollees in Medicare and Medicaide plans, compared with 63% of enrollees in commercial plans.

WASHINGTON — Patients who read at or below the 6th-grade level had a low level of comprehension of instructions on the labels of five commonly-used medications, according to a study led by Terry Davis, Ph.D., of the Louisiana State University.

Even though labels seem short and to the point, “many patients need more specific, concrete information,” including instructions on exactly what time of day to take a medication, Ms. Davis said in presenting the findings at a conference on health literacy sponsored by the American College of Physicians.

Along with colleagues at Northwestern University, the University of North Carolina, Western Michigan Area Health Education Center, and Emory University, she queried 395 patients at three clinics that primarily serve the indigent about their understanding of labels for the following drugs: amoxicillin for pediatric use, trimethoprim, guaifenesin, felodipine, and furosemide.

The goal was to determine whether primary care patients could read and correctly state how to take medicines after reading the labels on actual pill bottles, Ms. Davis said. The researchers hypothesized that patients with low literacy were more likely to misunderstand instructions. They also believed that the increasing number of medications taken by Americans is leading to growing confusion and medication errors.

Participants spoke English as a primary language and were not hearing or vision impaired. Half were African American and half were white. The mean age was 45 years, and 29% had a less than high school education. Literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM) test. Of the 395 patients, 19% (75) were deemed to have low literacy, reading at or below a 6th-grade level, and 29% (114) had marginal literacy, reading at the 7th- to 8th-grade level.

All patients were asked how they would take the medicine. A “correct” answer was given if they included all aspects of the label instruction, including dosage, timing, and duration. Overall, 47% (185) of patients misunderstood at least one of the instructions. For marginal literacy patients, 51% (201) misunderstood one or more instructions, and for low literacy patients, 63% (249) misunderstood.

The majority—91%, or 359 patients—understood the felodipine instructions, which were, “Take one tablet by mouth once each day.” The lowest level of comprehension was for trimethoprim, which had a label instructing to “take one tablet by mouth twice daily for seven days.”

Higher literacy patients routinely understood instructions better than those with lower literacy, Ms. Davis said. The adjusted odds ratio of misunderstanding for low literacy was 2.32, and for marginal literacy, 1.94. Most misunderstandings had to do with dosage. For instance, patients often believed they should give children a tablespoon instead of a teaspoon of amoxicillin.

Patients who took more medications were also more likely to misunderstand labels, with the adjusted relative risk rising from 2.29 for 1–2 medications to 2.98 for 5 or more medications.

In a substudy, patients were tested on their understanding of the instruction, “Take two tablets by mouth twice daily,” on a bottle of guaifenesin. Overall, 84% were able to correctly state the instruction, but fewer patients knew how many pills to take. Among those with adequate literacy, 80% counted out the correct number of pills. That ability decreased with declining literacy: 63% of marginal literacy patients and 35% of those with low literacy could correctly count. The researchers said that although this may have reflected patients' numeracy skills more than reading skills, numeracy is an aspect of literacy.

Study limitations included the fact that the authors only examined understanding of the primary label. They did not assess patients' actual compliance or drug-taking behavior, whether medication errors occurred, or if any of the patients had experience with any of the five medications.

The study was published in Annals of Internal Medicine (Ann. Intern. Med. 2006; 145: 887–94).

WASHINGTON — Patients who read at or below the 6th-grade level had a low level of comprehension of instructions on the labels of five commonly-used medications, according to a study led by Terry Davis, Ph.D., of the Louisiana State University.

Even though labels seem short and to the point, “many patients need more specific, concrete information,” including instructions on exactly what time of day to take a medication, Ms. Davis said in presenting the findings at a conference on health literacy sponsored by the American College of Physicians.

Along with colleagues at Northwestern University, the University of North Carolina, Western Michigan Area Health Education Center, and Emory University, she queried 395 patients at three clinics that primarily serve the indigent about their understanding of labels for the following drugs: amoxicillin for pediatric use, trimethoprim, guaifenesin, felodipine, and furosemide.

The goal was to determine whether primary care patients could read and correctly state how to take medicines after reading the labels on actual pill bottles, Ms. Davis said. The researchers hypothesized that patients with low literacy were more likely to misunderstand instructions. They also believed that the increasing number of medications taken by Americans is leading to growing confusion and medication errors.

Participants spoke English as a primary language and were not hearing or vision impaired. Half were African American and half were white. The mean age was 45 years, and 29% had a less than high school education. Literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM) test. Of the 395 patients, 19% (75) were deemed to have low literacy, reading at or below a 6th-grade level, and 29% (114) had marginal literacy, reading at the 7th- to 8th-grade level.

All patients were asked how they would take the medicine. A “correct” answer was given if they included all aspects of the label instruction, including dosage, timing, and duration. Overall, 47% (185) of patients misunderstood at least one of the instructions. For marginal literacy patients, 51% (201) misunderstood one or more instructions, and for low literacy patients, 63% (249) misunderstood.

The majority—91%, or 359 patients—understood the felodipine instructions, which were, “Take one tablet by mouth once each day.” The lowest level of comprehension was for trimethoprim, which had a label instructing to “take one tablet by mouth twice daily for seven days.”

Higher literacy patients routinely understood instructions better than those with lower literacy, Ms. Davis said. The adjusted odds ratio of misunderstanding for low literacy was 2.32, and for marginal literacy, 1.94. Most misunderstandings had to do with dosage. For instance, patients often believed they should give children a tablespoon instead of a teaspoon of amoxicillin.

Patients who took more medications were also more likely to misunderstand labels, with the adjusted relative risk rising from 2.29 for 1–2 medications to 2.98 for 5 or more medications.

In a substudy, patients were tested on their understanding of the instruction, “Take two tablets by mouth twice daily,” on a bottle of guaifenesin. Overall, 84% were able to correctly state the instruction, but fewer patients knew how many pills to take. Among those with adequate literacy, 80% counted out the correct number of pills. That ability decreased with declining literacy: 63% of marginal literacy patients and 35% of those with low literacy could correctly count. The researchers said that although this may have reflected patients' numeracy skills more than reading skills, numeracy is an aspect of literacy.

Study limitations included the fact that the authors only examined understanding of the primary label. They did not assess patients' actual compliance or drug-taking behavior, whether medication errors occurred, or if any of the patients had experience with any of the five medications.

The study was published in Annals of Internal Medicine (Ann. Intern. Med. 2006; 145: 887–94).

WASHINGTON — Patients who read at or below the 6th-grade level had a low level of comprehension of instructions on the labels of five commonly-used medications, according to a study led by Terry Davis, Ph.D., of the Louisiana State University.

Even though labels seem short and to the point, “many patients need more specific, concrete information,” including instructions on exactly what time of day to take a medication, Ms. Davis said in presenting the findings at a conference on health literacy sponsored by the American College of Physicians.

Along with colleagues at Northwestern University, the University of North Carolina, Western Michigan Area Health Education Center, and Emory University, she queried 395 patients at three clinics that primarily serve the indigent about their understanding of labels for the following drugs: amoxicillin for pediatric use, trimethoprim, guaifenesin, felodipine, and furosemide.

The goal was to determine whether primary care patients could read and correctly state how to take medicines after reading the labels on actual pill bottles, Ms. Davis said. The researchers hypothesized that patients with low literacy were more likely to misunderstand instructions. They also believed that the increasing number of medications taken by Americans is leading to growing confusion and medication errors.

Participants spoke English as a primary language and were not hearing or vision impaired. Half were African American and half were white. The mean age was 45 years, and 29% had a less than high school education. Literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM) test. Of the 395 patients, 19% (75) were deemed to have low literacy, reading at or below a 6th-grade level, and 29% (114) had marginal literacy, reading at the 7th- to 8th-grade level.

All patients were asked how they would take the medicine. A “correct” answer was given if they included all aspects of the label instruction, including dosage, timing, and duration. Overall, 47% (185) of patients misunderstood at least one of the instructions. For marginal literacy patients, 51% (201) misunderstood one or more instructions, and for low literacy patients, 63% (249) misunderstood.

The majority—91%, or 359 patients—understood the felodipine instructions, which were, “Take one tablet by mouth once each day.” The lowest level of comprehension was for trimethoprim, which had a label instructing to “take one tablet by mouth twice daily for seven days.”

Higher literacy patients routinely understood instructions better than those with lower literacy, Ms. Davis said. The adjusted odds ratio of misunderstanding for low literacy was 2.32, and for marginal literacy, 1.94. Most misunderstandings had to do with dosage. For instance, patients often believed they should give children a tablespoon instead of a teaspoon of amoxicillin.

Patients who took more medications were also more likely to misunderstand labels, with the adjusted relative risk rising from 2.29 for 1–2 medications to 2.98 for 5 or more medications.

In a substudy, patients were tested on their understanding of the instruction, “Take two tablets by mouth twice daily,” on a bottle of guaifenesin. Overall, 84% were able to correctly state the instruction, but fewer patients knew how many pills to take. Among those with adequate literacy, 80% counted out the correct number of pills. That ability decreased with declining literacy: 63% of marginal literacy patients and 35% of those with low literacy could correctly count. The researchers said that although this may have reflected patients' numeracy skills more than reading skills, numeracy is an aspect of literacy.

Study limitations included the fact that the authors only examined understanding of the primary label. They did not assess patients' actual compliance or drug-taking behavior, whether medication errors occurred, or if any of the patients had experience with any of the five medications.

The study was published in Annals of Internal Medicine (Ann. Intern. Med. 2006; 145: 887–94).

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions according to whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices were followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly.

Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which would provide money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the newly Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said NCQA general counsel Sharon Donohue. But there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group Medically Induced Trauma Support Services, said that patients should not be required to start the claims process, as is proposed under the health court system. An audience member representing Consumers Union said that her group did not like the idea of taking away a patient's right to a jury trial.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are due to systems issues; only 15% are competency-related, so solutions should focus on systems design, Dr. O'Leary said.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—maybe 450–500 a year, he said. Most reports concern errors that are not easy to hide, such as patient suicides—the top category—and surgical misadventures, the No. 2 category, Dr. O'Leary said. Surprisingly, at least eight cases a month of wrong-site surgery are reported, he added.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without it being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said. Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions according to whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices were followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly.

Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which would provide money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the newly Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said NCQA general counsel Sharon Donohue. But there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group Medically Induced Trauma Support Services, said that patients should not be required to start the claims process, as is proposed under the health court system. An audience member representing Consumers Union said that her group did not like the idea of taking away a patient's right to a jury trial.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are due to systems issues; only 15% are competency-related, so solutions should focus on systems design, Dr. O'Leary said.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—maybe 450–500 a year, he said. Most reports concern errors that are not easy to hide, such as patient suicides—the top category—and surgical misadventures, the No. 2 category, Dr. O'Leary said. Surprisingly, at least eight cases a month of wrong-site surgery are reported, he added.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without it being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said. Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions according to whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices were followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly.

Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which would provide money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the newly Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said NCQA general counsel Sharon Donohue. But there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group Medically Induced Trauma Support Services, said that patients should not be required to start the claims process, as is proposed under the health court system. An audience member representing Consumers Union said that her group did not like the idea of taking away a patient's right to a jury trial.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are due to systems issues; only 15% are competency-related, so solutions should focus on systems design, Dr. O'Leary said.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—maybe 450–500 a year, he said. Most reports concern errors that are not easy to hide, such as patient suicides—the top category—and surgical misadventures, the No. 2 category, Dr. O'Leary said. Surprisingly, at least eight cases a month of wrong-site surgery are reported, he added.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without it being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said. Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

In one of its last actions, the 109th Congress approved a sweeping tax and health bill that included a 1-year delay in the scheduled cut in physician fees under the federal Medicare program.

In 2007, physicians were due to see a 5% reduction in pay, thanks to targets set by a payment formula known as the Sustainable Growth Rate (SGR). However, under the package agreed upon by the House and Senate in mid-December, physician payments will instead be frozen at 2006 rates.

The fee freeze was included in H.R. 6111, The Tax Relief and Health Care Act of 2006. The bill was signed into law by President Bush last month.

When the pay fix is combined with updates in evaluation and management codes announced by the Centers for Medicare and Medicaid Services (CMS) in November, some physicians will actually see a pay increase in 2007. In addition, physicians will receive a 1.5% bonus if they meet certain quality reporting requirements.

Family physicians and internists are expecting an average 5% increase. That increase takes into account both the fee freeze and the new Evaluation and Management (E & M) rules, which, for instance, increase pay for a mid-level office visit by about $7, or 12%.

“That is the bread and butter code of internal medicine,” said Robert Doherty, a senior vice president for governmental affairs and public policy at the American College of Physicians, in an interview.

While ACP is happy that the cuts mandated by the SGR were averted and that E & M pay is being increased, the organization is still lobbying for a new way to calculate how physicians are paid under Medicare, said Mr. Doherty.

ACP is not alone. Nearly every professional society, a majority of Senators and House members, and many academic experts agree that the SGR needs to be replaced. If nothing is done in 2007, physicians may be looking at reductions of 5%–10% in 2008.

The 2008 cut was at least partially offset by Congress in the tax package. The legislators set aside $1.35 billion from the Medicare Advantage program and applied it toward 2008 payments to physicians.

Physician groups say the Democratic takeover of Congress will not add any special impetus to SGR replacement drive.

“We have not found anyone in Congress who does not agree that this formula is perverse,” said Dr. Cecil Wilson, board chair of the American Medical Association, in an interview. “The difficulty Congress has had is to find the money to do it.”

In the meantime, the Medicare Payment Advisory Commission (MedPAC) has been deliberating on a potential permanent SGR replacement.

At its December meeting, MedPAC staff member Kevin Hayes presented a plan he developed in conjunction with MedPAC Chairman Glenn Hackbarth. Initially, the SGR would be kept, but physicians would be paid bonuses for high performance.

In the second phase, the SGR would be replaced with a payment formula that uses targets and payments based on regional or statewide data, not national data. All of Medicare—hospitals, pharmaceuticals, home health—not just physicians, would be included in the targets. Physicians would be rewarded or penalized based on efficiency. Opportunities to share in savings would come later.

“We are talking realistically about a process that would unfold over a period of years, and I'm thinking more like 5 or 10 years as opposed to next year,” Mr. Hackbarth said.

Mr. Hackbarth noted that not all the MedPAC commissioners were convinced that the SGR should be replaced or that this phase-in was the best way to go. “I don't think there is unanimous agreement on any of these things,” he said.

MedPAC also wrestled with a recommendation on physician fees for 2008. Staff member Christina Boccuti said the commission was recommending a 2% increase. That figure was derived by taking physician price inflation—an estimated 3.3%—and subtracting out the productivity goal of 1.3%.

Ms. Boccuti said the Commission estimated that this increase would be adequate. But Mr. Hackbarth noted that there was no way to predict adequacy.

“The problem that we've often faced with the physician update in recent years is that we're asked to make an update recommendation for a future year when we don't even know what the rates will be for the current year, which is at least a difficult task,” he said.

MedPAC commissioners will vote on a potential SGR fix and payment rates for 2008 at its January meeting and present their final report to Congress in March.

In one of its last actions, the 109th Congress approved a sweeping tax and health bill that included a 1-year delay in the scheduled cut in physician fees under the federal Medicare program.

In 2007, physicians were due to see a 5% reduction in pay, thanks to targets set by a payment formula known as the Sustainable Growth Rate (SGR). However, under the package agreed upon by the House and Senate in mid-December, physician payments will instead be frozen at 2006 rates.

The fee freeze was included in H.R. 6111, The Tax Relief and Health Care Act of 2006. The bill was signed into law by President Bush last month.

When the pay fix is combined with updates in evaluation and management codes announced by the Centers for Medicare and Medicaid Services (CMS) in November, some physicians will actually see a pay increase in 2007. In addition, physicians will receive a 1.5% bonus if they meet certain quality reporting requirements.

Family physicians and internists are expecting an average 5% increase. That increase takes into account both the fee freeze and the new Evaluation and Management (E & M) rules, which, for instance, increase pay for a mid-level office visit by about $7, or 12%.

“That is the bread and butter code of internal medicine,” said Robert Doherty, a senior vice president for governmental affairs and public policy at the American College of Physicians, in an interview.

While ACP is happy that the cuts mandated by the SGR were averted and that E & M pay is being increased, the organization is still lobbying for a new way to calculate how physicians are paid under Medicare, said Mr. Doherty.

ACP is not alone. Nearly every professional society, a majority of Senators and House members, and many academic experts agree that the SGR needs to be replaced. If nothing is done in 2007, physicians may be looking at reductions of 5%–10% in 2008.

The 2008 cut was at least partially offset by Congress in the tax package. The legislators set aside $1.35 billion from the Medicare Advantage program and applied it toward 2008 payments to physicians.

Physician groups say the Democratic takeover of Congress will not add any special impetus to SGR replacement drive.

“We have not found anyone in Congress who does not agree that this formula is perverse,” said Dr. Cecil Wilson, board chair of the American Medical Association, in an interview. “The difficulty Congress has had is to find the money to do it.”

In the meantime, the Medicare Payment Advisory Commission (MedPAC) has been deliberating on a potential permanent SGR replacement.

At its December meeting, MedPAC staff member Kevin Hayes presented a plan he developed in conjunction with MedPAC Chairman Glenn Hackbarth. Initially, the SGR would be kept, but physicians would be paid bonuses for high performance.

In the second phase, the SGR would be replaced with a payment formula that uses targets and payments based on regional or statewide data, not national data. All of Medicare—hospitals, pharmaceuticals, home health—not just physicians, would be included in the targets. Physicians would be rewarded or penalized based on efficiency. Opportunities to share in savings would come later.

“We are talking realistically about a process that would unfold over a period of years, and I'm thinking more like 5 or 10 years as opposed to next year,” Mr. Hackbarth said.

Mr. Hackbarth noted that not all the MedPAC commissioners were convinced that the SGR should be replaced or that this phase-in was the best way to go. “I don't think there is unanimous agreement on any of these things,” he said.

MedPAC also wrestled with a recommendation on physician fees for 2008. Staff member Christina Boccuti said the commission was recommending a 2% increase. That figure was derived by taking physician price inflation—an estimated 3.3%—and subtracting out the productivity goal of 1.3%.

Ms. Boccuti said the Commission estimated that this increase would be adequate. But Mr. Hackbarth noted that there was no way to predict adequacy.

“The problem that we've often faced with the physician update in recent years is that we're asked to make an update recommendation for a future year when we don't even know what the rates will be for the current year, which is at least a difficult task,” he said.

MedPAC commissioners will vote on a potential SGR fix and payment rates for 2008 at its January meeting and present their final report to Congress in March.

In one of its last actions, the 109th Congress approved a sweeping tax and health bill that included a 1-year delay in the scheduled cut in physician fees under the federal Medicare program.

In 2007, physicians were due to see a 5% reduction in pay, thanks to targets set by a payment formula known as the Sustainable Growth Rate (SGR). However, under the package agreed upon by the House and Senate in mid-December, physician payments will instead be frozen at 2006 rates.

The fee freeze was included in H.R. 6111, The Tax Relief and Health Care Act of 2006. The bill was signed into law by President Bush last month.

When the pay fix is combined with updates in evaluation and management codes announced by the Centers for Medicare and Medicaid Services (CMS) in November, some physicians will actually see a pay increase in 2007. In addition, physicians will receive a 1.5% bonus if they meet certain quality reporting requirements.

Family physicians and internists are expecting an average 5% increase. That increase takes into account both the fee freeze and the new Evaluation and Management (E & M) rules, which, for instance, increase pay for a mid-level office visit by about $7, or 12%.

“That is the bread and butter code of internal medicine,” said Robert Doherty, a senior vice president for governmental affairs and public policy at the American College of Physicians, in an interview.

While ACP is happy that the cuts mandated by the SGR were averted and that E & M pay is being increased, the organization is still lobbying for a new way to calculate how physicians are paid under Medicare, said Mr. Doherty.

ACP is not alone. Nearly every professional society, a majority of Senators and House members, and many academic experts agree that the SGR needs to be replaced. If nothing is done in 2007, physicians may be looking at reductions of 5%–10% in 2008.

The 2008 cut was at least partially offset by Congress in the tax package. The legislators set aside $1.35 billion from the Medicare Advantage program and applied it toward 2008 payments to physicians.

Physician groups say the Democratic takeover of Congress will not add any special impetus to SGR replacement drive.

“We have not found anyone in Congress who does not agree that this formula is perverse,” said Dr. Cecil Wilson, board chair of the American Medical Association, in an interview. “The difficulty Congress has had is to find the money to do it.”

In the meantime, the Medicare Payment Advisory Commission (MedPAC) has been deliberating on a potential permanent SGR replacement.

At its December meeting, MedPAC staff member Kevin Hayes presented a plan he developed in conjunction with MedPAC Chairman Glenn Hackbarth. Initially, the SGR would be kept, but physicians would be paid bonuses for high performance.

In the second phase, the SGR would be replaced with a payment formula that uses targets and payments based on regional or statewide data, not national data. All of Medicare—hospitals, pharmaceuticals, home health—not just physicians, would be included in the targets. Physicians would be rewarded or penalized based on efficiency. Opportunities to share in savings would come later.

“We are talking realistically about a process that would unfold over a period of years, and I'm thinking more like 5 or 10 years as opposed to next year,” Mr. Hackbarth said.

Mr. Hackbarth noted that not all the MedPAC commissioners were convinced that the SGR should be replaced or that this phase-in was the best way to go. “I don't think there is unanimous agreement on any of these things,” he said.

MedPAC also wrestled with a recommendation on physician fees for 2008. Staff member Christina Boccuti said the commission was recommending a 2% increase. That figure was derived by taking physician price inflation—an estimated 3.3%—and subtracting out the productivity goal of 1.3%.

Ms. Boccuti said the Commission estimated that this increase would be adequate. But Mr. Hackbarth noted that there was no way to predict adequacy.

“The problem that we've often faced with the physician update in recent years is that we're asked to make an update recommendation for a future year when we don't even know what the rates will be for the current year, which is at least a difficult task,” he said.

MedPAC commissioners will vote on a potential SGR fix and payment rates for 2008 at its January meeting and present their final report to Congress in March.

WASHINGTON — Patients who read at or below the 6th-grade level had a low level of comprehension of instructions on the labels of five commonly-used medications, according to a study led by Terry Davis, Ph.D., of the Louisiana State University.

Even though labels seem short and to the point, “many patients need more specific, concrete information,” including instructions on exactly what time of day to take a medication, Dr. Davis said in presenting the findings at a conference on health literacy sponsored by the American College of Physicians.

Along with colleagues at Northwestern University, the University of North Carolina, Western Michigan Area Health Education Center, and Emory University, she queried 395 patients at three clinics that primarily serve the indigent about their understanding of labels for the following drugs: amoxicillin for pediatric use, trimethoprim, guaifenesin, felodipine, and furosemide.

The study was published online at the Annals of Internal Medicine Web site (www.annals.org/cgi/content/full/0000605-200612190-00144v1

The goal was to determine whether primary care patients could read and correctly state how to take medicines after reading the labels on actual pill bottles, Dr. Davis said. The researchers hypothesized that patients with low literacy were more likely to misunderstand instructions. They also believed that the increasing number of medications taken by Americans is leading to growing confusion and medication errors.

Participants spoke English as a primary language and were not hearing or vision impaired. Half were African American, and half were white. The mean age was 45 years, and 29% had a less than high school education. Literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM) test. Of the 395 patients, 19% (75) were deemed to have low literacy, reading at or below a 6th-grade level, and 29% (114) had marginal literacy, reading at the 7th- to 8th-grade level.

All patients were asked how they would take the medicine. A “correct” answer was given if they included all aspects of the label instruction. Overall, 47% (185) of patients misunderstood at least one of the instructions. For marginal literacy patients, 51% (201) misunderstood one or more instructions, and for low literacy patients, 63% (249) misunderstood.

The majority—91%, or 359 patients—understood the felodipine instructions, which were, “Take one tablet by mouth once each day.” The lowest level of comprehension was for trimethoprim, which had a label instructing to “take one tablet by mouth twice daily for seven days.”

Higher literacy patients routinely understood instructions better than those with lower literacy, Dr. Davis said. The adjusted odds ratio of misunderstanding for low literacy was 2.32, and for marginal literacy, 1.94. Most misunderstandings had to do with dosage. For instance, patients commonly believed they should give children a tablespoon instead of a teaspoon of amoxicillin.

Patients who took more medications were also more likely to misunderstand labels, with the adjusted relative risk rising from 2.29 for one to two medications to 2.98 for five or more medications.

In a substudy, patients were tested on their understanding of the instruction, “Take two tablets by mouth twice daily,” on a bottle of guaifenesin. Overall, 84% were able to correctly state the instruction, but fewer patients knew how many pills to take. Among those with adequate literacy, 80% counted out the correct number of pills. That ability decreased with declining literacy: 63% of marginal literacy patients and 35% of those with low literacy. Dr. Davis and colleagues said that although this may have reflected patients' numeracy skills more than reading skills, numeracy is an aspect of literacy.

Study limitations included the fact that the authors examined understanding of the primary label only. They did not assess patients' actual compliance or drug-taking behavior, whether medication errors occurred, or if any of the patients had experience with any of the five medications.

In an editorial accompanying Dr. Davis' study (www.annals.org/cgi/content/full/0000605-200612190-00145v1

But, he added, that “does not weaken the conclusion that many patients do not comprehend prescription labels and cannot act on their instructions,” said Dr. Schillinger, of the University of California, San Francisco.

He said the study should prod physicians to routinely ask patients if they understand what medications they have been prescribed and how to correctly take them.

This Month's Talk Back Questions

What has been your experience in caring for patients with low health literacy?

WASHINGTON — Patients who read at or below the 6th-grade level had a low level of comprehension of instructions on the labels of five commonly-used medications, according to a study led by Terry Davis, Ph.D., of the Louisiana State University.

Even though labels seem short and to the point, “many patients need more specific, concrete information,” including instructions on exactly what time of day to take a medication, Dr. Davis said in presenting the findings at a conference on health literacy sponsored by the American College of Physicians.

Along with colleagues at Northwestern University, the University of North Carolina, Western Michigan Area Health Education Center, and Emory University, she queried 395 patients at three clinics that primarily serve the indigent about their understanding of labels for the following drugs: amoxicillin for pediatric use, trimethoprim, guaifenesin, felodipine, and furosemide.

The study was published online at the Annals of Internal Medicine Web site (www.annals.org/cgi/content/full/0000605-200612190-00144v1

The goal was to determine whether primary care patients could read and correctly state how to take medicines after reading the labels on actual pill bottles, Dr. Davis said. The researchers hypothesized that patients with low literacy were more likely to misunderstand instructions. They also believed that the increasing number of medications taken by Americans is leading to growing confusion and medication errors.

Participants spoke English as a primary language and were not hearing or vision impaired. Half were African American, and half were white. The mean age was 45 years, and 29% had a less than high school education. Literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM) test. Of the 395 patients, 19% (75) were deemed to have low literacy, reading at or below a 6th-grade level, and 29% (114) had marginal literacy, reading at the 7th- to 8th-grade level.

All patients were asked how they would take the medicine. A “correct” answer was given if they included all aspects of the label instruction. Overall, 47% (185) of patients misunderstood at least one of the instructions. For marginal literacy patients, 51% (201) misunderstood one or more instructions, and for low literacy patients, 63% (249) misunderstood.

The majority—91%, or 359 patients—understood the felodipine instructions, which were, “Take one tablet by mouth once each day.” The lowest level of comprehension was for trimethoprim, which had a label instructing to “take one tablet by mouth twice daily for seven days.”

Higher literacy patients routinely understood instructions better than those with lower literacy, Dr. Davis said. The adjusted odds ratio of misunderstanding for low literacy was 2.32, and for marginal literacy, 1.94. Most misunderstandings had to do with dosage. For instance, patients commonly believed they should give children a tablespoon instead of a teaspoon of amoxicillin.

Patients who took more medications were also more likely to misunderstand labels, with the adjusted relative risk rising from 2.29 for one to two medications to 2.98 for five or more medications.

In a substudy, patients were tested on their understanding of the instruction, “Take two tablets by mouth twice daily,” on a bottle of guaifenesin. Overall, 84% were able to correctly state the instruction, but fewer patients knew how many pills to take. Among those with adequate literacy, 80% counted out the correct number of pills. That ability decreased with declining literacy: 63% of marginal literacy patients and 35% of those with low literacy. Dr. Davis and colleagues said that although this may have reflected patients' numeracy skills more than reading skills, numeracy is an aspect of literacy.

Study limitations included the fact that the authors examined understanding of the primary label only. They did not assess patients' actual compliance or drug-taking behavior, whether medication errors occurred, or if any of the patients had experience with any of the five medications.

In an editorial accompanying Dr. Davis' study (www.annals.org/cgi/content/full/0000605-200612190-00145v1

But, he added, that “does not weaken the conclusion that many patients do not comprehend prescription labels and cannot act on their instructions,” said Dr. Schillinger, of the University of California, San Francisco.

He said the study should prod physicians to routinely ask patients if they understand what medications they have been prescribed and how to correctly take them.

This Month's Talk Back Questions

What has been your experience in caring for patients with low health literacy?

WASHINGTON — Patients who read at or below the 6th-grade level had a low level of comprehension of instructions on the labels of five commonly-used medications, according to a study led by Terry Davis, Ph.D., of the Louisiana State University.

Even though labels seem short and to the point, “many patients need more specific, concrete information,” including instructions on exactly what time of day to take a medication, Dr. Davis said in presenting the findings at a conference on health literacy sponsored by the American College of Physicians.

Along with colleagues at Northwestern University, the University of North Carolina, Western Michigan Area Health Education Center, and Emory University, she queried 395 patients at three clinics that primarily serve the indigent about their understanding of labels for the following drugs: amoxicillin for pediatric use, trimethoprim, guaifenesin, felodipine, and furosemide.

The study was published online at the Annals of Internal Medicine Web site (www.annals.org/cgi/content/full/0000605-200612190-00144v1

The goal was to determine whether primary care patients could read and correctly state how to take medicines after reading the labels on actual pill bottles, Dr. Davis said. The researchers hypothesized that patients with low literacy were more likely to misunderstand instructions. They also believed that the increasing number of medications taken by Americans is leading to growing confusion and medication errors.

Participants spoke English as a primary language and were not hearing or vision impaired. Half were African American, and half were white. The mean age was 45 years, and 29% had a less than high school education. Literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine (REALM) test. Of the 395 patients, 19% (75) were deemed to have low literacy, reading at or below a 6th-grade level, and 29% (114) had marginal literacy, reading at the 7th- to 8th-grade level.

All patients were asked how they would take the medicine. A “correct” answer was given if they included all aspects of the label instruction. Overall, 47% (185) of patients misunderstood at least one of the instructions. For marginal literacy patients, 51% (201) misunderstood one or more instructions, and for low literacy patients, 63% (249) misunderstood.

The majority—91%, or 359 patients—understood the felodipine instructions, which were, “Take one tablet by mouth once each day.” The lowest level of comprehension was for trimethoprim, which had a label instructing to “take one tablet by mouth twice daily for seven days.”

Higher literacy patients routinely understood instructions better than those with lower literacy, Dr. Davis said. The adjusted odds ratio of misunderstanding for low literacy was 2.32, and for marginal literacy, 1.94. Most misunderstandings had to do with dosage. For instance, patients commonly believed they should give children a tablespoon instead of a teaspoon of amoxicillin.

Patients who took more medications were also more likely to misunderstand labels, with the adjusted relative risk rising from 2.29 for one to two medications to 2.98 for five or more medications.

In a substudy, patients were tested on their understanding of the instruction, “Take two tablets by mouth twice daily,” on a bottle of guaifenesin. Overall, 84% were able to correctly state the instruction, but fewer patients knew how many pills to take. Among those with adequate literacy, 80% counted out the correct number of pills. That ability decreased with declining literacy: 63% of marginal literacy patients and 35% of those with low literacy. Dr. Davis and colleagues said that although this may have reflected patients' numeracy skills more than reading skills, numeracy is an aspect of literacy.

Study limitations included the fact that the authors examined understanding of the primary label only. They did not assess patients' actual compliance or drug-taking behavior, whether medication errors occurred, or if any of the patients had experience with any of the five medications.

In an editorial accompanying Dr. Davis' study (www.annals.org/cgi/content/full/0000605-200612190-00145v1

But, he added, that “does not weaken the conclusion that many patients do not comprehend prescription labels and cannot act on their instructions,” said Dr. Schillinger, of the University of California, San Francisco.

He said the study should prod physicians to routinely ask patients if they understand what medications they have been prescribed and how to correctly take them.

This Month's Talk Back Questions

What has been your experience in caring for patients with low health literacy?

In one of its last actions, the 109th Congress approved a sweeping tax and health bill that included a 1-year delay in the scheduled cut in physician fees under the federal Medicare program.

This year, physicians were due to see a 5% reduction in pay, thanks to targets set by a payment formula known as the Sustainable Growth Rate (SGR). However, under the package agreed upon by the House and Senate in mid-December, physician payments will instead be frozen at 2006 rates.

The fee freeze was included in H.R. 6111, The Tax Relief and Health Care Act of 2006, which was signed into law by President Bush.

When the pay fix is combined with updates in evaluation and management codes announced by the Centers for Medicare and Medicaid Services (CMS), some physicians will actually see a pay increase this year. In addition, physicians will receive a 1.5% bonus if they meet certain quality reporting requirements.

Family physicians and internists are expecting an average 5% increase. That increase takes into account both the fee freeze and the new Evaluation and Management (E&M) rules, which, for instance, increase pay for a mid-level office visit by about $7, or 12%.

“That is the bread and butter code of internal medicine,” said Robert Doherty, a senior vice president for governmental affairs and public policy at the American College of Physicians, in an interview.

While ACP is happy that the cuts mandated by the SGR were averted and that E&M pay is being increased, the organization is still lobbying for a new way to calculate how physicians are paid under Medicare, said Mr. Doherty.

ACP is not alone. Nearly every professional society, a majority of Senators and House members, and many academic experts agree that the SGR needs to be replaced. If nothing is done this year, physicians may be looking at reductions of 5%–10% in 2008.

The 2008 cut was at least partially offset by Congress in the tax package. The legislators set aside $1.35 billion from the Medicare Advantage program and applied it toward 2008 payments to physicians.

Physician groups say the Democratic takeover of Congress will not add any special impetus to SGR replacement drive.

“We have not found anyone in Congress who does not agree that this formula is perverse,” said Dr. Cecil Wilson, board chair of the American Medical Association, in an interview. “The difficulty Congress has had is to find the money to do it.”

Mr. Doherty agrees that money is the issue, not politics. Democrats, however, tend to be more concerned with the impact any SGR fix will have on beneficiaries' out-of-pocket costs, he said. Even so, “I fully expect that they will make a valiant effort to find a way out of this,” said Mr. Doherty.

Physicians registered another victory with the Tax and Health Care Relief Act. Legislators directed the Health and Human Services department to establish a Medicare “Medical Home Demonstration Project.” The program was developed and espoused by the ACP and the American Association of Family Physicians.

The 3-year pilot will take place in eight states. Physicians in practices of any size will be eligible to receive a payment for coordinating care for people with chronic illness. If they meet certain criteria, they will also get 80% of the savings if a hospitalization is avoided.

“Even though it's just a pilot, it creates a foundation for a fundamental revamping of Medicare payment policy,” Mr. Doherty said. The Medicare Payment Advisory Commission (MedPAC) has been deliberating on a potential permanent SGR replacement.

At its December meeting, MedPAC staff member Kevin Hayes presented a plan he developed in conjunction with MedPAC Chairman Glenn Hackbarth. Initially, the SGR would be kept, but physicians would be paid bonuses for high performance.

In the second phase, the SGR would be replaced with a payment formula that uses targets and payments based on regional or statewide data, not national data. All of Medicare—hospitals, pharmaceuticals, home health—not just physicians, would be included in the targets. Physicians would be rewarded or penalized based on efficiency. Opportunities to share in savings would come later.

“We are talking realistically about a process that would unfold over a period of years, and I'm thinking more like 5 or 10 years as opposed to next year,” Mr. Hackbarth said, noting that not all the MedPAC commissioners were convinced that the SGR should be replaced or that this phase in was the best way to go. “I don't think there is unanimous agreement on any of these things, let alone on all of the pieces,” he said.

MedPAC also wrestled with a recommendation on physician fees for 2008. Staff member Christina Boccuti said the commission was recommending a 2% increase. That figure was derived by taking physician price inflation—an estimated 3.3%—and subtracting out the productivity goal of 1.3%.

Ms. Boccuti said the Commission estimated that this increase would be adequate. But Mr. Hackbarth noted that there was no way to predict adequacy.

“The problem that we've often faced with the physician update in recent years is that we're asked to make an update recommendation for a future year when we don't even know what the rates will be for the current year, which is at least a difficult task,” he said.

MedPAC commissioners will vote on a potential SGR fix and payment rates for 2008 at its meeting this month and present their final report to Congress in March.

In one of its last actions, the 109th Congress approved a sweeping tax and health bill that included a 1-year delay in the scheduled cut in physician fees under the federal Medicare program.

This year, physicians were due to see a 5% reduction in pay, thanks to targets set by a payment formula known as the Sustainable Growth Rate (SGR). However, under the package agreed upon by the House and Senate in mid-December, physician payments will instead be frozen at 2006 rates.

The fee freeze was included in H.R. 6111, The Tax Relief and Health Care Act of 2006, which was signed into law by President Bush.

When the pay fix is combined with updates in evaluation and management codes announced by the Centers for Medicare and Medicaid Services (CMS), some physicians will actually see a pay increase this year. In addition, physicians will receive a 1.5% bonus if they meet certain quality reporting requirements.

Family physicians and internists are expecting an average 5% increase. That increase takes into account both the fee freeze and the new Evaluation and Management (E&M) rules, which, for instance, increase pay for a mid-level office visit by about $7, or 12%.

“That is the bread and butter code of internal medicine,” said Robert Doherty, a senior vice president for governmental affairs and public policy at the American College of Physicians, in an interview.

While ACP is happy that the cuts mandated by the SGR were averted and that E&M pay is being increased, the organization is still lobbying for a new way to calculate how physicians are paid under Medicare, said Mr. Doherty.

ACP is not alone. Nearly every professional society, a majority of Senators and House members, and many academic experts agree that the SGR needs to be replaced. If nothing is done this year, physicians may be looking at reductions of 5%–10% in 2008.

The 2008 cut was at least partially offset by Congress in the tax package. The legislators set aside $1.35 billion from the Medicare Advantage program and applied it toward 2008 payments to physicians.

Physician groups say the Democratic takeover of Congress will not add any special impetus to SGR replacement drive.

“We have not found anyone in Congress who does not agree that this formula is perverse,” said Dr. Cecil Wilson, board chair of the American Medical Association, in an interview. “The difficulty Congress has had is to find the money to do it.”

Mr. Doherty agrees that money is the issue, not politics. Democrats, however, tend to be more concerned with the impact any SGR fix will have on beneficiaries' out-of-pocket costs, he said. Even so, “I fully expect that they will make a valiant effort to find a way out of this,” said Mr. Doherty.

Physicians registered another victory with the Tax and Health Care Relief Act. Legislators directed the Health and Human Services department to establish a Medicare “Medical Home Demonstration Project.” The program was developed and espoused by the ACP and the American Association of Family Physicians.

The 3-year pilot will take place in eight states. Physicians in practices of any size will be eligible to receive a payment for coordinating care for people with chronic illness. If they meet certain criteria, they will also get 80% of the savings if a hospitalization is avoided.

“Even though it's just a pilot, it creates a foundation for a fundamental revamping of Medicare payment policy,” Mr. Doherty said. The Medicare Payment Advisory Commission (MedPAC) has been deliberating on a potential permanent SGR replacement.

At its December meeting, MedPAC staff member Kevin Hayes presented a plan he developed in conjunction with MedPAC Chairman Glenn Hackbarth. Initially, the SGR would be kept, but physicians would be paid bonuses for high performance.

In the second phase, the SGR would be replaced with a payment formula that uses targets and payments based on regional or statewide data, not national data. All of Medicare—hospitals, pharmaceuticals, home health—not just physicians, would be included in the targets. Physicians would be rewarded or penalized based on efficiency. Opportunities to share in savings would come later.

“We are talking realistically about a process that would unfold over a period of years, and I'm thinking more like 5 or 10 years as opposed to next year,” Mr. Hackbarth said, noting that not all the MedPAC commissioners were convinced that the SGR should be replaced or that this phase in was the best way to go. “I don't think there is unanimous agreement on any of these things, let alone on all of the pieces,” he said.

MedPAC also wrestled with a recommendation on physician fees for 2008. Staff member Christina Boccuti said the commission was recommending a 2% increase. That figure was derived by taking physician price inflation—an estimated 3.3%—and subtracting out the productivity goal of 1.3%.

Ms. Boccuti said the Commission estimated that this increase would be adequate. But Mr. Hackbarth noted that there was no way to predict adequacy.

“The problem that we've often faced with the physician update in recent years is that we're asked to make an update recommendation for a future year when we don't even know what the rates will be for the current year, which is at least a difficult task,” he said.

MedPAC commissioners will vote on a potential SGR fix and payment rates for 2008 at its meeting this month and present their final report to Congress in March.

In one of its last actions, the 109th Congress approved a sweeping tax and health bill that included a 1-year delay in the scheduled cut in physician fees under the federal Medicare program.

This year, physicians were due to see a 5% reduction in pay, thanks to targets set by a payment formula known as the Sustainable Growth Rate (SGR). However, under the package agreed upon by the House and Senate in mid-December, physician payments will instead be frozen at 2006 rates.

The fee freeze was included in H.R. 6111, The Tax Relief and Health Care Act of 2006, which was signed into law by President Bush.

When the pay fix is combined with updates in evaluation and management codes announced by the Centers for Medicare and Medicaid Services (CMS), some physicians will actually see a pay increase this year. In addition, physicians will receive a 1.5% bonus if they meet certain quality reporting requirements.

Family physicians and internists are expecting an average 5% increase. That increase takes into account both the fee freeze and the new Evaluation and Management (E&M) rules, which, for instance, increase pay for a mid-level office visit by about $7, or 12%.

“That is the bread and butter code of internal medicine,” said Robert Doherty, a senior vice president for governmental affairs and public policy at the American College of Physicians, in an interview.

While ACP is happy that the cuts mandated by the SGR were averted and that E&M pay is being increased, the organization is still lobbying for a new way to calculate how physicians are paid under Medicare, said Mr. Doherty.

ACP is not alone. Nearly every professional society, a majority of Senators and House members, and many academic experts agree that the SGR needs to be replaced. If nothing is done this year, physicians may be looking at reductions of 5%–10% in 2008.

The 2008 cut was at least partially offset by Congress in the tax package. The legislators set aside $1.35 billion from the Medicare Advantage program and applied it toward 2008 payments to physicians.

Physician groups say the Democratic takeover of Congress will not add any special impetus to SGR replacement drive.

“We have not found anyone in Congress who does not agree that this formula is perverse,” said Dr. Cecil Wilson, board chair of the American Medical Association, in an interview. “The difficulty Congress has had is to find the money to do it.”

Mr. Doherty agrees that money is the issue, not politics. Democrats, however, tend to be more concerned with the impact any SGR fix will have on beneficiaries' out-of-pocket costs, he said. Even so, “I fully expect that they will make a valiant effort to find a way out of this,” said Mr. Doherty.

Physicians registered another victory with the Tax and Health Care Relief Act. Legislators directed the Health and Human Services department to establish a Medicare “Medical Home Demonstration Project.” The program was developed and espoused by the ACP and the American Association of Family Physicians.

The 3-year pilot will take place in eight states. Physicians in practices of any size will be eligible to receive a payment for coordinating care for people with chronic illness. If they meet certain criteria, they will also get 80% of the savings if a hospitalization is avoided.

“Even though it's just a pilot, it creates a foundation for a fundamental revamping of Medicare payment policy,” Mr. Doherty said. The Medicare Payment Advisory Commission (MedPAC) has been deliberating on a potential permanent SGR replacement.

At its December meeting, MedPAC staff member Kevin Hayes presented a plan he developed in conjunction with MedPAC Chairman Glenn Hackbarth. Initially, the SGR would be kept, but physicians would be paid bonuses for high performance.

In the second phase, the SGR would be replaced with a payment formula that uses targets and payments based on regional or statewide data, not national data. All of Medicare—hospitals, pharmaceuticals, home health—not just physicians, would be included in the targets. Physicians would be rewarded or penalized based on efficiency. Opportunities to share in savings would come later.

“We are talking realistically about a process that would unfold over a period of years, and I'm thinking more like 5 or 10 years as opposed to next year,” Mr. Hackbarth said, noting that not all the MedPAC commissioners were convinced that the SGR should be replaced or that this phase in was the best way to go. “I don't think there is unanimous agreement on any of these things, let alone on all of the pieces,” he said.

MedPAC also wrestled with a recommendation on physician fees for 2008. Staff member Christina Boccuti said the commission was recommending a 2% increase. That figure was derived by taking physician price inflation—an estimated 3.3%—and subtracting out the productivity goal of 1.3%.

Ms. Boccuti said the Commission estimated that this increase would be adequate. But Mr. Hackbarth noted that there was no way to predict adequacy.

“The problem that we've often faced with the physician update in recent years is that we're asked to make an update recommendation for a future year when we don't even know what the rates will be for the current year, which is at least a difficult task,” he said.

MedPAC commissioners will vote on a potential SGR fix and payment rates for 2008 at its meeting this month and present their final report to Congress in March.

Surprise! DES Suits Filed

It didn't take long—the nation's plaintiffs' attorneys have begun recruiting clients who allegedly were harmed by a drug-eluting stent. One suit, filed in Palm Beach, Fla., County Circuit Court, claims that Johnson & Johnson's Cordis unit failed to warn that its Cypher stent might be associated with a higher risk of clotting, heart attack, and death. The plaintiff, 46-year-old Sean O'Shea, said that he began having chest pains after he stopped taking clopidogrel (Plavix), which he'd taken after two procedures in 2005 in which he received five stents. Mr. O'Shea's attorneys, Babbitt, Johnson, Osborne, and LeClainche of West Palm Beach, allege that he suffers permanent disability, mostly from bleeding related to his now-resumed Plavix regimen. Plaintiffs' attorney firms have set up Web sites to recruit patients, including Pulaski & Middleman's

www.drugcoatedstentattorney.com

http://taxus.vanosteen.com

Generic Plavix Blocked Again

The reintroduction of a generic version of Plavix just got pushed further off into the future. The U.S. Court of Appeals for the Federal Circuit in Washington ruled last month that generic sales should be halted until the Plavix patent can be validated. The ruling was the latest in an ongoing battle among generic maker Apotex Inc. and the two companies that make and sell Plavix, Sanofi-Aventis and Bristol-Myers Squibb, which allege patent infringement by Apotex. In late August, the U.S. District Court for the Southern District of New York ruled in favor of the brand name companies and granted a preliminary injunction against sales of the generic, which had been on the market a few weeks. Apotex did not have to recall product already in distribution. The generic had made a significant dent in Plavix sales, pegged at $6.3 billion worldwide in 2005.

New Code for Plaque Test

The American Medical Association has issued a unique category I CPT code for a diagnostic that measures lipoprotein-associated phospholipase A2. That inflammatory enzyme is found in unstable, rupture-prone plaque. The only Food and Drug Administration-approved test is made and sold by diaDexus of South San Francisco. The company said the code—83698—was issued under the pathology and laboratory section of the CPT I schedule. The Centers for Medicare and Medicaid Services is recommending a payment of $47.43 for the blood test, effective January 1, 2007.

ACC-MedAxiom Alliance

The American College of Cardiology is joining forces with the quality improvement consulting company MedAxiom. ACC will promote MedAxiom's programs to its members, and MedAxiom will do likewise to its client base. Through March 2007, MedAxiom is offering ACC members a 10% discount on subscriptions to its services, which include statistical analyses and benchmark reporting systems, workflow and process redesign, and strategic planning. The two organizations also are developing a leadership institute, which they expect to launch in 2007, according to the ACC.

Von Eschenbach Confirmed for FDA

Almost 9 months after he was first nominated to be commissioner of the FDA, Dr. Andrew von Eschenbach was finally confirmed by the Senate by an 80–11 vote in the wee hours of the 109th Congress. Confirmation came after an 89–6 vote to limit debate on his nomination. The naysayers included Sen. Chuck Grassley (R-Iowa), who voted against invoking cloture and against confirmation. Sen. Grassley has been one of Dr. von Eschenbach's most vocal critics. As chairman of the Finance Committee, he and his staff have been investigating what they call an inappropriate approval of the antibiotic Ketek (telithromycin). Sen. Grassley maintains that Dr. von Eschenbach has stonewalled committee investigators, and in an agitated floor statement during the nomination vote, he accused the nominee of hiding documents and intimidating FDA employees who dissented. With Democrats taking control of Congress, Sen. Grassley will lose his Finance Committee chairmanship. But he warned his colleagues across the aisle that Dr. von Eschenbach was a prime illustration of concerns about the lack of Senate oversight of the Bush administration. “I believe we need to send a message to the executive branch that it's not okay to impede congressional investigations. It's not okay to limit the Senate's access to documents, information, and employees of the executive branch,” the senator said.

Poll: No Off-Label Use

About half of Americans said physicians should not be allowed to prescribe pharmaceuticals for unapproved uses, according to a recent WSJ.com/Harris Interactive poll. About half of those polled—approximately 3,000 adults in November—were not even aware that the FDA allowed off-label prescribing. But, 48% said it should not be allowed; 27% said it was fine, and 24% were not sure. A majority (69%) said drug companies should not be allowed to promote off-label uses, while only 12% said this was permissible. Sixty-two percent said they strongly agreed with the statement that prescription drug use for unapproved indications should be prohibited except in a clinical study.

Surprise! DES Suits Filed

It didn't take long—the nation's plaintiffs' attorneys have begun recruiting clients who allegedly were harmed by a drug-eluting stent. One suit, filed in Palm Beach, Fla., County Circuit Court, claims that Johnson & Johnson's Cordis unit failed to warn that its Cypher stent might be associated with a higher risk of clotting, heart attack, and death. The plaintiff, 46-year-old Sean O'Shea, said that he began having chest pains after he stopped taking clopidogrel (Plavix), which he'd taken after two procedures in 2005 in which he received five stents. Mr. O'Shea's attorneys, Babbitt, Johnson, Osborne, and LeClainche of West Palm Beach, allege that he suffers permanent disability, mostly from bleeding related to his now-resumed Plavix regimen. Plaintiffs' attorney firms have set up Web sites to recruit patients, including Pulaski & Middleman's

www.drugcoatedstentattorney.com

http://taxus.vanosteen.com

Generic Plavix Blocked Again

The reintroduction of a generic version of Plavix just got pushed further off into the future. The U.S. Court of Appeals for the Federal Circuit in Washington ruled last month that generic sales should be halted until the Plavix patent can be validated. The ruling was the latest in an ongoing battle among generic maker Apotex Inc. and the two companies that make and sell Plavix, Sanofi-Aventis and Bristol-Myers Squibb, which allege patent infringement by Apotex. In late August, the U.S. District Court for the Southern District of New York ruled in favor of the brand name companies and granted a preliminary injunction against sales of the generic, which had been on the market a few weeks. Apotex did not have to recall product already in distribution. The generic had made a significant dent in Plavix sales, pegged at $6.3 billion worldwide in 2005.

New Code for Plaque Test

The American Medical Association has issued a unique category I CPT code for a diagnostic that measures lipoprotein-associated phospholipase A2. That inflammatory enzyme is found in unstable, rupture-prone plaque. The only Food and Drug Administration-approved test is made and sold by diaDexus of South San Francisco. The company said the code—83698—was issued under the pathology and laboratory section of the CPT I schedule. The Centers for Medicare and Medicaid Services is recommending a payment of $47.43 for the blood test, effective January 1, 2007.

ACC-MedAxiom Alliance

The American College of Cardiology is joining forces with the quality improvement consulting company MedAxiom. ACC will promote MedAxiom's programs to its members, and MedAxiom will do likewise to its client base. Through March 2007, MedAxiom is offering ACC members a 10% discount on subscriptions to its services, which include statistical analyses and benchmark reporting systems, workflow and process redesign, and strategic planning. The two organizations also are developing a leadership institute, which they expect to launch in 2007, according to the ACC.

Von Eschenbach Confirmed for FDA

Almost 9 months after he was first nominated to be commissioner of the FDA, Dr. Andrew von Eschenbach was finally confirmed by the Senate by an 80–11 vote in the wee hours of the 109th Congress. Confirmation came after an 89–6 vote to limit debate on his nomination. The naysayers included Sen. Chuck Grassley (R-Iowa), who voted against invoking cloture and against confirmation. Sen. Grassley has been one of Dr. von Eschenbach's most vocal critics. As chairman of the Finance Committee, he and his staff have been investigating what they call an inappropriate approval of the antibiotic Ketek (telithromycin). Sen. Grassley maintains that Dr. von Eschenbach has stonewalled committee investigators, and in an agitated floor statement during the nomination vote, he accused the nominee of hiding documents and intimidating FDA employees who dissented. With Democrats taking control of Congress, Sen. Grassley will lose his Finance Committee chairmanship. But he warned his colleagues across the aisle that Dr. von Eschenbach was a prime illustration of concerns about the lack of Senate oversight of the Bush administration. “I believe we need to send a message to the executive branch that it's not okay to impede congressional investigations. It's not okay to limit the Senate's access to documents, information, and employees of the executive branch,” the senator said.

Poll: No Off-Label Use

About half of Americans said physicians should not be allowed to prescribe pharmaceuticals for unapproved uses, according to a recent WSJ.com/Harris Interactive poll. About half of those polled—approximately 3,000 adults in November—were not even aware that the FDA allowed off-label prescribing. But, 48% said it should not be allowed; 27% said it was fine, and 24% were not sure. A majority (69%) said drug companies should not be allowed to promote off-label uses, while only 12% said this was permissible. Sixty-two percent said they strongly agreed with the statement that prescription drug use for unapproved indications should be prohibited except in a clinical study.

Surprise! DES Suits Filed

It didn't take long—the nation's plaintiffs' attorneys have begun recruiting clients who allegedly were harmed by a drug-eluting stent. One suit, filed in Palm Beach, Fla., County Circuit Court, claims that Johnson & Johnson's Cordis unit failed to warn that its Cypher stent might be associated with a higher risk of clotting, heart attack, and death. The plaintiff, 46-year-old Sean O'Shea, said that he began having chest pains after he stopped taking clopidogrel (Plavix), which he'd taken after two procedures in 2005 in which he received five stents. Mr. O'Shea's attorneys, Babbitt, Johnson, Osborne, and LeClainche of West Palm Beach, allege that he suffers permanent disability, mostly from bleeding related to his now-resumed Plavix regimen. Plaintiffs' attorney firms have set up Web sites to recruit patients, including Pulaski & Middleman's

www.drugcoatedstentattorney.com

http://taxus.vanosteen.com

Generic Plavix Blocked Again

The reintroduction of a generic version of Plavix just got pushed further off into the future. The U.S. Court of Appeals for the Federal Circuit in Washington ruled last month that generic sales should be halted until the Plavix patent can be validated. The ruling was the latest in an ongoing battle among generic maker Apotex Inc. and the two companies that make and sell Plavix, Sanofi-Aventis and Bristol-Myers Squibb, which allege patent infringement by Apotex. In late August, the U.S. District Court for the Southern District of New York ruled in favor of the brand name companies and granted a preliminary injunction against sales of the generic, which had been on the market a few weeks. Apotex did not have to recall product already in distribution. The generic had made a significant dent in Plavix sales, pegged at $6.3 billion worldwide in 2005.

New Code for Plaque Test

The American Medical Association has issued a unique category I CPT code for a diagnostic that measures lipoprotein-associated phospholipase A2. That inflammatory enzyme is found in unstable, rupture-prone plaque. The only Food and Drug Administration-approved test is made and sold by diaDexus of South San Francisco. The company said the code—83698—was issued under the pathology and laboratory section of the CPT I schedule. The Centers for Medicare and Medicaid Services is recommending a payment of $47.43 for the blood test, effective January 1, 2007.

ACC-MedAxiom Alliance

The American College of Cardiology is joining forces with the quality improvement consulting company MedAxiom. ACC will promote MedAxiom's programs to its members, and MedAxiom will do likewise to its client base. Through March 2007, MedAxiom is offering ACC members a 10% discount on subscriptions to its services, which include statistical analyses and benchmark reporting systems, workflow and process redesign, and strategic planning. The two organizations also are developing a leadership institute, which they expect to launch in 2007, according to the ACC.

Von Eschenbach Confirmed for FDA

Almost 9 months after he was first nominated to be commissioner of the FDA, Dr. Andrew von Eschenbach was finally confirmed by the Senate by an 80–11 vote in the wee hours of the 109th Congress. Confirmation came after an 89–6 vote to limit debate on his nomination. The naysayers included Sen. Chuck Grassley (R-Iowa), who voted against invoking cloture and against confirmation. Sen. Grassley has been one of Dr. von Eschenbach's most vocal critics. As chairman of the Finance Committee, he and his staff have been investigating what they call an inappropriate approval of the antibiotic Ketek (telithromycin). Sen. Grassley maintains that Dr. von Eschenbach has stonewalled committee investigators, and in an agitated floor statement during the nomination vote, he accused the nominee of hiding documents and intimidating FDA employees who dissented. With Democrats taking control of Congress, Sen. Grassley will lose his Finance Committee chairmanship. But he warned his colleagues across the aisle that Dr. von Eschenbach was a prime illustration of concerns about the lack of Senate oversight of the Bush administration. “I believe we need to send a message to the executive branch that it's not okay to impede congressional investigations. It's not okay to limit the Senate's access to documents, information, and employees of the executive branch,” the senator said.

Poll: No Off-Label Use

About half of Americans said physicians should not be allowed to prescribe pharmaceuticals for unapproved uses, according to a recent WSJ.com/Harris Interactive poll. About half of those polled—approximately 3,000 adults in November—were not even aware that the FDA allowed off-label prescribing. But, 48% said it should not be allowed; 27% said it was fine, and 24% were not sure. A majority (69%) said drug companies should not be allowed to promote off-label uses, while only 12% said this was permissible. Sixty-two percent said they strongly agreed with the statement that prescription drug use for unapproved indications should be prohibited except in a clinical study.

Pennsylvania has issued hospital-specific data on infections among 1.6 million patients treated at 168 facilities statewide in 2005. The report, released by the Pennsylvania Health Care Cost Containment Council, marks the first time any state has issued data on individual hospitals, and is expected to establish a baseline for future performance and quality improvement. It also overturns a lot of conventional wisdom about how infections occur.

“It's a breakdown in processes that creates infections,” said Marc P. Volavka, executive director of the council, in an interview.

The detailed report, available at the council's Web site (www.phc4.org

Of 1.6 million patients treated at the 168 facilities, 19,154 had a hospital-acquired infection, for a rate of 12 per 1,000 cases. The infections accounted for 394,129 hospital days and $3.5 billion in charges.

The average length of stay was 20.6 days for those with an infection and 4.5 days for those without. Charges were higher for those with infections than for those without, averaging $185,260 and $31,389, respectively. Similarly, mortality was 13% and 2%, respectively.

Most cases were covered by Medicare or Medicaid. Only 276,523 of the patients had commercial insurance; among them, 1,522 acquired an infection in the hospital. Private payers covered only about $53,000 of an infection-related stay, but the total payout was $82 million.

Even though all hospitals are reporting, it is likely that the data hugely underestimate what actually occurs, said Mr. Volavka. He noted that the council has not asked hospitals to track infections subsequent to discharge, which may be when most surgical site infections develop.

The data collection began in 2004, when hospitals were required to report on surgical site infections for circulatory, neurologic, and orthopedic procedures; indwelling catheter-associated urinary tract infections; ventilator-associated pneumonia; and central-line-associated bloodstream infections. In the third and fourth quarters of 2005, hospitals had to expand reporting to include all surgical site infections. In the fourth quarter of 2005, pneumonia, bloodstream, and urinary tract infections not related to devices were added.

Urinary tract infections (UTIs) were the most common, affecting 11,265 patients, for an infection rate of 7.2 per 1,000. Those infections were particularly common in heart failure patients, followed by those admitted for other cardiac conditions.

Surgical site infections had the second-highest incidence rate, at 5.2 per 1,000, affecting 1,615 patients. Intestinal surgery accounted for the highest percentage of surgical site infections (9%), closely followed by angioplasty and surgery for osteoarthritis and leg fractures.

These surgical infections accounted for most of the infections in each age group, except for those patients older than 60 years, in whom UTIs were most common.

Aside from UTIs, the number of infections actually declines as patients age, a fact that runs counter to prevailing theories about older patients' being more vulnerable to infection, Mr. Volavka said. He added that more UTIs occur in the over-60 group because it comprises a preponderance of people who age in state hospitals, where they are catheterized instead of helped to the bathroom.

“It's not because the patients are by definition more at risk. It's the behavior of the hospitals that puts them at risk,” he said.

Several recently published studies appear to support Mr. Volavka's assertions. Researchers at Allegheny General Hospital in Pittsburgh found that severity of illness did not predict central-line bloodstream infections, and that the most common primary diagnoses among those infected—acute myocardial infarction, heart failure, respiratory failure, and deep venous thrombosis—were not usually considered risk factors (Am. J. Med. Qual. 2006;21[suppl]:7S-16S). A group at a clinical research organization had similar findings, concluding that sicker patients were not necessarily at higher risk for infections (Am. J. Med. Qual. 2006;21[suppl]:17S-28S). Finally, a third study found that hospital practices—such as method of hair removal, hand-washing, and operating room traffic flow—played an important role in predicting which patients were at risk for surgical site infections (Am. J. Med. Qual. 2006;21[suppl]:29S-34S).

The studies “make it clear that it is the process of care, not the underlying clinical condition of the patient, that drives the current epidemic of hospital-acquired infection,” said Dr. David B. Nash, chairman of the department of health policy at Jefferson Medical College in Philadelphia.

Pennsylvania has issued hospital-specific data on infections among 1.6 million patients treated at 168 facilities statewide in 2005. The report, released by the Pennsylvania Health Care Cost Containment Council, marks the first time any state has issued data on individual hospitals, and is expected to establish a baseline for future performance and quality improvement. It also overturns a lot of conventional wisdom about how infections occur.

“It's a breakdown in processes that creates infections,” said Marc P. Volavka, executive director of the council, in an interview.

The detailed report, available at the council's Web site (www.phc4.org

Of 1.6 million patients treated at the 168 facilities, 19,154 had a hospital-acquired infection, for a rate of 12 per 1,000 cases. The infections accounted for 394,129 hospital days and $3.5 billion in charges.

The average length of stay was 20.6 days for those with an infection and 4.5 days for those without. Charges were higher for those with infections than for those without, averaging $185,260 and $31,389, respectively. Similarly, mortality was 13% and 2%, respectively.

Most cases were covered by Medicare or Medicaid. Only 276,523 of the patients had commercial insurance; among them, 1,522 acquired an infection in the hospital. Private payers covered only about $53,000 of an infection-related stay, but the total payout was $82 million.

Even though all hospitals are reporting, it is likely that the data hugely underestimate what actually occurs, said Mr. Volavka. He noted that the council has not asked hospitals to track infections subsequent to discharge, which may be when most surgical site infections develop.

The data collection began in 2004, when hospitals were required to report on surgical site infections for circulatory, neurologic, and orthopedic procedures; indwelling catheter-associated urinary tract infections; ventilator-associated pneumonia; and central-line-associated bloodstream infections. In the third and fourth quarters of 2005, hospitals had to expand reporting to include all surgical site infections. In the fourth quarter of 2005, pneumonia, bloodstream, and urinary tract infections not related to devices were added.

Urinary tract infections (UTIs) were the most common, affecting 11,265 patients, for an infection rate of 7.2 per 1,000. Those infections were particularly common in heart failure patients, followed by those admitted for other cardiac conditions.

Surgical site infections had the second-highest incidence rate, at 5.2 per 1,000, affecting 1,615 patients. Intestinal surgery accounted for the highest percentage of surgical site infections (9%), closely followed by angioplasty and surgery for osteoarthritis and leg fractures.

These surgical infections accounted for most of the infections in each age group, except for those patients older than 60 years, in whom UTIs were most common.

Aside from UTIs, the number of infections actually declines as patients age, a fact that runs counter to prevailing theories about older patients' being more vulnerable to infection, Mr. Volavka said. He added that more UTIs occur in the over-60 group because it comprises a preponderance of people who age in state hospitals, where they are catheterized instead of helped to the bathroom.

“It's not because the patients are by definition more at risk. It's the behavior of the hospitals that puts them at risk,” he said.

Several recently published studies appear to support Mr. Volavka's assertions. Researchers at Allegheny General Hospital in Pittsburgh found that severity of illness did not predict central-line bloodstream infections, and that the most common primary diagnoses among those infected—acute myocardial infarction, heart failure, respiratory failure, and deep venous thrombosis—were not usually considered risk factors (Am. J. Med. Qual. 2006;21[suppl]:7S-16S). A group at a clinical research organization had similar findings, concluding that sicker patients were not necessarily at higher risk for infections (Am. J. Med. Qual. 2006;21[suppl]:17S-28S). Finally, a third study found that hospital practices—such as method of hair removal, hand-washing, and operating room traffic flow—played an important role in predicting which patients were at risk for surgical site infections (Am. J. Med. Qual. 2006;21[suppl]:29S-34S).

The studies “make it clear that it is the process of care, not the underlying clinical condition of the patient, that drives the current epidemic of hospital-acquired infection,” said Dr. David B. Nash, chairman of the department of health policy at Jefferson Medical College in Philadelphia.

Pennsylvania has issued hospital-specific data on infections among 1.6 million patients treated at 168 facilities statewide in 2005. The report, released by the Pennsylvania Health Care Cost Containment Council, marks the first time any state has issued data on individual hospitals, and is expected to establish a baseline for future performance and quality improvement. It also overturns a lot of conventional wisdom about how infections occur.

“It's a breakdown in processes that creates infections,” said Marc P. Volavka, executive director of the council, in an interview.

The detailed report, available at the council's Web site (www.phc4.org

Of 1.6 million patients treated at the 168 facilities, 19,154 had a hospital-acquired infection, for a rate of 12 per 1,000 cases. The infections accounted for 394,129 hospital days and $3.5 billion in charges.

The average length of stay was 20.6 days for those with an infection and 4.5 days for those without. Charges were higher for those with infections than for those without, averaging $185,260 and $31,389, respectively. Similarly, mortality was 13% and 2%, respectively.

Most cases were covered by Medicare or Medicaid. Only 276,523 of the patients had commercial insurance; among them, 1,522 acquired an infection in the hospital. Private payers covered only about $53,000 of an infection-related stay, but the total payout was $82 million.

Even though all hospitals are reporting, it is likely that the data hugely underestimate what actually occurs, said Mr. Volavka. He noted that the council has not asked hospitals to track infections subsequent to discharge, which may be when most surgical site infections develop.

The data collection began in 2004, when hospitals were required to report on surgical site infections for circulatory, neurologic, and orthopedic procedures; indwelling catheter-associated urinary tract infections; ventilator-associated pneumonia; and central-line-associated bloodstream infections. In the third and fourth quarters of 2005, hospitals had to expand reporting to include all surgical site infections. In the fourth quarter of 2005, pneumonia, bloodstream, and urinary tract infections not related to devices were added.

Urinary tract infections (UTIs) were the most common, affecting 11,265 patients, for an infection rate of 7.2 per 1,000. Those infections were particularly common in heart failure patients, followed by those admitted for other cardiac conditions.

Surgical site infections had the second-highest incidence rate, at 5.2 per 1,000, affecting 1,615 patients. Intestinal surgery accounted for the highest percentage of surgical site infections (9%), closely followed by angioplasty and surgery for osteoarthritis and leg fractures.

These surgical infections accounted for most of the infections in each age group, except for those patients older than 60 years, in whom UTIs were most common.

Aside from UTIs, the number of infections actually declines as patients age, a fact that runs counter to prevailing theories about older patients' being more vulnerable to infection, Mr. Volavka said. He added that more UTIs occur in the over-60 group because it comprises a preponderance of people who age in state hospitals, where they are catheterized instead of helped to the bathroom.

“It's not because the patients are by definition more at risk. It's the behavior of the hospitals that puts them at risk,” he said.

Several recently published studies appear to support Mr. Volavka's assertions. Researchers at Allegheny General Hospital in Pittsburgh found that severity of illness did not predict central-line bloodstream infections, and that the most common primary diagnoses among those infected—acute myocardial infarction, heart failure, respiratory failure, and deep venous thrombosis—were not usually considered risk factors (Am. J. Med. Qual. 2006;21[suppl]:7S-16S). A group at a clinical research organization had similar findings, concluding that sicker patients were not necessarily at higher risk for infections (Am. J. Med. Qual. 2006;21[suppl]:17S-28S). Finally, a third study found that hospital practices—such as method of hair removal, hand-washing, and operating room traffic flow—played an important role in predicting which patients were at risk for surgical site infections (Am. J. Med. Qual. 2006;21[suppl]:29S-34S).

The studies “make it clear that it is the process of care, not the underlying clinical condition of the patient, that drives the current epidemic of hospital-acquired infection,” said Dr. David B. Nash, chairman of the department of health policy at Jefferson Medical College in Philadelphia.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions according to whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices were followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly.

Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which would provide money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the newly Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said NCQA general counsel Sharon Donohue. But there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group Medically Induced Trauma Support Services, said that patients should not be required to start the claims process, as is proposed under the health court system. An audience member representing Consumers Union said that her group did not like the idea of taking away a patient's right to a jury trial.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are due to systems issues; only 15% are competency related, so solutions should focus on systems design, Dr. O'Leary said.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—maybe 450–500 a year, he said. Most reports concern problems that are not easy to hide, such as patient suicides—the top category—and surgical misadventures, the number two category, Dr. O'Leary said. Surprisingly, at least eight cases a month of wrong-site surgery are reported, he added.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without such statements' being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said.

Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions according to whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices were followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly.

Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which would provide money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the newly Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said NCQA general counsel Sharon Donohue. But there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group Medically Induced Trauma Support Services, said that patients should not be required to start the claims process, as is proposed under the health court system. An audience member representing Consumers Union said that her group did not like the idea of taking away a patient's right to a jury trial.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are due to systems issues; only 15% are competency related, so solutions should focus on systems design, Dr. O'Leary said.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—maybe 450–500 a year, he said. Most reports concern problems that are not easy to hide, such as patient suicides—the top category—and surgical misadventures, the number two category, Dr. O'Leary said. Surprisingly, at least eight cases a month of wrong-site surgery are reported, he added.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without such statements' being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said.

Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions according to whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices were followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly.

Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which would provide money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the newly Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said NCQA general counsel Sharon Donohue. But there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group Medically Induced Trauma Support Services, said that patients should not be required to start the claims process, as is proposed under the health court system. An audience member representing Consumers Union said that her group did not like the idea of taking away a patient's right to a jury trial.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are due to systems issues; only 15% are competency related, so solutions should focus on systems design, Dr. O'Leary said.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—maybe 450–500 a year, he said. Most reports concern problems that are not easy to hide, such as patient suicides—the top category—and surgical misadventures, the number two category, Dr. O'Leary said. Surprisingly, at least eight cases a month of wrong-site surgery are reported, he added.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without such statements' being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said.

Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions based on whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices had been followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly. Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which provided money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the incoming Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said Sharon Donohue, the committee's general counsel. But, there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group, Medically Induced Trauma Support Services, said patients should not be required to start the claims process, as is proposed under the health court system.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are owing to systems issues; only 15% are related to competency, so solutions should focus on systems design, he argued.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—about 450–500 a year. Most reports concern errors that are not easy to hide, such as patient suicides, the top category, and surgical misadventures, the number two category, Dr. O'Leary said. At least eight cases of wrong-site surgery are reported each month.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without it being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said. Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions based on whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices had been followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly. Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which provided money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the incoming Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said Sharon Donohue, the committee's general counsel. But, there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group, Medically Induced Trauma Support Services, said patients should not be required to start the claims process, as is proposed under the health court system.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are owing to systems issues; only 15% are related to competency, so solutions should focus on systems design, he argued.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—about 450–500 a year. Most reports concern errors that are not easy to hide, such as patient suicides, the top category, and surgical misadventures, the number two category, Dr. O'Leary said. At least eight cases of wrong-site surgery are reported each month.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without it being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said. Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.

WASHINGTON — The concept of using administrative law judges instead of civil jury trials to settle malpractice suits has gained some admirers in the U.S. Congress and generated interest among state legislatures. But it is uncertain whether such a system is the solution to skyrocketing malpractice premiums and jury awards, according to academics, attorneys, and consumer and legislative representatives who met at a meeting sponsored by Common Good and the Harvard School of Public Health, Boston.

Under the “health court” concept, fleshed out earlier this year by Michelle Mello and David Studdert of Harvard, specially trained judges would make compensation decisions based on whether an injury was “avoidable” or “preventable” (Milbank Quarterly 2006;3:459–92). The plaintiff would have to show that the injury would not have happened if best practices had been followed. Impartial experts would help set compensation, based on scientific evidence and what is known about avoidability of errors. Decisions would be made quickly. Such a system would likely increase the number of people eligible for compensation, but decrease the size of awards, Ms. Mello said.

Unlike the current tort system, a health court system could also help deter medical errors by collecting data that would then be given back to hospitals and practitioners for root-cause analyses, she explained.

In 2005, Sen. Michael Enzi (R-Wyo.) and Sen. Max Baucus (D-Mont.) introduced the Fair and Reliable Medical Justice Act (S. 1337), which provided money for demonstration projects on alternative methods to address malpractice, including health courts. The Senate Health, Education, Labor, and Pensions Committee held a hearing on the bill in June 2006, but there has been no further action.

At the symposium, Stephen Northrup, the health policy staff director for that committee, said it is not clear whether the incoming Democratic-controlled Congress will consider alternatives such as health courts. Because Democrats are unlikely to approve of caps on damages as a tort reform, he said, it is incumbent on physicians to promote alternatives.

The National Committee for Quality Assurance supports the move toward an administrative court, said Sharon Donohue, the committee's general counsel. But, there is no evidence that rewards will decrease, and with an expanding number of claimants, malpractice premiums might still increase because they are based on the number of claims paid, she said.

Some consumer groups oppose the idea. Linda Kenney, president of the advocacy group, Medically Induced Trauma Support Services, said patients should not be required to start the claims process, as is proposed under the health court system.

Dr. Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, also said he saw some basic impediments to using the courts to improve patient safety. Overall, 85% of errors are owing to systems issues; only 15% are related to competency, so solutions should focus on systems design, he argued.

Despite JCAHO's voluntary reporting requirements of the last 10 years, there are few reports of adverse events—about 450–500 a year. Most reports concern errors that are not easy to hide, such as patient suicides, the top category, and surgical misadventures, the number two category, Dr. O'Leary said. At least eight cases of wrong-site surgery are reported each month.

Several states have looked at or adopted “I'm sorry” statutes to address malpractice. Under the 2003 law, physicians can apologize, admit fault, and explain the cause of an error without it being held against them in court. The law has reduced the number of cases going to trial in Colorado.

So far, 2,835 of the 6,000 physicians covered by the COPIC Insurance Co., a malpractice insurer, have participated in a program implementing the law, said George Dikeou, a legislative consultant to the company. Participating physicians have had at least 3,200 discussions with patients, and in about 2,000 cases, the discussion was all that was needed to close the case, he said.

The insurer is authorized to pay up to $30,000 per case; the average payout over 711 cases has been about $5,300, Mr. Dikeou said. Of 116 cases that went to court, 54 cases were closed without payment and without attorney involvement. Six cases were closed with payment, 40 are still open, and 16 have gone to trial.