Alicia Ault

WASHINGTON – The Sustainable Growth Rate is "flawed in many ways," according to the Medicare Payment Advisory Commission, which presented several possible alternatives in its semiannual report to Congress issued June 15.

Reform of the Sustainable Growth Rate formula (SGR) is essential to fixing the American health care system, MedPAC chairman Glenn M. Hackbarth said in a statement. "The Commission believes payment reform is a necessary, although not sufficient, condition for reform of the health care delivery system."

It is not the first time that the MedPAC commissioners have expressed their concern about the SGR and its continuing threat to both physicians and patients. Under the SGR, Medicare is on track to cut physician pay by 30% in 2012.

To eliminate the cuts that have mounted over the years is an expensive proposition – about $300 billion, according to estimates by MedPAC and others.

Thus, the commission has suggested several alternatives as well as potential ways to create Medicare savings to cover the cost of replacing the SGR.

One idea that has garnered strong support from the commission is overhauling the fee-for-service system by rewarding primary care physicians and encouraging a medical home model of care. Under that scenario, payments essentially would be shifted away from specialty care and procedure-based medicine to primary care, said MedPAC executive director Mark Miller.

The report also called for possible short-term fixes to the SGR to last for at least 2 years. In 2010, updates were so short-lived that they were often applied retroactively. The lack of predictability was difficult for physician practices, according to the report, which added that "the most disturbing outcome resulting from the short-term fixes was damage to patients’ and providers’ confidence in Medicare."

Mr. Miller said that the SGR proposals are just a small facet of MedPAC’s goal to move Medicare away from its fee-for-service payment system. MedPAC commissioners have been discussing how to move Medicare toward a more global payment model, such as the accountable care organizations (ACOs) that are being proposed by the Centers for Medicare and Medicaid Services (CMS).

The report also made a series of recommendations to reduce the ever-rising cost of ancillary services provided by physicians, particularly imaging services. The commission is not anti-imaging, said Mr. Miller. But there has been such a spike in volume in the last decade – 6% growth per beneficiary per year from 2004-2008 and 2% per year from 2008-2009 – that commissioners felt it was imperative to suggest ways to curb the growth.

Among the suggestions: disallow multiple payments for imaging of multiple body parts that are carried out simultaneously and reduce fees for physicians who order a procedure and then perform it themselves.

The report also recommended that Medicare require prior authorization of magnetic resonance imaging, computed tomography, and nuclear imaging for physicians who order more of these tests than do their peers. This change would likely take an act of Congress, however.

The commission outlined a process whereby physicians who are found to order more – but within appropriate bounds – would merely be subject to a prior notification process.

The commissioners did not embrace outright the radiology benefits management (RBM) model that’s used in the private sector, but Mr. Miller said that ultimately a Medicare contractor would administer the process, and that an RBM might be eligible.

The report also contained recommendations on improving how Medicare can support physicians and other health care providers interested in improving the quality of care they deliver. Among the biggest changes: Taking some payments that would go to Quality Improvement Organizations and funneling them directly to providers or communities that want to band together to create their own quality improvement programs.

The report can be viewed online.

WASHINGTON – The Sustainable Growth Rate is "flawed in many ways," according to the Medicare Payment Advisory Commission, which presented several possible alternatives in its semiannual report to Congress issued June 15.

Reform of the Sustainable Growth Rate formula (SGR) is essential to fixing the American health care system, MedPAC chairman Glenn M. Hackbarth said in a statement. "The Commission believes payment reform is a necessary, although not sufficient, condition for reform of the health care delivery system."

It is not the first time that the MedPAC commissioners have expressed their concern about the SGR and its continuing threat to both physicians and patients. Under the SGR, Medicare is on track to cut physician pay by 30% in 2012.

To eliminate the cuts that have mounted over the years is an expensive proposition – about $300 billion, according to estimates by MedPAC and others.

Thus, the commission has suggested several alternatives as well as potential ways to create Medicare savings to cover the cost of replacing the SGR.

One idea that has garnered strong support from the commission is overhauling the fee-for-service system by rewarding primary care physicians and encouraging a medical home model of care. Under that scenario, payments essentially would be shifted away from specialty care and procedure-based medicine to primary care, said MedPAC executive director Mark Miller.

The report also called for possible short-term fixes to the SGR to last for at least 2 years. In 2010, updates were so short-lived that they were often applied retroactively. The lack of predictability was difficult for physician practices, according to the report, which added that "the most disturbing outcome resulting from the short-term fixes was damage to patients’ and providers’ confidence in Medicare."

Mr. Miller said that the SGR proposals are just a small facet of MedPAC’s goal to move Medicare away from its fee-for-service payment system. MedPAC commissioners have been discussing how to move Medicare toward a more global payment model, such as the accountable care organizations (ACOs) that are being proposed by the Centers for Medicare and Medicaid Services (CMS).

The report also made a series of recommendations to reduce the ever-rising cost of ancillary services provided by physicians, particularly imaging services. The commission is not anti-imaging, said Mr. Miller. But there has been such a spike in volume in the last decade – 6% growth per beneficiary per year from 2004-2008 and 2% per year from 2008-2009 – that commissioners felt it was imperative to suggest ways to curb the growth.

Among the suggestions: disallow multiple payments for imaging of multiple body parts that are carried out simultaneously and reduce fees for physicians who order a procedure and then perform it themselves.

The report also recommended that Medicare require prior authorization of magnetic resonance imaging, computed tomography, and nuclear imaging for physicians who order more of these tests than do their peers. This change would likely take an act of Congress, however.

The commission outlined a process whereby physicians who are found to order more – but within appropriate bounds – would merely be subject to a prior notification process.

The commissioners did not embrace outright the radiology benefits management (RBM) model that’s used in the private sector, but Mr. Miller said that ultimately a Medicare contractor would administer the process, and that an RBM might be eligible.

The report also contained recommendations on improving how Medicare can support physicians and other health care providers interested in improving the quality of care they deliver. Among the biggest changes: Taking some payments that would go to Quality Improvement Organizations and funneling them directly to providers or communities that want to band together to create their own quality improvement programs.

The report can be viewed online.

WASHINGTON – The Sustainable Growth Rate is "flawed in many ways," according to the Medicare Payment Advisory Commission, which presented several possible alternatives in its semiannual report to Congress issued June 15.

Reform of the Sustainable Growth Rate formula (SGR) is essential to fixing the American health care system, MedPAC chairman Glenn M. Hackbarth said in a statement. "The Commission believes payment reform is a necessary, although not sufficient, condition for reform of the health care delivery system."

It is not the first time that the MedPAC commissioners have expressed their concern about the SGR and its continuing threat to both physicians and patients. Under the SGR, Medicare is on track to cut physician pay by 30% in 2012.

To eliminate the cuts that have mounted over the years is an expensive proposition – about $300 billion, according to estimates by MedPAC and others.

Thus, the commission has suggested several alternatives as well as potential ways to create Medicare savings to cover the cost of replacing the SGR.

One idea that has garnered strong support from the commission is overhauling the fee-for-service system by rewarding primary care physicians and encouraging a medical home model of care. Under that scenario, payments essentially would be shifted away from specialty care and procedure-based medicine to primary care, said MedPAC executive director Mark Miller.

The report also called for possible short-term fixes to the SGR to last for at least 2 years. In 2010, updates were so short-lived that they were often applied retroactively. The lack of predictability was difficult for physician practices, according to the report, which added that "the most disturbing outcome resulting from the short-term fixes was damage to patients’ and providers’ confidence in Medicare."

Mr. Miller said that the SGR proposals are just a small facet of MedPAC’s goal to move Medicare away from its fee-for-service payment system. MedPAC commissioners have been discussing how to move Medicare toward a more global payment model, such as the accountable care organizations (ACOs) that are being proposed by the Centers for Medicare and Medicaid Services (CMS).

The report also made a series of recommendations to reduce the ever-rising cost of ancillary services provided by physicians, particularly imaging services. The commission is not anti-imaging, said Mr. Miller. But there has been such a spike in volume in the last decade – 6% growth per beneficiary per year from 2004-2008 and 2% per year from 2008-2009 – that commissioners felt it was imperative to suggest ways to curb the growth.

Among the suggestions: disallow multiple payments for imaging of multiple body parts that are carried out simultaneously and reduce fees for physicians who order a procedure and then perform it themselves.

The report also recommended that Medicare require prior authorization of magnetic resonance imaging, computed tomography, and nuclear imaging for physicians who order more of these tests than do their peers. This change would likely take an act of Congress, however.

The commission outlined a process whereby physicians who are found to order more – but within appropriate bounds – would merely be subject to a prior notification process.

The commissioners did not embrace outright the radiology benefits management (RBM) model that’s used in the private sector, but Mr. Miller said that ultimately a Medicare contractor would administer the process, and that an RBM might be eligible.

The report also contained recommendations on improving how Medicare can support physicians and other health care providers interested in improving the quality of care they deliver. Among the biggest changes: Taking some payments that would go to Quality Improvement Organizations and funneling them directly to providers or communities that want to band together to create their own quality improvement programs.

The report can be viewed online.

WASHINGTON – The Sustainable Growth Rate is "flawed in many ways," according to the Medicare Payment Advisory Commission, which presented several possible alternatives in its semiannual report to Congress issued June 15.

Reform of the Sustainable Growth Rate formula (SGR) is essential to fixing the American health care system, MedPAC chairman Glenn M. Hackbarth said in a statement. "The Commission believes payment reform is a necessary, although not sufficient, condition for reform of the health care delivery system."

It is not the first time that the MedPAC commissioners have expressed their concern about the SGR and its continuing threat to both physicians and patients. Under the SGR, Medicare is on track to cut physician pay by 30% in 2012.

To eliminate the cuts that have mounted over the years is an expensive proposition – about $300 billion, according to estimates by MedPAC and others.

Thus, the commission has suggested several alternatives as well as potential ways to create Medicare savings to cover the cost of replacing the SGR.

One idea that has garnered strong support from the commission is overhauling the fee-for-service system by rewarding primary care physicians and encouraging a medical home model of care. Under that scenario, payments essentially would be shifted away from specialty care and procedure-based medicine to primary care, said MedPAC executive director Mark Miller.

The report also called for possible short-term fixes to the SGR to last for at least 2 years. In 2010, updates were so short-lived that they were often applied retroactively. The lack of predictability was difficult for physician practices, according to the report, which added that "the most disturbing outcome resulting from the short-term fixes was damage to patients’ and providers’ confidence in Medicare."

Mr. Miller said that the SGR proposals are just a small facet of MedPAC’s goal to move Medicare away from its fee-for-service payment system. MedPAC commissioners have been discussing how to move Medicare toward a more global payment model, such as the accountable care organizations (ACOs) that are being proposed by the Centers for Medicare and Medicaid Services (CMS).

The report also made a series of recommendations to reduce the ever-rising cost of ancillary services provided by physicians, particularly imaging services. The commission is not anti-imaging, said Mr. Miller. But there has been such a spike in volume in the last decade – 6% growth per beneficiary per year from 2004-2008 and 2% per year from 2008-2009 – that commissioners felt it was imperative to suggest ways to curb the growth.

Among the suggestions: disallow multiple payments for imaging of multiple body parts that are carried out simultaneously and reduce fees for physicians who order a procedure and then perform it themselves.

The report also recommended that Medicare require prior authorization of magnetic resonance imaging, computed tomography, and nuclear imaging for physicians who order more of these tests than do their peers. This change would likely take an act of Congress, however.

The commission outlined a process whereby physicians who are found to order more – but within appropriate bounds – would merely be subject to a prior notification process.

The commissioners did not embrace outright the radiology benefits management (RBM) model that’s used in the private sector, but Mr. Miller said that ultimately a Medicare contractor would administer the process, and that an RBM might be eligible.

The report also contained recommendations on improving how Medicare can support physicians and other health care providers interested in improving the quality of care they deliver. Among the biggest changes: Taking some payments that would go to Quality Improvement Organizations and funneling them directly to providers or communities that want to band together to create their own quality improvement programs.

The report can be viewed online.

WASHINGTON – The Sustainable Growth Rate is "flawed in many ways," according to the Medicare Payment Advisory Commission, which presented several possible alternatives in its semiannual report to Congress issued June 15.

Reform of the Sustainable Growth Rate formula (SGR) is essential to fixing the American health care system, MedPAC chairman Glenn M. Hackbarth said in a statement. "The Commission believes payment reform is a necessary, although not sufficient, condition for reform of the health care delivery system."

It is not the first time that the MedPAC commissioners have expressed their concern about the SGR and its continuing threat to both physicians and patients. Under the SGR, Medicare is on track to cut physician pay by 30% in 2012.

To eliminate the cuts that have mounted over the years is an expensive proposition – about $300 billion, according to estimates by MedPAC and others.

Thus, the commission has suggested several alternatives as well as potential ways to create Medicare savings to cover the cost of replacing the SGR.

One idea that has garnered strong support from the commission is overhauling the fee-for-service system by rewarding primary care physicians and encouraging a medical home model of care. Under that scenario, payments essentially would be shifted away from specialty care and procedure-based medicine to primary care, said MedPAC executive director Mark Miller.

The report also called for possible short-term fixes to the SGR to last for at least 2 years. In 2010, updates were so short-lived that they were often applied retroactively. The lack of predictability was difficult for physician practices, according to the report, which added that "the most disturbing outcome resulting from the short-term fixes was damage to patients’ and providers’ confidence in Medicare."

Mr. Miller said that the SGR proposals are just a small facet of MedPAC’s goal to move Medicare away from its fee-for-service payment system. MedPAC commissioners have been discussing how to move Medicare toward a more global payment model, such as the accountable care organizations (ACOs) that are being proposed by the Centers for Medicare and Medicaid Services (CMS).

The report also made a series of recommendations to reduce the ever-rising cost of ancillary services provided by physicians, particularly imaging services. The commission is not anti-imaging, said Mr. Miller. But there has been such a spike in volume in the last decade – 6% growth per beneficiary per year from 2004-2008 and 2% per year from 2008-2009 – that commissioners felt it was imperative to suggest ways to curb the growth.

Among the suggestions: disallow multiple payments for imaging of multiple body parts that are carried out simultaneously and reduce fees for physicians who order a procedure and then perform it themselves.

The report also recommended that Medicare require prior authorization of magnetic resonance imaging, computed tomography, and nuclear imaging for physicians who order more of these tests than do their peers. This change would likely take an act of Congress, however.

The commission outlined a process whereby physicians who are found to order more – but within appropriate bounds – would merely be subject to a prior notification process.

The commissioners did not embrace outright the radiology benefits management (RBM) model that’s used in the private sector, but Mr. Miller said that ultimately a Medicare contractor would administer the process, and that an RBM might be eligible.

The report also contained recommendations on improving how Medicare can support physicians and other health care providers interested in improving the quality of care they deliver. Among the biggest changes: Taking some payments that would go to Quality Improvement Organizations and funneling them directly to providers or communities that want to band together to create their own quality improvement programs.

The report can be viewed online.

WASHINGTON – The Sustainable Growth Rate is "flawed in many ways," according to the Medicare Payment Advisory Commission, which presented several possible alternatives in its semiannual report to Congress issued June 15.

Reform of the Sustainable Growth Rate formula (SGR) is essential to fixing the American health care system, MedPAC chairman Glenn M. Hackbarth said in a statement. "The Commission believes payment reform is a necessary, although not sufficient, condition for reform of the health care delivery system."

It is not the first time that the MedPAC commissioners have expressed their concern about the SGR and its continuing threat to both physicians and patients. Under the SGR, Medicare is on track to cut physician pay by 30% in 2012.

To eliminate the cuts that have mounted over the years is an expensive proposition – about $300 billion, according to estimates by MedPAC and others.

Thus, the commission has suggested several alternatives as well as potential ways to create Medicare savings to cover the cost of replacing the SGR.

One idea that has garnered strong support from the commission is overhauling the fee-for-service system by rewarding primary care physicians and encouraging a medical home model of care. Under that scenario, payments essentially would be shifted away from specialty care and procedure-based medicine to primary care, said MedPAC executive director Mark Miller.

The report also called for possible short-term fixes to the SGR to last for at least 2 years. In 2010, updates were so short-lived that they were often applied retroactively. The lack of predictability was difficult for physician practices, according to the report, which added that "the most disturbing outcome resulting from the short-term fixes was damage to patients’ and providers’ confidence in Medicare."

Mr. Miller said that the SGR proposals are just a small facet of MedPAC’s goal to move Medicare away from its fee-for-service payment system. MedPAC commissioners have been discussing how to move Medicare toward a more global payment model, such as the accountable care organizations (ACOs) that are being proposed by the Centers for Medicare and Medicaid Services (CMS).

The report also made a series of recommendations to reduce the ever-rising cost of ancillary services provided by physicians, particularly imaging services. The commission is not anti-imaging, said Mr. Miller. But there has been such a spike in volume in the last decade – 6% growth per beneficiary per year from 2004-2008 and 2% per year from 2008-2009 – that commissioners felt it was imperative to suggest ways to curb the growth.

Among the suggestions: disallow multiple payments for imaging of multiple body parts that are carried out simultaneously and reduce fees for physicians who order a procedure and then perform it themselves.

The report also recommended that Medicare require prior authorization of magnetic resonance imaging, computed tomography, and nuclear imaging for physicians who order more of these tests than do their peers. This change would likely take an act of Congress, however.

The commission outlined a process whereby physicians who are found to order more – but within appropriate bounds – would merely be subject to a prior notification process.

The commissioners did not embrace outright the radiology benefits management (RBM) model that’s used in the private sector, but Mr. Miller said that ultimately a Medicare contractor would administer the process, and that an RBM might be eligible.

The report also contained recommendations on improving how Medicare can support physicians and other health care providers interested in improving the quality of care they deliver. Among the biggest changes: Taking some payments that would go to Quality Improvement Organizations and funneling them directly to providers or communities that want to band together to create their own quality improvement programs.

The report can be viewed online.

A group of professional societies on June 13 has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies on June 13 has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies on June 13 has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies on June 13 has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies on June 13 has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies on June 13 has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

A group of professional societies has issued the first set of quality improvement measures that focus on primary and secondary prevention of coronary artery disease and hypertension in the ambulatory setting.

The 10 measures were characterized as groundbreaking by the committee that wrote the guidelines, not only because they are the first to focus on outpatient care, but because they also go beyond just treatment recommendations to asking health care providers to control target goals. Patients are also urged to play a big role in improving the quality of their own care. According to the measures, patients are expected to keep appointments, modify their lifestyle, and adhere to medication regimens.

"It is our hope that application of these performance measures will provide a mechanism through which the quality of medical care can be measured and improved," wrote the authors.

The 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension were compiled by a writing committee that was led by the American College of Cardiology Foundation (ACCF), the American Medical Association, and the American Heart Association. They were published in Journal of the American College of Cardiology (JACC 2011 June 13 [doi:10.1016/j.jacc.2011.05.002]).

The last such measures were issued in 2005.

(c) Alexander Raths/Fotolia.com

Seven of the performance measures were carried over, but they were updated. For instance, in 2005, practitioners were asked to measure blood pressure in patients with coronary artery disease. The new measure requires blood pressure control, and gives the parameters for that control. Similarly, for lipids, the guideline has evolved from measuring and providing medications, to also reporting on control of the condition. In the past, symptoms and activity were evaluated separately, sometimes giving a false view of angina. Practitioners are now asked to assess the two simultaneously.

The measures also still urge tobacco use screening, and cessation and intervention, and contain guidelines on prescribing and monitoring beta-blocker, antiplatelet, and ACE inhibitor therapy. For hypertension, the new guidelines combined two measures on blood pressure measurement, and coming up with a plan of care, into one measure that tracks the control of blood pressure.

There are two new measures. The first puts an emphasis on symptom management. It requires physicians to track the percentage of patients 18 or older with a diagnosis of coronary artery disease seen within a 12-month period, reporting on activity evaluation – evaluation of the presence or absence of anginal symptoms with appropriate management of those symptoms. If there are symptoms, physicians should document a plan of care to control them.

A second measure calls on physicians to refer all patients who’ve had an acute myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina to a rehabilitation or secondary prevention program. The committee found that rehabilitation programs are severely underused and aims to use the measure to highlight the gap in care.

A measure requiring screening for diabetes in coronary artery disease patients was retired. It was considered "difficult to implement," according to the authors, and thus was not widely used.

Although compliance with medication therapy is crucial, the committee decided against adding a measure on medication adherence. It was debated, but the main objection was that "although prescribing physicians have some influence on patient choices, adherence is largely not in the individual physician’s locus of control." The committee envisioned that if such a measure existed, physicians might avoid caring for patients who were nonadherent.

It decided that adherence measures in guidelines in HEDIS (Healthcare Effectiveness Data and Information Set) would probably be more helpful, as those are used by insurers and employers to wield influence over patients.

The panel considered and rejected several other measures, including one that would have looked at overuse of stress testing, and others on appropriate use of percutaneous coronary intervention.

All of the measures were written to complement existing National Quality Forum–endorsed measures in coronary artery disease and hypertension, said the authors.

The committee also decided to go ahead with its recommendations, even though several other major guidelines are in the process of being written, said the authors. Those include the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8); an ACCF/AHA guideline on stable ischemic heart disease, and the Cholesterol Education Project’s Adult Treatment Panel IV.

The writing committee also included representatives from the American Academy of Clinical Endocrinologists, the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Academy of Family Physicians, the American College of Emergency Physicians, the American College of Radiology, the American Geriatrics Society, the American Nurses Association, the American Society of Health-System Pharmacists, the Society of Hospital Medicine, and the Society for Thoracic Surgeons.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

The federal government announced June 6 a series of initiatives designed to help states pay for better-coordinated care for HIV/AIDS patients including expanded testing and more pharmaceutical therapies.

The announcements were timed to coincide with the 30th anniversary of the first U.S. case reports that signaled the beginning of the HIV/AIDS epidemic. All the initiatives are designed to help implement the National HIV/AIDS Strategy introduced by President Obama in July 2010.

That was the first-ever federal strategy to comprehensively address HIV/AIDS, said Health and Human Services Secretary Kathleen Sebelius in a press briefing. Ms. Sebelius said that the government is pressing ahead with prevention and treatment programs, as the epidemic continues to be a threat.

Since the early 1980s, "more than 600,000 Americans have died long before they should have," Ms. Sebelius said.

Some 56,000 Americans are infected with HIV each year and 1.1 million are living with HIV/AIDS, said Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC), during the briefing.

The CDC is taking a close look at the resources it devotes to HIV/AIDS and restructuring how that money is spent, Dr. Frieden said. The agency will be making funds available to states to expand access to testing, in particular for men who have sex with men. That population is at highest risk for HIV infection; those men are also playing a big role in new infections, Dr. Frieden said.

The CDC also will be redirecting funds to help providers link HIV-positive patients to care and to help keep them in care, he said. "We know people in care are less likely to engage in risky behavior," Dr. Frieden said.

The agency also will be providing funds to state and local health agencies to more closely track viral load and CD4 counts in HIV-positive patients. The goal is to ensure that clinicians are keeping patients maximally suppressed and thus help reduce the risk of new infections, Dr. Frieden said.

States also will get a boost for their AIDS Drug Assistance Programs. The ADAP is administered by Health Resources and Services Administration (HRSA) as part of the Ryan White HIV/AIDS Program. Last July, HHS reallocated some $25 million for states to use to take people off waiting lists for ADAPs. In the current fiscal year (2010), HHS is making another $50 million available to states specifically to help take people off waiting lists, said HRSA Administrator Mary Wakefield during the briefing. That’s in addition to the $835 million HRSA already has allocated for ADAPs in fiscal 2010, she said.

Finally, the Centers for Medicare and Medicaid Services announced that it is giving states more flexibility in caring for HIV/AIDS patients on Medicaid. The agency sent a letter to state Medicaid directors explaining that they could apply for funding that would allow patients to be cared for at home or with community-based services. The agency is also going to make it easier for HIV-positive adults to receive Medicaid coverage, said Cindy Mann, director of the Center for Medicaid and State Operations, during the briefing.

Under the Affordable Care Act, beginning in 2014, all adults with incomes below 133% of the federal poverty level will be eligible for Medicaid. But many living with HIV do not have insurance or do not have incomes low enough to qualify for Medicaid currently, Ms. Mann said. So the agency is creating a fast track that will allow states to seek waivers specifically for their HIV/AIDS patients to receive Medicaid at that lower income level now, she said.

Thirty years after the first U.S. reports of pneumocystis pneumonia, a harbinger of the onslaught of the human immunodeficiency virus (HIV), primary care physicians find themselves again at the front lines of caring for patients with HIV/AIDS.

Like the illness itself, which has gone from a certain death sentence to a chronic disease, primary care practices evolved from first providing simple ministrations to the mostly untreatable to grappling with the specialized care needed for patients with active infectious disease, and the drug toxicities that go with their regimens. Now, HIV/AIDS care has entered a different phase over the past decade or so, in which physicians need both specialized knowledge and basic primary care skills. They must simultaneously address patients’ complications from living longer with the disease, along with their psychosocial issues and age-related comorbidities.

Photo credit: Cynthia Goldsmith, CDC

"For the first 15 years, we focused on helping people die," said Dr. Michael Saag, professor of medicine at the University of Alabama at Birmingham (UAB). "For the next 15 years, we’ve focused on helping people live – that’s a remarkable transition."

Dr. Saag said that primary care physicians who care for patients with HIV/AIDS can make an even bigger mark over the next 10-15 years. How? By showing that the care model they’ve been using perfectly demonstrates the power of the medical home.

Primary care physicians can, and should, be at the helm of HIV/AIDS care, agreed Dr. Peter Selwyn, chair of the department of family and social medicine at the Montefiore Medical Center and Albert Einstein College of Medicine, New York.

In HIV/AIDS care, "I’ve seen it start in primary care, then gravitate away, and then gravitate back," Dr. Selwyn said in an interview.

But workforce issues are a problem. Many of the primary care doctors who specialize in HIV/AIDS care now are readying for retirement. Meanwhile, some 50,000 Americans are infected each year, and the number living with the disease continues to rise. That ensures a growing patient population – unless prevention strategies, another challenge, gain more success.

And there are other hurdles, including early diagnosis and ensuring the continuation of funding under the Ryan White CARE Act, the 1990 law that has kept many HIV programs afloat.

Thirty years ago ... and today. According to the Centers for Disease Control and Prevention, the transmission of HIV in the United States has declined by 89% since the 1980s – the peak of the epidemic. With the advent of the first antiretroviral drug, AZT (zidovudine), in 1987, the number of people living with HIV/AIDS began to grow, while the number who died of it declined.

Still, today, there are 56,000 new cases a year, and some 18,000 people die annually, according to the CDC. As it was 30 years ago, men who have sex with men still make up the bulk of those infected (53%) and living with HIV/AIDS (48%). It is also the only group at risk in which new infections continue to increase.

More than a million people are living with HIV, but at least 20% don’t even know they are infected, according to the CDC.

Initially, the epidemic was concentrated in major cities on the two coasts. Now, infections are hitting Southern cities harder, and disproportionately affecting minorities. CDC data show that Miami; Jacksonville; Orlando; New Orleans; Baton Rouge, La.; Baltimore; Washington; Columbia, S.C.; Atlanta; San Juan, P.R.; and Jackson, Miss. have a high incidence of HIV. New York City and San Francisco remain epicenters.

African Americans make up only 14% of the U.S. population, but account for 46% of people living with HIV and 45% of new infections. Latinos make up 16% of the American population, but account for 18% of people living with HIV and 17% of new infections.

Patients also have a much lower socioeconomic status than they did in the past, said Dr. Donna E. Sweet, professor of internal medicine at the University of Kansas, Wichita. In her own practice, 50% of the patients are still men having sex with men, but they are less educated and less affluent, she said in an interview.

"It’s a financially and socioeconomically disenfranchised group of people compared to 20 years ago," she said.

The number of infected women in her practice also has increased. A decade or more ago, less than 10% of her patients were women. Now it’s closer to 26%; most have contracted HIV through unprotected vaginal sex, Dr. Sweet said.

At Southwest Boulevard Family Health Care Services of Greater Kansas City, the epidemic has continued to grow in the largely poor and minority population it serves, said Dr. Sharon Lee, a cofounder and CEO of the nonprofit clinic.

Of the 800-some patients with HIV, about a third are women, said Dr. Lee, professor of medicine in the department of family medicine at the University of Kansas. The women are acquiring the virus through sexual contact. Men having sex with men still make up the largest proportion of patients, and the majority are still white males, but minorities are disproportionately affected, she said in an interview.

Spiraling back around. While many primary care physicians found themselves treating HIV/AIDS patients at the dawn of the epidemic, that changed.

By the early 2000s, many primary care physicians didn’t feel as comfortable caring for HIV/AIDS patients because the field had become so specialized, Dr. Selwyn said.

But in the past 10 years, with HIV becoming a manageable chronic disease in this country, it is "not different in its acuity and time course from other chronic diseases that primary care doctors are used to taking care of," he said.

Dr. Lee said she became known for her specialization and often received referrals from other physicians for HIV care because the drug regimens were so complicated. But now, it makes more sense for HIV/AIDS patients to get care from a family physician or internist, she said. Primary care physicians have specific training to manage chronic diseases like diabetes, hypertension, and hypercholesterolemia, all of which are hitting HIV/AIDS patients hard.

"All of those things are things we are very well trained to care for. In fact, we are better trained than those specialists trained in infectious diseases," Dr. Lee said. The evolutionary path of HIV/AIDS care resembles "a pendulum of sorts, but more like a spiral – it’s spiraling back to primary care but it’s at a different level."

Dr. Sweet said that she’s been speaking around the country to physicians and administrators at community health centers and federally qualified health centers, urging them to funnel their HIV/AIDS patients into primary care. "It’s better to have one primary care physician than a dozen specialists," she tells them.

Building new capacity. Spreading the expertise is gaining urgency because many primary care doctors who focus on HIV/AIDS care are ready to retire. Many of these physicians belong to the HIV Medical Association or the American Academy of HIV Medicine; a majority of those members are within 10-15 years of retirement, said Dr. Selwyn, who has served on the HIVMA board of directors.

Dr. Lee, who currently serves on that board of directors, said that the organization has been seeking ways to increase training of primary care physicians in HIV/AIDS. The University of Kansas Medical Center is hoping to start an HIV medicine residency, she said.

The Albert Einstein College of Medicine has an active teaching program for family practice and internal medicine residents in HIV care and HIV primary care, Dr. Selwyn added.

Physicians and professional societies also are pushing the medical home concept as a viable model for offering lower-cost, high-quality HIV/AIDS care.

The Ryan White CARE Act, named after a teenage boy who died of AIDS in 1990, has become the main support for the AIDS-related medical home, according to Dr. Saag. The program is administered by the Health Resources and Services Administration (HRSA), a division of the Department of Health and Human Services. HRSA awards federal funds that are then used to deliver care and pay for medications. According to HRSA, the Ryan White HIV/AIDS Program is currently funded at $2.1 billion.

Funding via the Ryan White CARE Act led to the creation of multispecialty HIV clinics that deliver care through teams of providers. The clinics offer comprehensive care – from primary care to case management to counseling, social services, substance abuse treatment, palliative care, and pharmacy consultation.

The original model has evolved to helping people live, but "the overall effectiveness is just superb," said Dr. Saag, who says he believes he has data to prove the claim.

He and his colleagues studied the costs and reimbursement of caring for HIV/AIDS patients at the UAB clinic in 2006 (Clin. Infect. Dis. 2006;42:1003-10). Costs ranged from $13,885 per patient per year for those with early infection to $36,532 for those with more advanced disease. Three-quarters of the reimbursement was for medications, regardless of disease stage. Only 2% of the clinic’s actual costs for care was reimbursed. The study concluded that most HIV clinics would not survive without Ryan White CARE Act funds, as they make up a large amount of unreimbursed costs.

In a separate calculation, which has yet to be published, but was part of an editorial supporting the medical home published in the AIDS Reader, Dr. Saag estimated that it costs the UAB clinic about $2,700 per patient per year to offer a medical home.

It is his argument that it would be more efficient – and result in better-quality care – to take a portion of the money going to reimburse medications and instead direct it to primary care and the medical home.

"There’s a lot of money wasted in this field now," said Dr. Saag. "We just need to realign where that money is going."

Thirty years after the first U.S. reports of pneumocystis pneumonia, a harbinger of the onslaught of the human immunodeficiency virus (HIV), primary care physicians find themselves again at the front lines of caring for patients with HIV/AIDS.

Like the illness itself, which has gone from a certain death sentence to a chronic disease, primary care practices evolved from first providing simple ministrations to the mostly untreatable to grappling with the specialized care needed for patients with active infectious disease, and the drug toxicities that go with their regimens. Now, HIV/AIDS care has entered a different phase over the past decade or so, in which physicians need both specialized knowledge and basic primary care skills. They must simultaneously address patients’ complications from living longer with the disease, along with their psychosocial issues and age-related comorbidities.

Photo credit: Cynthia Goldsmith, CDC

"For the first 15 years, we focused on helping people die," said Dr. Michael Saag, professor of medicine at the University of Alabama at Birmingham (UAB). "For the next 15 years, we’ve focused on helping people live – that’s a remarkable transition."

Dr. Saag said that primary care physicians who care for patients with HIV/AIDS can make an even bigger mark over the next 10-15 years. How? By showing that the care model they’ve been using perfectly demonstrates the power of the medical home.

Primary care physicians can, and should, be at the helm of HIV/AIDS care, agreed Dr. Peter Selwyn, chair of the department of family and social medicine at the Montefiore Medical Center and Albert Einstein College of Medicine, New York.

In HIV/AIDS care, "I’ve seen it start in primary care, then gravitate away, and then gravitate back," Dr. Selwyn said in an interview.

But workforce issues are a problem. Many of the primary care doctors who specialize in HIV/AIDS care now are readying for retirement. Meanwhile, some 50,000 Americans are infected each year, and the number living with the disease continues to rise. That ensures a growing patient population – unless prevention strategies, another challenge, gain more success.

And there are other hurdles, including early diagnosis and ensuring the continuation of funding under the Ryan White CARE Act, the 1990 law that has kept many HIV programs afloat.

Thirty years ago ... and today. According to the Centers for Disease Control and Prevention, the transmission of HIV in the United States has declined by 89% since the 1980s – the peak of the epidemic. With the advent of the first antiretroviral drug, AZT (zidovudine), in 1987, the number of people living with HIV/AIDS began to grow, while the number who died of it declined.

Still, today, there are 56,000 new cases a year, and some 18,000 people die annually, according to the CDC. As it was 30 years ago, men who have sex with men still make up the bulk of those infected (53%) and living with HIV/AIDS (48%). It is also the only group at risk in which new infections continue to increase.

More than a million people are living with HIV, but at least 20% don’t even know they are infected, according to the CDC.

Initially, the epidemic was concentrated in major cities on the two coasts. Now, infections are hitting Southern cities harder, and disproportionately affecting minorities. CDC data show that Miami; Jacksonville; Orlando; New Orleans; Baton Rouge, La.; Baltimore; Washington; Columbia, S.C.; Atlanta; San Juan, P.R.; and Jackson, Miss. have a high incidence of HIV. New York City and San Francisco remain epicenters.

African Americans make up only 14% of the U.S. population, but account for 46% of people living with HIV and 45% of new infections. Latinos make up 16% of the American population, but account for 18% of people living with HIV and 17% of new infections.

Patients also have a much lower socioeconomic status than they did in the past, said Dr. Donna E. Sweet, professor of internal medicine at the University of Kansas, Wichita. In her own practice, 50% of the patients are still men having sex with men, but they are less educated and less affluent, she said in an interview.

"It’s a financially and socioeconomically disenfranchised group of people compared to 20 years ago," she said.

The number of infected women in her practice also has increased. A decade or more ago, less than 10% of her patients were women. Now it’s closer to 26%; most have contracted HIV through unprotected vaginal sex, Dr. Sweet said.

At Southwest Boulevard Family Health Care Services of Greater Kansas City, the epidemic has continued to grow in the largely poor and minority population it serves, said Dr. Sharon Lee, a cofounder and CEO of the nonprofit clinic.

Of the 800-some patients with HIV, about a third are women, said Dr. Lee, professor of medicine in the department of family medicine at the University of Kansas. The women are acquiring the virus through sexual contact. Men having sex with men still make up the largest proportion of patients, and the majority are still white males, but minorities are disproportionately affected, she said in an interview.

Spiraling back around. While many primary care physicians found themselves treating HIV/AIDS patients at the dawn of the epidemic, that changed.

By the early 2000s, many primary care physicians didn’t feel as comfortable caring for HIV/AIDS patients because the field had become so specialized, Dr. Selwyn said.

But in the past 10 years, with HIV becoming a manageable chronic disease in this country, it is "not different in its acuity and time course from other chronic diseases that primary care doctors are used to taking care of," he said.

Dr. Lee said she became known for her specialization and often received referrals from other physicians for HIV care because the drug regimens were so complicated. But now, it makes more sense for HIV/AIDS patients to get care from a family physician or internist, she said. Primary care physicians have specific training to manage chronic diseases like diabetes, hypertension, and hypercholesterolemia, all of which are hitting HIV/AIDS patients hard.

"All of those things are things we are very well trained to care for. In fact, we are better trained than those specialists trained in infectious diseases," Dr. Lee said. The evolutionary path of HIV/AIDS care resembles "a pendulum of sorts, but more like a spiral – it’s spiraling back to primary care but it’s at a different level."

Dr. Sweet said that she’s been speaking around the country to physicians and administrators at community health centers and federally qualified health centers, urging them to funnel their HIV/AIDS patients into primary care. "It’s better to have one primary care physician than a dozen specialists," she tells them.

Building new capacity. Spreading the expertise is gaining urgency because many primary care doctors who focus on HIV/AIDS care are ready to retire. Many of these physicians belong to the HIV Medical Association or the American Academy of HIV Medicine; a majority of those members are within 10-15 years of retirement, said Dr. Selwyn, who has served on the HIVMA board of directors.

Dr. Lee, who currently serves on that board of directors, said that the organization has been seeking ways to increase training of primary care physicians in HIV/AIDS. The University of Kansas Medical Center is hoping to start an HIV medicine residency, she said.

The Albert Einstein College of Medicine has an active teaching program for family practice and internal medicine residents in HIV care and HIV primary care, Dr. Selwyn added.

Physicians and professional societies also are pushing the medical home concept as a viable model for offering lower-cost, high-quality HIV/AIDS care.

The Ryan White CARE Act, named after a teenage boy who died of AIDS in 1990, has become the main support for the AIDS-related medical home, according to Dr. Saag. The program is administered by the Health Resources and Services Administration (HRSA), a division of the Department of Health and Human Services. HRSA awards federal funds that are then used to deliver care and pay for medications. According to HRSA, the Ryan White HIV/AIDS Program is currently funded at $2.1 billion.

Funding via the Ryan White CARE Act led to the creation of multispecialty HIV clinics that deliver care through teams of providers. The clinics offer comprehensive care – from primary care to case management to counseling, social services, substance abuse treatment, palliative care, and pharmacy consultation.

The original model has evolved to helping people live, but "the overall effectiveness is just superb," said Dr. Saag, who says he believes he has data to prove the claim.

He and his colleagues studied the costs and reimbursement of caring for HIV/AIDS patients at the UAB clinic in 2006 (Clin. Infect. Dis. 2006;42:1003-10). Costs ranged from $13,885 per patient per year for those with early infection to $36,532 for those with more advanced disease. Three-quarters of the reimbursement was for medications, regardless of disease stage. Only 2% of the clinic’s actual costs for care was reimbursed. The study concluded that most HIV clinics would not survive without Ryan White CARE Act funds, as they make up a large amount of unreimbursed costs.

In a separate calculation, which has yet to be published, but was part of an editorial supporting the medical home published in the AIDS Reader, Dr. Saag estimated that it costs the UAB clinic about $2,700 per patient per year to offer a medical home.

It is his argument that it would be more efficient – and result in better-quality care – to take a portion of the money going to reimburse medications and instead direct it to primary care and the medical home.

"There’s a lot of money wasted in this field now," said Dr. Saag. "We just need to realign where that money is going."

Thirty years after the first U.S. reports of pneumocystis pneumonia, a harbinger of the onslaught of the human immunodeficiency virus (HIV), primary care physicians find themselves again at the front lines of caring for patients with HIV/AIDS.

Like the illness itself, which has gone from a certain death sentence to a chronic disease, primary care practices evolved from first providing simple ministrations to the mostly untreatable to grappling with the specialized care needed for patients with active infectious disease, and the drug toxicities that go with their regimens. Now, HIV/AIDS care has entered a different phase over the past decade or so, in which physicians need both specialized knowledge and basic primary care skills. They must simultaneously address patients’ complications from living longer with the disease, along with their psychosocial issues and age-related comorbidities.

Photo credit: Cynthia Goldsmith, CDC

"For the first 15 years, we focused on helping people die," said Dr. Michael Saag, professor of medicine at the University of Alabama at Birmingham (UAB). "For the next 15 years, we’ve focused on helping people live – that’s a remarkable transition."

Dr. Saag said that primary care physicians who care for patients with HIV/AIDS can make an even bigger mark over the next 10-15 years. How? By showing that the care model they’ve been using perfectly demonstrates the power of the medical home.

Primary care physicians can, and should, be at the helm of HIV/AIDS care, agreed Dr. Peter Selwyn, chair of the department of family and social medicine at the Montefiore Medical Center and Albert Einstein College of Medicine, New York.

In HIV/AIDS care, "I’ve seen it start in primary care, then gravitate away, and then gravitate back," Dr. Selwyn said in an interview.

But workforce issues are a problem. Many of the primary care doctors who specialize in HIV/AIDS care now are readying for retirement. Meanwhile, some 50,000 Americans are infected each year, and the number living with the disease continues to rise. That ensures a growing patient population – unless prevention strategies, another challenge, gain more success.

And there are other hurdles, including early diagnosis and ensuring the continuation of funding under the Ryan White CARE Act, the 1990 law that has kept many HIV programs afloat.

Thirty years ago ... and today. According to the Centers for Disease Control and Prevention, the transmission of HIV in the United States has declined by 89% since the 1980s – the peak of the epidemic. With the advent of the first antiretroviral drug, AZT (zidovudine), in 1987, the number of people living with HIV/AIDS began to grow, while the number who died of it declined.

Still, today, there are 56,000 new cases a year, and some 18,000 people die annually, according to the CDC. As it was 30 years ago, men who have sex with men still make up the bulk of those infected (53%) and living with HIV/AIDS (48%). It is also the only group at risk in which new infections continue to increase.

More than a million people are living with HIV, but at least 20% don’t even know they are infected, according to the CDC.

Initially, the epidemic was concentrated in major cities on the two coasts. Now, infections are hitting Southern cities harder, and disproportionately affecting minorities. CDC data show that Miami; Jacksonville; Orlando; New Orleans; Baton Rouge, La.; Baltimore; Washington; Columbia, S.C.; Atlanta; San Juan, P.R.; and Jackson, Miss. have a high incidence of HIV. New York City and San Francisco remain epicenters.

African Americans make up only 14% of the U.S. population, but account for 46% of people living with HIV and 45% of new infections. Latinos make up 16% of the American population, but account for 18% of people living with HIV and 17% of new infections.

Patients also have a much lower socioeconomic status than they did in the past, said Dr. Donna E. Sweet, professor of internal medicine at the University of Kansas, Wichita. In her own practice, 50% of the patients are still men having sex with men, but they are less educated and less affluent, she said in an interview.

"It’s a financially and socioeconomically disenfranchised group of people compared to 20 years ago," she said.

The number of infected women in her practice also has increased. A decade or more ago, less than 10% of her patients were women. Now it’s closer to 26%; most have contracted HIV through unprotected vaginal sex, Dr. Sweet said.

At Southwest Boulevard Family Health Care Services of Greater Kansas City, the epidemic has continued to grow in the largely poor and minority population it serves, said Dr. Sharon Lee, a cofounder and CEO of the nonprofit clinic.

Of the 800-some patients with HIV, about a third are women, said Dr. Lee, professor of medicine in the department of family medicine at the University of Kansas. The women are acquiring the virus through sexual contact. Men having sex with men still make up the largest proportion of patients, and the majority are still white males, but minorities are disproportionately affected, she said in an interview.

Spiraling back around. While many primary care physicians found themselves treating HIV/AIDS patients at the dawn of the epidemic, that changed.

By the early 2000s, many primary care physicians didn’t feel as comfortable caring for HIV/AIDS patients because the field had become so specialized, Dr. Selwyn said.

But in the past 10 years, with HIV becoming a manageable chronic disease in this country, it is "not different in its acuity and time course from other chronic diseases that primary care doctors are used to taking care of," he said.

Dr. Lee said she became known for her specialization and often received referrals from other physicians for HIV care because the drug regimens were so complicated. But now, it makes more sense for HIV/AIDS patients to get care from a family physician or internist, she said. Primary care physicians have specific training to manage chronic diseases like diabetes, hypertension, and hypercholesterolemia, all of which are hitting HIV/AIDS patients hard.

"All of those things are things we are very well trained to care for. In fact, we are better trained than those specialists trained in infectious diseases," Dr. Lee said. The evolutionary path of HIV/AIDS care resembles "a pendulum of sorts, but more like a spiral – it’s spiraling back to primary care but it’s at a different level."

Dr. Sweet said that she’s been speaking around the country to physicians and administrators at community health centers and federally qualified health centers, urging them to funnel their HIV/AIDS patients into primary care. "It’s better to have one primary care physician than a dozen specialists," she tells them.

Building new capacity. Spreading the expertise is gaining urgency because many primary care doctors who focus on HIV/AIDS care are ready to retire. Many of these physicians belong to the HIV Medical Association or the American Academy of HIV Medicine; a majority of those members are within 10-15 years of retirement, said Dr. Selwyn, who has served on the HIVMA board of directors.

Dr. Lee, who currently serves on that board of directors, said that the organization has been seeking ways to increase training of primary care physicians in HIV/AIDS. The University of Kansas Medical Center is hoping to start an HIV medicine residency, she said.

The Albert Einstein College of Medicine has an active teaching program for family practice and internal medicine residents in HIV care and HIV primary care, Dr. Selwyn added.

Physicians and professional societies also are pushing the medical home concept as a viable model for offering lower-cost, high-quality HIV/AIDS care.

The Ryan White CARE Act, named after a teenage boy who died of AIDS in 1990, has become the main support for the AIDS-related medical home, according to Dr. Saag. The program is administered by the Health Resources and Services Administration (HRSA), a division of the Department of Health and Human Services. HRSA awards federal funds that are then used to deliver care and pay for medications. According to HRSA, the Ryan White HIV/AIDS Program is currently funded at $2.1 billion.

Funding via the Ryan White CARE Act led to the creation of multispecialty HIV clinics that deliver care through teams of providers. The clinics offer comprehensive care – from primary care to case management to counseling, social services, substance abuse treatment, palliative care, and pharmacy consultation.

The original model has evolved to helping people live, but "the overall effectiveness is just superb," said Dr. Saag, who says he believes he has data to prove the claim.

He and his colleagues studied the costs and reimbursement of caring for HIV/AIDS patients at the UAB clinic in 2006 (Clin. Infect. Dis. 2006;42:1003-10). Costs ranged from $13,885 per patient per year for those with early infection to $36,532 for those with more advanced disease. Three-quarters of the reimbursement was for medications, regardless of disease stage. Only 2% of the clinic’s actual costs for care was reimbursed. The study concluded that most HIV clinics would not survive without Ryan White CARE Act funds, as they make up a large amount of unreimbursed costs.

In a separate calculation, which has yet to be published, but was part of an editorial supporting the medical home published in the AIDS Reader, Dr. Saag estimated that it costs the UAB clinic about $2,700 per patient per year to offer a medical home.

It is his argument that it would be more efficient – and result in better-quality care – to take a portion of the money going to reimburse medications and instead direct it to primary care and the medical home.

"There’s a lot of money wasted in this field now," said Dr. Saag. "We just need to realign where that money is going."