Alicia Ault

PITTSBURGH — As more hospitals try to establish rapid response teams to handle decompensating patients, they often encounter entrenched cultures that may prevent the teams from proving their utility, several speakers said at a meeting on emergency response systems sponsored by the University of Pittsburgh Medical Center.

The teams go by different names: medical emergency teams (METs), rapid response teams, or critical care outreach teams. They are charged chiefly with trying to prevent cardiac arrest by intervening as early as possible. Typically, they are called when a patient is in respiratory distress, is hypotensive, has tachycardia, or has a change in consciousness (FAMILY PRACTICE NEWS, June 1, 2006, p. 64).

However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance, said Dr. Michael Buist, director of intensive care at Dandenong Hospital in Melbourne, Australia. If a nurse calls in a team, the nurse may be perceived as going over the head of the attending surgeon or resident, Dr. Buist said at the meeting. Several other speakers described incidents in which nurses were left in tears by angry physicians, even though the patient was better off for the intervention.

At Dandenong, a study showed that even when criteria existed for calling a rapid response team, nurses did not make the calls in 17% of the episodes. This was partly because the nurses did not want to go against the established culture, he said.

Rapid response teams are set up to prevent codes, but many physicians and hospital staff enjoy the drama of a code, said Dr. Geoff Lighthall, of Stanford (Calif.) University. He noted that incoming residents in particular might savor those opportunities. “There's a machismo that goes with answering codes,” he said.

At the University of California, San Francisco, Medical Center, the formation of a rapid response system was met with little enthusiasm, said Dr. Sumant Ranji, a professor of medicine. The hospital began a small rapid response program in mid-2005, rolling it out slowly by talking about it at monthly ward nurses' staff meetings and through e-mails to physicians and announcements at house staff conferences.

Most of the coverage was during the day, by a team comprising a hospitalist, a second-year resident, and a clinical nurse-specialist. At night, coverage was by an on-call resident from the intensive care unit. Usage was low initially—about 1–2 calls per week, which amounted to 2–3 calls per 1,000 patients. This can be compared with the 25 calls per 1,000 patients seen with long-established programs at the University of Pittsburgh Medical Center hospitals, for instance, Dr. Ranji said.

He and his colleagues set out to determine why no one was taking advantage of the rapid response team. One finding was that there was a misperception about when the teams would arrive. During the education process, nurses and physicians were told to call the primary team first and then the rapid response team if there was no response or an inadequate response within an hour. What they heard was that the team would not come at all until an hour had elapsed and that if they called the team, the patient would definitely be taken to the ICU, he said.

Nurses were reluctant to break the chain of command, especially on surgical wards, he said. “This is not a culture that can change by one intervention,” Dr. Ranji said. He also discovered that nurses and residents weren't calling the rapid response team because they made ample use of “curbside consults”—pulling ICU nurses or fellows aside in the hallway to get an informal opinion. “This might cut into our call rate for formal consults,” he said.

There has been no change in the number of codes called or in the rate of in-hospital cardiac arrest or mortality, even though the response teams are now available 24 hours a day, 7 days a week, Dr. Ranji said.

As a result, the San Francisco university is questioning whether it is using the right model. The hospital is considering using an ICU clinical nurse-specialist or a nurse-practitioner as the point person for the teams in the hopes that ward nurses will be more likely to call on these colleagues for help—as opposed to having to call physicians who aren't the primary ones on the patient team, he said.

It's been smoother sailing at the 300-bed Allegheny General Hospital, a tertiary care facility for Drexel University, Philadelphia. In the spring of 2006, the hospital added MET coverage to its code team. The MET has a hospitalist, ICU nurse, bed nurse, respiratory therapist, and intravenous team. The code team has a senior resident, ICU nurse, respiratory therapist, nurse-anesthetist or anesthesiologist, and senior surgical resident.

To facilitate use of the MET, ward staff are given laminated cards describing the teams—essentially who's on them and guidelines for when to call them—Dr. Sharon Kiely, an internist at Allegheny, said at the meeting.

In March, there were 12 calls, 11 of which truly needed an MET; 46% of the nursing units had made calls. By April, there were 30 calls, 28 of which needed an MET. The numbers of calls were the same the following month, but 85% of the nursing units had made calls, Dr. Kiely said. Overall, 66% of the patients were transferred to a higher level of care, 26% were stabilized in their rooms, and the remaining 8% died.

Dr. Kiely said it appeared that the MET concept was well received. During meetings with house staff, almost all had agreed that it made sense, and there had been no complaints from nurses, she added.

Rapid Response Pays, If Billed Correctly

Hospitals that employ rapid response teams are finding that it can be quite profitable—as long as they bill correctly for the services, Dawn Moody, R.N., a senior medical auditor, said at the meeting.

The care delivered by rapid response teams is considered critical care, which requires very different documentation than that provided for traditional evaluation and management, said Ms. Moody, who is in the division of general internal medicine at the University of Pittsburgh Medical Center.

First, it must meet the definition of critical care—the patient must have an illness or injury that impairs one or more vital organ systems to the point where there is a high probability of imminent or life-threatening deterioration of the patient's condition, she said.

The care does not necessarily have to be given in a critical care area, but the physician has to be completely devoted to that patient and not seeing any other patient during the time billed.

Time spent with the patient must be documented very specifically. A good way to do that is to include a note at the end of a patient's file stating that the physician spent 3 hours and 10 minutes managing the case. Physicians can include the time they spend away from the bedside if it is directly related to the patient's care. For instance, dictating or writing notes can be billed, as can time with families, if it is to get a medical history, review a condition, or deliver a prognosis, Ms. Moody said.

There are two current procedural terminology codes used for critical care Evaluation & Management: 99291, which is used for the first 30–74 minutes, and 99292, which is used for each additional 30-minute increment. In western Pennsylvania, the local Medicare carrier reimburses the first 30 minutes of critical care at $201.38, Ms. Moody said. That compares with a level V consult, which is reimbursed at $189. The second unit of critical care and each unit thereafter is reimbursed at $101, she said.

However, certain services can't be billed separately, including the interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, temporary transcutaneous pacing, ventilatory management, and vascular access procedures, Ms. Moody said.

There are also fairly strict criteria for critical care delivered in the academic setting. Critical care time can only be reimbursed when the resident and teaching physician both managed the patient together, or if the teaching physician was alone with the patient. Any time the resident spends alone with the patient—without the teaching physician around—can't be billed, she said, and most insurers will pay for only one physician's services per critical care episode.

PITTSBURGH — As more hospitals try to establish rapid response teams to handle decompensating patients, they often encounter entrenched cultures that may prevent the teams from proving their utility, several speakers said at a meeting on emergency response systems sponsored by the University of Pittsburgh Medical Center.

The teams go by different names: medical emergency teams (METs), rapid response teams, or critical care outreach teams. They are charged chiefly with trying to prevent cardiac arrest by intervening as early as possible. Typically, they are called when a patient is in respiratory distress, is hypotensive, has tachycardia, or has a change in consciousness (FAMILY PRACTICE NEWS, June 1, 2006, p. 64).

However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance, said Dr. Michael Buist, director of intensive care at Dandenong Hospital in Melbourne, Australia. If a nurse calls in a team, the nurse may be perceived as going over the head of the attending surgeon or resident, Dr. Buist said at the meeting. Several other speakers described incidents in which nurses were left in tears by angry physicians, even though the patient was better off for the intervention.

At Dandenong, a study showed that even when criteria existed for calling a rapid response team, nurses did not make the calls in 17% of the episodes. This was partly because the nurses did not want to go against the established culture, he said.

Rapid response teams are set up to prevent codes, but many physicians and hospital staff enjoy the drama of a code, said Dr. Geoff Lighthall, of Stanford (Calif.) University. He noted that incoming residents in particular might savor those opportunities. “There's a machismo that goes with answering codes,” he said.

At the University of California, San Francisco, Medical Center, the formation of a rapid response system was met with little enthusiasm, said Dr. Sumant Ranji, a professor of medicine. The hospital began a small rapid response program in mid-2005, rolling it out slowly by talking about it at monthly ward nurses' staff meetings and through e-mails to physicians and announcements at house staff conferences.

Most of the coverage was during the day, by a team comprising a hospitalist, a second-year resident, and a clinical nurse-specialist. At night, coverage was by an on-call resident from the intensive care unit. Usage was low initially—about 1–2 calls per week, which amounted to 2–3 calls per 1,000 patients. This can be compared with the 25 calls per 1,000 patients seen with long-established programs at the University of Pittsburgh Medical Center hospitals, for instance, Dr. Ranji said.

He and his colleagues set out to determine why no one was taking advantage of the rapid response team. One finding was that there was a misperception about when the teams would arrive. During the education process, nurses and physicians were told to call the primary team first and then the rapid response team if there was no response or an inadequate response within an hour. What they heard was that the team would not come at all until an hour had elapsed and that if they called the team, the patient would definitely be taken to the ICU, he said.

Nurses were reluctant to break the chain of command, especially on surgical wards, he said. “This is not a culture that can change by one intervention,” Dr. Ranji said. He also discovered that nurses and residents weren't calling the rapid response team because they made ample use of “curbside consults”—pulling ICU nurses or fellows aside in the hallway to get an informal opinion. “This might cut into our call rate for formal consults,” he said.

There has been no change in the number of codes called or in the rate of in-hospital cardiac arrest or mortality, even though the response teams are now available 24 hours a day, 7 days a week, Dr. Ranji said.

As a result, the San Francisco university is questioning whether it is using the right model. The hospital is considering using an ICU clinical nurse-specialist or a nurse-practitioner as the point person for the teams in the hopes that ward nurses will be more likely to call on these colleagues for help—as opposed to having to call physicians who aren't the primary ones on the patient team, he said.

It's been smoother sailing at the 300-bed Allegheny General Hospital, a tertiary care facility for Drexel University, Philadelphia. In the spring of 2006, the hospital added MET coverage to its code team. The MET has a hospitalist, ICU nurse, bed nurse, respiratory therapist, and intravenous team. The code team has a senior resident, ICU nurse, respiratory therapist, nurse-anesthetist or anesthesiologist, and senior surgical resident.

To facilitate use of the MET, ward staff are given laminated cards describing the teams—essentially who's on them and guidelines for when to call them—Dr. Sharon Kiely, an internist at Allegheny, said at the meeting.

In March, there were 12 calls, 11 of which truly needed an MET; 46% of the nursing units had made calls. By April, there were 30 calls, 28 of which needed an MET. The numbers of calls were the same the following month, but 85% of the nursing units had made calls, Dr. Kiely said. Overall, 66% of the patients were transferred to a higher level of care, 26% were stabilized in their rooms, and the remaining 8% died.

Dr. Kiely said it appeared that the MET concept was well received. During meetings with house staff, almost all had agreed that it made sense, and there had been no complaints from nurses, she added.

Rapid Response Pays, If Billed Correctly

Hospitals that employ rapid response teams are finding that it can be quite profitable—as long as they bill correctly for the services, Dawn Moody, R.N., a senior medical auditor, said at the meeting.

The care delivered by rapid response teams is considered critical care, which requires very different documentation than that provided for traditional evaluation and management, said Ms. Moody, who is in the division of general internal medicine at the University of Pittsburgh Medical Center.

First, it must meet the definition of critical care—the patient must have an illness or injury that impairs one or more vital organ systems to the point where there is a high probability of imminent or life-threatening deterioration of the patient's condition, she said.

The care does not necessarily have to be given in a critical care area, but the physician has to be completely devoted to that patient and not seeing any other patient during the time billed.

Time spent with the patient must be documented very specifically. A good way to do that is to include a note at the end of a patient's file stating that the physician spent 3 hours and 10 minutes managing the case. Physicians can include the time they spend away from the bedside if it is directly related to the patient's care. For instance, dictating or writing notes can be billed, as can time with families, if it is to get a medical history, review a condition, or deliver a prognosis, Ms. Moody said.

There are two current procedural terminology codes used for critical care Evaluation & Management: 99291, which is used for the first 30–74 minutes, and 99292, which is used for each additional 30-minute increment. In western Pennsylvania, the local Medicare carrier reimburses the first 30 minutes of critical care at $201.38, Ms. Moody said. That compares with a level V consult, which is reimbursed at $189. The second unit of critical care and each unit thereafter is reimbursed at $101, she said.

However, certain services can't be billed separately, including the interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, temporary transcutaneous pacing, ventilatory management, and vascular access procedures, Ms. Moody said.

There are also fairly strict criteria for critical care delivered in the academic setting. Critical care time can only be reimbursed when the resident and teaching physician both managed the patient together, or if the teaching physician was alone with the patient. Any time the resident spends alone with the patient—without the teaching physician around—can't be billed, she said, and most insurers will pay for only one physician's services per critical care episode.

PITTSBURGH — As more hospitals try to establish rapid response teams to handle decompensating patients, they often encounter entrenched cultures that may prevent the teams from proving their utility, several speakers said at a meeting on emergency response systems sponsored by the University of Pittsburgh Medical Center.

The teams go by different names: medical emergency teams (METs), rapid response teams, or critical care outreach teams. They are charged chiefly with trying to prevent cardiac arrest by intervening as early as possible. Typically, they are called when a patient is in respiratory distress, is hypotensive, has tachycardia, or has a change in consciousness (FAMILY PRACTICE NEWS, June 1, 2006, p. 64).

However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance, said Dr. Michael Buist, director of intensive care at Dandenong Hospital in Melbourne, Australia. If a nurse calls in a team, the nurse may be perceived as going over the head of the attending surgeon or resident, Dr. Buist said at the meeting. Several other speakers described incidents in which nurses were left in tears by angry physicians, even though the patient was better off for the intervention.

At Dandenong, a study showed that even when criteria existed for calling a rapid response team, nurses did not make the calls in 17% of the episodes. This was partly because the nurses did not want to go against the established culture, he said.

Rapid response teams are set up to prevent codes, but many physicians and hospital staff enjoy the drama of a code, said Dr. Geoff Lighthall, of Stanford (Calif.) University. He noted that incoming residents in particular might savor those opportunities. “There's a machismo that goes with answering codes,” he said.

At the University of California, San Francisco, Medical Center, the formation of a rapid response system was met with little enthusiasm, said Dr. Sumant Ranji, a professor of medicine. The hospital began a small rapid response program in mid-2005, rolling it out slowly by talking about it at monthly ward nurses' staff meetings and through e-mails to physicians and announcements at house staff conferences.

Most of the coverage was during the day, by a team comprising a hospitalist, a second-year resident, and a clinical nurse-specialist. At night, coverage was by an on-call resident from the intensive care unit. Usage was low initially—about 1–2 calls per week, which amounted to 2–3 calls per 1,000 patients. This can be compared with the 25 calls per 1,000 patients seen with long-established programs at the University of Pittsburgh Medical Center hospitals, for instance, Dr. Ranji said.

He and his colleagues set out to determine why no one was taking advantage of the rapid response team. One finding was that there was a misperception about when the teams would arrive. During the education process, nurses and physicians were told to call the primary team first and then the rapid response team if there was no response or an inadequate response within an hour. What they heard was that the team would not come at all until an hour had elapsed and that if they called the team, the patient would definitely be taken to the ICU, he said.

Nurses were reluctant to break the chain of command, especially on surgical wards, he said. “This is not a culture that can change by one intervention,” Dr. Ranji said. He also discovered that nurses and residents weren't calling the rapid response team because they made ample use of “curbside consults”—pulling ICU nurses or fellows aside in the hallway to get an informal opinion. “This might cut into our call rate for formal consults,” he said.

There has been no change in the number of codes called or in the rate of in-hospital cardiac arrest or mortality, even though the response teams are now available 24 hours a day, 7 days a week, Dr. Ranji said.

As a result, the San Francisco university is questioning whether it is using the right model. The hospital is considering using an ICU clinical nurse-specialist or a nurse-practitioner as the point person for the teams in the hopes that ward nurses will be more likely to call on these colleagues for help—as opposed to having to call physicians who aren't the primary ones on the patient team, he said.

It's been smoother sailing at the 300-bed Allegheny General Hospital, a tertiary care facility for Drexel University, Philadelphia. In the spring of 2006, the hospital added MET coverage to its code team. The MET has a hospitalist, ICU nurse, bed nurse, respiratory therapist, and intravenous team. The code team has a senior resident, ICU nurse, respiratory therapist, nurse-anesthetist or anesthesiologist, and senior surgical resident.

To facilitate use of the MET, ward staff are given laminated cards describing the teams—essentially who's on them and guidelines for when to call them—Dr. Sharon Kiely, an internist at Allegheny, said at the meeting.

In March, there were 12 calls, 11 of which truly needed an MET; 46% of the nursing units had made calls. By April, there were 30 calls, 28 of which needed an MET. The numbers of calls were the same the following month, but 85% of the nursing units had made calls, Dr. Kiely said. Overall, 66% of the patients were transferred to a higher level of care, 26% were stabilized in their rooms, and the remaining 8% died.

Dr. Kiely said it appeared that the MET concept was well received. During meetings with house staff, almost all had agreed that it made sense, and there had been no complaints from nurses, she added.

Rapid Response Pays, If Billed Correctly

Hospitals that employ rapid response teams are finding that it can be quite profitable—as long as they bill correctly for the services, Dawn Moody, R.N., a senior medical auditor, said at the meeting.

The care delivered by rapid response teams is considered critical care, which requires very different documentation than that provided for traditional evaluation and management, said Ms. Moody, who is in the division of general internal medicine at the University of Pittsburgh Medical Center.

First, it must meet the definition of critical care—the patient must have an illness or injury that impairs one or more vital organ systems to the point where there is a high probability of imminent or life-threatening deterioration of the patient's condition, she said.

The care does not necessarily have to be given in a critical care area, but the physician has to be completely devoted to that patient and not seeing any other patient during the time billed.

Time spent with the patient must be documented very specifically. A good way to do that is to include a note at the end of a patient's file stating that the physician spent 3 hours and 10 minutes managing the case. Physicians can include the time they spend away from the bedside if it is directly related to the patient's care. For instance, dictating or writing notes can be billed, as can time with families, if it is to get a medical history, review a condition, or deliver a prognosis, Ms. Moody said.

There are two current procedural terminology codes used for critical care Evaluation & Management: 99291, which is used for the first 30–74 minutes, and 99292, which is used for each additional 30-minute increment. In western Pennsylvania, the local Medicare carrier reimburses the first 30 minutes of critical care at $201.38, Ms. Moody said. That compares with a level V consult, which is reimbursed at $189. The second unit of critical care and each unit thereafter is reimbursed at $101, she said.

However, certain services can't be billed separately, including the interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, temporary transcutaneous pacing, ventilatory management, and vascular access procedures, Ms. Moody said.

There are also fairly strict criteria for critical care delivered in the academic setting. Critical care time can only be reimbursed when the resident and teaching physician both managed the patient together, or if the teaching physician was alone with the patient. Any time the resident spends alone with the patient—without the teaching physician around—can't be billed, she said, and most insurers will pay for only one physician's services per critical care episode.

PITTSBURGH — As more hospitals attempt to establish rapid response teams, they often encounter entrenched cultures that may prevent the teams from proving their utility, several speakers said at a meeting on emergency response systems sponsored by the University of Pittsburgh Medical Center.

The teams go by different names: medical emergency teams (METs), rapid response teams, or critical care outreach teams. They are charged chiefly with trying to prevent cardiac arrest by intervening as early as possible. Typically, they are called when a patient is in respiratory distress, is hypotensive, has tachycardia, or has a change in consciousness (INTERNAL MEDICINE NEWS, June 1, 2006, p. 1).

However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance, said Dr. Michael Buist, director of intensive care at Dandenong Hospital in Melbourne, Australia. If a nurse calls in a team, the nurse may be perceived as going over the head of the attending surgeon or resident, Dr. Buist said at the meeting. Several other speakers described incidents in which nurses were left in tears by angry physicians, even though the patient was better off for the intervention.

At Dandenong, a study showed that even when criteria existed for calling a rapid response team, nurses did not make the calls in 17% of the episodes.

Rapid response teams are set up to prevent codes, but many physicians and hospital staff enjoy the drama of a code, said Dr. Geoff Lighthall, an assistant professor of anesthesiology and critical care at Stanford (Calif.) University School of Medicine. He noted that incoming residents in particular might savor those opportunities. “There's a machismo that goes with answering codes,” he said.

At the University of California, San Francisco, Medical Center, the formation of a rapid response system was met with little enthusiasm, said Dr. Sumant Ranji, a professor of medicine. The hospital began a small rapid response program in mid-2005, rolling it out slowly by talking about it at monthly ward nurses' staff meetings and through e-mails to physicians and announcements at house staff conferences.

Most of the coverage was during the day, by a team comprising a hospitalist, a second-year resident, and a clinical nurse-specialist. At night, coverage was by an on-call resident from the ICU. Usage was low initially—about 1–2 calls per week, which amounted to 2–3 calls per 1,000 patients. This can be compared with the 25 calls per 1,000 patients seen with long-established programs at the University of Pittsburgh Medical Center hospitals, Dr. Ranji said.

He and his colleagues set out to determine why no one was taking advantage of the rapid response team. One finding was that there was a misperception about when the teams would arrive. During the education process, nurses and physicians were told to call the primary team first and then the rapid response team if there was no response or an inadequate response within an hour. What they heard was that the team would not come at all until an hour had elapsed and that if they called the team, the patient would definitely be taken to the ICU, he said.

Nurses were reluctant to break the chain of command, especially on surgical wards, he said. “This is not a culture that can change by one intervention,” Dr. Ranji said. He also discovered that nurses and residents weren't calling the rapid response team because they made ample use of “curbside consults”—pulling ICU nurses or fellows aside in the hallway to get an informal opinion.

There has been no change in the number of codes called or in the rate of in-hospital cardiac arrest or mortality, even though the response teams are now available 24 hours a day, 7 days a week, Dr. Ranji said. As a result, the San Francisco university is questioning whether it is using the right model. The hospital is considering using an ICU clinical nurse-specialist or a nurse-practitioner as the point person for the teams in the hopes that ward nurses will be more likely to call on these colleagues for help—as opposed to having to call physicians who aren't the primary ones on the patient team, he said.

It's been smoother sailing at Allegheny General Hospital, a tertiary care facility for Drexel University, Philadelphia. In spring 2006, the hospital added MET coverage to its code team. The MET has a hospitalist, ICU nurse, bed nurse, respiratory therapist, and intravenous team. The code team has a senior resident, ICU nurse, respiratory therapist, nurse-anesthetist or anesthesiologist, and senior surgical resident.

To facilitate use of the MET, ward staff are given laminated cards describing the teams—essentially who's on them and guidelines for when to call them—Dr. Sharon Kiely, an internist at Allegheny, said at the meeting.

In March, there were 12 calls, 11 of which truly needed a MET; 46% of the nursing units had made calls. By April, there were 30 calls, 28 of which needed a MET. The MET concept appeared to be well received: Almost all of the house staff agreed that it made sense, and there were no complaints from nurses, Dr. Kiely added.

Teams Can Bolster Hospital Revenues

Hospitals that employ rapid response teams are finding that it can be quite profitable—as long as they bill correctly for the services, Dawn Moody, R.N., a senior medical auditor, said at the meeting.

The care delivered by rapid response teams is considered critical care, which requires very different documentation than that provided for traditional evaluation and management, said Ms. Moody, who is in the division of general internal medicine at the University of Pittsburgh Medical Center.

First, it must meet the definition of critical care—the patient must have an illness or injury that impairs one or more vital organ systems to the point where there is a high probability of imminent or life-threatening deterioration of the patient's condition, she said.

The care does not necessarily have to be given in a critical care area, but the physician has to be completely devoted to that patient and not seeing any other patient during the time billed.

Time spent with the patient must be documented very specifically. A good way to do that is to include a note at the end of a patient's file stating that the physician spent 3 hours and 10 minutes managing the case. Physicians can include the time they spend away from the bedside if it is directly related to the patient's care. For instance, dictating or writing notes can be billed, as can time with families, if it is to get a medical history, review a condition, or deliver a prognosis, Ms. Moody said.

There are two current procedural terminology codes used for critical care Evaluation & Management: 99291, which is used for the first 30–74 minutes, and 99292, which is used for each additional 30-minute increment. In western Pennsylvania, the local Medicare carrier reimburses the first 30 minutes of critical care at $201.38, Ms. Moody said. That compares with a level V consult, which is reimbursed at $189. The second unit of critical care and each unit thereafter is reimbursed at $101, she said.

However, certain services can't be billed separately, including the interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, temporary transcutaneous pacing, ventilatory management, and vascular access procedures, Ms. Moody said.

There are also fairly strict criteria for critical care delivered in the academic setting. Critical care time can only be reimbursed when the resident and teaching physician both managed the patient together, or if the teaching physician was alone with the patient. Any time the resident spends alone with the patient—without the teaching physician around—can't be billed, she said.

Most insurers will pay for only one physician's services per critical care episode, but the hospital can bill separately for a rapid response team or ICU response, she added.

PITTSBURGH — As more hospitals attempt to establish rapid response teams, they often encounter entrenched cultures that may prevent the teams from proving their utility, several speakers said at a meeting on emergency response systems sponsored by the University of Pittsburgh Medical Center.

The teams go by different names: medical emergency teams (METs), rapid response teams, or critical care outreach teams. They are charged chiefly with trying to prevent cardiac arrest by intervening as early as possible. Typically, they are called when a patient is in respiratory distress, is hypotensive, has tachycardia, or has a change in consciousness (INTERNAL MEDICINE NEWS, June 1, 2006, p. 1).

However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance, said Dr. Michael Buist, director of intensive care at Dandenong Hospital in Melbourne, Australia. If a nurse calls in a team, the nurse may be perceived as going over the head of the attending surgeon or resident, Dr. Buist said at the meeting. Several other speakers described incidents in which nurses were left in tears by angry physicians, even though the patient was better off for the intervention.

At Dandenong, a study showed that even when criteria existed for calling a rapid response team, nurses did not make the calls in 17% of the episodes.

Rapid response teams are set up to prevent codes, but many physicians and hospital staff enjoy the drama of a code, said Dr. Geoff Lighthall, an assistant professor of anesthesiology and critical care at Stanford (Calif.) University School of Medicine. He noted that incoming residents in particular might savor those opportunities. “There's a machismo that goes with answering codes,” he said.

At the University of California, San Francisco, Medical Center, the formation of a rapid response system was met with little enthusiasm, said Dr. Sumant Ranji, a professor of medicine. The hospital began a small rapid response program in mid-2005, rolling it out slowly by talking about it at monthly ward nurses' staff meetings and through e-mails to physicians and announcements at house staff conferences.

Most of the coverage was during the day, by a team comprising a hospitalist, a second-year resident, and a clinical nurse-specialist. At night, coverage was by an on-call resident from the ICU. Usage was low initially—about 1–2 calls per week, which amounted to 2–3 calls per 1,000 patients. This can be compared with the 25 calls per 1,000 patients seen with long-established programs at the University of Pittsburgh Medical Center hospitals, Dr. Ranji said.

He and his colleagues set out to determine why no one was taking advantage of the rapid response team. One finding was that there was a misperception about when the teams would arrive. During the education process, nurses and physicians were told to call the primary team first and then the rapid response team if there was no response or an inadequate response within an hour. What they heard was that the team would not come at all until an hour had elapsed and that if they called the team, the patient would definitely be taken to the ICU, he said.

Nurses were reluctant to break the chain of command, especially on surgical wards, he said. “This is not a culture that can change by one intervention,” Dr. Ranji said. He also discovered that nurses and residents weren't calling the rapid response team because they made ample use of “curbside consults”—pulling ICU nurses or fellows aside in the hallway to get an informal opinion.

There has been no change in the number of codes called or in the rate of in-hospital cardiac arrest or mortality, even though the response teams are now available 24 hours a day, 7 days a week, Dr. Ranji said. As a result, the San Francisco university is questioning whether it is using the right model. The hospital is considering using an ICU clinical nurse-specialist or a nurse-practitioner as the point person for the teams in the hopes that ward nurses will be more likely to call on these colleagues for help—as opposed to having to call physicians who aren't the primary ones on the patient team, he said.

It's been smoother sailing at Allegheny General Hospital, a tertiary care facility for Drexel University, Philadelphia. In spring 2006, the hospital added MET coverage to its code team. The MET has a hospitalist, ICU nurse, bed nurse, respiratory therapist, and intravenous team. The code team has a senior resident, ICU nurse, respiratory therapist, nurse-anesthetist or anesthesiologist, and senior surgical resident.

To facilitate use of the MET, ward staff are given laminated cards describing the teams—essentially who's on them and guidelines for when to call them—Dr. Sharon Kiely, an internist at Allegheny, said at the meeting.

In March, there were 12 calls, 11 of which truly needed a MET; 46% of the nursing units had made calls. By April, there were 30 calls, 28 of which needed a MET. The MET concept appeared to be well received: Almost all of the house staff agreed that it made sense, and there were no complaints from nurses, Dr. Kiely added.

Teams Can Bolster Hospital Revenues

Hospitals that employ rapid response teams are finding that it can be quite profitable—as long as they bill correctly for the services, Dawn Moody, R.N., a senior medical auditor, said at the meeting.

The care delivered by rapid response teams is considered critical care, which requires very different documentation than that provided for traditional evaluation and management, said Ms. Moody, who is in the division of general internal medicine at the University of Pittsburgh Medical Center.

First, it must meet the definition of critical care—the patient must have an illness or injury that impairs one or more vital organ systems to the point where there is a high probability of imminent or life-threatening deterioration of the patient's condition, she said.

The care does not necessarily have to be given in a critical care area, but the physician has to be completely devoted to that patient and not seeing any other patient during the time billed.

Time spent with the patient must be documented very specifically. A good way to do that is to include a note at the end of a patient's file stating that the physician spent 3 hours and 10 minutes managing the case. Physicians can include the time they spend away from the bedside if it is directly related to the patient's care. For instance, dictating or writing notes can be billed, as can time with families, if it is to get a medical history, review a condition, or deliver a prognosis, Ms. Moody said.

There are two current procedural terminology codes used for critical care Evaluation & Management: 99291, which is used for the first 30–74 minutes, and 99292, which is used for each additional 30-minute increment. In western Pennsylvania, the local Medicare carrier reimburses the first 30 minutes of critical care at $201.38, Ms. Moody said. That compares with a level V consult, which is reimbursed at $189. The second unit of critical care and each unit thereafter is reimbursed at $101, she said.

However, certain services can't be billed separately, including the interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, temporary transcutaneous pacing, ventilatory management, and vascular access procedures, Ms. Moody said.

There are also fairly strict criteria for critical care delivered in the academic setting. Critical care time can only be reimbursed when the resident and teaching physician both managed the patient together, or if the teaching physician was alone with the patient. Any time the resident spends alone with the patient—without the teaching physician around—can't be billed, she said.

Most insurers will pay for only one physician's services per critical care episode, but the hospital can bill separately for a rapid response team or ICU response, she added.

PITTSBURGH — As more hospitals attempt to establish rapid response teams, they often encounter entrenched cultures that may prevent the teams from proving their utility, several speakers said at a meeting on emergency response systems sponsored by the University of Pittsburgh Medical Center.

The teams go by different names: medical emergency teams (METs), rapid response teams, or critical care outreach teams. They are charged chiefly with trying to prevent cardiac arrest by intervening as early as possible. Typically, they are called when a patient is in respiratory distress, is hypotensive, has tachycardia, or has a change in consciousness (INTERNAL MEDICINE NEWS, June 1, 2006, p. 1).

However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance, said Dr. Michael Buist, director of intensive care at Dandenong Hospital in Melbourne, Australia. If a nurse calls in a team, the nurse may be perceived as going over the head of the attending surgeon or resident, Dr. Buist said at the meeting. Several other speakers described incidents in which nurses were left in tears by angry physicians, even though the patient was better off for the intervention.

At Dandenong, a study showed that even when criteria existed for calling a rapid response team, nurses did not make the calls in 17% of the episodes.

Rapid response teams are set up to prevent codes, but many physicians and hospital staff enjoy the drama of a code, said Dr. Geoff Lighthall, an assistant professor of anesthesiology and critical care at Stanford (Calif.) University School of Medicine. He noted that incoming residents in particular might savor those opportunities. “There's a machismo that goes with answering codes,” he said.

At the University of California, San Francisco, Medical Center, the formation of a rapid response system was met with little enthusiasm, said Dr. Sumant Ranji, a professor of medicine. The hospital began a small rapid response program in mid-2005, rolling it out slowly by talking about it at monthly ward nurses' staff meetings and through e-mails to physicians and announcements at house staff conferences.

Most of the coverage was during the day, by a team comprising a hospitalist, a second-year resident, and a clinical nurse-specialist. At night, coverage was by an on-call resident from the ICU. Usage was low initially—about 1–2 calls per week, which amounted to 2–3 calls per 1,000 patients. This can be compared with the 25 calls per 1,000 patients seen with long-established programs at the University of Pittsburgh Medical Center hospitals, Dr. Ranji said.

He and his colleagues set out to determine why no one was taking advantage of the rapid response team. One finding was that there was a misperception about when the teams would arrive. During the education process, nurses and physicians were told to call the primary team first and then the rapid response team if there was no response or an inadequate response within an hour. What they heard was that the team would not come at all until an hour had elapsed and that if they called the team, the patient would definitely be taken to the ICU, he said.

Nurses were reluctant to break the chain of command, especially on surgical wards, he said. “This is not a culture that can change by one intervention,” Dr. Ranji said. He also discovered that nurses and residents weren't calling the rapid response team because they made ample use of “curbside consults”—pulling ICU nurses or fellows aside in the hallway to get an informal opinion.

There has been no change in the number of codes called or in the rate of in-hospital cardiac arrest or mortality, even though the response teams are now available 24 hours a day, 7 days a week, Dr. Ranji said. As a result, the San Francisco university is questioning whether it is using the right model. The hospital is considering using an ICU clinical nurse-specialist or a nurse-practitioner as the point person for the teams in the hopes that ward nurses will be more likely to call on these colleagues for help—as opposed to having to call physicians who aren't the primary ones on the patient team, he said.

It's been smoother sailing at Allegheny General Hospital, a tertiary care facility for Drexel University, Philadelphia. In spring 2006, the hospital added MET coverage to its code team. The MET has a hospitalist, ICU nurse, bed nurse, respiratory therapist, and intravenous team. The code team has a senior resident, ICU nurse, respiratory therapist, nurse-anesthetist or anesthesiologist, and senior surgical resident.

To facilitate use of the MET, ward staff are given laminated cards describing the teams—essentially who's on them and guidelines for when to call them—Dr. Sharon Kiely, an internist at Allegheny, said at the meeting.

In March, there were 12 calls, 11 of which truly needed a MET; 46% of the nursing units had made calls. By April, there were 30 calls, 28 of which needed a MET. The MET concept appeared to be well received: Almost all of the house staff agreed that it made sense, and there were no complaints from nurses, Dr. Kiely added.

Teams Can Bolster Hospital Revenues

Hospitals that employ rapid response teams are finding that it can be quite profitable—as long as they bill correctly for the services, Dawn Moody, R.N., a senior medical auditor, said at the meeting.

The care delivered by rapid response teams is considered critical care, which requires very different documentation than that provided for traditional evaluation and management, said Ms. Moody, who is in the division of general internal medicine at the University of Pittsburgh Medical Center.

First, it must meet the definition of critical care—the patient must have an illness or injury that impairs one or more vital organ systems to the point where there is a high probability of imminent or life-threatening deterioration of the patient's condition, she said.

The care does not necessarily have to be given in a critical care area, but the physician has to be completely devoted to that patient and not seeing any other patient during the time billed.

Time spent with the patient must be documented very specifically. A good way to do that is to include a note at the end of a patient's file stating that the physician spent 3 hours and 10 minutes managing the case. Physicians can include the time they spend away from the bedside if it is directly related to the patient's care. For instance, dictating or writing notes can be billed, as can time with families, if it is to get a medical history, review a condition, or deliver a prognosis, Ms. Moody said.

There are two current procedural terminology codes used for critical care Evaluation & Management: 99291, which is used for the first 30–74 minutes, and 99292, which is used for each additional 30-minute increment. In western Pennsylvania, the local Medicare carrier reimburses the first 30 minutes of critical care at $201.38, Ms. Moody said. That compares with a level V consult, which is reimbursed at $189. The second unit of critical care and each unit thereafter is reimbursed at $101, she said.

However, certain services can't be billed separately, including the interpretation of cardiac output measurements, chest x-rays, pulse oximetry, blood gases, gastric intubation, temporary transcutaneous pacing, ventilatory management, and vascular access procedures, Ms. Moody said.

There are also fairly strict criteria for critical care delivered in the academic setting. Critical care time can only be reimbursed when the resident and teaching physician both managed the patient together, or if the teaching physician was alone with the patient. Any time the resident spends alone with the patient—without the teaching physician around—can't be billed, she said.

Most insurers will pay for only one physician's services per critical care episode, but the hospital can bill separately for a rapid response team or ICU response, she added.

WASHINGTON — Using validated functional performance measures is better than relying on patient reporting to determine walking ability and the effects of treatments in peripheral arterial disease, according to Dr. Mary McGrae McDermott.

PAD patients may underreport leg symptoms because they often restrict their activity to avoid experiencing those symptoms, said Dr. McDermott at a conference sponsored by the Society for Vascular Surgery. The use of functional measures such as the 6-minute walk test can substantially increase diagnostic and treatment accuracy, said Dr. McDermott, of the department of medicine at Northwestern University, Chicago.

Each measure has positives and negatives, said Dr. McDermott, the lead investigator in (the Walking and Leg Circulation Study, WALCS). That study used several performance measures of walking and leg function, including the 6-minute walk test, repeated chair stands, a standing balance test, and a test of walking speed (Ann. Intern. Med. 2002;136:1–32).

One of the most often-used performance measures is the treadmill walking test, but some data suggest it might not mimic actual walking, Dr. McDermott said. And older patients may experience anxiety or balance problems that have an impact on results, she said. A 6-minute walk test conducted in a corridor may be easier and more productive for older patients, according to Dr. McDermott. The test should be done in a 100-foot-long hallway, with patients told to walk as far as they can during the 6 minutes, with no conversation during the test.

The 6-minute walk test was shown to be reliable in a 1998 study (J. Amer. Geriatr. Soc. 1998;46:706–11). Dr. McDermott and her colleagues have completed a study, which has been submitted for publication, showing that 6-minute walk performance at baseline predicts mortality. In addition to the 6-minute walk, clinicians should consider three other tests that measure leg strength, balance, and walking speed. Together, these additional diagnostics constitute the summary performance score (SPS). Each is scored on a 0–4 scale and is added to create a total score of 0–12.

The first component is the 4-meter walk test, which is conducted in a corridor with a stopwatch. Dr. McDermott has found that patients who do not walk regularly for exercise have the greatest decline in the 4-meter speed. The SPS also includes a standing balance test and time to arise five times consecutively from a seated position. Lower SPS scores are associated with a higher risk of death, nursing home placement, and a reduction in the ability to perform activities of daily living, she said.

Physical activity can be measured with a vertical accelerometer, said Dr. McDermott, who has conducted several validation studies of the Caltrac version (Muscle Dynamics Fitness Network).

In the trials, PAD patients were given the beeperlike device to wear for 7 days, except when sleeping or bathing. Dr. McDermott and her colleagues found that PAD patients had much lower activity than non-PAD patients, and that the performance correlated with 6-minute walk test results (J. Am. Geriatr. Soc. 2001;49:747–54).

WASHINGTON — Using validated functional performance measures is better than relying on patient reporting to determine walking ability and the effects of treatments in peripheral arterial disease, according to Dr. Mary McGrae McDermott.

PAD patients may underreport leg symptoms because they often restrict their activity to avoid experiencing those symptoms, said Dr. McDermott at a conference sponsored by the Society for Vascular Surgery. The use of functional measures such as the 6-minute walk test can substantially increase diagnostic and treatment accuracy, said Dr. McDermott, of the department of medicine at Northwestern University, Chicago.

Each measure has positives and negatives, said Dr. McDermott, the lead investigator in (the Walking and Leg Circulation Study, WALCS). That study used several performance measures of walking and leg function, including the 6-minute walk test, repeated chair stands, a standing balance test, and a test of walking speed (Ann. Intern. Med. 2002;136:1–32).

One of the most often-used performance measures is the treadmill walking test, but some data suggest it might not mimic actual walking, Dr. McDermott said. And older patients may experience anxiety or balance problems that have an impact on results, she said. A 6-minute walk test conducted in a corridor may be easier and more productive for older patients, according to Dr. McDermott. The test should be done in a 100-foot-long hallway, with patients told to walk as far as they can during the 6 minutes, with no conversation during the test.

The 6-minute walk test was shown to be reliable in a 1998 study (J. Amer. Geriatr. Soc. 1998;46:706–11). Dr. McDermott and her colleagues have completed a study, which has been submitted for publication, showing that 6-minute walk performance at baseline predicts mortality. In addition to the 6-minute walk, clinicians should consider three other tests that measure leg strength, balance, and walking speed. Together, these additional diagnostics constitute the summary performance score (SPS). Each is scored on a 0–4 scale and is added to create a total score of 0–12.

The first component is the 4-meter walk test, which is conducted in a corridor with a stopwatch. Dr. McDermott has found that patients who do not walk regularly for exercise have the greatest decline in the 4-meter speed. The SPS also includes a standing balance test and time to arise five times consecutively from a seated position. Lower SPS scores are associated with a higher risk of death, nursing home placement, and a reduction in the ability to perform activities of daily living, she said.

Physical activity can be measured with a vertical accelerometer, said Dr. McDermott, who has conducted several validation studies of the Caltrac version (Muscle Dynamics Fitness Network).

In the trials, PAD patients were given the beeperlike device to wear for 7 days, except when sleeping or bathing. Dr. McDermott and her colleagues found that PAD patients had much lower activity than non-PAD patients, and that the performance correlated with 6-minute walk test results (J. Am. Geriatr. Soc. 2001;49:747–54).

WASHINGTON — Using validated functional performance measures is better than relying on patient reporting to determine walking ability and the effects of treatments in peripheral arterial disease, according to Dr. Mary McGrae McDermott.

PAD patients may underreport leg symptoms because they often restrict their activity to avoid experiencing those symptoms, said Dr. McDermott at a conference sponsored by the Society for Vascular Surgery. The use of functional measures such as the 6-minute walk test can substantially increase diagnostic and treatment accuracy, said Dr. McDermott, of the department of medicine at Northwestern University, Chicago.

Each measure has positives and negatives, said Dr. McDermott, the lead investigator in (the Walking and Leg Circulation Study, WALCS). That study used several performance measures of walking and leg function, including the 6-minute walk test, repeated chair stands, a standing balance test, and a test of walking speed (Ann. Intern. Med. 2002;136:1–32).

One of the most often-used performance measures is the treadmill walking test, but some data suggest it might not mimic actual walking, Dr. McDermott said. And older patients may experience anxiety or balance problems that have an impact on results, she said. A 6-minute walk test conducted in a corridor may be easier and more productive for older patients, according to Dr. McDermott. The test should be done in a 100-foot-long hallway, with patients told to walk as far as they can during the 6 minutes, with no conversation during the test.

The 6-minute walk test was shown to be reliable in a 1998 study (J. Amer. Geriatr. Soc. 1998;46:706–11). Dr. McDermott and her colleagues have completed a study, which has been submitted for publication, showing that 6-minute walk performance at baseline predicts mortality. In addition to the 6-minute walk, clinicians should consider three other tests that measure leg strength, balance, and walking speed. Together, these additional diagnostics constitute the summary performance score (SPS). Each is scored on a 0–4 scale and is added to create a total score of 0–12.

The first component is the 4-meter walk test, which is conducted in a corridor with a stopwatch. Dr. McDermott has found that patients who do not walk regularly for exercise have the greatest decline in the 4-meter speed. The SPS also includes a standing balance test and time to arise five times consecutively from a seated position. Lower SPS scores are associated with a higher risk of death, nursing home placement, and a reduction in the ability to perform activities of daily living, she said.

Physical activity can be measured with a vertical accelerometer, said Dr. McDermott, who has conducted several validation studies of the Caltrac version (Muscle Dynamics Fitness Network).

In the trials, PAD patients were given the beeperlike device to wear for 7 days, except when sleeping or bathing. Dr. McDermott and her colleagues found that PAD patients had much lower activity than non-PAD patients, and that the performance correlated with 6-minute walk test results (J. Am. Geriatr. Soc. 2001;49:747–54).

Rich and Educated Burn More

Wealthier and better-educated Americans get sunburn more often, according to a study published in the Journal of the American Academy of Dermatology. University of Pennsylvania researchers used data from the 2003 Behavioral Risk Factor Surveillance Survey, a random sample of 248,000 Americans conducted by the Centers for Disease Control and Prevention. About 85% of the respondents self-identified as white; overall, half were female, and the mean age was 47 years. Thirty-nine percent said they'd had at least one sunburn in the year before their interview; 26% said they'd had two or more burns, 15% had three or more, and 9% had four or more. Not surprisingly, sunburns were more prevalent in the 18- to 24-year-old age group, and decreased with age, becoming least prevalent in those over age 75. Prevalence was highest in those making more than $50,000 annually and who had a college degree, and decreased with less income and lower education. Adjusting for age and alcohol and tobacco use attenuated some of the income and wealth effect, but higher education and earnings were still positively associated with sunburn, said the researchers.

Report Faults Wound Payment

Medicare needs to improve the way it pays for wound management, according to a new report by AdvaMed, a trade association for medical device companies. "Coverage and reimbursement policies in the nation's Medicare system currently do not reflect technological advances in wound care management, are too comprehensive, and can cause disruptions in delivering appropriate care to patients," the report's authors said. "Medicare often focuses narrowly on a specific unit cost or the cost of wound care at a specific site, while not considering the long-term costs of caring for patients." AdvaMed urged the Centers for Medicare and Medicaid Services to increase the amount of money the agency pays for wound care supplies used by hospitals, nursing homes, and outpatient clinics. The recommendations also included prevention: AdvaMed suggested the agency provide coverage as part of Medicare's surgical dressing benefit for "preventive and early intervention technologies for tissue damage."

Fix the SGR, Delay Imaging Cuts

Rep. Michael Burgess (R-Tex.), an ob.gyn., has introduced legislation (H.R. 5866) that would put an end to physician fee cuts under Medicare by halting application of the sustainable growth rate by Jan. 1, 2007. Each year, the SGR has contributed to a decrease in payments; in 2007, that cut will be at least 4.6%. Rep. Burgess is proposing to tie physician fees to one factor only: the Medicare Economic Index minus 1%. According to Rep. Burgess, this places "more value on actual cost inputs." The bill also would establish a system of quality measures to give patients more information about Medicare providers, delay by 1 year proposed cuts in imaging services reimbursement, and require the Institute of Medicine to perform a study on the question of whether imaging saves money. The American Medical Association called the Medicare Physician Payment Reform Bill and Quality Improvement Act of 2006 an "important step toward replacing the flawed Medicare physician payment formula." Rep. Burgess' bill is the third in the House to delay or repeal the cuts in imaging fees. Rep. Joseph Pitts (R-Pa.) has called for a 2-year delay in H.R. 5704; a similar bill was recently introduced by Sen. Gordon Smith (R-Ore.) and Sen. Jay Rockefeller (D-W.Va.).

Senate Bill to Boost Drug Safety

After months of public discourse, Sen. Edward Kennedy (D-Mass.) and Sen. Mike Enzi (R-Wyo.) have introduced a bill that aims to increase assurances that drugs are safe before they reach the marketplace, or at least have a plan in place to more closely monitor when they need to be withdrawn. The Enhancing Drug Safety and Innovation Act would require pharmaceutical manufacturers to be more proactive about safety problems. Companies would have to establish risk evaluation and management strategies that will be agreed upon by the manufacturer and the Food and Drug Administration before the product is approved. The companies would have to submit adverse event reports every 15 days, quarterly, and annually. If a company knowingly does not comply with the agreed-upon strategy, the FDA can impose monetary penalties. The senators also proposed that manufacturers make clinical trial results public. Fuller disclosure "will help patients and their health care providers make better informed decisions about treatment," Sen. Kennedy said in a statement. Finally, the bill would overhaul the FDA's process for vetting outside advisory panel members, with a goal of minimizing conflicts of interest and then ensuring that they are fully disclosed.

Poll: Live Unhealthy, Pay the Price

More than half of respondents to a Wall Street Journal/Harris Interactive poll say that people who smoke or choose not to wear seat belts should pay a higher health insurance premium, but most did not feel the same way about people who were overweight or didn't exercise enough. Only 27% of the poll's 2,200 respondents thought that overweight people should pay more for insurance than slimmer people; the same percentage favored having people who did not exercise regularly pay more. The amount of education the respondent had affected the responses given: Those with some college education were more likely to agree that those with unhealthy lifestyles should pay higher premiums, compared with respondents with a high school education or less. The poll had a 3.3% margin of error.

Rich and Educated Burn More

Wealthier and better-educated Americans get sunburn more often, according to a study published in the Journal of the American Academy of Dermatology. University of Pennsylvania researchers used data from the 2003 Behavioral Risk Factor Surveillance Survey, a random sample of 248,000 Americans conducted by the Centers for Disease Control and Prevention. About 85% of the respondents self-identified as white; overall, half were female, and the mean age was 47 years. Thirty-nine percent said they'd had at least one sunburn in the year before their interview; 26% said they'd had two or more burns, 15% had three or more, and 9% had four or more. Not surprisingly, sunburns were more prevalent in the 18- to 24-year-old age group, and decreased with age, becoming least prevalent in those over age 75. Prevalence was highest in those making more than $50,000 annually and who had a college degree, and decreased with less income and lower education. Adjusting for age and alcohol and tobacco use attenuated some of the income and wealth effect, but higher education and earnings were still positively associated with sunburn, said the researchers.

Report Faults Wound Payment

Medicare needs to improve the way it pays for wound management, according to a new report by AdvaMed, a trade association for medical device companies. "Coverage and reimbursement policies in the nation's Medicare system currently do not reflect technological advances in wound care management, are too comprehensive, and can cause disruptions in delivering appropriate care to patients," the report's authors said. "Medicare often focuses narrowly on a specific unit cost or the cost of wound care at a specific site, while not considering the long-term costs of caring for patients." AdvaMed urged the Centers for Medicare and Medicaid Services to increase the amount of money the agency pays for wound care supplies used by hospitals, nursing homes, and outpatient clinics. The recommendations also included prevention: AdvaMed suggested the agency provide coverage as part of Medicare's surgical dressing benefit for "preventive and early intervention technologies for tissue damage."

Fix the SGR, Delay Imaging Cuts

Rep. Michael Burgess (R-Tex.), an ob.gyn., has introduced legislation (H.R. 5866) that would put an end to physician fee cuts under Medicare by halting application of the sustainable growth rate by Jan. 1, 2007. Each year, the SGR has contributed to a decrease in payments; in 2007, that cut will be at least 4.6%. Rep. Burgess is proposing to tie physician fees to one factor only: the Medicare Economic Index minus 1%. According to Rep. Burgess, this places "more value on actual cost inputs." The bill also would establish a system of quality measures to give patients more information about Medicare providers, delay by 1 year proposed cuts in imaging services reimbursement, and require the Institute of Medicine to perform a study on the question of whether imaging saves money. The American Medical Association called the Medicare Physician Payment Reform Bill and Quality Improvement Act of 2006 an "important step toward replacing the flawed Medicare physician payment formula." Rep. Burgess' bill is the third in the House to delay or repeal the cuts in imaging fees. Rep. Joseph Pitts (R-Pa.) has called for a 2-year delay in H.R. 5704; a similar bill was recently introduced by Sen. Gordon Smith (R-Ore.) and Sen. Jay Rockefeller (D-W.Va.).

Senate Bill to Boost Drug Safety

After months of public discourse, Sen. Edward Kennedy (D-Mass.) and Sen. Mike Enzi (R-Wyo.) have introduced a bill that aims to increase assurances that drugs are safe before they reach the marketplace, or at least have a plan in place to more closely monitor when they need to be withdrawn. The Enhancing Drug Safety and Innovation Act would require pharmaceutical manufacturers to be more proactive about safety problems. Companies would have to establish risk evaluation and management strategies that will be agreed upon by the manufacturer and the Food and Drug Administration before the product is approved. The companies would have to submit adverse event reports every 15 days, quarterly, and annually. If a company knowingly does not comply with the agreed-upon strategy, the FDA can impose monetary penalties. The senators also proposed that manufacturers make clinical trial results public. Fuller disclosure "will help patients and their health care providers make better informed decisions about treatment," Sen. Kennedy said in a statement. Finally, the bill would overhaul the FDA's process for vetting outside advisory panel members, with a goal of minimizing conflicts of interest and then ensuring that they are fully disclosed.

Poll: Live Unhealthy, Pay the Price

More than half of respondents to a Wall Street Journal/Harris Interactive poll say that people who smoke or choose not to wear seat belts should pay a higher health insurance premium, but most did not feel the same way about people who were overweight or didn't exercise enough. Only 27% of the poll's 2,200 respondents thought that overweight people should pay more for insurance than slimmer people; the same percentage favored having people who did not exercise regularly pay more. The amount of education the respondent had affected the responses given: Those with some college education were more likely to agree that those with unhealthy lifestyles should pay higher premiums, compared with respondents with a high school education or less. The poll had a 3.3% margin of error.

Rich and Educated Burn More

Wealthier and better-educated Americans get sunburn more often, according to a study published in the Journal of the American Academy of Dermatology. University of Pennsylvania researchers used data from the 2003 Behavioral Risk Factor Surveillance Survey, a random sample of 248,000 Americans conducted by the Centers for Disease Control and Prevention. About 85% of the respondents self-identified as white; overall, half were female, and the mean age was 47 years. Thirty-nine percent said they'd had at least one sunburn in the year before their interview; 26% said they'd had two or more burns, 15% had three or more, and 9% had four or more. Not surprisingly, sunburns were more prevalent in the 18- to 24-year-old age group, and decreased with age, becoming least prevalent in those over age 75. Prevalence was highest in those making more than $50,000 annually and who had a college degree, and decreased with less income and lower education. Adjusting for age and alcohol and tobacco use attenuated some of the income and wealth effect, but higher education and earnings were still positively associated with sunburn, said the researchers.

Report Faults Wound Payment

Medicare needs to improve the way it pays for wound management, according to a new report by AdvaMed, a trade association for medical device companies. "Coverage and reimbursement policies in the nation's Medicare system currently do not reflect technological advances in wound care management, are too comprehensive, and can cause disruptions in delivering appropriate care to patients," the report's authors said. "Medicare often focuses narrowly on a specific unit cost or the cost of wound care at a specific site, while not considering the long-term costs of caring for patients." AdvaMed urged the Centers for Medicare and Medicaid Services to increase the amount of money the agency pays for wound care supplies used by hospitals, nursing homes, and outpatient clinics. The recommendations also included prevention: AdvaMed suggested the agency provide coverage as part of Medicare's surgical dressing benefit for "preventive and early intervention technologies for tissue damage."

Fix the SGR, Delay Imaging Cuts

Rep. Michael Burgess (R-Tex.), an ob.gyn., has introduced legislation (H.R. 5866) that would put an end to physician fee cuts under Medicare by halting application of the sustainable growth rate by Jan. 1, 2007. Each year, the SGR has contributed to a decrease in payments; in 2007, that cut will be at least 4.6%. Rep. Burgess is proposing to tie physician fees to one factor only: the Medicare Economic Index minus 1%. According to Rep. Burgess, this places "more value on actual cost inputs." The bill also would establish a system of quality measures to give patients more information about Medicare providers, delay by 1 year proposed cuts in imaging services reimbursement, and require the Institute of Medicine to perform a study on the question of whether imaging saves money. The American Medical Association called the Medicare Physician Payment Reform Bill and Quality Improvement Act of 2006 an "important step toward replacing the flawed Medicare physician payment formula." Rep. Burgess' bill is the third in the House to delay or repeal the cuts in imaging fees. Rep. Joseph Pitts (R-Pa.) has called for a 2-year delay in H.R. 5704; a similar bill was recently introduced by Sen. Gordon Smith (R-Ore.) and Sen. Jay Rockefeller (D-W.Va.).

Senate Bill to Boost Drug Safety

After months of public discourse, Sen. Edward Kennedy (D-Mass.) and Sen. Mike Enzi (R-Wyo.) have introduced a bill that aims to increase assurances that drugs are safe before they reach the marketplace, or at least have a plan in place to more closely monitor when they need to be withdrawn. The Enhancing Drug Safety and Innovation Act would require pharmaceutical manufacturers to be more proactive about safety problems. Companies would have to establish risk evaluation and management strategies that will be agreed upon by the manufacturer and the Food and Drug Administration before the product is approved. The companies would have to submit adverse event reports every 15 days, quarterly, and annually. If a company knowingly does not comply with the agreed-upon strategy, the FDA can impose monetary penalties. The senators also proposed that manufacturers make clinical trial results public. Fuller disclosure "will help patients and their health care providers make better informed decisions about treatment," Sen. Kennedy said in a statement. Finally, the bill would overhaul the FDA's process for vetting outside advisory panel members, with a goal of minimizing conflicts of interest and then ensuring that they are fully disclosed.

Poll: Live Unhealthy, Pay the Price

More than half of respondents to a Wall Street Journal/Harris Interactive poll say that people who smoke or choose not to wear seat belts should pay a higher health insurance premium, but most did not feel the same way about people who were overweight or didn't exercise enough. Only 27% of the poll's 2,200 respondents thought that overweight people should pay more for insurance than slimmer people; the same percentage favored having people who did not exercise regularly pay more. The amount of education the respondent had affected the responses given: Those with some college education were more likely to agree that those with unhealthy lifestyles should pay higher premiums, compared with respondents with a high school education or less. The poll had a 3.3% margin of error.

The Food and Drug Administration announced that it is renewing efforts to ensure that all drugs currently sold by prescription either go through its formal approval process or be taken off the market.

The agency has periodically targeted some of these products using its existing authority. Now, the FDA has issued more formal guidance that spells out for manufacturers how it will prioritize enforcement, and what route they can take to prove the safety and efficacy of their products.

There are many reasons why unapproved products are on the market, said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research, at a press briefing sponsored by the agency.

Most of these products were marketed before passage of the 1962 Food, Drug, and Cosmetic Act, which required formal proof of safety and efficacy. Or their makers may simply have begun selling the products without seeking the agency's approval, he said, noting that the FDA will issue a new drug code (NDC) number for a product even if it was never approved.

In very few cases, the products are grandfathered in under existing laws, agency officials said.

Many of the unapproved drugs are listed in the Physicians' Desk Reference, and some are advertised in medical journals.

Those initially flagged for attention include products that are potentially hazardous, lack evidence of effectiveness, or appear to be fraudulent.

If the manufacturers do not seek approval, they will be subject to enforcement action, Dr. Galson said. But in most cases, the FDA will not remove a drug from the market if it has been shown to have some medical utility. Examples include some manufacturers' levothyroxine and phenobarbital products.

“While we want to ensure continued patient access to necessary treatments, as a physician I feel strongly that patients expect and deserve all their prescription medicines to be approved by the FDA,” said Dr. Andrew C. von Eschenbach, acting FDA commissioner, in a statement.

The agency estimates that less than 2% of prescription drugs have not received its imprimatur. That still means potentially thousands of products that are not approved.

Many of the drugs are cough and cold preparations that include pheniramine maleate and dexbrompheniramine maleate, or single-ingredient narcotics such as codeine phosphate and oxycodone HCl. Sedatives like chloral hydrate are also unapproved.

The agency recently announced that it is requiring makers of carbinoxamine-containing products to seek approval by late September. Any unapproved products still on the shelves at that date will be ordered off the market, said Deborah M. Autor, FDA associate director for compliance policy. Carbinoxamine is used in cough and cold treatments, mostly for children, that have been associated with 21 reported deaths since 1983.

Physicians, pharmacists, and patients can go to the FDA's Web site (www.accessdata.fda.gov/scripts/cder/drugsatfda

The Food and Drug Administration announced that it is renewing efforts to ensure that all drugs currently sold by prescription either go through its formal approval process or be taken off the market.

The agency has periodically targeted some of these products using its existing authority. Now, the FDA has issued more formal guidance that spells out for manufacturers how it will prioritize enforcement, and what route they can take to prove the safety and efficacy of their products.

There are many reasons why unapproved products are on the market, said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research, at a press briefing sponsored by the agency.

Most of these products were marketed before passage of the 1962 Food, Drug, and Cosmetic Act, which required formal proof of safety and efficacy. Or their makers may simply have begun selling the products without seeking the agency's approval, he said, noting that the FDA will issue a new drug code (NDC) number for a product even if it was never approved.

In very few cases, the products are grandfathered in under existing laws, agency officials said.

Many of the unapproved drugs are listed in the Physicians' Desk Reference, and some are advertised in medical journals.

Those initially flagged for attention include products that are potentially hazardous, lack evidence of effectiveness, or appear to be fraudulent.

If the manufacturers do not seek approval, they will be subject to enforcement action, Dr. Galson said. But in most cases, the FDA will not remove a drug from the market if it has been shown to have some medical utility. Examples include some manufacturers' levothyroxine and phenobarbital products.

“While we want to ensure continued patient access to necessary treatments, as a physician I feel strongly that patients expect and deserve all their prescription medicines to be approved by the FDA,” said Dr. Andrew C. von Eschenbach, acting FDA commissioner, in a statement.

The agency estimates that less than 2% of prescription drugs have not received its imprimatur. That still means potentially thousands of products that are not approved.

Many of the drugs are cough and cold preparations that include pheniramine maleate and dexbrompheniramine maleate, or single-ingredient narcotics such as codeine phosphate and oxycodone HCl. Sedatives like chloral hydrate are also unapproved.

The agency recently announced that it is requiring makers of carbinoxamine-containing products to seek approval by late September. Any unapproved products still on the shelves at that date will be ordered off the market, said Deborah M. Autor, FDA associate director for compliance policy. Carbinoxamine is used in cough and cold treatments, mostly for children, that have been associated with 21 reported deaths since 1983.

Physicians, pharmacists, and patients can go to the FDA's Web site (www.accessdata.fda.gov/scripts/cder/drugsatfda

The Food and Drug Administration announced that it is renewing efforts to ensure that all drugs currently sold by prescription either go through its formal approval process or be taken off the market.

The agency has periodically targeted some of these products using its existing authority. Now, the FDA has issued more formal guidance that spells out for manufacturers how it will prioritize enforcement, and what route they can take to prove the safety and efficacy of their products.

There are many reasons why unapproved products are on the market, said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research, at a press briefing sponsored by the agency.

Most of these products were marketed before passage of the 1962 Food, Drug, and Cosmetic Act, which required formal proof of safety and efficacy. Or their makers may simply have begun selling the products without seeking the agency's approval, he said, noting that the FDA will issue a new drug code (NDC) number for a product even if it was never approved.

In very few cases, the products are grandfathered in under existing laws, agency officials said.

Many of the unapproved drugs are listed in the Physicians' Desk Reference, and some are advertised in medical journals.

Those initially flagged for attention include products that are potentially hazardous, lack evidence of effectiveness, or appear to be fraudulent.

If the manufacturers do not seek approval, they will be subject to enforcement action, Dr. Galson said. But in most cases, the FDA will not remove a drug from the market if it has been shown to have some medical utility. Examples include some manufacturers' levothyroxine and phenobarbital products.

“While we want to ensure continued patient access to necessary treatments, as a physician I feel strongly that patients expect and deserve all their prescription medicines to be approved by the FDA,” said Dr. Andrew C. von Eschenbach, acting FDA commissioner, in a statement.

The agency estimates that less than 2% of prescription drugs have not received its imprimatur. That still means potentially thousands of products that are not approved.

Many of the drugs are cough and cold preparations that include pheniramine maleate and dexbrompheniramine maleate, or single-ingredient narcotics such as codeine phosphate and oxycodone HCl. Sedatives like chloral hydrate are also unapproved.

The agency recently announced that it is requiring makers of carbinoxamine-containing products to seek approval by late September. Any unapproved products still on the shelves at that date will be ordered off the market, said Deborah M. Autor, FDA associate director for compliance policy. Carbinoxamine is used in cough and cold treatments, mostly for children, that have been associated with 21 reported deaths since 1983.

Physicians, pharmacists, and patients can go to the FDA's Web site (www.accessdata.fda.gov/scripts/cder/drugsatfda

In an assessment of performance by one of the nation's largest physician revenue management companies, Humana and Medicare were rated highest when it came to paying quickly and being easy to work with.

The performance data were tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available—free of charge—Jeremy Delinsky, director of process innovation at AthenaHealth, said “we were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more leverage in contracting and a better opportunity to improve their bottom line, he said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005. To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000.

Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

In addition to financial performance, the index included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working within the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to physicians to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance.

In the northeast, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than national insurers, Mr. Delinsky said. National payers have been growing in size, but “it's unclear to us whether consolidation has resulted in the scale they hoped for,” he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. However, he suggested that physicians could use his company's rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt. The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

If there is a delay in payment, it's often because the claim has not been received in a timely manner from the physician's office, according to AHIP. The group said that 3 in 10 claims were received more than 30 days after the date of service. Paper claims are more likely to get held up. A third of paper claims took 60 days or more to reach the payer, AHIP said.

The performance rankings are posted at www.athenapayerview.com

In an assessment of performance by one of the nation's largest physician revenue management companies, Humana and Medicare were rated highest when it came to paying quickly and being easy to work with.

The performance data were tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available—free of charge—Jeremy Delinsky, director of process innovation at AthenaHealth, said “we were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more leverage in contracting and a better opportunity to improve their bottom line, he said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005. To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000.

Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

In addition to financial performance, the index included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working within the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to physicians to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance.

In the northeast, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than national insurers, Mr. Delinsky said. National payers have been growing in size, but “it's unclear to us whether consolidation has resulted in the scale they hoped for,” he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. However, he suggested that physicians could use his company's rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt. The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

If there is a delay in payment, it's often because the claim has not been received in a timely manner from the physician's office, according to AHIP. The group said that 3 in 10 claims were received more than 30 days after the date of service. Paper claims are more likely to get held up. A third of paper claims took 60 days or more to reach the payer, AHIP said.

The performance rankings are posted at www.athenapayerview.com

In an assessment of performance by one of the nation's largest physician revenue management companies, Humana and Medicare were rated highest when it came to paying quickly and being easy to work with.

The performance data were tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available—free of charge—Jeremy Delinsky, director of process innovation at AthenaHealth, said “we were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more leverage in contracting and a better opportunity to improve their bottom line, he said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005. To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000.

Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

In addition to financial performance, the index included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working within the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to physicians to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance.

In the northeast, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than national insurers, Mr. Delinsky said. National payers have been growing in size, but “it's unclear to us whether consolidation has resulted in the scale they hoped for,” he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. However, he suggested that physicians could use his company's rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt. The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

If there is a delay in payment, it's often because the claim has not been received in a timely manner from the physician's office, according to AHIP. The group said that 3 in 10 claims were received more than 30 days after the date of service. Paper claims are more likely to get held up. A third of paper claims took 60 days or more to reach the payer, AHIP said.

The performance rankings are posted at www.athenapayerview.com

The Food and Drug Administration announced that it is renewing efforts to ensure that all drugs currently sold by prescription either go through its formal approval process or be taken off the market.

There are many reasons why unapproved products are on the market, said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research, at a press briefing sponsored by the agency.

Most were marketed before passage of the 1962 Food, Drug, and Cosmetic Act, which required formal proof of safety and efficacy. Or their makers may simply have begun selling the products without seeking the agency's approval, he said, noting that the FDA will issue a new drug code (NDC) number for a product even if it was never approved.

In very few cases, the products are grandfathered in under existing laws.

Many of the unapproved drugs are listed in the Physicians' Desk Reference. Some are advertised in medical journals.

Those initially flagged for attention include products that are potentially hazardous, lack evidence of effectiveness, or appear to be fraudulent.

If the manufacturers don't seek approval, they will be subject to enforcement, Dr. Galson said. But in most cases, the FDA will not remove a drug shown to have some medical utility. Examples include some manufacturers' levothyroxine and phenobarbital products.

“While we want to ensure continued patient access to necessary treatments, as a physician I feel strongly that patients expect and deserve all their prescription medicines to be FDA approved,” said Dr. Andrew C. von Eschenbach, acting FDA commissioner, in a statement.

The agency estimates that less than 2% of prescription drugs have not received its imprimatur. That still means potentially thousands of products that aren't approved. Many are cough and cold preparations that include pheniramine maleate and dexbrompheniramine maleate, or single-ingredient narcotics such as codeine phosphate and oxycodone HCl. Sedatives like chloral hydrate are also unapproved.

Physicians, pharmacists, and patients can go to the FDA's Web site (www.accessdata.fda.gov/scripts/cder/drugsatfda

The Food and Drug Administration announced that it is renewing efforts to ensure that all drugs currently sold by prescription either go through its formal approval process or be taken off the market.

There are many reasons why unapproved products are on the market, said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research, at a press briefing sponsored by the agency.

Most were marketed before passage of the 1962 Food, Drug, and Cosmetic Act, which required formal proof of safety and efficacy. Or their makers may simply have begun selling the products without seeking the agency's approval, he said, noting that the FDA will issue a new drug code (NDC) number for a product even if it was never approved.

In very few cases, the products are grandfathered in under existing laws.

Many of the unapproved drugs are listed in the Physicians' Desk Reference. Some are advertised in medical journals.

Those initially flagged for attention include products that are potentially hazardous, lack evidence of effectiveness, or appear to be fraudulent.

If the manufacturers don't seek approval, they will be subject to enforcement, Dr. Galson said. But in most cases, the FDA will not remove a drug shown to have some medical utility. Examples include some manufacturers' levothyroxine and phenobarbital products.

“While we want to ensure continued patient access to necessary treatments, as a physician I feel strongly that patients expect and deserve all their prescription medicines to be FDA approved,” said Dr. Andrew C. von Eschenbach, acting FDA commissioner, in a statement.

The agency estimates that less than 2% of prescription drugs have not received its imprimatur. That still means potentially thousands of products that aren't approved. Many are cough and cold preparations that include pheniramine maleate and dexbrompheniramine maleate, or single-ingredient narcotics such as codeine phosphate and oxycodone HCl. Sedatives like chloral hydrate are also unapproved.

Physicians, pharmacists, and patients can go to the FDA's Web site (www.accessdata.fda.gov/scripts/cder/drugsatfda

The Food and Drug Administration announced that it is renewing efforts to ensure that all drugs currently sold by prescription either go through its formal approval process or be taken off the market.

There are many reasons why unapproved products are on the market, said Dr. Steven Galson, director of the FDA's Center for Drug Evaluation and Research, at a press briefing sponsored by the agency.

Most were marketed before passage of the 1962 Food, Drug, and Cosmetic Act, which required formal proof of safety and efficacy. Or their makers may simply have begun selling the products without seeking the agency's approval, he said, noting that the FDA will issue a new drug code (NDC) number for a product even if it was never approved.

In very few cases, the products are grandfathered in under existing laws.

Many of the unapproved drugs are listed in the Physicians' Desk Reference. Some are advertised in medical journals.

Those initially flagged for attention include products that are potentially hazardous, lack evidence of effectiveness, or appear to be fraudulent.

If the manufacturers don't seek approval, they will be subject to enforcement, Dr. Galson said. But in most cases, the FDA will not remove a drug shown to have some medical utility. Examples include some manufacturers' levothyroxine and phenobarbital products.

“While we want to ensure continued patient access to necessary treatments, as a physician I feel strongly that patients expect and deserve all their prescription medicines to be FDA approved,” said Dr. Andrew C. von Eschenbach, acting FDA commissioner, in a statement.

The agency estimates that less than 2% of prescription drugs have not received its imprimatur. That still means potentially thousands of products that aren't approved. Many are cough and cold preparations that include pheniramine maleate and dexbrompheniramine maleate, or single-ingredient narcotics such as codeine phosphate and oxycodone HCl. Sedatives like chloral hydrate are also unapproved.

Physicians, pharmacists, and patients can go to the FDA's Web site (www.accessdata.fda.gov/scripts/cder/drugsatfda

Humana and Medicare were rated highest when it came to paying quickly and being easy to work with, based on an assessment of performance by one of the nation's largest physician revenue management companies.

The performance data was tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available free of charge, Jeremy Delinsky, director of process innovation at AthenaHealth, said, “We were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more contracting leverage and a better chance to improve their bottom line, Mr. Delinsky said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005. To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000.

Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

The index also included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working by the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to physicians to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance. In the northeast, for example, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than the national insurers, he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. However, he suggested that physicians could use his company's rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt.

The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

The rankings are posted at www.athenapayerview.com

Humana and Medicare were rated highest when it came to paying quickly and being easy to work with, based on an assessment of performance by one of the nation's largest physician revenue management companies.

The performance data was tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available free of charge, Jeremy Delinsky, director of process innovation at AthenaHealth, said, “We were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more contracting leverage and a better chance to improve their bottom line, Mr. Delinsky said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005. To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000.

Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

The index also included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working by the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to physicians to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance. In the northeast, for example, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than the national insurers, he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. However, he suggested that physicians could use his company's rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt.

The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

The rankings are posted at www.athenapayerview.com

Humana and Medicare were rated highest when it came to paying quickly and being easy to work with, based on an assessment of performance by one of the nation's largest physician revenue management companies.

The performance data was tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available free of charge, Jeremy Delinsky, director of process innovation at AthenaHealth, said, “We were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more contracting leverage and a better chance to improve their bottom line, Mr. Delinsky said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005. To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000.

Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

The index also included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working by the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to physicians to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance. In the northeast, for example, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than the national insurers, he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. However, he suggested that physicians could use his company's rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt.

The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

The rankings are posted at www.athenapayerview.com

In an assessment of performance by one of the nation's largest physician revenue management companies, Humana and Medicare were rated highest when it came to paying quickly and being easy to work with.

The performance data was tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available—free of charge—Jeremy Delinsky, director of process innovation at AthenaHealth, said, “We were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more leverage in contracting and a better opportunity to improve their bottom line, he said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005.

To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000. Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

In addition to financial performance, the index included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working within the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to the physician to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance. In the northeast, for example, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than the national insurers, said Mr. Delinsky. National payers have been growing in size, but “it's unclear to us whether consolidation has resulted in the scale they hoped for,” he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. He suggested that physicians could use the rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt. The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

The rankings are posted at www.athenapayerview.com

In an assessment of performance by one of the nation's largest physician revenue management companies, Humana and Medicare were rated highest when it came to paying quickly and being easy to work with.

The performance data was tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available—free of charge—Jeremy Delinsky, director of process innovation at AthenaHealth, said, “We were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more leverage in contracting and a better opportunity to improve their bottom line, he said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005.

To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000. Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

In addition to financial performance, the index included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working within the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to the physician to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance. In the northeast, for example, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than the national insurers, said Mr. Delinsky. National payers have been growing in size, but “it's unclear to us whether consolidation has resulted in the scale they hoped for,” he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. He suggested that physicians could use the rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt. The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

The rankings are posted at www.athenapayerview.com

In an assessment of performance by one of the nation's largest physician revenue management companies, Humana and Medicare were rated highest when it came to paying quickly and being easy to work with.

The performance data was tabulated and made public by AthenaHealth, a Watertown, Mass.-based company that manages $2 billion in revenues for 7,000 physicians, nurses, and other health care providers in 33 states.

In explaining why the company decided to make the data available—free of charge—Jeremy Delinsky, director of process innovation at AthenaHealth, said, “We were a little skittish about making it public, but we found the story was too compelling to sit on.” And, physicians who know more about their insurers will have more leverage in contracting and a better opportunity to improve their bottom line, he said.

The company assessed 5 million “charge lines” worth of claims data from the fourth quarter of 2005.

To be a part of the ranking, national payers had to have at least 10,000 “charge lines,” or line items, and regional payers at least 3,000. Insurers were ranked according to an overall index that gave the most weight to financial performance. That performance included days in accounts receivable, percentage of claims paid and closed on the first pass, and percentage of charges transferred to the patient.

In addition to financial performance, the index included an administrative measure encompassing the claims denial rate, the percentage requiring a phone call to clarify a response from the insurer, and the percentage of claims lost. Finally, a small amount of weight was given to the difficulty of working within the payer's rules.

Nationally, Humana ranked number one, followed by Medicare, United Health Group, Aetna, Cigna, Champus, and Wellpoint. According to AthenaHealth, Aetna denies claims twice as often as Humana, and the reasons are so unclear that 17% of claims need follow-up calls. Wellpoint tended to take the longest to pay, and more than any other payer, the company aggressively shifts responsibility to the physician to get payment from the patient.

For all payers, claims stay in accounts receivable for an average of 38 days.

On the regional level, there was a wide variation in performance. In the northeast, for example, BlueCross BlueShield of Pennsylvania/Independence BlueCross was the top-ranked plan, followed by Tufts Health Plan and Fallon Health Plan. In the west, PacifiCare was first, followed by Medicare B in Texas and United Health Group. The largest regional payers mostly provided clear reasons for denials, rarely shifted the responsibility to physicians to secure payment, and paid most claims upon first submission and within 30 days.

Regional payers appeared to be more efficient and perhaps even more powerful than the national insurers, said Mr. Delinsky. National payers have been growing in size, but “it's unclear to us whether consolidation has resulted in the scale they hoped for,” he said.

AthenaHealth did not assess payers' relative reimbursement rates because it would not be legal to publicize those rates, Mr. Delinsky said. He suggested that physicians could use the rankings to negotiate for a higher fee if the payer is hard to work with, or potentially accept a lower payment rate if the insurer pays more quickly and imposes less of an administrative burden.

The insurance industry did not respond directly to the rankings, but America's Health Insurance Plans, a national trade association, completed a study recently showing that 98% of claims submitted electronically are processed within a month of receipt. The study, based on aggregated data from 25 million claims processed by a sample of 26 health insurers, found that 75% of all claims are submitted electronically, up from 24% in 1995.

The rankings are posted at www.athenapayerview.com

Hold Sought on Imaging Pay Cuts

With Medicare due to slash payments for imaging services by 35%–55% in January 2007, provider organizations are rallying to delay or repeal the cuts, which call for payments for the technical component—equipment, supplies, and overhead for imaging services—to be reimbursed at the hospital outpatient payment rate if it is lower than the physician fee schedule. At a hearing of the House Energy and Commerce Health Subcommittee, Democrats and Republicans said they were concerned the reductions were enacted without public input and without any assessment of the impact on beneficiaries. The cuts were inserted into the Deficit Reduction Act during a House-Senate conference; the act was signed in February 2006. “We don't know exactly what we've done, or how well or how poorly we've done it,” said Rep. John Dingell (D-Mich.) at the hearing. H.R. 5704, sponsored by Rep. Joseph Pitts (R-Penn.), would institute a 2-year moratorium. Many medical organizations voiced objections to the cuts, including the American College of Cardiology, the Society for Vascular Surgery, and the Society for Cardiovascular Angiography and Interventions. The ACC “cautiously supports” the Pitts bill, said Dr. Kim A. Williams, director of nuclear cardiology at the University of Chicago and cochair of the ACC's Cardiovascular Imaging Collaborative, at a briefing with reporters. It's not clear how the cuts could be eliminated without causing reductions in other areas, he said. Rep. Carolyn McCarthy (D-N.Y.) has introduced a bill that would repeal the cuts (H.R. 5238).

Call to Action on Risk Factors

The American Heart Association and the American Diabetes Association have issued a call to action to assess patients for their global risk of cardiovascular disease and diabetes. The groups cowrote a document published in both Circulation and Diabetes Care in part to dispel the notion that there is disagreement between them about the need to assess patients for risk factors such as prediabetes, hypertension, dyslipidemia, obesity, and smoking. The debate between the groups has been specifically about the clinical utility of the term “metabolic syndrome,” not about the overall need to screen patients' risk for cardiovascular disease (CVD), they said. “We are concerned that the presumed dispute will lead to a reduction in the favorable trend of many aspects of CVD risk factor reduction,” said AHA president Dr. Robert H. Eckel and ADA president Dr. Robert Rizza, along with science advisers Richard Kahn, Ph.D., of the ADA and Dr. Rose Marie Robertson of the AHA. Risk assessment and adherence to national guidelines remains “woefully suboptimal,” they said.

Postmarketing Study Failure

The Food and Drug Administration is doing a poor job of ensuring that pharmaceutical companies live up to postmarketing study commitments, according to a new report by the Department of Health and Human Services' Office of Inspector General. Among the findings: that the FDA can't easily identify if the studies are progressing or what stage they are in, and that monitoring postmarketing studies “is not a top priority at FDA.” The OIG reviewed new drug applications from 1990 to 2004; 48% of those applications had at least one postmarketing study commitment. Drug makers are required to submit annual status reports. The OIG found that 35% of the reports that should have been submitted in fiscal 2004 were missing or had no information on the study commitments. The OIG noted that the FDA has limited enforcement power in this area, but suggested that the agency require more, and more relevant, information from drug makers. In response, the FDA said it could not do that without additional regulations, but agreed that it needed to do more to improve its monitoring and to ensure that commitments are honored and that annual reports are thorough.

Supplement Side Effects

Dietary supplement makers and producers of over-the-counter drugs would be required to report serious adverse events to the FDA within 15 business days, under the Dietary Supplement and Nonprescription Drug Consumer Protection Act (S. 3456), currently pending in the U.S. Senate. The bill was introduced by strange bedfellows: Sen. Orrin Hatch (R-Utah), who crafted the 1994 Dietary Supplement Health and Education Act (DSHEA), which is widely seen as a loophole for the products, along with two frequent critics of DSHEA: Sen. Tom Harkin (D-Iowa) and Sen. Richard Durbin (D-Ill.). The proposal also has the backing of consumer advocates such as Consumer Reports and the Center for Science in the Public Interest, and of several industry groups. The bill has been reported out of the Senate Health, Education, Labor, and Pension Committee and next will go before the full Senate.

Latest Vioxx Ruling

Merck has collected another win in its defense of Vioxx. A jury last month rejected the charge that the company was liable for a New Jersey woman's heart attack after nearly 3 years of taking Vioxx. Elaine Doherty of Lawrenceville said she took Vioxx daily from June 2001 until her heart attack in January 2004 at age 65, and then continued on the drug until it was withdrawn from the market in September 2004. But Merck attorneys countered that she had multiple risk factors for heart disease, such as high cholesterol, diabetes, high blood pressure, and obesity. “The company acted responsibly, the science was on our side, and the jury agreed,” said Jim Fitzpatrick of Hughes Hubbard and Reed, a member of the Merck defense team in the case, in a statement.

Hold Sought on Imaging Pay Cuts

With Medicare due to slash payments for imaging services by 35%–55% in January 2007, provider organizations are rallying to delay or repeal the cuts, which call for payments for the technical component—equipment, supplies, and overhead for imaging services—to be reimbursed at the hospital outpatient payment rate if it is lower than the physician fee schedule. At a hearing of the House Energy and Commerce Health Subcommittee, Democrats and Republicans said they were concerned the reductions were enacted without public input and without any assessment of the impact on beneficiaries. The cuts were inserted into the Deficit Reduction Act during a House-Senate conference; the act was signed in February 2006. “We don't know exactly what we've done, or how well or how poorly we've done it,” said Rep. John Dingell (D-Mich.) at the hearing. H.R. 5704, sponsored by Rep. Joseph Pitts (R-Penn.), would institute a 2-year moratorium. Many medical organizations voiced objections to the cuts, including the American College of Cardiology, the Society for Vascular Surgery, and the Society for Cardiovascular Angiography and Interventions. The ACC “cautiously supports” the Pitts bill, said Dr. Kim A. Williams, director of nuclear cardiology at the University of Chicago and cochair of the ACC's Cardiovascular Imaging Collaborative, at a briefing with reporters. It's not clear how the cuts could be eliminated without causing reductions in other areas, he said. Rep. Carolyn McCarthy (D-N.Y.) has introduced a bill that would repeal the cuts (H.R. 5238).

Call to Action on Risk Factors

The American Heart Association and the American Diabetes Association have issued a call to action to assess patients for their global risk of cardiovascular disease and diabetes. The groups cowrote a document published in both Circulation and Diabetes Care in part to dispel the notion that there is disagreement between them about the need to assess patients for risk factors such as prediabetes, hypertension, dyslipidemia, obesity, and smoking. The debate between the groups has been specifically about the clinical utility of the term “metabolic syndrome,” not about the overall need to screen patients' risk for cardiovascular disease (CVD), they said. “We are concerned that the presumed dispute will lead to a reduction in the favorable trend of many aspects of CVD risk factor reduction,” said AHA president Dr. Robert H. Eckel and ADA president Dr. Robert Rizza, along with science advisers Richard Kahn, Ph.D., of the ADA and Dr. Rose Marie Robertson of the AHA. Risk assessment and adherence to national guidelines remains “woefully suboptimal,” they said.

Postmarketing Study Failure

The Food and Drug Administration is doing a poor job of ensuring that pharmaceutical companies live up to postmarketing study commitments, according to a new report by the Department of Health and Human Services' Office of Inspector General. Among the findings: that the FDA can't easily identify if the studies are progressing or what stage they are in, and that monitoring postmarketing studies “is not a top priority at FDA.” The OIG reviewed new drug applications from 1990 to 2004; 48% of those applications had at least one postmarketing study commitment. Drug makers are required to submit annual status reports. The OIG found that 35% of the reports that should have been submitted in fiscal 2004 were missing or had no information on the study commitments. The OIG noted that the FDA has limited enforcement power in this area, but suggested that the agency require more, and more relevant, information from drug makers. In response, the FDA said it could not do that without additional regulations, but agreed that it needed to do more to improve its monitoring and to ensure that commitments are honored and that annual reports are thorough.

Supplement Side Effects

Dietary supplement makers and producers of over-the-counter drugs would be required to report serious adverse events to the FDA within 15 business days, under the Dietary Supplement and Nonprescription Drug Consumer Protection Act (S. 3456), currently pending in the U.S. Senate. The bill was introduced by strange bedfellows: Sen. Orrin Hatch (R-Utah), who crafted the 1994 Dietary Supplement Health and Education Act (DSHEA), which is widely seen as a loophole for the products, along with two frequent critics of DSHEA: Sen. Tom Harkin (D-Iowa) and Sen. Richard Durbin (D-Ill.). The proposal also has the backing of consumer advocates such as Consumer Reports and the Center for Science in the Public Interest, and of several industry groups. The bill has been reported out of the Senate Health, Education, Labor, and Pension Committee and next will go before the full Senate.

Latest Vioxx Ruling

Merck has collected another win in its defense of Vioxx. A jury last month rejected the charge that the company was liable for a New Jersey woman's heart attack after nearly 3 years of taking Vioxx. Elaine Doherty of Lawrenceville said she took Vioxx daily from June 2001 until her heart attack in January 2004 at age 65, and then continued on the drug until it was withdrawn from the market in September 2004. But Merck attorneys countered that she had multiple risk factors for heart disease, such as high cholesterol, diabetes, high blood pressure, and obesity. “The company acted responsibly, the science was on our side, and the jury agreed,” said Jim Fitzpatrick of Hughes Hubbard and Reed, a member of the Merck defense team in the case, in a statement.

Hold Sought on Imaging Pay Cuts

With Medicare due to slash payments for imaging services by 35%–55% in January 2007, provider organizations are rallying to delay or repeal the cuts, which call for payments for the technical component—equipment, supplies, and overhead for imaging services—to be reimbursed at the hospital outpatient payment rate if it is lower than the physician fee schedule. At a hearing of the House Energy and Commerce Health Subcommittee, Democrats and Republicans said they were concerned the reductions were enacted without public input and without any assessment of the impact on beneficiaries. The cuts were inserted into the Deficit Reduction Act during a House-Senate conference; the act was signed in February 2006. “We don't know exactly what we've done, or how well or how poorly we've done it,” said Rep. John Dingell (D-Mich.) at the hearing. H.R. 5704, sponsored by Rep. Joseph Pitts (R-Penn.), would institute a 2-year moratorium. Many medical organizations voiced objections to the cuts, including the American College of Cardiology, the Society for Vascular Surgery, and the Society for Cardiovascular Angiography and Interventions. The ACC “cautiously supports” the Pitts bill, said Dr. Kim A. Williams, director of nuclear cardiology at the University of Chicago and cochair of the ACC's Cardiovascular Imaging Collaborative, at a briefing with reporters. It's not clear how the cuts could be eliminated without causing reductions in other areas, he said. Rep. Carolyn McCarthy (D-N.Y.) has introduced a bill that would repeal the cuts (H.R. 5238).

Call to Action on Risk Factors

The American Heart Association and the American Diabetes Association have issued a call to action to assess patients for their global risk of cardiovascular disease and diabetes. The groups cowrote a document published in both Circulation and Diabetes Care in part to dispel the notion that there is disagreement between them about the need to assess patients for risk factors such as prediabetes, hypertension, dyslipidemia, obesity, and smoking. The debate between the groups has been specifically about the clinical utility of the term “metabolic syndrome,” not about the overall need to screen patients' risk for cardiovascular disease (CVD), they said. “We are concerned that the presumed dispute will lead to a reduction in the favorable trend of many aspects of CVD risk factor reduction,” said AHA president Dr. Robert H. Eckel and ADA president Dr. Robert Rizza, along with science advisers Richard Kahn, Ph.D., of the ADA and Dr. Rose Marie Robertson of the AHA. Risk assessment and adherence to national guidelines remains “woefully suboptimal,” they said.

Postmarketing Study Failure

The Food and Drug Administration is doing a poor job of ensuring that pharmaceutical companies live up to postmarketing study commitments, according to a new report by the Department of Health and Human Services' Office of Inspector General. Among the findings: that the FDA can't easily identify if the studies are progressing or what stage they are in, and that monitoring postmarketing studies “is not a top priority at FDA.” The OIG reviewed new drug applications from 1990 to 2004; 48% of those applications had at least one postmarketing study commitment. Drug makers are required to submit annual status reports. The OIG found that 35% of the reports that should have been submitted in fiscal 2004 were missing or had no information on the study commitments. The OIG noted that the FDA has limited enforcement power in this area, but suggested that the agency require more, and more relevant, information from drug makers. In response, the FDA said it could not do that without additional regulations, but agreed that it needed to do more to improve its monitoring and to ensure that commitments are honored and that annual reports are thorough.

Supplement Side Effects

Dietary supplement makers and producers of over-the-counter drugs would be required to report serious adverse events to the FDA within 15 business days, under the Dietary Supplement and Nonprescription Drug Consumer Protection Act (S. 3456), currently pending in the U.S. Senate. The bill was introduced by strange bedfellows: Sen. Orrin Hatch (R-Utah), who crafted the 1994 Dietary Supplement Health and Education Act (DSHEA), which is widely seen as a loophole for the products, along with two frequent critics of DSHEA: Sen. Tom Harkin (D-Iowa) and Sen. Richard Durbin (D-Ill.). The proposal also has the backing of consumer advocates such as Consumer Reports and the Center for Science in the Public Interest, and of several industry groups. The bill has been reported out of the Senate Health, Education, Labor, and Pension Committee and next will go before the full Senate.

Latest Vioxx Ruling

Merck has collected another win in its defense of Vioxx. A jury last month rejected the charge that the company was liable for a New Jersey woman's heart attack after nearly 3 years of taking Vioxx. Elaine Doherty of Lawrenceville said she took Vioxx daily from June 2001 until her heart attack in January 2004 at age 65, and then continued on the drug until it was withdrawn from the market in September 2004. But Merck attorneys countered that she had multiple risk factors for heart disease, such as high cholesterol, diabetes, high blood pressure, and obesity. “The company acted responsibly, the science was on our side, and the jury agreed,” said Jim Fitzpatrick of Hughes Hubbard and Reed, a member of the Merck defense team in the case, in a statement.