Alicia Ault

Although the Republican primaries this year have been anything but predictable, one thing is fairly certain: Health care issues will play a more prominent role in the Florida primary on Jan. 31 than they have so far.

Florida is a coveted win for the GOP contenders in part because 50 delegates are at stake, but also because the state is more diverse – racially, ethnically, and politically – than Iowa, New Hampshire, and South Carolina, where primaries have already been held. As such, it’s considered a better reflection of the general election.

With its large elderly population and hard-hit economy, social welfare programs like Social Security, Medicare, and Medicaid are very important to Florida voters.

"Medicare is certainly the third rail in Florida among the sizeable senior population, but so too is Medicaid," said Daniel A. Smith, Ph.D., professor of political science at the University of Florida, Gainesville.

Many seniors depend on both Medicare and Medicaid for their health care needs: Medicare for basic doctor and hospital care and Medicaid for long-term care, Dr. Smith pointed out.

That means Republican candidates should consider treading lightly when they talk about Social Security, Medicare, or Medicaid, he said, noting that in 1992, Ross Perot’s presidential bid was derailed in Florida after he said he would favor having wealthier Americans pay more for Social Security and Medicare.

"Retirees aren’t interested in dismantling the welfare state," Mr. Smith said. "Even those Floridians of means are not interested in having their benefits cut."

Health Care Platforms

At the Republican debate in Tampa on Jan. 23, Rick Santorum went after putative front-runner Mitt Romney for creating what he called a "government-run" health care plan when Mr. Romney was governor of Massachusetts. Mr. Santorum, a former senator from Pennsylvania, called that plan "RomneyCare," a play on the dismissive "Obamacare" moniker that Republicans have given to the Affordable Care Act.

In the past, Mr. Santorum, who at press time was polling a distant third in Florida, has supported a plan by Rep. Paul Ryan (R-Wisc.) to essentially privatize Medicare. On his official campaign website, he says his first priority as President would be to repeal the Affordable Care Act. He also has said he would encourage the purchase of health insurance across state lines, push for block grants to states for Medicaid, and bolster health savings accounts. Mr. Santorum also backs medical liability reform.

Like Mr. Santorum, Newt Gingrich is calling for more competition in health care, block grants for Medicaid, and a repeal of the ACA. But the former Speaker of the House presents a more detailed plan for health care that includes reforming the Food and Drug Administration, investing more in health research, and putting a premium on quality of care.

Mr. Gingrich and Mr. Romney have traded the lead in Florida for the last several months, with Mr. Romney leading fairly broadly before the South Carolina primary on Jan. 21. Then, just as Mr. Romney won New Hampshire, Mr. Santorum was belatedly declared the winner in Iowa. Mr. Gingrich handily beat Mr. Romney in South Carolina, 40% to 28%.

According to the University of Florida’s Dr. Smith, Mr. Romney has actively courted health care executives in Florida. But it may not be enough to fend off continued brickbats thrown at him for the Massachusetts plan. He has repeatedly disavowed the notion that the plan was the model for the Affordable Care Act. On his website he says his first priority will be a repeal of Obamacare. Mr. Romney, like the other candidates, says he supports less regulation, more competition, and medical liability reform.

Although his platform makes no overt mention of Medicare, analysis by the Center on Budget and Policy Priorities noted that, if enacted, Mr. Romney’s proposal to cap total spending and balance the budget would lead to a 17%-24% cut to Medicare by 2016.

Interestingly, the American Federation of State, County and Municipal Employees has purchased air time in Florida to attack Mr. Romney for what it calls "Medicare fraud."

"Retirees aren’t interested in dismantling the welfare state."

The 30-second spot says that, while Mr. Romney worked for the Damon Corp., the company defrauded Medicare. The spot then goes on to morph Mr. Romney’s face into that of Florida Governor Rick Scott’s, with the tag line, "Sound familiar?"

Gov. Scott, a Republican, was the CEO of HCA (then called Columbia/HCA) during a period when the company was found guilty of defrauding Medicare. He was forced to resign and the company paid a record fine to the government. Gov. Scott has seen his approval ratings in Florida bottom out, in part because he proposed to finance public education through reductions in Medicaid payments to hospitals.

Gov. Scott has not endorsed any of the GOP candidates. "He knows that his poll numbers are quite toxic. As a result I don’t think his endorsement behooves anyone right now," Dr. Smith said.

The Doctors Stand Clear

Several major physicians’ organizations have so far demurred on endorsing any of the candidates. A spokesperson said that the Florida Medical Association did not feel it was appropriate to even comment on a potential endorsement, given that its membership holds a variety of views.

Dr. John A. Gross, a member of the board of the Florida Academy of Family Physicians (that state’s chapter of the American Academy of Family Physicians), said that the FAFP would not be endorsing any candidates at this time either.

The FAFP is "looking for candidates that are willing to stand up for the patient," said Dr. Gross, who chairs the group’s government relations committee. Family physicians would be interested in candidates who support the patient-centered medical home and new models that provide high quality care.

Tort reform also is a huge issue for Florida physicians, Dr. Gross noted. In a recent poll, physicians in the state estimated that 1 of every 3 health care dollars in Florida is spent on so-called defensive medical costs. The poll was conducted by Patients for Fair Compensation, a nonprofit established by the for-profit physician staffing company Jackson Healthcare.

Dr. Gross said that medical liability reform is a priority issue for the FAFP every year.

The latest bill to address tort reform was introduced in mid-January in the Florida House and Senate.

Abortion is also a hot-button issue in Florida. The state is regarded as anti-choice by NARAL Pro-Choice America.

Mr. Santorum describes himself as strongly pro-life. Mr. Gingrich has said he supports ending federal subsidies for abortion and defunding Planned Parenthood. Mr. Romney had a much-publicized change in position, seemingly going from supporting a woman’s right to choose to being against abortion. He does not have an official stance listed on his campaign website.

This is the first in a series of articles looking at the Republican presidential primaries through the eyes of physicians. Next up: The race moves on to Minnesota and Colorado, which hold their primaries Feb. 7.

Although the Republican primaries this year have been anything but predictable, one thing is fairly certain: Health care issues will play a more prominent role in the Florida primary on Jan. 31 than they have so far.

Florida is a coveted win for the GOP contenders in part because 50 delegates are at stake, but also because the state is more diverse – racially, ethnically, and politically – than Iowa, New Hampshire, and South Carolina, where primaries have already been held. As such, it’s considered a better reflection of the general election.

With its large elderly population and hard-hit economy, social welfare programs like Social Security, Medicare, and Medicaid are very important to Florida voters.

"Medicare is certainly the third rail in Florida among the sizeable senior population, but so too is Medicaid," said Daniel A. Smith, Ph.D., professor of political science at the University of Florida, Gainesville.

Many seniors depend on both Medicare and Medicaid for their health care needs: Medicare for basic doctor and hospital care and Medicaid for long-term care, Dr. Smith pointed out.

That means Republican candidates should consider treading lightly when they talk about Social Security, Medicare, or Medicaid, he said, noting that in 1992, Ross Perot’s presidential bid was derailed in Florida after he said he would favor having wealthier Americans pay more for Social Security and Medicare.

"Retirees aren’t interested in dismantling the welfare state," Mr. Smith said. "Even those Floridians of means are not interested in having their benefits cut."

Health Care Platforms

At the Republican debate in Tampa on Jan. 23, Rick Santorum went after putative front-runner Mitt Romney for creating what he called a "government-run" health care plan when Mr. Romney was governor of Massachusetts. Mr. Santorum, a former senator from Pennsylvania, called that plan "RomneyCare," a play on the dismissive "Obamacare" moniker that Republicans have given to the Affordable Care Act.

In the past, Mr. Santorum, who at press time was polling a distant third in Florida, has supported a plan by Rep. Paul Ryan (R-Wisc.) to essentially privatize Medicare. On his official campaign website, he says his first priority as President would be to repeal the Affordable Care Act. He also has said he would encourage the purchase of health insurance across state lines, push for block grants to states for Medicaid, and bolster health savings accounts. Mr. Santorum also backs medical liability reform.

Like Mr. Santorum, Newt Gingrich is calling for more competition in health care, block grants for Medicaid, and a repeal of the ACA. But the former Speaker of the House presents a more detailed plan for health care that includes reforming the Food and Drug Administration, investing more in health research, and putting a premium on quality of care.

Mr. Gingrich and Mr. Romney have traded the lead in Florida for the last several months, with Mr. Romney leading fairly broadly before the South Carolina primary on Jan. 21. Then, just as Mr. Romney won New Hampshire, Mr. Santorum was belatedly declared the winner in Iowa. Mr. Gingrich handily beat Mr. Romney in South Carolina, 40% to 28%.

According to the University of Florida’s Dr. Smith, Mr. Romney has actively courted health care executives in Florida. But it may not be enough to fend off continued brickbats thrown at him for the Massachusetts plan. He has repeatedly disavowed the notion that the plan was the model for the Affordable Care Act. On his website he says his first priority will be a repeal of Obamacare. Mr. Romney, like the other candidates, says he supports less regulation, more competition, and medical liability reform.

Although his platform makes no overt mention of Medicare, analysis by the Center on Budget and Policy Priorities noted that, if enacted, Mr. Romney’s proposal to cap total spending and balance the budget would lead to a 17%-24% cut to Medicare by 2016.

Interestingly, the American Federation of State, County and Municipal Employees has purchased air time in Florida to attack Mr. Romney for what it calls "Medicare fraud."

"Retirees aren’t interested in dismantling the welfare state."

The 30-second spot says that, while Mr. Romney worked for the Damon Corp., the company defrauded Medicare. The spot then goes on to morph Mr. Romney’s face into that of Florida Governor Rick Scott’s, with the tag line, "Sound familiar?"

Gov. Scott, a Republican, was the CEO of HCA (then called Columbia/HCA) during a period when the company was found guilty of defrauding Medicare. He was forced to resign and the company paid a record fine to the government. Gov. Scott has seen his approval ratings in Florida bottom out, in part because he proposed to finance public education through reductions in Medicaid payments to hospitals.

Gov. Scott has not endorsed any of the GOP candidates. "He knows that his poll numbers are quite toxic. As a result I don’t think his endorsement behooves anyone right now," Dr. Smith said.

The Doctors Stand Clear

Several major physicians’ organizations have so far demurred on endorsing any of the candidates. A spokesperson said that the Florida Medical Association did not feel it was appropriate to even comment on a potential endorsement, given that its membership holds a variety of views.

Dr. John A. Gross, a member of the board of the Florida Academy of Family Physicians (that state’s chapter of the American Academy of Family Physicians), said that the FAFP would not be endorsing any candidates at this time either.

The FAFP is "looking for candidates that are willing to stand up for the patient," said Dr. Gross, who chairs the group’s government relations committee. Family physicians would be interested in candidates who support the patient-centered medical home and new models that provide high quality care.

Tort reform also is a huge issue for Florida physicians, Dr. Gross noted. In a recent poll, physicians in the state estimated that 1 of every 3 health care dollars in Florida is spent on so-called defensive medical costs. The poll was conducted by Patients for Fair Compensation, a nonprofit established by the for-profit physician staffing company Jackson Healthcare.

Dr. Gross said that medical liability reform is a priority issue for the FAFP every year.

The latest bill to address tort reform was introduced in mid-January in the Florida House and Senate.

Abortion is also a hot-button issue in Florida. The state is regarded as anti-choice by NARAL Pro-Choice America.

Mr. Santorum describes himself as strongly pro-life. Mr. Gingrich has said he supports ending federal subsidies for abortion and defunding Planned Parenthood. Mr. Romney had a much-publicized change in position, seemingly going from supporting a woman’s right to choose to being against abortion. He does not have an official stance listed on his campaign website.

This is the first in a series of articles looking at the Republican presidential primaries through the eyes of physicians. Next up: The race moves on to Minnesota and Colorado, which hold their primaries Feb. 7.

Although the Republican primaries this year have been anything but predictable, one thing is fairly certain: Health care issues will play a more prominent role in the Florida primary on Jan. 31 than they have so far.

Florida is a coveted win for the GOP contenders in part because 50 delegates are at stake, but also because the state is more diverse – racially, ethnically, and politically – than Iowa, New Hampshire, and South Carolina, where primaries have already been held. As such, it’s considered a better reflection of the general election.

With its large elderly population and hard-hit economy, social welfare programs like Social Security, Medicare, and Medicaid are very important to Florida voters.

"Medicare is certainly the third rail in Florida among the sizeable senior population, but so too is Medicaid," said Daniel A. Smith, Ph.D., professor of political science at the University of Florida, Gainesville.

Many seniors depend on both Medicare and Medicaid for their health care needs: Medicare for basic doctor and hospital care and Medicaid for long-term care, Dr. Smith pointed out.

That means Republican candidates should consider treading lightly when they talk about Social Security, Medicare, or Medicaid, he said, noting that in 1992, Ross Perot’s presidential bid was derailed in Florida after he said he would favor having wealthier Americans pay more for Social Security and Medicare.

"Retirees aren’t interested in dismantling the welfare state," Mr. Smith said. "Even those Floridians of means are not interested in having their benefits cut."

Health Care Platforms

At the Republican debate in Tampa on Jan. 23, Rick Santorum went after putative front-runner Mitt Romney for creating what he called a "government-run" health care plan when Mr. Romney was governor of Massachusetts. Mr. Santorum, a former senator from Pennsylvania, called that plan "RomneyCare," a play on the dismissive "Obamacare" moniker that Republicans have given to the Affordable Care Act.

In the past, Mr. Santorum, who at press time was polling a distant third in Florida, has supported a plan by Rep. Paul Ryan (R-Wisc.) to essentially privatize Medicare. On his official campaign website, he says his first priority as President would be to repeal the Affordable Care Act. He also has said he would encourage the purchase of health insurance across state lines, push for block grants to states for Medicaid, and bolster health savings accounts. Mr. Santorum also backs medical liability reform.

Like Mr. Santorum, Newt Gingrich is calling for more competition in health care, block grants for Medicaid, and a repeal of the ACA. But the former Speaker of the House presents a more detailed plan for health care that includes reforming the Food and Drug Administration, investing more in health research, and putting a premium on quality of care.

Mr. Gingrich and Mr. Romney have traded the lead in Florida for the last several months, with Mr. Romney leading fairly broadly before the South Carolina primary on Jan. 21. Then, just as Mr. Romney won New Hampshire, Mr. Santorum was belatedly declared the winner in Iowa. Mr. Gingrich handily beat Mr. Romney in South Carolina, 40% to 28%.

According to the University of Florida’s Dr. Smith, Mr. Romney has actively courted health care executives in Florida. But it may not be enough to fend off continued brickbats thrown at him for the Massachusetts plan. He has repeatedly disavowed the notion that the plan was the model for the Affordable Care Act. On his website he says his first priority will be a repeal of Obamacare. Mr. Romney, like the other candidates, says he supports less regulation, more competition, and medical liability reform.

Although his platform makes no overt mention of Medicare, analysis by the Center on Budget and Policy Priorities noted that, if enacted, Mr. Romney’s proposal to cap total spending and balance the budget would lead to a 17%-24% cut to Medicare by 2016.

Interestingly, the American Federation of State, County and Municipal Employees has purchased air time in Florida to attack Mr. Romney for what it calls "Medicare fraud."

"Retirees aren’t interested in dismantling the welfare state."

The 30-second spot says that, while Mr. Romney worked for the Damon Corp., the company defrauded Medicare. The spot then goes on to morph Mr. Romney’s face into that of Florida Governor Rick Scott’s, with the tag line, "Sound familiar?"

Gov. Scott, a Republican, was the CEO of HCA (then called Columbia/HCA) during a period when the company was found guilty of defrauding Medicare. He was forced to resign and the company paid a record fine to the government. Gov. Scott has seen his approval ratings in Florida bottom out, in part because he proposed to finance public education through reductions in Medicaid payments to hospitals.

Gov. Scott has not endorsed any of the GOP candidates. "He knows that his poll numbers are quite toxic. As a result I don’t think his endorsement behooves anyone right now," Dr. Smith said.

The Doctors Stand Clear

Several major physicians’ organizations have so far demurred on endorsing any of the candidates. A spokesperson said that the Florida Medical Association did not feel it was appropriate to even comment on a potential endorsement, given that its membership holds a variety of views.

Dr. John A. Gross, a member of the board of the Florida Academy of Family Physicians (that state’s chapter of the American Academy of Family Physicians), said that the FAFP would not be endorsing any candidates at this time either.

The FAFP is "looking for candidates that are willing to stand up for the patient," said Dr. Gross, who chairs the group’s government relations committee. Family physicians would be interested in candidates who support the patient-centered medical home and new models that provide high quality care.

Tort reform also is a huge issue for Florida physicians, Dr. Gross noted. In a recent poll, physicians in the state estimated that 1 of every 3 health care dollars in Florida is spent on so-called defensive medical costs. The poll was conducted by Patients for Fair Compensation, a nonprofit established by the for-profit physician staffing company Jackson Healthcare.

Dr. Gross said that medical liability reform is a priority issue for the FAFP every year.

The latest bill to address tort reform was introduced in mid-January in the Florida House and Senate.

Abortion is also a hot-button issue in Florida. The state is regarded as anti-choice by NARAL Pro-Choice America.

Mr. Santorum describes himself as strongly pro-life. Mr. Gingrich has said he supports ending federal subsidies for abortion and defunding Planned Parenthood. Mr. Romney had a much-publicized change in position, seemingly going from supporting a woman’s right to choose to being against abortion. He does not have an official stance listed on his campaign website.

This is the first in a series of articles looking at the Republican presidential primaries through the eyes of physicians. Next up: The race moves on to Minnesota and Colorado, which hold their primaries Feb. 7.

NEW ORLEANS – The American Medical Association’s policy-making body wrapped up 2 and a half days of meetings Nov. 15 by calling for a delay in implementation of the ICD-10 coding system, and reiterating its intention to seek the ability to privately broker fees with Medicare patients.

Physicians have long sought to be allowed to engage in so-called "private contracting" with Medicare patients. Under that scenario, Medicare patients could use their benefits to see a physician that does not accept Medicare. Currently, patients have to pay for the entire visit out of pocket if their physician does not accept Medicare.

The AMA says private contracting will empower patients – and, the group is supporting legislation sponsored by Rep. Tom Price (R-Ga.) that would allow such private contracting. The Medicare Patient Empowerment Act (H.R. 1700) was introduced last May; a companion bill was introduced in the Senate by Lisa Murkowski (R-Alaska).

The AMA House of Delegates reaffirmed support of the legislation, but also called upon the AMA to start a grassroots campaign to get patients involved.

Alabama delegate Dr. Jeff Terry and president of the Medical Association of the State of Alabama said, "A grassroots campaign will allow our politicians to do the right thing." Such a campaign will let politicians know "that we don’t want our congressmen to walk out on a political limb not supported by the public."

The emphasis on private contracting was in part a symptom of the high-pressure environment physicians find themselves in, facing a potential 27% cut in Medicare payments as well as high-cost requirements to implement electronic medical records, said Dr. Robert Wah, chairman of the AMA Board of Trustees.

"The fact that patients may be able to take their benefit where they’d like to, to see the doctors they want to see, is a potential safety valve to all this pressure being exerted on physician practices and patients in the Medicare system," Dr. Wah said in an interview. "So we’re actively pushing at the local level for people to go to their congressmen and ask them to sign on to this legislation."

The push back against the coming implementation of the new ICD-10 coding system in 2013 is also a symptom of physicians feeling overwhelmed by their changing practice environment, Dr. Wah said. The House approved a resolution sponsored by the Alabama and Mississippi delegations, to take action to stop the implementation.

The ICD-10 will consist of 69,000 codes, as compared with the 14,000 in ICD-9, currently in use. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel said in a statement.

The ICD-10 system has been in development for 10 years but has been delayed several times already. The House of Delegates called on the AMA to mount "a vigorous campaign to seek delay of the implementation date," according to Dr. Wah. ☐

NEW ORLEANS – The American Medical Association’s policy-making body wrapped up 2 and a half days of meetings Nov. 15 by calling for a delay in implementation of the ICD-10 coding system, and reiterating its intention to seek the ability to privately broker fees with Medicare patients.

Physicians have long sought to be allowed to engage in so-called "private contracting" with Medicare patients. Under that scenario, Medicare patients could use their benefits to see a physician that does not accept Medicare. Currently, patients have to pay for the entire visit out of pocket if their physician does not accept Medicare.

The AMA says private contracting will empower patients – and, the group is supporting legislation sponsored by Rep. Tom Price (R-Ga.) that would allow such private contracting. The Medicare Patient Empowerment Act (H.R. 1700) was introduced last May; a companion bill was introduced in the Senate by Lisa Murkowski (R-Alaska).

The AMA House of Delegates reaffirmed support of the legislation, but also called upon the AMA to start a grassroots campaign to get patients involved.

Alabama delegate Dr. Jeff Terry and president of the Medical Association of the State of Alabama said, "A grassroots campaign will allow our politicians to do the right thing." Such a campaign will let politicians know "that we don’t want our congressmen to walk out on a political limb not supported by the public."

The emphasis on private contracting was in part a symptom of the high-pressure environment physicians find themselves in, facing a potential 27% cut in Medicare payments as well as high-cost requirements to implement electronic medical records, said Dr. Robert Wah, chairman of the AMA Board of Trustees.

"The fact that patients may be able to take their benefit where they’d like to, to see the doctors they want to see, is a potential safety valve to all this pressure being exerted on physician practices and patients in the Medicare system," Dr. Wah said in an interview. "So we’re actively pushing at the local level for people to go to their congressmen and ask them to sign on to this legislation."

The push back against the coming implementation of the new ICD-10 coding system in 2013 is also a symptom of physicians feeling overwhelmed by their changing practice environment, Dr. Wah said. The House approved a resolution sponsored by the Alabama and Mississippi delegations, to take action to stop the implementation.

The ICD-10 will consist of 69,000 codes, as compared with the 14,000 in ICD-9, currently in use. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel said in a statement.

The ICD-10 system has been in development for 10 years but has been delayed several times already. The House of Delegates called on the AMA to mount "a vigorous campaign to seek delay of the implementation date," according to Dr. Wah. ☐

NEW ORLEANS – The American Medical Association’s policy-making body wrapped up 2 and a half days of meetings Nov. 15 by calling for a delay in implementation of the ICD-10 coding system, and reiterating its intention to seek the ability to privately broker fees with Medicare patients.

Physicians have long sought to be allowed to engage in so-called "private contracting" with Medicare patients. Under that scenario, Medicare patients could use their benefits to see a physician that does not accept Medicare. Currently, patients have to pay for the entire visit out of pocket if their physician does not accept Medicare.

The AMA says private contracting will empower patients – and, the group is supporting legislation sponsored by Rep. Tom Price (R-Ga.) that would allow such private contracting. The Medicare Patient Empowerment Act (H.R. 1700) was introduced last May; a companion bill was introduced in the Senate by Lisa Murkowski (R-Alaska).

The AMA House of Delegates reaffirmed support of the legislation, but also called upon the AMA to start a grassroots campaign to get patients involved.

Alabama delegate Dr. Jeff Terry and president of the Medical Association of the State of Alabama said, "A grassroots campaign will allow our politicians to do the right thing." Such a campaign will let politicians know "that we don’t want our congressmen to walk out on a political limb not supported by the public."

The emphasis on private contracting was in part a symptom of the high-pressure environment physicians find themselves in, facing a potential 27% cut in Medicare payments as well as high-cost requirements to implement electronic medical records, said Dr. Robert Wah, chairman of the AMA Board of Trustees.

"The fact that patients may be able to take their benefit where they’d like to, to see the doctors they want to see, is a potential safety valve to all this pressure being exerted on physician practices and patients in the Medicare system," Dr. Wah said in an interview. "So we’re actively pushing at the local level for people to go to their congressmen and ask them to sign on to this legislation."

The push back against the coming implementation of the new ICD-10 coding system in 2013 is also a symptom of physicians feeling overwhelmed by their changing practice environment, Dr. Wah said. The House approved a resolution sponsored by the Alabama and Mississippi delegations, to take action to stop the implementation.

The ICD-10 will consist of 69,000 codes, as compared with the 14,000 in ICD-9, currently in use. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel said in a statement.

The ICD-10 system has been in development for 10 years but has been delayed several times already. The House of Delegates called on the AMA to mount "a vigorous campaign to seek delay of the implementation date," according to Dr. Wah. ☐

New Jersey Governor Chris Christie (R) has signed a bill that repeals the state’s so-called "BoTax." The bill (S-1988/A-3646) phases out a 6% tax on gross receipts from cosmetic procedures that was instituted in 2004. Examples of procedures that were taxable included cosmetic surgery, hair transplants, cosmetic injections, cosmetic soft tissue fillers, dermabrasion, chemical peels, laser hair removal, laser skin resurfacing, laser treatment of leg veins, sclerotherapy, and cosmetic dentistry.

Governor's Office/Jody Somers

The tax will be lowered to 4% on March 1 and to 2% on July 1, and will be completely eliminated as of July 1, 2013. The state was collecting about $11 million a year from the tax. The collections were put into a fund for medical care for the poor. A previous effort to repeal the tax was vetoed by former Governor Jon Corzine (D).

New Jersey Governor Chris Christie (R) has signed a bill that repeals the state’s so-called "BoTax." The bill (S-1988/A-3646) phases out a 6% tax on gross receipts from cosmetic procedures that was instituted in 2004. Examples of procedures that were taxable included cosmetic surgery, hair transplants, cosmetic injections, cosmetic soft tissue fillers, dermabrasion, chemical peels, laser hair removal, laser skin resurfacing, laser treatment of leg veins, sclerotherapy, and cosmetic dentistry.

Governor's Office/Jody Somers

The tax will be lowered to 4% on March 1 and to 2% on July 1, and will be completely eliminated as of July 1, 2013. The state was collecting about $11 million a year from the tax. The collections were put into a fund for medical care for the poor. A previous effort to repeal the tax was vetoed by former Governor Jon Corzine (D).

New Jersey Governor Chris Christie (R) has signed a bill that repeals the state’s so-called "BoTax." The bill (S-1988/A-3646) phases out a 6% tax on gross receipts from cosmetic procedures that was instituted in 2004. Examples of procedures that were taxable included cosmetic surgery, hair transplants, cosmetic injections, cosmetic soft tissue fillers, dermabrasion, chemical peels, laser hair removal, laser skin resurfacing, laser treatment of leg veins, sclerotherapy, and cosmetic dentistry.

Governor's Office/Jody Somers

The tax will be lowered to 4% on March 1 and to 2% on July 1, and will be completely eliminated as of July 1, 2013. The state was collecting about $11 million a year from the tax. The collections were put into a fund for medical care for the poor. A previous effort to repeal the tax was vetoed by former Governor Jon Corzine (D).

Glucarpidase, an intravenously delivered recombinant enzyme, was approved on Jan. 17 for the treatment of patients with toxic levels of methotrexate in their blood due to kidney failure, according to the Food and Drug Administration.

Patients receiving high doses of methotrexate can develop renal failure, which allows the chemotherapy drug to accumulate. Glucarpidase (Voraxaze) rapidly breaks down methotrexate into a form that can then be eliminated from the body, according to the agency.

In addition to kidney failure, prolonged exposure to high levels of methotrexate can result in "liver damage, severe mouth sores, damage to the lining of the intestine, skin rashes, and death due to low blood counts," Dr. Richard Pazdur, director of the FDA’s Office of Hematology and Oncology Products, said in a statement. "Voraxaze is an important new treatment option for cancer patients aimed at preventing these toxicities associated with sustained high levels of methotrexate," he added.

According to glucarpidase’s manufacturer, BTG Plc, high-dose methotrexate is used to treat or prevent the recurrence of certain types of cancer, such as osteosarcoma, leukemia, and lymphoma.

Methotrexate also is used to treat rheumatologic conditions, such as rheumatoid arthritis.

The enzyme had been available to some patients under the FDA’s investigational new drug designation. In 2008, Protherics Inc., which previously owned the rights to glucarpidase, was warned by the FDA against promoting the drug before it was approved.

Glucarpidase received orphan drug status, which put it on a priority review track.

Approval was based on two studies: a single clinical study of 22 patients that evaluated effectiveness and a 290-patient trial that evaluated safety.

According to the FDA, treatment was considered successful if methotrexate levels fell below a critical level within 15 minutes and stayed below the critical level for 8 days. That result was seen in 10 of the 22 patients. BTG said that there was a 95% reduction in methotrexate concentration from pretreatment baseline levels, maintained for up to 8 days, in all evaluable patients.

The most common side effects were hypotension, headache, nausea, vomiting, flushing, and paraesthesia.

Louise Makin, chief executive officer of BTG, said in a statement that glucarpidase "is the first product BTG has taken through to approval in the U.S. and we look forward to its launch over coming months."

Glucarpidase, an intravenously delivered recombinant enzyme, was approved on Jan. 17 for the treatment of patients with toxic levels of methotrexate in their blood due to kidney failure, according to the Food and Drug Administration.

Patients receiving high doses of methotrexate can develop renal failure, which allows the chemotherapy drug to accumulate. Glucarpidase (Voraxaze) rapidly breaks down methotrexate into a form that can then be eliminated from the body, according to the agency.

In addition to kidney failure, prolonged exposure to high levels of methotrexate can result in "liver damage, severe mouth sores, damage to the lining of the intestine, skin rashes, and death due to low blood counts," Dr. Richard Pazdur, director of the FDA’s Office of Hematology and Oncology Products, said in a statement. "Voraxaze is an important new treatment option for cancer patients aimed at preventing these toxicities associated with sustained high levels of methotrexate," he added.

According to glucarpidase’s manufacturer, BTG Plc, high-dose methotrexate is used to treat or prevent the recurrence of certain types of cancer, such as osteosarcoma, leukemia, and lymphoma.

Methotrexate also is used to treat rheumatologic conditions, such as rheumatoid arthritis.

The enzyme had been available to some patients under the FDA’s investigational new drug designation. In 2008, Protherics Inc., which previously owned the rights to glucarpidase, was warned by the FDA against promoting the drug before it was approved.

Glucarpidase received orphan drug status, which put it on a priority review track.

Approval was based on two studies: a single clinical study of 22 patients that evaluated effectiveness and a 290-patient trial that evaluated safety.

According to the FDA, treatment was considered successful if methotrexate levels fell below a critical level within 15 minutes and stayed below the critical level for 8 days. That result was seen in 10 of the 22 patients. BTG said that there was a 95% reduction in methotrexate concentration from pretreatment baseline levels, maintained for up to 8 days, in all evaluable patients.

The most common side effects were hypotension, headache, nausea, vomiting, flushing, and paraesthesia.

Louise Makin, chief executive officer of BTG, said in a statement that glucarpidase "is the first product BTG has taken through to approval in the U.S. and we look forward to its launch over coming months."

Glucarpidase, an intravenously delivered recombinant enzyme, was approved on Jan. 17 for the treatment of patients with toxic levels of methotrexate in their blood due to kidney failure, according to the Food and Drug Administration.

Patients receiving high doses of methotrexate can develop renal failure, which allows the chemotherapy drug to accumulate. Glucarpidase (Voraxaze) rapidly breaks down methotrexate into a form that can then be eliminated from the body, according to the agency.

In addition to kidney failure, prolonged exposure to high levels of methotrexate can result in "liver damage, severe mouth sores, damage to the lining of the intestine, skin rashes, and death due to low blood counts," Dr. Richard Pazdur, director of the FDA’s Office of Hematology and Oncology Products, said in a statement. "Voraxaze is an important new treatment option for cancer patients aimed at preventing these toxicities associated with sustained high levels of methotrexate," he added.

According to glucarpidase’s manufacturer, BTG Plc, high-dose methotrexate is used to treat or prevent the recurrence of certain types of cancer, such as osteosarcoma, leukemia, and lymphoma.

Methotrexate also is used to treat rheumatologic conditions, such as rheumatoid arthritis.

The enzyme had been available to some patients under the FDA’s investigational new drug designation. In 2008, Protherics Inc., which previously owned the rights to glucarpidase, was warned by the FDA against promoting the drug before it was approved.

Glucarpidase received orphan drug status, which put it on a priority review track.

Approval was based on two studies: a single clinical study of 22 patients that evaluated effectiveness and a 290-patient trial that evaluated safety.

According to the FDA, treatment was considered successful if methotrexate levels fell below a critical level within 15 minutes and stayed below the critical level for 8 days. That result was seen in 10 of the 22 patients. BTG said that there was a 95% reduction in methotrexate concentration from pretreatment baseline levels, maintained for up to 8 days, in all evaluable patients.

The most common side effects were hypotension, headache, nausea, vomiting, flushing, and paraesthesia.

Louise Makin, chief executive officer of BTG, said in a statement that glucarpidase "is the first product BTG has taken through to approval in the U.S. and we look forward to its launch over coming months."

The Food and Drug Administration has sent recommendations to Congress on establishing user fee programs for generic and biosimilar drugs.

Legislation is required to create the new programs, which would be modeled on the 20-year-old Prescription Drug User Fee Act (PDUFA), according to the agency.

Under PDUFA, the FDA collects fees for certain applications for a new drugs or biologics, and it also assesses fees on certain manufacturing establishments. In fiscal 2012, for instance, a new drug application that includes clinical data costs $1.8 million; establishment fees are $520,000. In return, the FDA agrees to review applications according to set deadlines.

"Human drug user fees have revolutionized the drug review process in the United States since they were adopted 20 years ago, allowing the FDA to speed the application review process without compromising the agency’s high standards," said FDA Commissioner Margaret Hamburg in a statement.

The PDUFA requires congressional reauthorization every 5 years. The current program expires in September, so the FDA also sent recommendations to Capitol Hill on how the next PDUFA program should look.

A generic drug user fee program is crucial because the agency is being flooded with applications, according to the agency. Generics now account for two-thirds of prescriptions written in the United States. The FDA receives 800-900 generic-drug-related applications each year. With user fees, the agency aims to eliminate a backlog of reviews and "achieve parity between surveillance inspections of foreign and domestic establishments by the 2017 fiscal year." Many generic products are manufactured overseas.

The Generic Pharmaceutical Association said that under the agency plan, the industry would pay $299 million a year for 5 years, beginning in fiscal 2012. In a statement, GPhA lauded the agency for completing its recommendations.

"This is an important landmark that could not have been achieved without the extraordinary efforts of the FDA, my colleagues in the generic industry, and all other stakeholders," said GPhA president and CEO Ralph G. Neas.

For biosimilar drugs – essentially generic forms of biologic products – the FDA said that the fees it recommended would apply to products in development now, to "generate revenue in the near-term and to provide FDA with the resources needed to support development-phase meetings with sponsors of biosimilar biological product candidates."

The agency expects more of these products to come online in the future, in part because the Affordable Care Act created a quicker path to market through a subtitle of the law, the Biologics Price Competition and Innovation Act (BPCI).

The Biotechnology Industry Organization (BIO) did not comment specifically on the biosimilar user fee program, but it has expressed support for the program, with caveats, in the past.

BIO president and CEO Jim Greenwood commended the FDA for completing recommendations on the PDUFA reauthorization, noting in a statement that the law had "contributed to the approval of more than 1,200 new medicines and initially reduced review times for the newest, most innovative drugs by more than a year."

Mr. Greenwood added, "In light of the scientific and regulatory complexities of modern drug development, the PDUFA V recommendations include a set of enhancements that seek to reinforce FDA’s review performance and get back-to-basics for patients with the goal of minimizing development and review issues that can delay patient access to needed treatments."

The Food and Drug Administration has sent recommendations to Congress on establishing user fee programs for generic and biosimilar drugs.

Legislation is required to create the new programs, which would be modeled on the 20-year-old Prescription Drug User Fee Act (PDUFA), according to the agency.

Under PDUFA, the FDA collects fees for certain applications for a new drugs or biologics, and it also assesses fees on certain manufacturing establishments. In fiscal 2012, for instance, a new drug application that includes clinical data costs $1.8 million; establishment fees are $520,000. In return, the FDA agrees to review applications according to set deadlines.

"Human drug user fees have revolutionized the drug review process in the United States since they were adopted 20 years ago, allowing the FDA to speed the application review process without compromising the agency’s high standards," said FDA Commissioner Margaret Hamburg in a statement.

The PDUFA requires congressional reauthorization every 5 years. The current program expires in September, so the FDA also sent recommendations to Capitol Hill on how the next PDUFA program should look.

A generic drug user fee program is crucial because the agency is being flooded with applications, according to the agency. Generics now account for two-thirds of prescriptions written in the United States. The FDA receives 800-900 generic-drug-related applications each year. With user fees, the agency aims to eliminate a backlog of reviews and "achieve parity between surveillance inspections of foreign and domestic establishments by the 2017 fiscal year." Many generic products are manufactured overseas.

The Generic Pharmaceutical Association said that under the agency plan, the industry would pay $299 million a year for 5 years, beginning in fiscal 2012. In a statement, GPhA lauded the agency for completing its recommendations.

"This is an important landmark that could not have been achieved without the extraordinary efforts of the FDA, my colleagues in the generic industry, and all other stakeholders," said GPhA president and CEO Ralph G. Neas.

For biosimilar drugs – essentially generic forms of biologic products – the FDA said that the fees it recommended would apply to products in development now, to "generate revenue in the near-term and to provide FDA with the resources needed to support development-phase meetings with sponsors of biosimilar biological product candidates."

The agency expects more of these products to come online in the future, in part because the Affordable Care Act created a quicker path to market through a subtitle of the law, the Biologics Price Competition and Innovation Act (BPCI).

The Biotechnology Industry Organization (BIO) did not comment specifically on the biosimilar user fee program, but it has expressed support for the program, with caveats, in the past.

BIO president and CEO Jim Greenwood commended the FDA for completing recommendations on the PDUFA reauthorization, noting in a statement that the law had "contributed to the approval of more than 1,200 new medicines and initially reduced review times for the newest, most innovative drugs by more than a year."

Mr. Greenwood added, "In light of the scientific and regulatory complexities of modern drug development, the PDUFA V recommendations include a set of enhancements that seek to reinforce FDA’s review performance and get back-to-basics for patients with the goal of minimizing development and review issues that can delay patient access to needed treatments."

The Food and Drug Administration has sent recommendations to Congress on establishing user fee programs for generic and biosimilar drugs.

Legislation is required to create the new programs, which would be modeled on the 20-year-old Prescription Drug User Fee Act (PDUFA), according to the agency.

Under PDUFA, the FDA collects fees for certain applications for a new drugs or biologics, and it also assesses fees on certain manufacturing establishments. In fiscal 2012, for instance, a new drug application that includes clinical data costs $1.8 million; establishment fees are $520,000. In return, the FDA agrees to review applications according to set deadlines.

"Human drug user fees have revolutionized the drug review process in the United States since they were adopted 20 years ago, allowing the FDA to speed the application review process without compromising the agency’s high standards," said FDA Commissioner Margaret Hamburg in a statement.

The PDUFA requires congressional reauthorization every 5 years. The current program expires in September, so the FDA also sent recommendations to Capitol Hill on how the next PDUFA program should look.

A generic drug user fee program is crucial because the agency is being flooded with applications, according to the agency. Generics now account for two-thirds of prescriptions written in the United States. The FDA receives 800-900 generic-drug-related applications each year. With user fees, the agency aims to eliminate a backlog of reviews and "achieve parity between surveillance inspections of foreign and domestic establishments by the 2017 fiscal year." Many generic products are manufactured overseas.

The Generic Pharmaceutical Association said that under the agency plan, the industry would pay $299 million a year for 5 years, beginning in fiscal 2012. In a statement, GPhA lauded the agency for completing its recommendations.

"This is an important landmark that could not have been achieved without the extraordinary efforts of the FDA, my colleagues in the generic industry, and all other stakeholders," said GPhA president and CEO Ralph G. Neas.

For biosimilar drugs – essentially generic forms of biologic products – the FDA said that the fees it recommended would apply to products in development now, to "generate revenue in the near-term and to provide FDA with the resources needed to support development-phase meetings with sponsors of biosimilar biological product candidates."

The agency expects more of these products to come online in the future, in part because the Affordable Care Act created a quicker path to market through a subtitle of the law, the Biologics Price Competition and Innovation Act (BPCI).

The Biotechnology Industry Organization (BIO) did not comment specifically on the biosimilar user fee program, but it has expressed support for the program, with caveats, in the past.

BIO president and CEO Jim Greenwood commended the FDA for completing recommendations on the PDUFA reauthorization, noting in a statement that the law had "contributed to the approval of more than 1,200 new medicines and initially reduced review times for the newest, most innovative drugs by more than a year."

Mr. Greenwood added, "In light of the scientific and regulatory complexities of modern drug development, the PDUFA V recommendations include a set of enhancements that seek to reinforce FDA’s review performance and get back-to-basics for patients with the goal of minimizing development and review issues that can delay patient access to needed treatments."

WASHINGTON – The historically low growth in health spending in 2009 and the first half of 2010 continued through the end of 2010*, driven largely by the recession, Centers for Medicare and Medicaid officials announced Jan. 9.

U.S. health spending grew 3.9% in 2010, to a total of $2.6 trillion or $8,402 per person. That was a 0.1% rise from 2009, which was already at an all-time low growth rate.

Photo (c) sndr/iStock.com

As the nation’s economy slumped throughout 2009 and 2010, consumers cut back on elective surgical procedures, emergency room visits, physician office visits, and prescription drug use, according to the officials.

"Even though the recession officially ended in 2009, its impact on the health sector appears to have continued into 2010," said Anne Martin, an economist with the CMS.

Employers shifted the costs of insurance and care to employees, which drove up out-of-pocket spending in 2010. But consumers overall spent only 1.8% more out-of-pocket in 2010 than they had in 2009, which was a slow rate of growth when compared with historical patterns, Ms. Martin said.

Consumers reacted to cost-shifting by choosing health insurance plans with lower premiums and higher deductibles, and by reducing, where they could, use of personal health care services. Medical prices and the U.S. population remained relatively stable before, during, and after the recession, and yet, personal health spending fell, indicating a willful pullback.

"The slower growth in personal health care spending was mainly driven by the slowdown in the use and intensity of health care goods and services," Ms. Martin said. The agency documented a shrinkage in use of hospital care and physician services as compared with historical levels.

Hospital spending grew only 5% to $814 billion in 2010, compared to 6% in 2009. There was a decline in median inpatient admissions, and slower growth in emergency department visits, outpatient visits, and outpatient surgeries.

Overall spending on physicians and clinical services – totaling $515 billion in 2010 – accounted for 20% of total health spending. As consumers went to the doctor less frequently, fewer prescriptions were written. And, many of those dispensed were for less expensive generic drugs. These and other factors led to the slowest rate of growth in prescription drug spending ever recorded – a 1% increase from 2009 to $259 billion. The data were published in the journal Health Affairs (Health Aff.2012 [doi: 10.1377/hlthaff.2011.1135]).

Growth in spending on physician and clinical services also was historically low, growing 2.5% in 2010 as compared with 3.3% in 2009, said Ms. Martin.

Meanwhile, as employers and private insurers reduced the amount they spent on health care, the federal government’s share of health spending rose – to 29% or a total of $742 billion in 2010. The rise in federal spending also was attributed to federal subsidies to state Medicaid programs. Medicaid was about 15% of the nation’s health bill in 2010, at $401 billion.

In 2009, the federal government spent 22% more than in 2008; in 2010, spending rose by almost 9%. That compares to a 10% decrease in spending by states and localities in 2008, and a 4% increase in 2010.

Medicare saw an increase in enrollment, both in Medicare Advantage managed care program and traditional fee-for-service Medicare. The increase in traditional enrollment reversed a several-year pattern of decline. Overall, Medicare spending increased 5% in 2010 to $524 billion, but per-enrollee spending did not rise as quickly as it had in 2009.

This is because there was a big reduction in payments for certain types of home health services, but also because of low use of physician services. Small increases in physician fees in 2009 and 2010 also kept a lid on Medicare spending.

Those increases were instituted by Congress in response to cuts that would otherwise have been required by Medicare’s Sustainable Growth Rate formula.

The Affordable Care Act had a negligible impact on overall spending, perhaps accounting for less than 0.1% of the slowdown, according to the CMS economists. This is because few provisions were in effect in 2010, and some, such as coverage for patients with preexisting conditions, did not enroll as many people as had been expected.

*Correction, January 19, 2012: An earlier version of this story misstated the years covered by the reported data.

WASHINGTON – The historically low growth in health spending in 2009 and the first half of 2010 continued through the end of 2010*, driven largely by the recession, Centers for Medicare and Medicaid officials announced Jan. 9.

U.S. health spending grew 3.9% in 2010, to a total of $2.6 trillion or $8,402 per person. That was a 0.1% rise from 2009, which was already at an all-time low growth rate.

Photo (c) sndr/iStock.com

As the nation’s economy slumped throughout 2009 and 2010, consumers cut back on elective surgical procedures, emergency room visits, physician office visits, and prescription drug use, according to the officials.

"Even though the recession officially ended in 2009, its impact on the health sector appears to have continued into 2010," said Anne Martin, an economist with the CMS.

Employers shifted the costs of insurance and care to employees, which drove up out-of-pocket spending in 2010. But consumers overall spent only 1.8% more out-of-pocket in 2010 than they had in 2009, which was a slow rate of growth when compared with historical patterns, Ms. Martin said.

Consumers reacted to cost-shifting by choosing health insurance plans with lower premiums and higher deductibles, and by reducing, where they could, use of personal health care services. Medical prices and the U.S. population remained relatively stable before, during, and after the recession, and yet, personal health spending fell, indicating a willful pullback.

"The slower growth in personal health care spending was mainly driven by the slowdown in the use and intensity of health care goods and services," Ms. Martin said. The agency documented a shrinkage in use of hospital care and physician services as compared with historical levels.

Hospital spending grew only 5% to $814 billion in 2010, compared to 6% in 2009. There was a decline in median inpatient admissions, and slower growth in emergency department visits, outpatient visits, and outpatient surgeries.

Overall spending on physicians and clinical services – totaling $515 billion in 2010 – accounted for 20% of total health spending. As consumers went to the doctor less frequently, fewer prescriptions were written. And, many of those dispensed were for less expensive generic drugs. These and other factors led to the slowest rate of growth in prescription drug spending ever recorded – a 1% increase from 2009 to $259 billion. The data were published in the journal Health Affairs (Health Aff.2012 [doi: 10.1377/hlthaff.2011.1135]).

Growth in spending on physician and clinical services also was historically low, growing 2.5% in 2010 as compared with 3.3% in 2009, said Ms. Martin.

Meanwhile, as employers and private insurers reduced the amount they spent on health care, the federal government’s share of health spending rose – to 29% or a total of $742 billion in 2010. The rise in federal spending also was attributed to federal subsidies to state Medicaid programs. Medicaid was about 15% of the nation’s health bill in 2010, at $401 billion.

In 2009, the federal government spent 22% more than in 2008; in 2010, spending rose by almost 9%. That compares to a 10% decrease in spending by states and localities in 2008, and a 4% increase in 2010.

Medicare saw an increase in enrollment, both in Medicare Advantage managed care program and traditional fee-for-service Medicare. The increase in traditional enrollment reversed a several-year pattern of decline. Overall, Medicare spending increased 5% in 2010 to $524 billion, but per-enrollee spending did not rise as quickly as it had in 2009.

This is because there was a big reduction in payments for certain types of home health services, but also because of low use of physician services. Small increases in physician fees in 2009 and 2010 also kept a lid on Medicare spending.

Those increases were instituted by Congress in response to cuts that would otherwise have been required by Medicare’s Sustainable Growth Rate formula.

The Affordable Care Act had a negligible impact on overall spending, perhaps accounting for less than 0.1% of the slowdown, according to the CMS economists. This is because few provisions were in effect in 2010, and some, such as coverage for patients with preexisting conditions, did not enroll as many people as had been expected.

*Correction, January 19, 2012: An earlier version of this story misstated the years covered by the reported data.

WASHINGTON – The historically low growth in health spending in 2009 and the first half of 2010 continued through the end of 2010*, driven largely by the recession, Centers for Medicare and Medicaid officials announced Jan. 9.

U.S. health spending grew 3.9% in 2010, to a total of $2.6 trillion or $8,402 per person. That was a 0.1% rise from 2009, which was already at an all-time low growth rate.

Photo (c) sndr/iStock.com

As the nation’s economy slumped throughout 2009 and 2010, consumers cut back on elective surgical procedures, emergency room visits, physician office visits, and prescription drug use, according to the officials.

"Even though the recession officially ended in 2009, its impact on the health sector appears to have continued into 2010," said Anne Martin, an economist with the CMS.

Employers shifted the costs of insurance and care to employees, which drove up out-of-pocket spending in 2010. But consumers overall spent only 1.8% more out-of-pocket in 2010 than they had in 2009, which was a slow rate of growth when compared with historical patterns, Ms. Martin said.

Consumers reacted to cost-shifting by choosing health insurance plans with lower premiums and higher deductibles, and by reducing, where they could, use of personal health care services. Medical prices and the U.S. population remained relatively stable before, during, and after the recession, and yet, personal health spending fell, indicating a willful pullback.

"The slower growth in personal health care spending was mainly driven by the slowdown in the use and intensity of health care goods and services," Ms. Martin said. The agency documented a shrinkage in use of hospital care and physician services as compared with historical levels.

Hospital spending grew only 5% to $814 billion in 2010, compared to 6% in 2009. There was a decline in median inpatient admissions, and slower growth in emergency department visits, outpatient visits, and outpatient surgeries.

Overall spending on physicians and clinical services – totaling $515 billion in 2010 – accounted for 20% of total health spending. As consumers went to the doctor less frequently, fewer prescriptions were written. And, many of those dispensed were for less expensive generic drugs. These and other factors led to the slowest rate of growth in prescription drug spending ever recorded – a 1% increase from 2009 to $259 billion. The data were published in the journal Health Affairs (Health Aff.2012 [doi: 10.1377/hlthaff.2011.1135]).

Growth in spending on physician and clinical services also was historically low, growing 2.5% in 2010 as compared with 3.3% in 2009, said Ms. Martin.

Meanwhile, as employers and private insurers reduced the amount they spent on health care, the federal government’s share of health spending rose – to 29% or a total of $742 billion in 2010. The rise in federal spending also was attributed to federal subsidies to state Medicaid programs. Medicaid was about 15% of the nation’s health bill in 2010, at $401 billion.

In 2009, the federal government spent 22% more than in 2008; in 2010, spending rose by almost 9%. That compares to a 10% decrease in spending by states and localities in 2008, and a 4% increase in 2010.

Medicare saw an increase in enrollment, both in Medicare Advantage managed care program and traditional fee-for-service Medicare. The increase in traditional enrollment reversed a several-year pattern of decline. Overall, Medicare spending increased 5% in 2010 to $524 billion, but per-enrollee spending did not rise as quickly as it had in 2009.

This is because there was a big reduction in payments for certain types of home health services, but also because of low use of physician services. Small increases in physician fees in 2009 and 2010 also kept a lid on Medicare spending.

Those increases were instituted by Congress in response to cuts that would otherwise have been required by Medicare’s Sustainable Growth Rate formula.

The Affordable Care Act had a negligible impact on overall spending, perhaps accounting for less than 0.1% of the slowdown, according to the CMS economists. This is because few provisions were in effect in 2010, and some, such as coverage for patients with preexisting conditions, did not enroll as many people as had been expected.

*Correction, January 19, 2012: An earlier version of this story misstated the years covered by the reported data.

HOT SPRINGS, VA – Using risk adjustment alone to compare surgical site infection rates among hospitals may not be valid, judging by a retrospective analysis of data on colorectal procedures.

An examination of data submitted on 336,190 cases by 237 hospitals participating in the National Surgical Quality Improvement Project (NSQIP) in 2009 revealed that a patient’s underlying disease state is an important contributor to the risk of surgical site infection, said Dr. Robert Cima.

Dr. Cima and his colleagues at the Mayo Clinic Rochester, Minn., identified 24,673 colorectal procedures, using CPT codes. Of those procedures, 6,324 patients had colon cancer, 2,061 had benign neoplasm, 2,859 had rectal cancer, 4,821 had diverticular disease, 764 had ulcerative colitis, 862 had regional enteritis (Crohn’s disease), and 6,982 had other conditions, which included perforation, volvulus, intestinal obstruction, rectal prolapse, fistula, vascular insufficiency and unspecified neoplasms.

"Comparisons between hospitals could be misleading if they don’t include case mix," Dr. Cima said.

They specifically analyzed colorectal procedures because they are associated with the largest rate of surgical site infections (SSI; 5%-30%) and those infections led to a longer length of stay, higher costs, and higher mortality.

To get a baseline rate of SSIs for comparison purposes, the authors queried the data set to determine which procedure had the lowest rate. Benign neoplasms had the lowest overall rate, and because they were not caused by underlying disorders or malignancies, that rate was chosen as the reference, Dr. Cima said at the annual meeting of the Southern Surgical Association.

The authors conducted a regression analysis using the same factors used in the NSQIP risk adjustment: age, body mass index, American Society of Anesthesiology classification, wound classification, and relative value units (RVU) used, which are a surrogate for CPT codes. Odds ratios for SSIs were then calculated for each procedure.

Overall, 13.5% of patients developed an SSI. Rectal cancer patients had the highest overall odds ratio at 1.9, followed by Crohn’s disease, at 1.7. Rectal cancer patients also had the highest risk of superficial incisional SSI at 1.6; diverticular disease patients had a 1.6-fold higher risk than did those with benign neoplasms.

The patients at highest risk for deep incisional infections were those with ulcerative colitis (OR, 2.4), followed by rectal cancer (2.1). Both of those conditions also put patients at higher risk for organ/space infections (OR, 2.2 and 2.1).

The difference in infection rates by underlying disease led the researchers to question whether case mix might have an effect on the infection rates at individual institutions. Looking at the Mayo Clinic’s profile, compared with all NSQIP facilities’ case mix, they found that there was a higher percentage of patients with the higher-risk conditions: rectal cancer, regional enteritis, and ulcerative colitis.

The NSQIP data include a disease diagnosis, but it does not factor that into risk-adjusted figures, which will soon be publicly reported, noted Dr. Cima. Comparisons between hospitals could be misleading if they don’t include case mix, he said. And, there are implications for quality improvement, said Dr. Cima.

"If we had just looked at the overall surgical site infection rate and tried to design studies or processes to just reduce it without consideration of case mix, we would not be able to really determine whether or not we can drive it down," he said.

"This is a provocative and important study," said Dr. Danny Jacobs, chairman of the department of surgery at Duke University, Durham, N.C., in commenting on the paper. And, he said, it raises questions about whether the risk-adjustment system being used by NSQIP is adequate.

Dr. Susan Galandiuk, a professor of surgery at the University of Louisville (Ky.), questioned whether infection rates weren’t also influenced by the duration of surgery and whether patients were given appropriate antibiotic prophylaxis.

Dr. Cima said that while many studies have shown that infections rise as the length of surgery increases, it was not clear whether that was a factor in his study.

He agreed with Dr. Jacobs that the paper raised questions. The data do "go to the very heart of using data sets to drive quality improvement," he said.

HOT SPRINGS, VA – Using risk adjustment alone to compare surgical site infection rates among hospitals may not be valid, judging by a retrospective analysis of data on colorectal procedures.

An examination of data submitted on 336,190 cases by 237 hospitals participating in the National Surgical Quality Improvement Project (NSQIP) in 2009 revealed that a patient’s underlying disease state is an important contributor to the risk of surgical site infection, said Dr. Robert Cima.

Dr. Cima and his colleagues at the Mayo Clinic Rochester, Minn., identified 24,673 colorectal procedures, using CPT codes. Of those procedures, 6,324 patients had colon cancer, 2,061 had benign neoplasm, 2,859 had rectal cancer, 4,821 had diverticular disease, 764 had ulcerative colitis, 862 had regional enteritis (Crohn’s disease), and 6,982 had other conditions, which included perforation, volvulus, intestinal obstruction, rectal prolapse, fistula, vascular insufficiency and unspecified neoplasms.

"Comparisons between hospitals could be misleading if they don’t include case mix," Dr. Cima said.

They specifically analyzed colorectal procedures because they are associated with the largest rate of surgical site infections (SSI; 5%-30%) and those infections led to a longer length of stay, higher costs, and higher mortality.

To get a baseline rate of SSIs for comparison purposes, the authors queried the data set to determine which procedure had the lowest rate. Benign neoplasms had the lowest overall rate, and because they were not caused by underlying disorders or malignancies, that rate was chosen as the reference, Dr. Cima said at the annual meeting of the Southern Surgical Association.

The authors conducted a regression analysis using the same factors used in the NSQIP risk adjustment: age, body mass index, American Society of Anesthesiology classification, wound classification, and relative value units (RVU) used, which are a surrogate for CPT codes. Odds ratios for SSIs were then calculated for each procedure.

Overall, 13.5% of patients developed an SSI. Rectal cancer patients had the highest overall odds ratio at 1.9, followed by Crohn’s disease, at 1.7. Rectal cancer patients also had the highest risk of superficial incisional SSI at 1.6; diverticular disease patients had a 1.6-fold higher risk than did those with benign neoplasms.

The patients at highest risk for deep incisional infections were those with ulcerative colitis (OR, 2.4), followed by rectal cancer (2.1). Both of those conditions also put patients at higher risk for organ/space infections (OR, 2.2 and 2.1).

The difference in infection rates by underlying disease led the researchers to question whether case mix might have an effect on the infection rates at individual institutions. Looking at the Mayo Clinic’s profile, compared with all NSQIP facilities’ case mix, they found that there was a higher percentage of patients with the higher-risk conditions: rectal cancer, regional enteritis, and ulcerative colitis.

The NSQIP data include a disease diagnosis, but it does not factor that into risk-adjusted figures, which will soon be publicly reported, noted Dr. Cima. Comparisons between hospitals could be misleading if they don’t include case mix, he said. And, there are implications for quality improvement, said Dr. Cima.

"If we had just looked at the overall surgical site infection rate and tried to design studies or processes to just reduce it without consideration of case mix, we would not be able to really determine whether or not we can drive it down," he said.

"This is a provocative and important study," said Dr. Danny Jacobs, chairman of the department of surgery at Duke University, Durham, N.C., in commenting on the paper. And, he said, it raises questions about whether the risk-adjustment system being used by NSQIP is adequate.

Dr. Susan Galandiuk, a professor of surgery at the University of Louisville (Ky.), questioned whether infection rates weren’t also influenced by the duration of surgery and whether patients were given appropriate antibiotic prophylaxis.

Dr. Cima said that while many studies have shown that infections rise as the length of surgery increases, it was not clear whether that was a factor in his study.

He agreed with Dr. Jacobs that the paper raised questions. The data do "go to the very heart of using data sets to drive quality improvement," he said.

HOT SPRINGS, VA – Using risk adjustment alone to compare surgical site infection rates among hospitals may not be valid, judging by a retrospective analysis of data on colorectal procedures.

An examination of data submitted on 336,190 cases by 237 hospitals participating in the National Surgical Quality Improvement Project (NSQIP) in 2009 revealed that a patient’s underlying disease state is an important contributor to the risk of surgical site infection, said Dr. Robert Cima.

Dr. Cima and his colleagues at the Mayo Clinic Rochester, Minn., identified 24,673 colorectal procedures, using CPT codes. Of those procedures, 6,324 patients had colon cancer, 2,061 had benign neoplasm, 2,859 had rectal cancer, 4,821 had diverticular disease, 764 had ulcerative colitis, 862 had regional enteritis (Crohn’s disease), and 6,982 had other conditions, which included perforation, volvulus, intestinal obstruction, rectal prolapse, fistula, vascular insufficiency and unspecified neoplasms.

"Comparisons between hospitals could be misleading if they don’t include case mix," Dr. Cima said.

They specifically analyzed colorectal procedures because they are associated with the largest rate of surgical site infections (SSI; 5%-30%) and those infections led to a longer length of stay, higher costs, and higher mortality.

To get a baseline rate of SSIs for comparison purposes, the authors queried the data set to determine which procedure had the lowest rate. Benign neoplasms had the lowest overall rate, and because they were not caused by underlying disorders or malignancies, that rate was chosen as the reference, Dr. Cima said at the annual meeting of the Southern Surgical Association.

The authors conducted a regression analysis using the same factors used in the NSQIP risk adjustment: age, body mass index, American Society of Anesthesiology classification, wound classification, and relative value units (RVU) used, which are a surrogate for CPT codes. Odds ratios for SSIs were then calculated for each procedure.

Overall, 13.5% of patients developed an SSI. Rectal cancer patients had the highest overall odds ratio at 1.9, followed by Crohn’s disease, at 1.7. Rectal cancer patients also had the highest risk of superficial incisional SSI at 1.6; diverticular disease patients had a 1.6-fold higher risk than did those with benign neoplasms.

The patients at highest risk for deep incisional infections were those with ulcerative colitis (OR, 2.4), followed by rectal cancer (2.1). Both of those conditions also put patients at higher risk for organ/space infections (OR, 2.2 and 2.1).

The difference in infection rates by underlying disease led the researchers to question whether case mix might have an effect on the infection rates at individual institutions. Looking at the Mayo Clinic’s profile, compared with all NSQIP facilities’ case mix, they found that there was a higher percentage of patients with the higher-risk conditions: rectal cancer, regional enteritis, and ulcerative colitis.

The NSQIP data include a disease diagnosis, but it does not factor that into risk-adjusted figures, which will soon be publicly reported, noted Dr. Cima. Comparisons between hospitals could be misleading if they don’t include case mix, he said. And, there are implications for quality improvement, said Dr. Cima.

"If we had just looked at the overall surgical site infection rate and tried to design studies or processes to just reduce it without consideration of case mix, we would not be able to really determine whether or not we can drive it down," he said.

"This is a provocative and important study," said Dr. Danny Jacobs, chairman of the department of surgery at Duke University, Durham, N.C., in commenting on the paper. And, he said, it raises questions about whether the risk-adjustment system being used by NSQIP is adequate.

Dr. Susan Galandiuk, a professor of surgery at the University of Louisville (Ky.), questioned whether infection rates weren’t also influenced by the duration of surgery and whether patients were given appropriate antibiotic prophylaxis.

Dr. Cima said that while many studies have shown that infections rise as the length of surgery increases, it was not clear whether that was a factor in his study.

He agreed with Dr. Jacobs that the paper raised questions. The data do "go to the very heart of using data sets to drive quality improvement," he said.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – Payer mix improved and collections for all surgical departments increased at Wake Forest University’s Baptist Medical Center after an acute care surgery practice was created at the 872-bed hospital.

Acute care surgery combines trauma, critical care, and emergency general surgery with an eye toward both filling gaps in care for critically injured patients and taking some of the pressures off crowded emergency departments, said Dr. Preston W. Miller of the department of surgery at Wake Forest University in Winston-Salem, N.C. The American Association for the Surgery of Trauma (AAST) has developed a curriculum as well as training programs for acute care surgery, which has led to the accreditation of seven such programs so far, according to Dr. Miller.

Before the acute care service was begun in September 2008, the trauma and critical care service was staffed by three surgeons, with an additional two surgeons participating in call, he said. Emergency general surgery was conducted by seven surgeons who also had elective specialties.

When the acute service was established, all responsibility for emergency surgery was transferred to six surgeons: the three original trauma surgeons and an additional three surgeons who were hired for the service. Trauma and critical care surgery was managed by the acute service, and the elective surgery was provided by the original group of seven surgeons with elective specialties.

Dr. Miller and his colleagues retrospectively studied the impact of the acute care program on the elective service at Baptist Medical Center. They defined elective surgery as any procedure done on a weekday between 6:30 a.m. and 5:00 p.m. Nonelective procedures were listed as emergent in the operative case log, were conducted between 5:01 p.m. and 6:29 a.m., or were performed on weekends.

Work relative value units for the surgery department increased from 102,740 in 2007 to 124,432 in 2008, when the acute care surgery unit was launched. Total RVUs increased to 137,584 in 2009 and held steady at 136,263 in 2010. Most of the increase occurred in the acute care service, but there was only a minimal decline in RVUs on the elective side in 2009 and 2010.

Total collections jumped from $5.8 million in 2007 to $7 million in 2008 and to $8 million in 2009. There was a slight decline to $7.8 million in 2010. About $3 million of the total was for the acute care service in 2009 and 2010.

There was a shift toward more private payers and less Medicare, Medicaid, and self-pay in 2009 and 2010, said Dr. Miller. Private payers increased by 40%. Meanwhile, there was a 77% decrease in Medicaid and an 86% drop in self-pay.

From 2008 to 2009 (the first full year of the acute care service), nonelective cases on the elective service dropped from 470 to 157. Elective cases increased from 2,162 to 2,372. The trends continued into 2010.

Similarly, on the acute care service, nonelective cases increased from 391 in 2007 to 614 in 2008, and to 997 in 2009. By 2010, nonelective cases had risen to 1,328. Elective cases on the service rose from 533 in 2008 to 649 in 2009, but declined to 325 cases in 2010.

Elective RVUs decreased by 8% but collections increased by 7%, most likely because of the better reimbursement offered by private payers. The combined collections for the acute service and the elective service increased the contribution to the surgery department by more than $2 million a year, he said.

Dr. Martin A. Croce said that the acute care service "is really becoming the last bastion of the essence of general surgery," but that Dr. Miller’s paper shows that it will not take cases away from nontrauma general surgeons.

"The group from Wake has demonstrated that the formation of an acute care service creates a win-win-win situation," said Dr. Croce, professor of surgery and chief of the division of trauma and critical care at the University of Tennessee Health Science Center, Memphis.

Trauma surgeons, general surgeons, and the hospital all benefit, said Dr. Croce.

Dr. L.D. Britt, the Brickhouse Professor of Surgery and chairman of the department of surgery at Eastern Virginia Medical School, Norfolk, said that acute care surgery "is an evolving specialty that is indeed an important concept." He lauded the study, but also said that many questions remain about how to operate and optimize such a service. For instance, he asked, how many surgeons are necessary to sustain a service?

Responding to the comments, Dr. J. Wayne Meredith, president of the Southern Surgical Association and chair of general surgery at Wake Forest Baptist, said he believed that it took at least seven surgeons to have an effective service.

At Baptist, there was an increase in elective surgeries because the acute care service addressed a backlog. And it freed up capacity in the operating room: Some surgeries – like gallbladders – could be moved to night.

There is an agreement among the Wake Forest Baptist surgeons that those who are there at night can decide whether to operate; but if they are not there at night, they also should not refuse to take a case that requires their help then, Dr. Meredith said.

He added that patient outcomes had improved since the institution of the acute care service. Length of stay for emergency surgery has dropped from 10 days to 8 days.

HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.

Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don’t have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.

He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. "A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients," said Dr. Inabnet at the annual meeting of the Southern Surgical Association.

The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.

BOLD is maintained by the American Society for Metabolic and Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.

A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)

Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m².

Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers "were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches."

At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.

Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.

Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.

Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors’ regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.

Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.

Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.

The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the "study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity," said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.

The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. "This paper is important because it’s another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice," said Dr. Richards.

He questioned whether the low mortality rate was a reflection of surgeons’ opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.

Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it doesn’t seem that older patients are being operated on less often than are younger patients.

"What is the best operation? That really is the million dollar question," he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.

Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.

HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.

Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don’t have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.

He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. "A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients," said Dr. Inabnet at the annual meeting of the Southern Surgical Association.

The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.

BOLD is maintained by the American Society for Metabolic and Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.

A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)

Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m².

Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers "were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches."

At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.

Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.

Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.

Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors’ regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.

Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.

Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.

The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the "study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity," said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.

The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. "This paper is important because it’s another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice," said Dr. Richards.

He questioned whether the low mortality rate was a reflection of surgeons’ opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.

Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it doesn’t seem that older patients are being operated on less often than are younger patients.

"What is the best operation? That really is the million dollar question," he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.

Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.

HOT SPRINGS, VA. – An analysis of a large database of bariatric surgery patients has found that those with metabolic syndrome had dramatic improvements in comorbidities but a slightly higher rate of adverse events after 90 days.

Overall, patients with metabolic syndrome tend to be sicker and to have a greater incidence of adverse outcomes and higher mortality than do obese patients who don’t have the syndrome, said Dr. William B. Inabnet III, professor of surgery at Mount Sinai School of Medicine in New York.

He and his colleagues at Mount Sinai also determined that the reduction in weight was procedure dependent. "A careful assessment of risk-benefit ratio is warranted to develop the optimal clinical pathway for treating these patients," said Dr. Inabnet at the annual meeting of the Southern Surgical Association.

The researchers examined BOLD (Bariatric Outcomes Longitudinal Database) to identify patients who had undergone bariatric surgery from June 2007 to November 2010 and had metabolic syndrome.

BOLD is maintained by the American Society for Metabolic and Bariatric Surgery Center of Excellence program, and includes 1,157 surgeons at 884 hospitals. The data are self-reported, but some data are verified by on-site inspections. The surgical interventions covered in the registry include gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.

A modified scoring system (0-5) was used to assess comorbidities. For the purposes of the study, metabolic syndrome was defined as a hypertension score greater than 3, a diabetes score greater than 2, a dyslipidemia score greater than 2, and a sleep apnea score greater than 3. (Sleep apnea is not usually included in the definition of metabolic syndrome, but the researchers were interested in the condition as a comorbidity, said Dr. Inabnet.)

Overall, there were 186,567 patients in BOLD, including 23,106 patients who had metabolic syndrome. Those with metabolic syndrome were more likely than other obese patients to be male, older, and white, and to have sleep apnea and an ASA (American Society of Anesthesiologists) classification of 3 or greater. Body mass index was similar for both groups at 47 kg/m².

Gastric bypass was the most commonly performed procedure, and was the preferred method in patients with metabolic syndrome, followed by gastric banding, sleeve gastrectomy, and duodenal switch. And, said Dr. Inabnet, the researchers "were truly amazed to see that the vast majority of these cases were performed with laparoscopic approaches."

At 30 days, those with metabolic syndrome had increases in mortality, serious complications, readmissions, and reoperations, compared with other obese patients. The increases continued as time went on, and became more pronounced at 90 days post surgery, said Dr. Inabnet.

Overall mortality was very low (0.1%) for the entire cohort of 186,567 patients.

Mortality rates differed by procedure, however. The gastric band patients had the lowest rate (0.1%), followed by 1.2% for duodenal switch, 0.3% for sleeve gastrectomy, and 0.4% for gastric bypass. The serious complications, readmissions, and reoperations at 90 days were also lowest for gastric band patients, followed by duodenal switch, sleeve gastrectomy, and gastric bypass patients.

Metabolic syndrome was associated with the greatest risk for serious complications, according to the authors’ regression model. Those who received the gastric band had a 2.79-fold increase in risk at 90 days, compared with bypass patients, who had a 1.34-fold increased risk.

Follow-up data at 1 year were available for a little more than half of those with metabolic syndrome (12,144 patients). The data show that the decrease in BMI was procedure dependent. The greatest decrease in mean BMI (from 51 to 32) was seen in those who had a biliopancreatic diversion. Mean BMI dropped from 46 to 39 in gastric band patients, from 49 to 36 in those who had a sleeve gastrectomy, and from 48 to 32 in those who had the bypass.

Reduction of comorbidities was also greatest in the duodenal switch group, followed by the bypass, sleeve, and gastric band procedures. For instance, diabetes resolved in 74% of patients who had the duodenal switch, compared with only 28% of those who received the band. There were big reductions in hyperlipidemia and sleep apnea for all the procedures.

The data are limited in that they are self-reported, noted Dr. Inabnet. Even so, the "study confirms the previously held hypothesis that metabolic syndrome confers increased morbidity," said Dr. Bruce Schirmer, vice-chair of the department of surgery at the University of Virginia, Charlottesville. In discussing the paper, Dr. Schirmer noted that BOLD also seemed to show lower overall weight loss and resolution of comorbidities than was previously reported by individual institutions.

The database, however, has its advantages, said another discussant, Dr. William O. Richards, chair of the department of surgery and director of the surgical weight loss center at the University of South Alabama, Mobile. "This paper is important because it’s another one of the studies emanating from prospective [collections of data across the United States] from hundreds of surgeons, and convinces me we are ever more confident in reporting results not just from a single surgeon but from actual practice," said Dr. Richards.

He questioned whether the low mortality rate was a reflection of surgeons’ opting to avoid procedures in high-risk, older obese patients, or whether it was a reflection of the success of the centers of excellence system.

Dr. Inabnet said that there were 200 patients older than age 75, and although the data are currently too young to allow the measurement of any trends, it doesn’t seem that older patients are being operated on less often than are younger patients.

"What is the best operation? That really is the million dollar question," he said. The data show that the Roux-en-Y procedure provides the best overall risk profile, but he added that the sleeve gastrectomy is increasing in prevalence and may eventually prove to be a good choice.

Dr. Inabnet, Dr. Schirmer, and Dr. Richards reported no conflicts.

HOT SPRINGS, VA. – Since tort reform in Texas, the number of lawsuits and associated costs have decreased, but patient complaints to the state medical board and board investigations of physicians have risen, according to an analysis presented at the meeting.

Dr. Ronald M. Stewart and his colleagues from the University of Texas Health Science Center at San Antonio obtained publicly available data from the Texas Medical Board and compared the 7-year period before tort reform (1996-2002) and the 6 years after the law was enacted (2004-2010).

The data were adjusted for the increase in the physician population; before reform there were about 170 physicians per 100,000 residents. After the law went into effect, the number rose to 195 physicians per 100,000, said Dr. Stewart, chairman of the department of surgery.

Before reform, about 125 complaints per 1,000 physicians were made to the medical board. That number increased by 13% after reform, to 140 complaints per 1,000 physicians, said Dr. Stewart.

The rate of investigations increased from 38 per 1,000 to 52 per 1,000, with 5% of physicians the subject of a medical board inquiry. Postreform, there were more disciplinary actions when compared to open investigations, at about 8 per 1,000 in the latter period. Before reform, 0.5 per 1,000 physicians were ordered to revoke or to voluntarily surrender their licenses; after reform, that value rose to 0.8 per 1,000, a significant increase, noted Dr. Stewart.

The most striking change before and after reform was the decline in financial penalties. The state collected a total of $4.7 million in the postreform period. To put that figure into context, the San Antonio department of surgery alone spent $4.8 million on liability settlements in the prereform period, he said.

It's not clear why complaints and disciplinary actions went up, Dr. Stewart said. Having access to electronic information and greater awareness of the ability to complain to the medical board probably spurred more patient reporting. The increases in investigations and disciplinary actions were mainly driven by the legislature, according to Dr. Stewart.

“It appears that tort reform in Texas has done what it was intended to do,” increased the activity of the Texas Medical Board, and decreased the activity of the medical liability tort system, said Dr. Russell Postier, chairman of surgery at the University of Oklahoma, Oklahoma City, in discussing the paper.

Further, it appears to have increased the number of physicians practicing in the state, which could “make other states take notice and potentially enact tort reform,” Dr. Postier said.

Dr. Stewart and Dr. Postier reported no financial conflicts.

The activity of the medical liability tort system has ebbed in Texas.

Source ©Oxford/iStockphoto.com

HOT SPRINGS, VA. – Since tort reform in Texas, the number of lawsuits and associated costs have decreased, but patient complaints to the state medical board and board investigations of physicians have risen, according to an analysis presented at the meeting.

Dr. Ronald M. Stewart and his colleagues from the University of Texas Health Science Center at San Antonio obtained publicly available data from the Texas Medical Board and compared the 7-year period before tort reform (1996-2002) and the 6 years after the law was enacted (2004-2010).

The data were adjusted for the increase in the physician population; before reform there were about 170 physicians per 100,000 residents. After the law went into effect, the number rose to 195 physicians per 100,000, said Dr. Stewart, chairman of the department of surgery.

Before reform, about 125 complaints per 1,000 physicians were made to the medical board. That number increased by 13% after reform, to 140 complaints per 1,000 physicians, said Dr. Stewart.

The rate of investigations increased from 38 per 1,000 to 52 per 1,000, with 5% of physicians the subject of a medical board inquiry. Postreform, there were more disciplinary actions when compared to open investigations, at about 8 per 1,000 in the latter period. Before reform, 0.5 per 1,000 physicians were ordered to revoke or to voluntarily surrender their licenses; after reform, that value rose to 0.8 per 1,000, a significant increase, noted Dr. Stewart.

The most striking change before and after reform was the decline in financial penalties. The state collected a total of $4.7 million in the postreform period. To put that figure into context, the San Antonio department of surgery alone spent $4.8 million on liability settlements in the prereform period, he said.

It's not clear why complaints and disciplinary actions went up, Dr. Stewart said. Having access to electronic information and greater awareness of the ability to complain to the medical board probably spurred more patient reporting. The increases in investigations and disciplinary actions were mainly driven by the legislature, according to Dr. Stewart.

“It appears that tort reform in Texas has done what it was intended to do,” increased the activity of the Texas Medical Board, and decreased the activity of the medical liability tort system, said Dr. Russell Postier, chairman of surgery at the University of Oklahoma, Oklahoma City, in discussing the paper.

Further, it appears to have increased the number of physicians practicing in the state, which could “make other states take notice and potentially enact tort reform,” Dr. Postier said.

Dr. Stewart and Dr. Postier reported no financial conflicts.

The activity of the medical liability tort system has ebbed in Texas.

Source ©Oxford/iStockphoto.com

HOT SPRINGS, VA. – Since tort reform in Texas, the number of lawsuits and associated costs have decreased, but patient complaints to the state medical board and board investigations of physicians have risen, according to an analysis presented at the meeting.

Dr. Ronald M. Stewart and his colleagues from the University of Texas Health Science Center at San Antonio obtained publicly available data from the Texas Medical Board and compared the 7-year period before tort reform (1996-2002) and the 6 years after the law was enacted (2004-2010).

The data were adjusted for the increase in the physician population; before reform there were about 170 physicians per 100,000 residents. After the law went into effect, the number rose to 195 physicians per 100,000, said Dr. Stewart, chairman of the department of surgery.

Before reform, about 125 complaints per 1,000 physicians were made to the medical board. That number increased by 13% after reform, to 140 complaints per 1,000 physicians, said Dr. Stewart.

The rate of investigations increased from 38 per 1,000 to 52 per 1,000, with 5% of physicians the subject of a medical board inquiry. Postreform, there were more disciplinary actions when compared to open investigations, at about 8 per 1,000 in the latter period. Before reform, 0.5 per 1,000 physicians were ordered to revoke or to voluntarily surrender their licenses; after reform, that value rose to 0.8 per 1,000, a significant increase, noted Dr. Stewart.

The most striking change before and after reform was the decline in financial penalties. The state collected a total of $4.7 million in the postreform period. To put that figure into context, the San Antonio department of surgery alone spent $4.8 million on liability settlements in the prereform period, he said.

It's not clear why complaints and disciplinary actions went up, Dr. Stewart said. Having access to electronic information and greater awareness of the ability to complain to the medical board probably spurred more patient reporting. The increases in investigations and disciplinary actions were mainly driven by the legislature, according to Dr. Stewart.

“It appears that tort reform in Texas has done what it was intended to do,” increased the activity of the Texas Medical Board, and decreased the activity of the medical liability tort system, said Dr. Russell Postier, chairman of surgery at the University of Oklahoma, Oklahoma City, in discussing the paper.

Further, it appears to have increased the number of physicians practicing in the state, which could “make other states take notice and potentially enact tort reform,” Dr. Postier said.

Dr. Stewart and Dr. Postier reported no financial conflicts.

The activity of the medical liability tort system has ebbed in Texas.

Source ©Oxford/iStockphoto.com