Alicia Ault

The Centers for Medicare and Medicaid Services issued its final rule governing physician fees for 2011 on Nov. 3, offering a 10% incentive payment to primary care physicians, but taking away an additional 2% across the board as a result of the statutory requirements of the sustainable growth rate formula.

Unless Congress acts, physician fees under Medicare will be cut by 23% on Dec. 1 as mandated by the SGR; just about 2% more will be cut Jan. 1, brining the total cut for 2011 to 25%.

Although CMS Administrator Don Berwick has called for a permanent overhaul of the SGR, it was not mentioned in the materials that went out with the new rule. Instead, Dr. Berwick touted the new preventive care benefits that will be covered, and thus reimbursed, as a result of the Affordable Care Act.

Under the final rule, which implements certain ACA provisions, Medicare will pay for an annual wellness visit, "that will allow a physician and patient to develop a closer partnership to improve the patient’s long term health," said Dr. Berwick in a statement. "The rule will also eliminate out-of-pocket costs for most preventive services beginning Jan. 1, 2011, reducing barriers to access for many beneficiaries," he added.

The wellness visit will be paid at the rate of a level 4 office visit for a new patient.

The ACA also provided the primary care bonus, which is separate from the fee cuts. The payment is available to family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants who can show that 60% or more of their Medicare allowable charges were for primary care.

The incentive payments will be made quarterly, based on the services provided in the previous quarter.

A similar 10% quarterly incentive payment will be made in 2011 to general surgeons in Health Professional Shortage Areas.

The fee schedule also implements a provision of the ACA that increases payment for two codes for dual energy x-ray absorptiometry (DXA) for both 2010 and 2011.

The ACA also dictated new requirements for physicians who refer patients to MRI, CT, and PET facilities in which they have an ownership interest. Now, the physician will have to disclose in writing to patients that they can receive the service elsewhere. Referring physicians will also have to provide a list of five alternatives within 25 miles of the physician’s office.

Payment for imaging procedures will also be reduced. Previously, the CMS reimbursed based on the assumption that equipment was used 100% of the time. That assumption has been changed to 75%.

The ACA also reduced incentives for the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative). In 2011, physicians will be eligible for an incentive payment equal to 1% of the total Medicare charges during the reporting period. For 2012 through 2014, the payment drops to 0.5% of charges. After 2014, physicians who do not report data could see a 1.5% cut in Medicare fees; the penalty increases each year.

There is a carrot, though. Physicians who use a Maintenance of Certification program to report PQRS data will get an additional 0.5%.

The incentive payment for e-prescribing in 2011 will be 1% of charges during the calendar year. But in 2012, payments will be reduced if physicians are "not successful e-prescribers," according to the CMS.

The final fee schedule rule will be published Nov. 29 in the Federal Register.

The Centers for Medicare and Medicaid Services issued its final rule governing physician fees for 2011 on Nov. 3, offering a 10% incentive payment to primary care physicians, but taking away an additional 2% across the board as a result of the statutory requirements of the sustainable growth rate formula.

Unless Congress acts, physician fees under Medicare will be cut by 23% on Dec. 1 as mandated by the SGR; just about 2% more will be cut Jan. 1, brining the total cut for 2011 to 25%.

Although CMS Administrator Don Berwick has called for a permanent overhaul of the SGR, it was not mentioned in the materials that went out with the new rule. Instead, Dr. Berwick touted the new preventive care benefits that will be covered, and thus reimbursed, as a result of the Affordable Care Act.

Under the final rule, which implements certain ACA provisions, Medicare will pay for an annual wellness visit, "that will allow a physician and patient to develop a closer partnership to improve the patient’s long term health," said Dr. Berwick in a statement. "The rule will also eliminate out-of-pocket costs for most preventive services beginning Jan. 1, 2011, reducing barriers to access for many beneficiaries," he added.

The wellness visit will be paid at the rate of a level 4 office visit for a new patient.

The ACA also provided the primary care bonus, which is separate from the fee cuts. The payment is available to family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants who can show that 60% or more of their Medicare allowable charges were for primary care.

The incentive payments will be made quarterly, based on the services provided in the previous quarter.

A similar 10% quarterly incentive payment will be made in 2011 to general surgeons in Health Professional Shortage Areas.

The fee schedule also implements a provision of the ACA that increases payment for two codes for dual energy x-ray absorptiometry (DXA) for both 2010 and 2011.

The ACA also dictated new requirements for physicians who refer patients to MRI, CT, and PET facilities in which they have an ownership interest. Now, the physician will have to disclose in writing to patients that they can receive the service elsewhere. Referring physicians will also have to provide a list of five alternatives within 25 miles of the physician’s office.

Payment for imaging procedures will also be reduced. Previously, the CMS reimbursed based on the assumption that equipment was used 100% of the time. That assumption has been changed to 75%.

The ACA also reduced incentives for the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative). In 2011, physicians will be eligible for an incentive payment equal to 1% of the total Medicare charges during the reporting period. For 2012 through 2014, the payment drops to 0.5% of charges. After 2014, physicians who do not report data could see a 1.5% cut in Medicare fees; the penalty increases each year.

There is a carrot, though. Physicians who use a Maintenance of Certification program to report PQRS data will get an additional 0.5%.

The incentive payment for e-prescribing in 2011 will be 1% of charges during the calendar year. But in 2012, payments will be reduced if physicians are "not successful e-prescribers," according to the CMS.

The final fee schedule rule will be published Nov. 29 in the Federal Register.

The Centers for Medicare and Medicaid Services issued its final rule governing physician fees for 2011 on Nov. 3, offering a 10% incentive payment to primary care physicians, but taking away an additional 2% across the board as a result of the statutory requirements of the sustainable growth rate formula.

Unless Congress acts, physician fees under Medicare will be cut by 23% on Dec. 1 as mandated by the SGR; just about 2% more will be cut Jan. 1, brining the total cut for 2011 to 25%.

Although CMS Administrator Don Berwick has called for a permanent overhaul of the SGR, it was not mentioned in the materials that went out with the new rule. Instead, Dr. Berwick touted the new preventive care benefits that will be covered, and thus reimbursed, as a result of the Affordable Care Act.

Under the final rule, which implements certain ACA provisions, Medicare will pay for an annual wellness visit, "that will allow a physician and patient to develop a closer partnership to improve the patient’s long term health," said Dr. Berwick in a statement. "The rule will also eliminate out-of-pocket costs for most preventive services beginning Jan. 1, 2011, reducing barriers to access for many beneficiaries," he added.

The wellness visit will be paid at the rate of a level 4 office visit for a new patient.

The ACA also provided the primary care bonus, which is separate from the fee cuts. The payment is available to family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants who can show that 60% or more of their Medicare allowable charges were for primary care.

The incentive payments will be made quarterly, based on the services provided in the previous quarter.

A similar 10% quarterly incentive payment will be made in 2011 to general surgeons in Health Professional Shortage Areas.

The fee schedule also implements a provision of the ACA that increases payment for two codes for dual energy x-ray absorptiometry (DXA) for both 2010 and 2011.

The ACA also dictated new requirements for physicians who refer patients to MRI, CT, and PET facilities in which they have an ownership interest. Now, the physician will have to disclose in writing to patients that they can receive the service elsewhere. Referring physicians will also have to provide a list of five alternatives within 25 miles of the physician’s office.

Payment for imaging procedures will also be reduced. Previously, the CMS reimbursed based on the assumption that equipment was used 100% of the time. That assumption has been changed to 75%.

The ACA also reduced incentives for the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative). In 2011, physicians will be eligible for an incentive payment equal to 1% of the total Medicare charges during the reporting period. For 2012 through 2014, the payment drops to 0.5% of charges. After 2014, physicians who do not report data could see a 1.5% cut in Medicare fees; the penalty increases each year.

There is a carrot, though. Physicians who use a Maintenance of Certification program to report PQRS data will get an additional 0.5%.

The incentive payment for e-prescribing in 2011 will be 1% of charges during the calendar year. But in 2012, payments will be reduced if physicians are "not successful e-prescribers," according to the CMS.

The final fee schedule rule will be published Nov. 29 in the Federal Register.

The Centers for Medicare and Medicaid Services issued its final rule governing physician fees for 2011 on Nov. 3, offering a 10% incentive payment to primary care physicians, but taking away an additional 2% across the board as a result of the statutory requirements of the sustainable growth rate formula.

Unless Congress acts, physician fees under Medicare will be cut by 23% on Dec. 1 as mandated by the SGR; just about 2% more will be cut Jan. 1, bring the total cut for 2011 to 25%.

Although CMS Administrator Don Berwick has called for a permanent overhaul of the SGR, it was not mentioned in the materials that went out with the new rule. Instead, Dr. Berwick touted the new preventive care benefits that will be covered, and thus reimbursed, as a result of the Affordable Care Act.

Under the final rule, which implements certain ACA provisions, Medicare will pay for an annual wellness visit, "that will allow a physician and patient to develop a closer partnership to improve the patient's long term health," said Dr. Berwick in a statement. "The rule will also eliminate out-of-pocket costs for most preventive services beginning Jan. 1, 2011, reducing barriers to access for many beneficiaries," he added.

The wellness visit will be paid at the rate of a level 4 office visit for a new patient.

The ACA also provided the primary care bonus, which is separate from the fee cuts. The payment is available to family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants who can show that 60% or more of their Medicare allowable charges were for primary care.

The incentive payments will be made quarterly, based on the services provided in the previous quarter.

A similar 10% quarterly incentive payment will be made in 2011 to general surgeons in Health Professional Shortage Areas.

The fee schedule also implements a provision of the ACA that increases payment for two codes for dual energy x-ray absorptiometry (DXA) for both 2010 and 2011.

The ACA also dictated new requirements for physicians who refer patients to MRI, CT, and PET facilities in which they have an ownership interest. Now, the physician will have to disclose in writing to patients that they can receive the service elsewhere. Referring physicians will also have to provide a list of five alternatives within 25 miles of the physician's office.

Payment for imaging procedures will also be reduced. Previously, the CMS reimbursed based on the assumption that equipment was used 100% of the time. That assumption has been changed to 75%.

The ACA also reduced incentives for the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative). In 2011, physicians will be eligible for an incentive payment equal to 1% of the total Medicare charges during the reporting period. For 2012 through 2014, the payment drops to 0.5% of charges. After 2014, physicians who do not report data could see a 1.5% cut in Medicare fees; the penalty increases each year.

There is a carrot, though. Physicians who use a Maintenance of Certification program to report PQRS data will get an additional 0.5%.

The incentive payment for e-prescribing in 2011 will be 1% of charges during the calendar year. But in 2012, payments will be reduced if physicians are "not successful e-prescribers," according to the CMS.

The final fee schedule rule will be published Nov. 29 in the Federal Register.

The Centers for Medicare and Medicaid Services issued its final rule governing physician fees for 2011 on Nov. 3, offering a 10% incentive payment to primary care physicians, but taking away an additional 2% across the board as a result of the statutory requirements of the sustainable growth rate formula.

Unless Congress acts, physician fees under Medicare will be cut by 23% on Dec. 1 as mandated by the SGR; just about 2% more will be cut Jan. 1, bring the total cut for 2011 to 25%.

Although CMS Administrator Don Berwick has called for a permanent overhaul of the SGR, it was not mentioned in the materials that went out with the new rule. Instead, Dr. Berwick touted the new preventive care benefits that will be covered, and thus reimbursed, as a result of the Affordable Care Act.

Under the final rule, which implements certain ACA provisions, Medicare will pay for an annual wellness visit, "that will allow a physician and patient to develop a closer partnership to improve the patient's long term health," said Dr. Berwick in a statement. "The rule will also eliminate out-of-pocket costs for most preventive services beginning Jan. 1, 2011, reducing barriers to access for many beneficiaries," he added.

The wellness visit will be paid at the rate of a level 4 office visit for a new patient.

The ACA also provided the primary care bonus, which is separate from the fee cuts. The payment is available to family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants who can show that 60% or more of their Medicare allowable charges were for primary care.

The incentive payments will be made quarterly, based on the services provided in the previous quarter.

A similar 10% quarterly incentive payment will be made in 2011 to general surgeons in Health Professional Shortage Areas.

The fee schedule also implements a provision of the ACA that increases payment for two codes for dual energy x-ray absorptiometry (DXA) for both 2010 and 2011.

The ACA also dictated new requirements for physicians who refer patients to MRI, CT, and PET facilities in which they have an ownership interest. Now, the physician will have to disclose in writing to patients that they can receive the service elsewhere. Referring physicians will also have to provide a list of five alternatives within 25 miles of the physician's office.

Payment for imaging procedures will also be reduced. Previously, the CMS reimbursed based on the assumption that equipment was used 100% of the time. That assumption has been changed to 75%.

The ACA also reduced incentives for the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative). In 2011, physicians will be eligible for an incentive payment equal to 1% of the total Medicare charges during the reporting period. For 2012 through 2014, the payment drops to 0.5% of charges. After 2014, physicians who do not report data could see a 1.5% cut in Medicare fees; the penalty increases each year.

There is a carrot, though. Physicians who use a Maintenance of Certification program to report PQRS data will get an additional 0.5%.

The incentive payment for e-prescribing in 2011 will be 1% of charges during the calendar year. But in 2012, payments will be reduced if physicians are "not successful e-prescribers," according to the CMS.

The final fee schedule rule will be published Nov. 29 in the Federal Register.

The Centers for Medicare and Medicaid Services issued its final rule governing physician fees for 2011 on Nov. 3, offering a 10% incentive payment to primary care physicians, but taking away an additional 2% across the board as a result of the statutory requirements of the sustainable growth rate formula.

Unless Congress acts, physician fees under Medicare will be cut by 23% on Dec. 1 as mandated by the SGR; just about 2% more will be cut Jan. 1, bring the total cut for 2011 to 25%.

Although CMS Administrator Don Berwick has called for a permanent overhaul of the SGR, it was not mentioned in the materials that went out with the new rule. Instead, Dr. Berwick touted the new preventive care benefits that will be covered, and thus reimbursed, as a result of the Affordable Care Act.

Under the final rule, which implements certain ACA provisions, Medicare will pay for an annual wellness visit, "that will allow a physician and patient to develop a closer partnership to improve the patient's long term health," said Dr. Berwick in a statement. "The rule will also eliminate out-of-pocket costs for most preventive services beginning Jan. 1, 2011, reducing barriers to access for many beneficiaries," he added.

The wellness visit will be paid at the rate of a level 4 office visit for a new patient.

The ACA also provided the primary care bonus, which is separate from the fee cuts. The payment is available to family physicians, general internists, geriatricians, pediatricians, nurse practitioners, clinical nurse specialists, and physician assistants who can show that 60% or more of their Medicare allowable charges were for primary care.

The incentive payments will be made quarterly, based on the services provided in the previous quarter.

A similar 10% quarterly incentive payment will be made in 2011 to general surgeons in Health Professional Shortage Areas.

The fee schedule also implements a provision of the ACA that increases payment for two codes for dual energy x-ray absorptiometry (DXA) for both 2010 and 2011.

The ACA also dictated new requirements for physicians who refer patients to MRI, CT, and PET facilities in which they have an ownership interest. Now, the physician will have to disclose in writing to patients that they can receive the service elsewhere. Referring physicians will also have to provide a list of five alternatives within 25 miles of the physician's office.

Payment for imaging procedures will also be reduced. Previously, the CMS reimbursed based on the assumption that equipment was used 100% of the time. That assumption has been changed to 75%.

The ACA also reduced incentives for the Physician Quality Reporting System (formerly known as the Physician Quality Reporting Initiative). In 2011, physicians will be eligible for an incentive payment equal to 1% of the total Medicare charges during the reporting period. For 2012 through 2014, the payment drops to 0.5% of charges. After 2014, physicians who do not report data could see a 1.5% cut in Medicare fees; the penalty increases each year.

There is a carrot, though. Physicians who use a Maintenance of Certification program to report PQRS data will get an additional 0.5%.

The incentive payment for e-prescribing in 2011 will be 1% of charges during the calendar year. But in 2012, payments will be reduced if physicians are "not successful e-prescribers," according to the CMS.

The final fee schedule rule will be published Nov. 29 in the Federal Register.

The use of comparative effectiveness research would give Medicare a sophisticated tool for making coverage decisions on the basis of quality, but the federal health program's ability to use such data is hamstrung by political interests and the health reform law, according to two researchers.

“We believe that the time is ripe for Medicare to use comparative effectiveness research to reach a new paradigm of paying equally for services that provide equivalent results,” the authors wrote.

Dr. Steven D. Pearson, president of the Institute for Clinical and Economic Review in Boston, and Dr. Peter B. Bach, an attending physician at Memorial Sloan-Kettering Cancer Center in New York, say that Medicare can take advantage of the burgeoning comparative effectiveness movement to change its ways (Health Affairs 2010;29:1796–804).

The Obama administration is helping create a larger comparative effectiveness enterprise through some $1.1 billion that was set aside as part of the American Recovery and Reinvestment Act of 2009. In March 2009, the Department of Health and Human Services announced that 15 experts would guide investments and coordinate research through the Federal Coordinating Council for Comparative Effectiveness Research.

However, the council's role is limited in that it will not set clinical guidelines, or establish payment rates or tell Medicare what to cover. The Affordable Care Act further spelled out restrictions on how comparative effectiveness findings could be used by the federal government.

Currently, Medicare covers a drug, device, product, or service if evidence supports its effectiveness. No comparisons are made to other products. Payment is set separately, based on arcane formulas that cover cost and maybe a small profit.

Dr. Pearson and Dr. Bach propose that Medicare instead link coverage and payment decisions at the outset. The program could still use the “reasonable and necessary” threshold in deciding when to cover a product or service. But regulators could adopt a three-tiered effectiveness scale that would let them assign differing reimbursement to each level.

For instance, a superior rating would garner the highest payment. Such a product would have the fewest side effects or offer the most effective treatment when compared with similar treatments.

Next down would be the “comparable” product or service. Payment would be slightly less than that for the superior product, as in the difference between what is paid for a brand name and a generic pharmaceutical, for example.

The lowest rating, “insufficient evidence,” would be covered and reimbursed at the conventional cost plus a small profit, but the payment level would be reevaluated every 3 years.

The authors said a 3-year time frame can act as both a carrot and a stick. Having coverage – at current Medicare rates – is better than not having coverage, so innovation will not be stifled. Limiting that rate to only 3 years gives manufacturers and clinicians greater incentives to conduct comparative effectiveness studies.

Dr. Pearson reported no conflicts. He is a member of the National Institutes of Health's Comparative Effectiveness Research Steering Committee and was a previous vice chair of the Medicare Evidence Development and Coverage Advisory Committee. Dr. Bach made no disclosures. He serves on the Committee on Performance Management of the National Committee for Quality Assurance and the Institute of Medicine's National Cancer Policy Forum.

The use of comparative effectiveness research would give Medicare a sophisticated tool for making coverage decisions on the basis of quality, but the federal health program's ability to use such data is hamstrung by political interests and the health reform law, according to two researchers.

“We believe that the time is ripe for Medicare to use comparative effectiveness research to reach a new paradigm of paying equally for services that provide equivalent results,” the authors wrote.

Dr. Steven D. Pearson, president of the Institute for Clinical and Economic Review in Boston, and Dr. Peter B. Bach, an attending physician at Memorial Sloan-Kettering Cancer Center in New York, say that Medicare can take advantage of the burgeoning comparative effectiveness movement to change its ways (Health Affairs 2010;29:1796–804).

The Obama administration is helping create a larger comparative effectiveness enterprise through some $1.1 billion that was set aside as part of the American Recovery and Reinvestment Act of 2009. In March 2009, the Department of Health and Human Services announced that 15 experts would guide investments and coordinate research through the Federal Coordinating Council for Comparative Effectiveness Research.

However, the council's role is limited in that it will not set clinical guidelines, or establish payment rates or tell Medicare what to cover. The Affordable Care Act further spelled out restrictions on how comparative effectiveness findings could be used by the federal government.

Currently, Medicare covers a drug, device, product, or service if evidence supports its effectiveness. No comparisons are made to other products. Payment is set separately, based on arcane formulas that cover cost and maybe a small profit.

Dr. Pearson and Dr. Bach propose that Medicare instead link coverage and payment decisions at the outset. The program could still use the “reasonable and necessary” threshold in deciding when to cover a product or service. But regulators could adopt a three-tiered effectiveness scale that would let them assign differing reimbursement to each level.

For instance, a superior rating would garner the highest payment. Such a product would have the fewest side effects or offer the most effective treatment when compared with similar treatments.

Next down would be the “comparable” product or service. Payment would be slightly less than that for the superior product, as in the difference between what is paid for a brand name and a generic pharmaceutical, for example.

The lowest rating, “insufficient evidence,” would be covered and reimbursed at the conventional cost plus a small profit, but the payment level would be reevaluated every 3 years.

The authors said a 3-year time frame can act as both a carrot and a stick. Having coverage – at current Medicare rates – is better than not having coverage, so innovation will not be stifled. Limiting that rate to only 3 years gives manufacturers and clinicians greater incentives to conduct comparative effectiveness studies.

Dr. Pearson reported no conflicts. He is a member of the National Institutes of Health's Comparative Effectiveness Research Steering Committee and was a previous vice chair of the Medicare Evidence Development and Coverage Advisory Committee. Dr. Bach made no disclosures. He serves on the Committee on Performance Management of the National Committee for Quality Assurance and the Institute of Medicine's National Cancer Policy Forum.

The use of comparative effectiveness research would give Medicare a sophisticated tool for making coverage decisions on the basis of quality, but the federal health program's ability to use such data is hamstrung by political interests and the health reform law, according to two researchers.

“We believe that the time is ripe for Medicare to use comparative effectiveness research to reach a new paradigm of paying equally for services that provide equivalent results,” the authors wrote.

Dr. Steven D. Pearson, president of the Institute for Clinical and Economic Review in Boston, and Dr. Peter B. Bach, an attending physician at Memorial Sloan-Kettering Cancer Center in New York, say that Medicare can take advantage of the burgeoning comparative effectiveness movement to change its ways (Health Affairs 2010;29:1796–804).

The Obama administration is helping create a larger comparative effectiveness enterprise through some $1.1 billion that was set aside as part of the American Recovery and Reinvestment Act of 2009. In March 2009, the Department of Health and Human Services announced that 15 experts would guide investments and coordinate research through the Federal Coordinating Council for Comparative Effectiveness Research.

However, the council's role is limited in that it will not set clinical guidelines, or establish payment rates or tell Medicare what to cover. The Affordable Care Act further spelled out restrictions on how comparative effectiveness findings could be used by the federal government.

Currently, Medicare covers a drug, device, product, or service if evidence supports its effectiveness. No comparisons are made to other products. Payment is set separately, based on arcane formulas that cover cost and maybe a small profit.

Dr. Pearson and Dr. Bach propose that Medicare instead link coverage and payment decisions at the outset. The program could still use the “reasonable and necessary” threshold in deciding when to cover a product or service. But regulators could adopt a three-tiered effectiveness scale that would let them assign differing reimbursement to each level.

For instance, a superior rating would garner the highest payment. Such a product would have the fewest side effects or offer the most effective treatment when compared with similar treatments.

Next down would be the “comparable” product or service. Payment would be slightly less than that for the superior product, as in the difference between what is paid for a brand name and a generic pharmaceutical, for example.

The lowest rating, “insufficient evidence,” would be covered and reimbursed at the conventional cost plus a small profit, but the payment level would be reevaluated every 3 years.

The authors said a 3-year time frame can act as both a carrot and a stick. Having coverage – at current Medicare rates – is better than not having coverage, so innovation will not be stifled. Limiting that rate to only 3 years gives manufacturers and clinicians greater incentives to conduct comparative effectiveness studies.

Dr. Pearson reported no conflicts. He is a member of the National Institutes of Health's Comparative Effectiveness Research Steering Committee and was a previous vice chair of the Medicare Evidence Development and Coverage Advisory Committee. Dr. Bach made no disclosures. He serves on the Committee on Performance Management of the National Committee for Quality Assurance and the Institute of Medicine's National Cancer Policy Forum.

California Limits CT Radiation

California Gov. Arnold Schwarzenegger (R) has signed a bill that limits the radiation dose provided in computed tomography scans. The new law comes in the wake of patients at at least six California hospitals having received up to eight times the normal radiation from their CT scans. Beginning in 2012, technicians must record the radiation dose from every scan, and radiology reports must include that information. Each year, a medical physicist will be required to confirm each CT machine's readings. Beginning in 2013, medical imaging facilities need to report to the state any medical injury from CT radiation and any instance in which certain doses have been exceeded.

Off-Label Promotion Targeted

The Food and Drug Administration is warning that it will pursue disciplinary action against physicians, other practitioners, and manufacturers that promote medical devices for off-label uses, according to the Gray Sheet. The newsletter (published by Elsevier, as is this newspaper) reported that Deborah Wolf, a regulatory counsel in the Center for Devices and Radiological Health's Office of Compliance, said that the agency has been sending warning letters to physicians and others. An FDA staff member gave an example of a violation: a laser that is FDA approved for osteoarthritis treatment being promoted for killing toe fungus. “FDA doesn't regulate the practice of medicine but does in fact regulate promotion,” Ms. Wolf said. She spoke to the industry group called the Food and Drug Law Institute.

Stop-Smoking Coverage Expanded

Physicians will be reimbursed for counseling any Medicare patient about smoking cessation, not just those with tobacco-related illness, under new guidelines approved by the CMS. Previously, a patient needed to at least show signs of illness related to smoking before Medicare would pay. Now, any smoker covered by Medicare can have up to eight smoking cessation sessions per year from a physician or another Medicare-recognized health practitioner, CMS said. American Medical Association President Cecil Wilson applauded the coverage expansion. “More than 400,000 Americans die needlessly every year as a direct result of tobacco use,” Dr. Wilson said in a statement. “This expansion of coverage takes an important step toward helping Medicare patients lead healthier, tobacco-free lives.”

Productivity, Ownership Linked

Billable work per patient appears to be increasing only at physician groups under the “private practice model,” but expenses have also grown, according to a Medical Group Management Association study. Over the past 5 years, relative value units per patient rose by 13% at private medical practices, but declined nearly 18% at practices owned by hospitals or integrated delivery systems, analysts found. Meanwhile, operating costs for private practices increased by nearly 2% last year, in contrast to a slight decline for practices owned by the larger entities. MGMA attributed part of the increase in expenses for private practices to the cost of implementing electronic health record systems. “In the private practice model, EHR incentives have provided a catalyst for practices to purchase systems and deploy electronic health records, therefore increasing the practice's information technology expenditures,” said Kenneth Hertz, a principal with MGMA Health Care Consulting Group, in a statement.

Outcomes Research Funded

HHS will provide grants totaling nearly $17 million for “patient-centered outcomes research” (PCOR), which focuses on treatments and strategies that might improve health outcomes from the patient's point of view. Most of the announced grants will support outcomes research in primary care, HHS said. As part of the grant program, five health organizations will attempt to show that providers and academic institutions can partner on PCOR. Each organization – in California, Illinois, Massachusetts, New York, and Oregon – will receive about $2 million over 3 years to create a national network for evaluating the patient-centered approach in patient populations that are not always adequately represented in other studies, according to HHS. “Patient-centered outcomes research can improve health outcomes by developing and disseminating evidence-based information to patients, providers and decision-makers about the effectiveness of different treatments,” said HHS Secretary Kathleen Sebelius in a statement.

Claims Processors Deemed So-So

About 70% of physicians reported they were satisfied with the contractors who process their Medicare claims, in the annual Centers for Medicare and Medicaid Services survey on contractor performance. Meanwhile, 14% of physicians said they were neither satisfied nor dissatisfied, and more than 15% said they were dissatisfied with contractor performance. Hospitals were slightly happier, with three-quarters saying they were satisfied with contractor performance. Improvements in several areas would increase provider satisfaction, according to the CMS. For example, providers said they don't like having to make multiple inquires of claims processors to resolve problems. They also want better information through an automated telephone system, promptly returned calls, and consistently correct information.

California Limits CT Radiation

California Gov. Arnold Schwarzenegger (R) has signed a bill that limits the radiation dose provided in computed tomography scans. The new law comes in the wake of patients at at least six California hospitals having received up to eight times the normal radiation from their CT scans. Beginning in 2012, technicians must record the radiation dose from every scan, and radiology reports must include that information. Each year, a medical physicist will be required to confirm each CT machine's readings. Beginning in 2013, medical imaging facilities need to report to the state any medical injury from CT radiation and any instance in which certain doses have been exceeded.

Off-Label Promotion Targeted

The Food and Drug Administration is warning that it will pursue disciplinary action against physicians, other practitioners, and manufacturers that promote medical devices for off-label uses, according to the Gray Sheet. The newsletter (published by Elsevier, as is this newspaper) reported that Deborah Wolf, a regulatory counsel in the Center for Devices and Radiological Health's Office of Compliance, said that the agency has been sending warning letters to physicians and others. An FDA staff member gave an example of a violation: a laser that is FDA approved for osteoarthritis treatment being promoted for killing toe fungus. “FDA doesn't regulate the practice of medicine but does in fact regulate promotion,” Ms. Wolf said. She spoke to the industry group called the Food and Drug Law Institute.

Stop-Smoking Coverage Expanded

Physicians will be reimbursed for counseling any Medicare patient about smoking cessation, not just those with tobacco-related illness, under new guidelines approved by the CMS. Previously, a patient needed to at least show signs of illness related to smoking before Medicare would pay. Now, any smoker covered by Medicare can have up to eight smoking cessation sessions per year from a physician or another Medicare-recognized health practitioner, CMS said. American Medical Association President Cecil Wilson applauded the coverage expansion. “More than 400,000 Americans die needlessly every year as a direct result of tobacco use,” Dr. Wilson said in a statement. “This expansion of coverage takes an important step toward helping Medicare patients lead healthier, tobacco-free lives.”

Productivity, Ownership Linked

Billable work per patient appears to be increasing only at physician groups under the “private practice model,” but expenses have also grown, according to a Medical Group Management Association study. Over the past 5 years, relative value units per patient rose by 13% at private medical practices, but declined nearly 18% at practices owned by hospitals or integrated delivery systems, analysts found. Meanwhile, operating costs for private practices increased by nearly 2% last year, in contrast to a slight decline for practices owned by the larger entities. MGMA attributed part of the increase in expenses for private practices to the cost of implementing electronic health record systems. “In the private practice model, EHR incentives have provided a catalyst for practices to purchase systems and deploy electronic health records, therefore increasing the practice's information technology expenditures,” said Kenneth Hertz, a principal with MGMA Health Care Consulting Group, in a statement.

Outcomes Research Funded

HHS will provide grants totaling nearly $17 million for “patient-centered outcomes research” (PCOR), which focuses on treatments and strategies that might improve health outcomes from the patient's point of view. Most of the announced grants will support outcomes research in primary care, HHS said. As part of the grant program, five health organizations will attempt to show that providers and academic institutions can partner on PCOR. Each organization – in California, Illinois, Massachusetts, New York, and Oregon – will receive about $2 million over 3 years to create a national network for evaluating the patient-centered approach in patient populations that are not always adequately represented in other studies, according to HHS. “Patient-centered outcomes research can improve health outcomes by developing and disseminating evidence-based information to patients, providers and decision-makers about the effectiveness of different treatments,” said HHS Secretary Kathleen Sebelius in a statement.

Claims Processors Deemed So-So

About 70% of physicians reported they were satisfied with the contractors who process their Medicare claims, in the annual Centers for Medicare and Medicaid Services survey on contractor performance. Meanwhile, 14% of physicians said they were neither satisfied nor dissatisfied, and more than 15% said they were dissatisfied with contractor performance. Hospitals were slightly happier, with three-quarters saying they were satisfied with contractor performance. Improvements in several areas would increase provider satisfaction, according to the CMS. For example, providers said they don't like having to make multiple inquires of claims processors to resolve problems. They also want better information through an automated telephone system, promptly returned calls, and consistently correct information.

California Limits CT Radiation

California Gov. Arnold Schwarzenegger (R) has signed a bill that limits the radiation dose provided in computed tomography scans. The new law comes in the wake of patients at at least six California hospitals having received up to eight times the normal radiation from their CT scans. Beginning in 2012, technicians must record the radiation dose from every scan, and radiology reports must include that information. Each year, a medical physicist will be required to confirm each CT machine's readings. Beginning in 2013, medical imaging facilities need to report to the state any medical injury from CT radiation and any instance in which certain doses have been exceeded.

Off-Label Promotion Targeted

The Food and Drug Administration is warning that it will pursue disciplinary action against physicians, other practitioners, and manufacturers that promote medical devices for off-label uses, according to the Gray Sheet. The newsletter (published by Elsevier, as is this newspaper) reported that Deborah Wolf, a regulatory counsel in the Center for Devices and Radiological Health's Office of Compliance, said that the agency has been sending warning letters to physicians and others. An FDA staff member gave an example of a violation: a laser that is FDA approved for osteoarthritis treatment being promoted for killing toe fungus. “FDA doesn't regulate the practice of medicine but does in fact regulate promotion,” Ms. Wolf said. She spoke to the industry group called the Food and Drug Law Institute.

Stop-Smoking Coverage Expanded

Physicians will be reimbursed for counseling any Medicare patient about smoking cessation, not just those with tobacco-related illness, under new guidelines approved by the CMS. Previously, a patient needed to at least show signs of illness related to smoking before Medicare would pay. Now, any smoker covered by Medicare can have up to eight smoking cessation sessions per year from a physician or another Medicare-recognized health practitioner, CMS said. American Medical Association President Cecil Wilson applauded the coverage expansion. “More than 400,000 Americans die needlessly every year as a direct result of tobacco use,” Dr. Wilson said in a statement. “This expansion of coverage takes an important step toward helping Medicare patients lead healthier, tobacco-free lives.”

Productivity, Ownership Linked

Billable work per patient appears to be increasing only at physician groups under the “private practice model,” but expenses have also grown, according to a Medical Group Management Association study. Over the past 5 years, relative value units per patient rose by 13% at private medical practices, but declined nearly 18% at practices owned by hospitals or integrated delivery systems, analysts found. Meanwhile, operating costs for private practices increased by nearly 2% last year, in contrast to a slight decline for practices owned by the larger entities. MGMA attributed part of the increase in expenses for private practices to the cost of implementing electronic health record systems. “In the private practice model, EHR incentives have provided a catalyst for practices to purchase systems and deploy electronic health records, therefore increasing the practice's information technology expenditures,” said Kenneth Hertz, a principal with MGMA Health Care Consulting Group, in a statement.

Outcomes Research Funded

HHS will provide grants totaling nearly $17 million for “patient-centered outcomes research” (PCOR), which focuses on treatments and strategies that might improve health outcomes from the patient's point of view. Most of the announced grants will support outcomes research in primary care, HHS said. As part of the grant program, five health organizations will attempt to show that providers and academic institutions can partner on PCOR. Each organization – in California, Illinois, Massachusetts, New York, and Oregon – will receive about $2 million over 3 years to create a national network for evaluating the patient-centered approach in patient populations that are not always adequately represented in other studies, according to HHS. “Patient-centered outcomes research can improve health outcomes by developing and disseminating evidence-based information to patients, providers and decision-makers about the effectiveness of different treatments,” said HHS Secretary Kathleen Sebelius in a statement.

Claims Processors Deemed So-So

About 70% of physicians reported they were satisfied with the contractors who process their Medicare claims, in the annual Centers for Medicare and Medicaid Services survey on contractor performance. Meanwhile, 14% of physicians said they were neither satisfied nor dissatisfied, and more than 15% said they were dissatisfied with contractor performance. Hospitals were slightly happier, with three-quarters saying they were satisfied with contractor performance. Improvements in several areas would increase provider satisfaction, according to the CMS. For example, providers said they don't like having to make multiple inquires of claims processors to resolve problems. They also want better information through an automated telephone system, promptly returned calls, and consistently correct information.

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation's almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago's National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he is also on call.

After hearing CCP's pitch, Dr. Levinson says he was sold, largely because the company's model would give him an opportunity to keep his existing patients. He and his partner have 3,500-4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice's patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, he said.

Dr. Levinson said that his office has a separate staff member who's devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He's also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he's capping the number of patients he'll enroll at 150.

Aside from the revenue boost that's come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner. The traditional practice patients reap the benefits of his lowered stress levels. “Overall, I'm happier. I enjoy my job more because I'm not beating myself up to make a living,” he said.

Dr. Robert Altbaum, an internist in Westport, Conn., said that he's also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. Ironically, a few years later, some of the practice's patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, four of the seven partners decided to give it a try a year ago.

Dr. Altbaum said he's limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day – which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it's made him more available to his other patients because, in a sense, he's now seeing 100 fewer patients.

All his patients are “uniformly happy,” he said, adding that he's more relaxed.

Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Dr. Gary Levinson has less than 100 concierge patients out of 3,500-4,000 in the practice.

Source Courtesy Dr. Ari Laliotis

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation's almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago's National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he is also on call.

After hearing CCP's pitch, Dr. Levinson says he was sold, largely because the company's model would give him an opportunity to keep his existing patients. He and his partner have 3,500-4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice's patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, he said.

Dr. Levinson said that his office has a separate staff member who's devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He's also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he's capping the number of patients he'll enroll at 150.

Aside from the revenue boost that's come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner. The traditional practice patients reap the benefits of his lowered stress levels. “Overall, I'm happier. I enjoy my job more because I'm not beating myself up to make a living,” he said.

Dr. Robert Altbaum, an internist in Westport, Conn., said that he's also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. Ironically, a few years later, some of the practice's patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, four of the seven partners decided to give it a try a year ago.

Dr. Altbaum said he's limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day – which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it's made him more available to his other patients because, in a sense, he's now seeing 100 fewer patients.

All his patients are “uniformly happy,” he said, adding that he's more relaxed.

Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Dr. Gary Levinson has less than 100 concierge patients out of 3,500-4,000 in the practice.

Source Courtesy Dr. Ari Laliotis

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation's almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago's National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he is also on call.

After hearing CCP's pitch, Dr. Levinson says he was sold, largely because the company's model would give him an opportunity to keep his existing patients. He and his partner have 3,500-4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice's patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, he said.

Dr. Levinson said that his office has a separate staff member who's devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He's also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he's capping the number of patients he'll enroll at 150.

Aside from the revenue boost that's come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner. The traditional practice patients reap the benefits of his lowered stress levels. “Overall, I'm happier. I enjoy my job more because I'm not beating myself up to make a living,” he said.

Dr. Robert Altbaum, an internist in Westport, Conn., said that he's also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. Ironically, a few years later, some of the practice's patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, four of the seven partners decided to give it a try a year ago.

Dr. Altbaum said he's limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day – which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it's made him more available to his other patients because, in a sense, he's now seeing 100 fewer patients.

All his patients are “uniformly happy,” he said, adding that he's more relaxed.

Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Dr. Gary Levinson has less than 100 concierge patients out of 3,500-4,000 in the practice.

Source Courtesy Dr. Ari Laliotis

Immunization rates for infants and toddlers in commercial health plans declined in 2009, as did patient satisfaction with health plan performance, while other quality measures rose markedly, according to a yearly accounting compiled by the National Committee for Quality Assurance.

The data for the NCQA State of Health Care Quality Report came from 1,000 HMOs and PPOs providing coverage for about 118 million U.S. residents insured by Medicare, Medicaid, or a private health plan. This is the 14th year that NCQA has compiled and analyzed data from its Healthcare Effectiveness Data and Information Set (HEDIS), which managed health plans use to measure their own performance.

In 2009, there was a "disturbing drop in commercially insured immunization rates," most likely resulting from the "suburban legend" that vaccinations are linked to autism, said NCQA President Margaret E. O'Kane during a briefing Oct. 13.

Under Medicaid plans, childhood immunization rates improved by 1% from 2008 to 2009 to about 70% coverage; however, coverage in private plans declined 4% to about 72% coverage.

"The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation," said Ms. O'Kane.

Patient satisfaction with private plans declined slightly, and was low compared with that of the public plans, according to Ms. O'Kane.

In 2009, about 60% of beneficiaries gave Medicare high marks, compared with 51% of Medicaid recipients and 39% of private health plan patients, according to data gleaned from the federally funded Consumer Assessment of Healthcare Providers and Systems survey.

Those rates have been somewhat steady since 2007, but Ms. O'Kane said she thought that attacks on health insurers during the health reform debates may have led to greater negative impressions of the private plans.

The report also covered a number of medical care measures. For example, beta-blocker use after myocardial infarction rose across all types of insurers, with 82% of those in Medicare plans receiving the treatment, compared with 76% of those on Medicaid and 74% of commercial patients. Colon cancer screening also rose, as did screening for chlamydia, with Medicaid plans screening 57% of patients for that sexually transmitted disease, compared with 43% of commercial plans.

The report tallied the lives and dollars saved from improvements on the five most costly conditions. By improving beta-blocker treatment, cholesterol management, blood pressure control, hemoglobin A1c management, approximately 272,000 to 1.7 million lives were saved, according to the report.

Adding in measures such as breast cancer screening, smoking cessation, and osteoporosis management led to some $2.4 billion to $6.5 billion in hospital savings, Ms. O'Kane said.

The full report can be found at www.ncqa.org.

Immunization rates for infants and toddlers in commercial health plans declined in 2009, as did patient satisfaction with health plan performance, while other quality measures rose markedly, according to a yearly accounting compiled by the National Committee for Quality Assurance.

The data for the NCQA State of Health Care Quality Report came from 1,000 HMOs and PPOs providing coverage for about 118 million U.S. residents insured by Medicare, Medicaid, or a private health plan. This is the 14th year that NCQA has compiled and analyzed data from its Healthcare Effectiveness Data and Information Set (HEDIS), which managed health plans use to measure their own performance.

In 2009, there was a "disturbing drop in commercially insured immunization rates," most likely resulting from the "suburban legend" that vaccinations are linked to autism, said NCQA President Margaret E. O'Kane during a briefing Oct. 13.

Under Medicaid plans, childhood immunization rates improved by 1% from 2008 to 2009 to about 70% coverage; however, coverage in private plans declined 4% to about 72% coverage.

"The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation," said Ms. O'Kane.

Patient satisfaction with private plans declined slightly, and was low compared with that of the public plans, according to Ms. O'Kane.

In 2009, about 60% of beneficiaries gave Medicare high marks, compared with 51% of Medicaid recipients and 39% of private health plan patients, according to data gleaned from the federally funded Consumer Assessment of Healthcare Providers and Systems survey.

Those rates have been somewhat steady since 2007, but Ms. O'Kane said she thought that attacks on health insurers during the health reform debates may have led to greater negative impressions of the private plans.

The report also covered a number of medical care measures. For example, beta-blocker use after myocardial infarction rose across all types of insurers, with 82% of those in Medicare plans receiving the treatment, compared with 76% of those on Medicaid and 74% of commercial patients. Colon cancer screening also rose, as did screening for chlamydia, with Medicaid plans screening 57% of patients for that sexually transmitted disease, compared with 43% of commercial plans.

The report tallied the lives and dollars saved from improvements on the five most costly conditions. By improving beta-blocker treatment, cholesterol management, blood pressure control, hemoglobin A1c management, approximately 272,000 to 1.7 million lives were saved, according to the report.

Adding in measures such as breast cancer screening, smoking cessation, and osteoporosis management led to some $2.4 billion to $6.5 billion in hospital savings, Ms. O'Kane said.

The full report can be found at www.ncqa.org.

Immunization rates for infants and toddlers in commercial health plans declined in 2009, as did patient satisfaction with health plan performance, while other quality measures rose markedly, according to a yearly accounting compiled by the National Committee for Quality Assurance.

The data for the NCQA State of Health Care Quality Report came from 1,000 HMOs and PPOs providing coverage for about 118 million U.S. residents insured by Medicare, Medicaid, or a private health plan. This is the 14th year that NCQA has compiled and analyzed data from its Healthcare Effectiveness Data and Information Set (HEDIS), which managed health plans use to measure their own performance.

In 2009, there was a "disturbing drop in commercially insured immunization rates," most likely resulting from the "suburban legend" that vaccinations are linked to autism, said NCQA President Margaret E. O'Kane during a briefing Oct. 13.

Under Medicaid plans, childhood immunization rates improved by 1% from 2008 to 2009 to about 70% coverage; however, coverage in private plans declined 4% to about 72% coverage.

"The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation," said Ms. O'Kane.

Patient satisfaction with private plans declined slightly, and was low compared with that of the public plans, according to Ms. O'Kane.

In 2009, about 60% of beneficiaries gave Medicare high marks, compared with 51% of Medicaid recipients and 39% of private health plan patients, according to data gleaned from the federally funded Consumer Assessment of Healthcare Providers and Systems survey.

Those rates have been somewhat steady since 2007, but Ms. O'Kane said she thought that attacks on health insurers during the health reform debates may have led to greater negative impressions of the private plans.

The report also covered a number of medical care measures. For example, beta-blocker use after myocardial infarction rose across all types of insurers, with 82% of those in Medicare plans receiving the treatment, compared with 76% of those on Medicaid and 74% of commercial patients. Colon cancer screening also rose, as did screening for chlamydia, with Medicaid plans screening 57% of patients for that sexually transmitted disease, compared with 43% of commercial plans.

The report tallied the lives and dollars saved from improvements on the five most costly conditions. By improving beta-blocker treatment, cholesterol management, blood pressure control, hemoglobin A1c management, approximately 272,000 to 1.7 million lives were saved, according to the report.

Adding in measures such as breast cancer screening, smoking cessation, and osteoporosis management led to some $2.4 billion to $6.5 billion in hospital savings, Ms. O'Kane said.

The full report can be found at www.ncqa.org.

Immunization rates for infants and toddlers in commercial health plans declined in 2009, as did patient satisfaction with health plan performance, while other quality measures rose markedly, according to a yearly accounting compiled by the National Committee for Quality Assurance.

The data for the NCQA State of Health Care Quality Report came from 1,000 HMOs and PPOs providing coverage for about 118 million U.S. residents insured by Medicare, Medicaid, or a private health plan. This is the 14th year that NCQA has compiled and analyzed data from its Healthcare Effectiveness Data and Information Set (HEDIS), which managed health plans use to measure their own performance.

In 2009, there was a “disturbing drop in commercially insured immunization rates,” most likely resulting from the “suburban legend” that vaccinations are linked to autism, said NCQA President Margaret E. O’Kane during a briefing Oct. 13.

Under Medicaid plans, childhood immunization rates improved by 1% from 2008 to 2009 to about 70% coverage; however, coverage in private plans declined 4% to about 72% coverage.

“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said Ms. O’Kane.

Patient satisfaction with private plans declined slightly, and was low compared with that of the public plans, according to Ms. O’Kane.

In 2009, about 60% of beneficiaries gave Medicare high marks, compared with 51% of Medicaid recipients and 39% of private health plan patients, according to data gleaned from the federally funded Consumer Assessment of Healthcare Providers and Systems survey.

Those rates have been somewhat steady since 2007, but Ms. O’Kane said she thought that attacks on health insurers during the health reform debates may have led to greater negative impressions of the private plans.

The report also covered a number of medical care measures. For example, beta-blocker use after myocardial infarction rose across all types of insurers, with 82% of those in Medicare plans receiving the treatment, compared with 76% of those on Medicaid and 74% of commercial patients. Colon cancer screening also rose, as did screening for chlamydia, with Medicaid plans screening 57% of patients for that sexually transmitted disease, compared with 43% of commercial plans.

The report tallied the lives and dollars saved from improvements on the five most costly conditions. By improving beta-blocker treatment, cholesterol management, blood pressure control, hemoglobin A1c management, approximately 272,000 to 1.7 million lives were saved, according to the report.

Adding in measures such as breast cancer screening, smoking cessation, and osteoporosis management led to some $2.4 billion to $6.5 billion in hospital savings, Ms. O’Kane said.

Areas for improvement included preventing falls and reducing inappropriate use of imaging for lower back pain, she said.

Physicians can have a huge impact on fall prevention, she said, noting, however, that the report found only about a third of Medicare patients discussed falls or gait problems with their physicians in the last year. That number has been unchanged the last several years. Evidence-based guidelines suggest that older people should be asked about falls once a year and should receive an assessment or advice on how to avoid falls.

“We’re not taking this seriously enough,” Ms. O’Kane said.

The full report can be found at www.ncqa.org.

Immunization rates for infants and toddlers in commercial health plans declined in 2009, as did patient satisfaction with health plan performance, while other quality measures rose markedly, according to a yearly accounting compiled by the National Committee for Quality Assurance.

The data for the NCQA State of Health Care Quality Report came from 1,000 HMOs and PPOs providing coverage for about 118 million U.S. residents insured by Medicare, Medicaid, or a private health plan. This is the 14th year that NCQA has compiled and analyzed data from its Healthcare Effectiveness Data and Information Set (HEDIS), which managed health plans use to measure their own performance.

In 2009, there was a “disturbing drop in commercially insured immunization rates,” most likely resulting from the “suburban legend” that vaccinations are linked to autism, said NCQA President Margaret E. O’Kane during a briefing Oct. 13.

Under Medicaid plans, childhood immunization rates improved by 1% from 2008 to 2009 to about 70% coverage; however, coverage in private plans declined 4% to about 72% coverage.

“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said Ms. O’Kane.

Patient satisfaction with private plans declined slightly, and was low compared with that of the public plans, according to Ms. O’Kane.

In 2009, about 60% of beneficiaries gave Medicare high marks, compared with 51% of Medicaid recipients and 39% of private health plan patients, according to data gleaned from the federally funded Consumer Assessment of Healthcare Providers and Systems survey.

Those rates have been somewhat steady since 2007, but Ms. O’Kane said she thought that attacks on health insurers during the health reform debates may have led to greater negative impressions of the private plans.

The report also covered a number of medical care measures. For example, beta-blocker use after myocardial infarction rose across all types of insurers, with 82% of those in Medicare plans receiving the treatment, compared with 76% of those on Medicaid and 74% of commercial patients. Colon cancer screening also rose, as did screening for chlamydia, with Medicaid plans screening 57% of patients for that sexually transmitted disease, compared with 43% of commercial plans.

The report tallied the lives and dollars saved from improvements on the five most costly conditions. By improving beta-blocker treatment, cholesterol management, blood pressure control, hemoglobin A1c management, approximately 272,000 to 1.7 million lives were saved, according to the report.

Adding in measures such as breast cancer screening, smoking cessation, and osteoporosis management led to some $2.4 billion to $6.5 billion in hospital savings, Ms. O’Kane said.

Areas for improvement included preventing falls and reducing inappropriate use of imaging for lower back pain, she said.

Physicians can have a huge impact on fall prevention, she said, noting, however, that the report found only about a third of Medicare patients discussed falls or gait problems with their physicians in the last year. That number has been unchanged the last several years. Evidence-based guidelines suggest that older people should be asked about falls once a year and should receive an assessment or advice on how to avoid falls.

“We’re not taking this seriously enough,” Ms. O’Kane said.

The full report can be found at www.ncqa.org.

Immunization rates for infants and toddlers in commercial health plans declined in 2009, as did patient satisfaction with health plan performance, while other quality measures rose markedly, according to a yearly accounting compiled by the National Committee for Quality Assurance.

The data for the NCQA State of Health Care Quality Report came from 1,000 HMOs and PPOs providing coverage for about 118 million U.S. residents insured by Medicare, Medicaid, or a private health plan. This is the 14th year that NCQA has compiled and analyzed data from its Healthcare Effectiveness Data and Information Set (HEDIS), which managed health plans use to measure their own performance.

In 2009, there was a “disturbing drop in commercially insured immunization rates,” most likely resulting from the “suburban legend” that vaccinations are linked to autism, said NCQA President Margaret E. O’Kane during a briefing Oct. 13.

Under Medicaid plans, childhood immunization rates improved by 1% from 2008 to 2009 to about 70% coverage; however, coverage in private plans declined 4% to about 72% coverage.

“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said Ms. O’Kane.

Patient satisfaction with private plans declined slightly, and was low compared with that of the public plans, according to Ms. O’Kane.

In 2009, about 60% of beneficiaries gave Medicare high marks, compared with 51% of Medicaid recipients and 39% of private health plan patients, according to data gleaned from the federally funded Consumer Assessment of Healthcare Providers and Systems survey.

Those rates have been somewhat steady since 2007, but Ms. O’Kane said she thought that attacks on health insurers during the health reform debates may have led to greater negative impressions of the private plans.

The report also covered a number of medical care measures. For example, beta-blocker use after myocardial infarction rose across all types of insurers, with 82% of those in Medicare plans receiving the treatment, compared with 76% of those on Medicaid and 74% of commercial patients. Colon cancer screening also rose, as did screening for chlamydia, with Medicaid plans screening 57% of patients for that sexually transmitted disease, compared with 43% of commercial plans.

The report tallied the lives and dollars saved from improvements on the five most costly conditions. By improving beta-blocker treatment, cholesterol management, blood pressure control, hemoglobin A1c management, approximately 272,000 to 1.7 million lives were saved, according to the report.

Adding in measures such as breast cancer screening, smoking cessation, and osteoporosis management led to some $2.4 billion to $6.5 billion in hospital savings, Ms. O’Kane said.

Areas for improvement included preventing falls and reducing inappropriate use of imaging for lower back pain, she said.

Physicians can have a huge impact on fall prevention, she said, noting, however, that the report found only about a third of Medicare patients discussed falls or gait problems with their physicians in the last year. That number has been unchanged the last several years. Evidence-based guidelines suggest that older people should be asked about falls once a year and should receive an assessment or advice on how to avoid falls.

“We’re not taking this seriously enough,” Ms. O’Kane said.

The full report can be found at www.ncqa.org.

WASHINGTON — More than a quarter (28%) of all U.S. acute care visits are made to the emergency department, while slightly less than half (42%) take place in primary care physicians' offices.

Another 20% of acute care visits are made to subspecialist offices, lead study author Dr. Stephen R. Pitts said at the briefing.

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta, noting that, “too often, patients can't get the care they need, when they need it, from their family doctor.”

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, according to the study, which appears in the journal's September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Those presenting to a primary care physician for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Disclosures: One of Dr. Pitts' coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts.

WASHINGTON — More than a quarter (28%) of all U.S. acute care visits are made to the emergency department, while slightly less than half (42%) take place in primary care physicians' offices.

Another 20% of acute care visits are made to subspecialist offices, lead study author Dr. Stephen R. Pitts said at the briefing.

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta, noting that, “too often, patients can't get the care they need, when they need it, from their family doctor.”

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, according to the study, which appears in the journal's September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Those presenting to a primary care physician for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Disclosures: One of Dr. Pitts' coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts.

WASHINGTON — More than a quarter (28%) of all U.S. acute care visits are made to the emergency department, while slightly less than half (42%) take place in primary care physicians' offices.

Another 20% of acute care visits are made to subspecialist offices, lead study author Dr. Stephen R. Pitts said at the briefing.

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta, noting that, “too often, patients can't get the care they need, when they need it, from their family doctor.”

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, according to the study, which appears in the journal's September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Those presenting to a primary care physician for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Disclosures: One of Dr. Pitts' coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts.

A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.

The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill's introduction in the state Senate (S. 4498 and A. 7617) to its signing.

Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It's a nice thought, but I don't know how they're going to put it into effect.”

Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient's legal rights to comprehensive pain and symptom management at the end of life.”

The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.

There is no reimbursement offered for the required services.

Because it is an amendment to the state's public health law, violations of the new law could result in penalties or fines. It's not clear how it will be enforced or what might trigger the penalties; the health department has until the law's effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.

That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.

The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients' wishes aren't being respected, to the detriment of both patients and the practice of medicine.

The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.

Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.

She said she wasn't sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.

The law will be positive, however, she said. Palliative care won't just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.

But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It's a very hard discussion to have; it's not something doctors are trained to do.”

A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.

Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society's senior vice president for legislative and regulatory affairs.

Mandating that information be given on palliative care “may undermine the patient's belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.

The medical society also said that physicians are not licensed to provide legal advice in areas such as pain or symptom management, and that they may not know what they are supposed to be communicating to patients under certain provisions, while still being subject to penalties.

Although the medical society might object to requiring any such talk, both Dr. Flansbaum and Dr. Edwards said that, realistically, the law should be requiring palliative care to be offered sooner in the disease process and to a broader group of patients, such as those who have chronic life-limiting conditions such as heart failure.

“By the time you're invoking palliative care in terminal patients, you're behind the curve,” said Dr. Flansbaum.

A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.

The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill's introduction in the state Senate (S. 4498 and A. 7617) to its signing.

Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It's a nice thought, but I don't know how they're going to put it into effect.”

Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient's legal rights to comprehensive pain and symptom management at the end of life.”

The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.

There is no reimbursement offered for the required services.

Because it is an amendment to the state's public health law, violations of the new law could result in penalties or fines. It's not clear how it will be enforced or what might trigger the penalties; the health department has until the law's effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.

That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.

The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients' wishes aren't being respected, to the detriment of both patients and the practice of medicine.

The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.

Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.

She said she wasn't sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.

The law will be positive, however, she said. Palliative care won't just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.

But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It's a very hard discussion to have; it's not something doctors are trained to do.”

A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.

Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society's senior vice president for legislative and regulatory affairs.

Mandating that information be given on palliative care “may undermine the patient's belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.

The medical society also said that physicians are not licensed to provide legal advice in areas such as pain or symptom management, and that they may not know what they are supposed to be communicating to patients under certain provisions, while still being subject to penalties.

Although the medical society might object to requiring any such talk, both Dr. Flansbaum and Dr. Edwards said that, realistically, the law should be requiring palliative care to be offered sooner in the disease process and to a broader group of patients, such as those who have chronic life-limiting conditions such as heart failure.

“By the time you're invoking palliative care in terminal patients, you're behind the curve,” said Dr. Flansbaum.

A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.

The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill's introduction in the state Senate (S. 4498 and A. 7617) to its signing.

Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It's a nice thought, but I don't know how they're going to put it into effect.”

Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient's legal rights to comprehensive pain and symptom management at the end of life.”

The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.

There is no reimbursement offered for the required services.

Because it is an amendment to the state's public health law, violations of the new law could result in penalties or fines. It's not clear how it will be enforced or what might trigger the penalties; the health department has until the law's effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.

That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.

The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients' wishes aren't being respected, to the detriment of both patients and the practice of medicine.

The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.

Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.

She said she wasn't sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.

The law will be positive, however, she said. Palliative care won't just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.

But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It's a very hard discussion to have; it's not something doctors are trained to do.”

A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.

Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society's senior vice president for legislative and regulatory affairs.

Mandating that information be given on palliative care “may undermine the patient's belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.

The medical society also said that physicians are not licensed to provide legal advice in areas such as pain or symptom management, and that they may not know what they are supposed to be communicating to patients under certain provisions, while still being subject to penalties.

Although the medical society might object to requiring any such talk, both Dr. Flansbaum and Dr. Edwards said that, realistically, the law should be requiring palliative care to be offered sooner in the disease process and to a broader group of patients, such as those who have chronic life-limiting conditions such as heart failure.

“By the time you're invoking palliative care in terminal patients, you're behind the curve,” said Dr. Flansbaum.

The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty, according to an article published online in the New England Journal of Medicine.

The 16-member ACGME task force that wrote the standards will review public comments and make modifications before July 2011, when the new standards will go into effect. The original 2003 standards have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.

According to the latest report, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:

▸ The limits on duty hours may have created a “shift mentality” among residents.

▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.

▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.

In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.

The ACGME task force considered ways to reconcile the IOM's suggestion for an across-the-board restriction on duty hours vs. the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]). For surgery, in particular, it would be difficult — and contrary to learning — to have a resident leave in the midst of a procedure because his or her duty hours had been reached. The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors.

According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm, whereby first-year residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision. All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs — an area of concern for patient safety.

The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty,” said the authors.

The IOM had also criticized the ACGME for not properly enforcing the duty hours. The ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems. The reports will be made available to the public, said the authors.

Wake Up Doctor, a coalition of public interest and patient safety groups, gave the ACGME “Fs” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents and for failing to better monitor compliance with the standards. However, the recommendation for greater supervision of first-year residents got higher marks.

“I think the acid test will be in the details,” said Helen Haskell, founder of Mothers Against Medical Error and a coalition member, in a statement.

The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty, according to an article published online in the New England Journal of Medicine.

The 16-member ACGME task force that wrote the standards will review public comments and make modifications before July 2011, when the new standards will go into effect. The original 2003 standards have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.

According to the latest report, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:

▸ The limits on duty hours may have created a “shift mentality” among residents.

▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.

▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.

In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.

The ACGME task force considered ways to reconcile the IOM's suggestion for an across-the-board restriction on duty hours vs. the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]). For surgery, in particular, it would be difficult — and contrary to learning — to have a resident leave in the midst of a procedure because his or her duty hours had been reached. The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors.

According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm, whereby first-year residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision. All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs — an area of concern for patient safety.

The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty,” said the authors.

The IOM had also criticized the ACGME for not properly enforcing the duty hours. The ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems. The reports will be made available to the public, said the authors.

Wake Up Doctor, a coalition of public interest and patient safety groups, gave the ACGME “Fs” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents and for failing to better monitor compliance with the standards. However, the recommendation for greater supervision of first-year residents got higher marks.

“I think the acid test will be in the details,” said Helen Haskell, founder of Mothers Against Medical Error and a coalition member, in a statement.

The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty, according to an article published online in the New England Journal of Medicine.

The 16-member ACGME task force that wrote the standards will review public comments and make modifications before July 2011, when the new standards will go into effect. The original 2003 standards have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.

According to the latest report, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:

▸ The limits on duty hours may have created a “shift mentality” among residents.

▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.

▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.

In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.

The ACGME task force considered ways to reconcile the IOM's suggestion for an across-the-board restriction on duty hours vs. the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]). For surgery, in particular, it would be difficult — and contrary to learning — to have a resident leave in the midst of a procedure because his or her duty hours had been reached. The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors.

According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm, whereby first-year residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision. All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs — an area of concern for patient safety.

The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty,” said the authors.

The IOM had also criticized the ACGME for not properly enforcing the duty hours. The ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems. The reports will be made available to the public, said the authors.

Wake Up Doctor, a coalition of public interest and patient safety groups, gave the ACGME “Fs” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents and for failing to better monitor compliance with the standards. However, the recommendation for greater supervision of first-year residents got higher marks.

“I think the acid test will be in the details,” said Helen Haskell, founder of Mothers Against Medical Error and a coalition member, in a statement.