Jane M. Anderson

Administration Posts Filling Up

The Obama administration has named officials to several top health care-related positions that do not require Senate confirmation, including the administrator of the Health Resources and Services Administration and the new National Coordinator for Health Information Technology. Rural health expert Mary Wakefield, Ph.D., R.N., was selected to head the HRSA, joining the agency from the University of North Dakota. Internist David Blumenthal, former director of the Institute for Health Policy at Massachusetts General Hospital, will take the lead on creating a nationwide HIT infrastructure. And three new members will join the U.S. Preventive Services Task Force: Susan Curry, Ph.D., of Iowa City, an expert on tobacco use; Dr. Joy Melnikow of Sacramento, a family physician; and Dr. Wanda Nicholson of Baltimore, a board-certified obstetrician-gynecologist and a perinatal epidemiologist.

Virtual Colonoscopy Supported

More than 40 members of Congress have signed a letter urging the Centers for Medicare and Medicaid Services to cover computed tomography colonography (CTC), or virtual colonoscopy. The letter responded to a proposed decision by the CMS not to cover the noninvasive procedure because of what the agency considers to be insufficient evidence that it improves the health of Medicare patients. “Medicare coverage of CTC could prevent unnecessary deaths,” the lawmakers said in the letter. “Many Americans forgo the colorectal screening process … so an alternative such as CTC should be covered by Medicare.” The lawmakers noted that Walter Reed Army Medical Center has called its CTC program a success and is working with the Department of Veterans Affairs to deploy CTC screening throughout the VA Health System.

NQF Adds Safe Practices

The National Quality Forum has recommended seven new practices that it said have been proved effective in reducing adverse events; the practices include efforts to prevent falls, eradicate multidrug-resistant organisms, and improve glycemic control in diabetic patients. The membership group also recommended improvements in care for clinical providers, staff, and administrators who are harmed in the course of their work, interventions to prevent catheter-associated urinary tract infections, appropriate hospital policies on organ donation, and safe practices for children receiving CT scans. These seven new recommendations were included among 34 safe practices promoted in the National Quality Forum's 2009 Safe Practices for Better Healthcare report and year-long Webinar series. Forum members include the American College of Physicians and the American Academy of Family Physicians.

Americans Struggle on Costs

About one in five Americans reported having difficulty paying for necessary health care in December 2008, 3 percentage points higher than in January 2008, according to a Gallup poll commissioned by the disease-management company Healthways. More than half of the uninsured struggled to pay their medical bills, as did 30% of all Hispanic and black Americans. The percentage of people receiving employer-based insurance is only 58%, the poll found. The score on the poll's overall “well-being” index, which combines physical and emotional health, healthy behavior, work environment, and access to care, fell significantly over the past year.

Loneliness, Poor Health Linked

Not having many close friends maycontribute to poorer health for many older adults, and feeling lonely is associated with increased health risks, according to a study from the University of Chicago. Researchers measured the degree to which older adults were socially connected and active. They also assessed whether the elders felt lonely and expected friends and family to help them in times of need. The study found that the most socially connected older adults were three times as likely to report being in very good or excellent health, compared with those who were least connected, regardless of whether they felt isolated. But older adults who felt least isolated were five times as likely to report being in very good or excellent health, compared with those who felt most isolated, regardless of their actual level of social connectedness. The study was published in the Journal of Health and Social Behavior.

Upcoding Alleged in MA Plans

The problem of overpayments to Medicare Advantage plans will not be solved until Congress addresses the plans' upcoding practices, according to a new report from the Center on Budget and Policy Priorities, a progressive think tank. “Upcoding helps private plans financially by inflating the payments that Medicare makes to them,” according to the report. An analysis of 2007 data from the CMS showed that the severity of the diagnosis codes is rising faster among beneficiaries in Medicare Advantage plans than among those in traditional Medicare. Until that problem is addressed, “private plans will continue to receive overpayments … because the private plan beneficiaries' actual health status will be better than their reported health status,” the authors wrote.

Administration Posts Filling Up

The Obama administration has named officials to several top health care-related positions that do not require Senate confirmation, including the administrator of the Health Resources and Services Administration and the new National Coordinator for Health Information Technology. Rural health expert Mary Wakefield, Ph.D., R.N., was selected to head the HRSA, joining the agency from the University of North Dakota. Internist David Blumenthal, former director of the Institute for Health Policy at Massachusetts General Hospital, will take the lead on creating a nationwide HIT infrastructure. And three new members will join the U.S. Preventive Services Task Force: Susan Curry, Ph.D., of Iowa City, an expert on tobacco use; Dr. Joy Melnikow of Sacramento, a family physician; and Dr. Wanda Nicholson of Baltimore, a board-certified obstetrician-gynecologist and a perinatal epidemiologist.

Virtual Colonoscopy Supported

More than 40 members of Congress have signed a letter urging the Centers for Medicare and Medicaid Services to cover computed tomography colonography (CTC), or virtual colonoscopy. The letter responded to a proposed decision by the CMS not to cover the noninvasive procedure because of what the agency considers to be insufficient evidence that it improves the health of Medicare patients. “Medicare coverage of CTC could prevent unnecessary deaths,” the lawmakers said in the letter. “Many Americans forgo the colorectal screening process … so an alternative such as CTC should be covered by Medicare.” The lawmakers noted that Walter Reed Army Medical Center has called its CTC program a success and is working with the Department of Veterans Affairs to deploy CTC screening throughout the VA Health System.

NQF Adds Safe Practices

The National Quality Forum has recommended seven new practices that it said have been proved effective in reducing adverse events; the practices include efforts to prevent falls, eradicate multidrug-resistant organisms, and improve glycemic control in diabetic patients. The membership group also recommended improvements in care for clinical providers, staff, and administrators who are harmed in the course of their work, interventions to prevent catheter-associated urinary tract infections, appropriate hospital policies on organ donation, and safe practices for children receiving CT scans. These seven new recommendations were included among 34 safe practices promoted in the National Quality Forum's 2009 Safe Practices for Better Healthcare report and year-long Webinar series. Forum members include the American College of Physicians and the American Academy of Family Physicians.

Americans Struggle on Costs

About one in five Americans reported having difficulty paying for necessary health care in December 2008, 3 percentage points higher than in January 2008, according to a Gallup poll commissioned by the disease-management company Healthways. More than half of the uninsured struggled to pay their medical bills, as did 30% of all Hispanic and black Americans. The percentage of people receiving employer-based insurance is only 58%, the poll found. The score on the poll's overall “well-being” index, which combines physical and emotional health, healthy behavior, work environment, and access to care, fell significantly over the past year.

Loneliness, Poor Health Linked

Not having many close friends maycontribute to poorer health for many older adults, and feeling lonely is associated with increased health risks, according to a study from the University of Chicago. Researchers measured the degree to which older adults were socially connected and active. They also assessed whether the elders felt lonely and expected friends and family to help them in times of need. The study found that the most socially connected older adults were three times as likely to report being in very good or excellent health, compared with those who were least connected, regardless of whether they felt isolated. But older adults who felt least isolated were five times as likely to report being in very good or excellent health, compared with those who felt most isolated, regardless of their actual level of social connectedness. The study was published in the Journal of Health and Social Behavior.

Upcoding Alleged in MA Plans

The problem of overpayments to Medicare Advantage plans will not be solved until Congress addresses the plans' upcoding practices, according to a new report from the Center on Budget and Policy Priorities, a progressive think tank. “Upcoding helps private plans financially by inflating the payments that Medicare makes to them,” according to the report. An analysis of 2007 data from the CMS showed that the severity of the diagnosis codes is rising faster among beneficiaries in Medicare Advantage plans than among those in traditional Medicare. Until that problem is addressed, “private plans will continue to receive overpayments … because the private plan beneficiaries' actual health status will be better than their reported health status,” the authors wrote.

Administration Posts Filling Up

The Obama administration has named officials to several top health care-related positions that do not require Senate confirmation, including the administrator of the Health Resources and Services Administration and the new National Coordinator for Health Information Technology. Rural health expert Mary Wakefield, Ph.D., R.N., was selected to head the HRSA, joining the agency from the University of North Dakota. Internist David Blumenthal, former director of the Institute for Health Policy at Massachusetts General Hospital, will take the lead on creating a nationwide HIT infrastructure. And three new members will join the U.S. Preventive Services Task Force: Susan Curry, Ph.D., of Iowa City, an expert on tobacco use; Dr. Joy Melnikow of Sacramento, a family physician; and Dr. Wanda Nicholson of Baltimore, a board-certified obstetrician-gynecologist and a perinatal epidemiologist.

Virtual Colonoscopy Supported

More than 40 members of Congress have signed a letter urging the Centers for Medicare and Medicaid Services to cover computed tomography colonography (CTC), or virtual colonoscopy. The letter responded to a proposed decision by the CMS not to cover the noninvasive procedure because of what the agency considers to be insufficient evidence that it improves the health of Medicare patients. “Medicare coverage of CTC could prevent unnecessary deaths,” the lawmakers said in the letter. “Many Americans forgo the colorectal screening process … so an alternative such as CTC should be covered by Medicare.” The lawmakers noted that Walter Reed Army Medical Center has called its CTC program a success and is working with the Department of Veterans Affairs to deploy CTC screening throughout the VA Health System.

NQF Adds Safe Practices

The National Quality Forum has recommended seven new practices that it said have been proved effective in reducing adverse events; the practices include efforts to prevent falls, eradicate multidrug-resistant organisms, and improve glycemic control in diabetic patients. The membership group also recommended improvements in care for clinical providers, staff, and administrators who are harmed in the course of their work, interventions to prevent catheter-associated urinary tract infections, appropriate hospital policies on organ donation, and safe practices for children receiving CT scans. These seven new recommendations were included among 34 safe practices promoted in the National Quality Forum's 2009 Safe Practices for Better Healthcare report and year-long Webinar series. Forum members include the American College of Physicians and the American Academy of Family Physicians.

Americans Struggle on Costs

About one in five Americans reported having difficulty paying for necessary health care in December 2008, 3 percentage points higher than in January 2008, according to a Gallup poll commissioned by the disease-management company Healthways. More than half of the uninsured struggled to pay their medical bills, as did 30% of all Hispanic and black Americans. The percentage of people receiving employer-based insurance is only 58%, the poll found. The score on the poll's overall “well-being” index, which combines physical and emotional health, healthy behavior, work environment, and access to care, fell significantly over the past year.

Loneliness, Poor Health Linked

Not having many close friends maycontribute to poorer health for many older adults, and feeling lonely is associated with increased health risks, according to a study from the University of Chicago. Researchers measured the degree to which older adults were socially connected and active. They also assessed whether the elders felt lonely and expected friends and family to help them in times of need. The study found that the most socially connected older adults were three times as likely to report being in very good or excellent health, compared with those who were least connected, regardless of whether they felt isolated. But older adults who felt least isolated were five times as likely to report being in very good or excellent health, compared with those who felt most isolated, regardless of their actual level of social connectedness. The study was published in the Journal of Health and Social Behavior.

Upcoding Alleged in MA Plans

The problem of overpayments to Medicare Advantage plans will not be solved until Congress addresses the plans' upcoding practices, according to a new report from the Center on Budget and Policy Priorities, a progressive think tank. “Upcoding helps private plans financially by inflating the payments that Medicare makes to them,” according to the report. An analysis of 2007 data from the CMS showed that the severity of the diagnosis codes is rising faster among beneficiaries in Medicare Advantage plans than among those in traditional Medicare. Until that problem is addressed, “private plans will continue to receive overpayments … because the private plan beneficiaries' actual health status will be better than their reported health status,” the authors wrote.

Administration Posts Filling Up

The Obama administration has named officials to several top health care-related positions that do not require Senate confirmation, including the administrator of the Health Resources and Services Administration and the new National Coordinator for Health Information Technology. Rural health expert Mary Wakefield, Ph.D., R.N., was selected to head the HRSA, joining the agency from the University of North Dakota. Internist David Blumenthal, former director of the Institute for Health Policy at Massachusetts General Hospital, will take the lead on creating a nationwide HIT infrastructure. And three new members will join the U.S. Preventive Services Task Force: Susan Curry, Ph.D., of Iowa City, an expert on tobacco use; Dr. Joy Melnikow of Sacramento, Calif., a family physician; and Dr. Wanda Nicholson of Baltimore, a board-certified obstetrician-gynecologist and a perinatal epidemiologist.

Virtual Colonoscopy Supported

More than 40 members of Congress have signed a letter urging the Centers for Medicare and Medicaid Services to cover computed tomography colonography (CTC), or virtual colonoscopy. The letter responded to a proposed decision by the CMS not to cover the noninvasive procedure because of what the agency considers to be insufficient evidence that it improves the health of Medicare patients. “Medicare coverage of CTC could prevent unnecessary deaths,” the lawmakers said in the letter. “Many Americans forgo the colorectal screening process … so an alternative such as CTC should be covered by Medicare.” The lawmakers noted that Walter Reed Army Medical Center has called its CTC program a success and is working with the Department of Veterans Affairs to deploy CTC screening throughout the VA Health System.

Americans Struggle on Costs

About one in five Americans reported having difficulty paying for necessary health care in December 2008, 3 percentage points higher than in January 2008, according to a Gallup poll commissioned by the disease-management company Healthways. More than half of the uninsured struggled to pay their medical bills, as did 30% of all Hispanic and black Americans. The percentage of people receiving employer-based insurance is only 58%, the poll found. The score on the poll's overall “well-being” index, which combines physical and emotional health, healthy behavior, work environment, and access to care, fell significantly over the past year.

NQF Adds Safe Practices

The National Quality Forum has recommended seven new practices that it said have been proved effective in reducing adverse events. The practices include efforts to prevent falls, eradicate multidrug-resistant organisms, and improve glycemic control in diabetic patients. The membership group also recommended improvements in care for clinical providers, staff, and administrators who are harmed in the course of their work, interventions to prevent catheter-associated urinary tract infections, appropriate hospital policies on organ donation, and safe practices for children receiving CT scans. These seven new recommendations were included among the 34 safe practices that are being promoted in the National Quality Forum's 2009 Safe Practices for Better Healthcare report and year-long Webinar series. Forum members include the American College of Physicians and the American Academy of Family Physicians.

Loneliness, Poor Health Linked

Not having many close friends may contribute to poorer health for many older adults, and feeling lonely is associated with increased health risks, according to a study from the University of Chicago. Researchers measured the degree to which older adults were socially connected and active. They also assessed whether the elders felt lonely and expected friends and family to help them in times of need. The study found that the most socially connected older adults were three times as likely to report being in very good or excellent health, compared with those who were least connected, regardless of whether they felt isolated. But older adults who felt least isolated were five times as likely to report being in very good or excellent health, compared with those who felt most isolated, regardless of their actual level of social connectedness. The study was published in the Journal of Health and Social Behavior.

Upcoding Alleged in MA Plans

The problem of overpayments to Medicare Advantage plans will not be solved until Congress addresses the plans' upcoding practices, according to a new report from the Center on Budget and Policy Priorities, a progressive think tank. “Upcoding helps private plans financially by inflating the payments that Medicare makes to them,” according to the report. An analysis of 2007 data from the CMS showed that the severity of the diagnosis codes is rising faster among beneficiaries in Medicare Advantage plans than among those in traditional Medicare. Until that problem is addressed, “private plans will continue to receive overpayments … because the private plan beneficiaries' actual health status will be better than their reported health status,” the authors wrote.

Administration Posts Filling Up

The Obama administration has named officials to several top health care-related positions that do not require Senate confirmation, including the administrator of the Health Resources and Services Administration and the new National Coordinator for Health Information Technology. Rural health expert Mary Wakefield, Ph.D., R.N., was selected to head the HRSA, joining the agency from the University of North Dakota. Internist David Blumenthal, former director of the Institute for Health Policy at Massachusetts General Hospital, will take the lead on creating a nationwide HIT infrastructure. And three new members will join the U.S. Preventive Services Task Force: Susan Curry, Ph.D., of Iowa City, an expert on tobacco use; Dr. Joy Melnikow of Sacramento, Calif., a family physician; and Dr. Wanda Nicholson of Baltimore, a board-certified obstetrician-gynecologist and a perinatal epidemiologist.

Virtual Colonoscopy Supported

More than 40 members of Congress have signed a letter urging the Centers for Medicare and Medicaid Services to cover computed tomography colonography (CTC), or virtual colonoscopy. The letter responded to a proposed decision by the CMS not to cover the noninvasive procedure because of what the agency considers to be insufficient evidence that it improves the health of Medicare patients. “Medicare coverage of CTC could prevent unnecessary deaths,” the lawmakers said in the letter. “Many Americans forgo the colorectal screening process … so an alternative such as CTC should be covered by Medicare.” The lawmakers noted that Walter Reed Army Medical Center has called its CTC program a success and is working with the Department of Veterans Affairs to deploy CTC screening throughout the VA Health System.

Americans Struggle on Costs

About one in five Americans reported having difficulty paying for necessary health care in December 2008, 3 percentage points higher than in January 2008, according to a Gallup poll commissioned by the disease-management company Healthways. More than half of the uninsured struggled to pay their medical bills, as did 30% of all Hispanic and black Americans. The percentage of people receiving employer-based insurance is only 58%, the poll found. The score on the poll's overall “well-being” index, which combines physical and emotional health, healthy behavior, work environment, and access to care, fell significantly over the past year.

NQF Adds Safe Practices

The National Quality Forum has recommended seven new practices that it said have been proved effective in reducing adverse events. The practices include efforts to prevent falls, eradicate multidrug-resistant organisms, and improve glycemic control in diabetic patients. The membership group also recommended improvements in care for clinical providers, staff, and administrators who are harmed in the course of their work, interventions to prevent catheter-associated urinary tract infections, appropriate hospital policies on organ donation, and safe practices for children receiving CT scans. These seven new recommendations were included among the 34 safe practices that are being promoted in the National Quality Forum's 2009 Safe Practices for Better Healthcare report and year-long Webinar series. Forum members include the American College of Physicians and the American Academy of Family Physicians.

Loneliness, Poor Health Linked

Not having many close friends may contribute to poorer health for many older adults, and feeling lonely is associated with increased health risks, according to a study from the University of Chicago. Researchers measured the degree to which older adults were socially connected and active. They also assessed whether the elders felt lonely and expected friends and family to help them in times of need. The study found that the most socially connected older adults were three times as likely to report being in very good or excellent health, compared with those who were least connected, regardless of whether they felt isolated. But older adults who felt least isolated were five times as likely to report being in very good or excellent health, compared with those who felt most isolated, regardless of their actual level of social connectedness. The study was published in the Journal of Health and Social Behavior.

Upcoding Alleged in MA Plans

The problem of overpayments to Medicare Advantage plans will not be solved until Congress addresses the plans' upcoding practices, according to a new report from the Center on Budget and Policy Priorities, a progressive think tank. “Upcoding helps private plans financially by inflating the payments that Medicare makes to them,” according to the report. An analysis of 2007 data from the CMS showed that the severity of the diagnosis codes is rising faster among beneficiaries in Medicare Advantage plans than among those in traditional Medicare. Until that problem is addressed, “private plans will continue to receive overpayments … because the private plan beneficiaries' actual health status will be better than their reported health status,” the authors wrote.

Administration Posts Filling Up

The Obama administration has named officials to several top health care-related positions that do not require Senate confirmation, including the administrator of the Health Resources and Services Administration and the new National Coordinator for Health Information Technology. Rural health expert Mary Wakefield, Ph.D., R.N., was selected to head the HRSA, joining the agency from the University of North Dakota. Internist David Blumenthal, former director of the Institute for Health Policy at Massachusetts General Hospital, will take the lead on creating a nationwide HIT infrastructure. And three new members will join the U.S. Preventive Services Task Force: Susan Curry, Ph.D., of Iowa City, an expert on tobacco use; Dr. Joy Melnikow of Sacramento, Calif., a family physician; and Dr. Wanda Nicholson of Baltimore, a board-certified obstetrician-gynecologist and a perinatal epidemiologist.

Virtual Colonoscopy Supported

More than 40 members of Congress have signed a letter urging the Centers for Medicare and Medicaid Services to cover computed tomography colonography (CTC), or virtual colonoscopy. The letter responded to a proposed decision by the CMS not to cover the noninvasive procedure because of what the agency considers to be insufficient evidence that it improves the health of Medicare patients. “Medicare coverage of CTC could prevent unnecessary deaths,” the lawmakers said in the letter. “Many Americans forgo the colorectal screening process … so an alternative such as CTC should be covered by Medicare.” The lawmakers noted that Walter Reed Army Medical Center has called its CTC program a success and is working with the Department of Veterans Affairs to deploy CTC screening throughout the VA Health System.

Americans Struggle on Costs

About one in five Americans reported having difficulty paying for necessary health care in December 2008, 3 percentage points higher than in January 2008, according to a Gallup poll commissioned by the disease-management company Healthways. More than half of the uninsured struggled to pay their medical bills, as did 30% of all Hispanic and black Americans. The percentage of people receiving employer-based insurance is only 58%, the poll found. The score on the poll's overall “well-being” index, which combines physical and emotional health, healthy behavior, work environment, and access to care, fell significantly over the past year.

NQF Adds Safe Practices

The National Quality Forum has recommended seven new practices that it said have been proved effective in reducing adverse events. The practices include efforts to prevent falls, eradicate multidrug-resistant organisms, and improve glycemic control in diabetic patients. The membership group also recommended improvements in care for clinical providers, staff, and administrators who are harmed in the course of their work, interventions to prevent catheter-associated urinary tract infections, appropriate hospital policies on organ donation, and safe practices for children receiving CT scans. These seven new recommendations were included among the 34 safe practices that are being promoted in the National Quality Forum's 2009 Safe Practices for Better Healthcare report and year-long Webinar series. Forum members include the American College of Physicians and the American Academy of Family Physicians.

Loneliness, Poor Health Linked

Not having many close friends may contribute to poorer health for many older adults, and feeling lonely is associated with increased health risks, according to a study from the University of Chicago. Researchers measured the degree to which older adults were socially connected and active. They also assessed whether the elders felt lonely and expected friends and family to help them in times of need. The study found that the most socially connected older adults were three times as likely to report being in very good or excellent health, compared with those who were least connected, regardless of whether they felt isolated. But older adults who felt least isolated were five times as likely to report being in very good or excellent health, compared with those who felt most isolated, regardless of their actual level of social connectedness. The study was published in the Journal of Health and Social Behavior.

Upcoding Alleged in MA Plans

The problem of overpayments to Medicare Advantage plans will not be solved until Congress addresses the plans' upcoding practices, according to a new report from the Center on Budget and Policy Priorities, a progressive think tank. “Upcoding helps private plans financially by inflating the payments that Medicare makes to them,” according to the report. An analysis of 2007 data from the CMS showed that the severity of the diagnosis codes is rising faster among beneficiaries in Medicare Advantage plans than among those in traditional Medicare. Until that problem is addressed, “private plans will continue to receive overpayments … because the private plan beneficiaries' actual health status will be better than their reported health status,” the authors wrote.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned in examining health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

“Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care,” the ACP position paper said.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, which can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

In Denmark, for example, primary care physicians receive a capitated payment for providing care coordination and case management by telephone or e-mail, in addition to receiving fee-for-service payments for office visits, according to the ACP position paper.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom have implemented performance measures linked to quality, he said, as has the U.S. Veterans Health Administration.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology lead to reliance on outdated technologies and medical equipment, and delay patient access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper said. Much of this information is shared through the Network of Agencies for Health Technology Assessment, of which the U.S. Agency for Healthcare Research and Quality (AHRQ) is a member, the paper said.

Many of these lessons could be applied to reforming the U.S. health care system so that it could cover everyone while still controlling costs, Mr. Doherty said.

Any solution for the United States “will be unique to our political and social culture,” Mr. Doherty said. “Unlike many of the countries studied, [the United States] has a larger and more diverse population with a tradition of individualism and distrust of the government.” Also, free speech—including commercial free speech—is protected by the U.S. Constitution, and there's a deeply rooted system of employer-based coverage, tied to a powerful industry invested in maintaining private insurance and employer-based coverage.

“We're not going to simply take what they've developed [in other countries] and implement it” in the United States, he said. Instead, the goal should be to identify approaches that the evidence shows are more likely to be effective and determine if they can be adapted to the unique circumstances in the United States, he said.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned in examining health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

“Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care,” the ACP position paper said.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, which can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

In Denmark, for example, primary care physicians receive a capitated payment for providing care coordination and case management by telephone or e-mail, in addition to receiving fee-for-service payments for office visits, according to the ACP position paper.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom have implemented performance measures linked to quality, he said, as has the U.S. Veterans Health Administration.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology lead to reliance on outdated technologies and medical equipment, and delay patient access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper said. Much of this information is shared through the Network of Agencies for Health Technology Assessment, of which the U.S. Agency for Healthcare Research and Quality (AHRQ) is a member, the paper said.

Many of these lessons could be applied to reforming the U.S. health care system so that it could cover everyone while still controlling costs, Mr. Doherty said.

Any solution for the United States “will be unique to our political and social culture,” Mr. Doherty said. “Unlike many of the countries studied, [the United States] has a larger and more diverse population with a tradition of individualism and distrust of the government.” Also, free speech—including commercial free speech—is protected by the U.S. Constitution, and there's a deeply rooted system of employer-based coverage, tied to a powerful industry invested in maintaining private insurance and employer-based coverage.

“We're not going to simply take what they've developed [in other countries] and implement it” in the United States, he said. Instead, the goal should be to identify approaches that the evidence shows are more likely to be effective and determine if they can be adapted to the unique circumstances in the United States, he said.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned in examining health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

“Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care,” the ACP position paper said.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, which can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

In Denmark, for example, primary care physicians receive a capitated payment for providing care coordination and case management by telephone or e-mail, in addition to receiving fee-for-service payments for office visits, according to the ACP position paper.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom have implemented performance measures linked to quality, he said, as has the U.S. Veterans Health Administration.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology lead to reliance on outdated technologies and medical equipment, and delay patient access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper said. Much of this information is shared through the Network of Agencies for Health Technology Assessment, of which the U.S. Agency for Healthcare Research and Quality (AHRQ) is a member, the paper said.

Many of these lessons could be applied to reforming the U.S. health care system so that it could cover everyone while still controlling costs, Mr. Doherty said.

Any solution for the United States “will be unique to our political and social culture,” Mr. Doherty said. “Unlike many of the countries studied, [the United States] has a larger and more diverse population with a tradition of individualism and distrust of the government.” Also, free speech—including commercial free speech—is protected by the U.S. Constitution, and there's a deeply rooted system of employer-based coverage, tied to a powerful industry invested in maintaining private insurance and employer-based coverage.

“We're not going to simply take what they've developed [in other countries] and implement it” in the United States, he said. Instead, the goal should be to identify approaches that the evidence shows are more likely to be effective and determine if they can be adapted to the unique circumstances in the United States, he said.

WASHINGTON — Prometheus Payment Inc., a nonprofit group seeking to implement a better way to pay providers, intends to launch pilot projects this year that will test a new form of payment featuring a negotiated flat fee for guideline-based care of patients with specific conditions.

The program, supported by a 3-year, $6-million Robert Wood Johnson Foundation grant, will be piloted in Minneapolis, Rockford, Ill., as well as at two other sites that have not yet been announced by Prometheus.

The developers believe that it could represent the basis of a payment system that moves beyond pay for performance to integrate evidence-based medicine, said Alice Gosfield, a Philadelphia-based attorney and a past chairwoman of the National Committee for Quality Assurance, who heads the effort.

The intent of the Prometheus payment system is to get beyond pay for performance, "which is not going to be sustainable," Ms. Gosfield said at the annual meeting of the American College of Physicians.

Pay for performance "is not sustainable because if the whole class gets an A in diabetes, what happens next? Do we take that money and put it on asthma? If so, what happens to diabetes performance?" Ms. Gosfield asked. "If we add more money for asthma, how is that going to keep costs down?"

She also said that physicians are suspicious of where pay-for-performance money comes from. "They believe that either the money comes from what could be paid to other doctors, or it is money that isn't being paid to increase fee schedules," she said.

In addition, some of the documentation required for pay for performance wastes time.

Dr. Keith Michl, a general internist in Manchester Center, Vt., who has been involved in the development of Prometheus, said that the system would reward primary care physicians for saving money by keeping people healthier.

Under the Prometheus system, he said, case rates are standardized, and physicians who provide good care consistently will see a profit.

"This provides a powerful incentive to develop new systems of cost-effective care with much more validation than is provided by current pay-for-performance methods," he added.

The Prometheus group held its first meeting in December 2004 and has met monthly since. The Commonwealth Fund provided some of the initial funding to develop the group's evidence-informed case rates (ECRs), which are used as the foundation of the payment system.

The system aims to create regionally adjusted ECRs for patients with specific conditions, such as controlled diabetes. Providers will be asked to take responsibility for well-defined parts of the care for such patients.

For example, if a provider group agrees to be responsible for 70% of a patient's care, that group would receive 70% of the ECR, Ms. Gosfield said.

The ECRs would replace any other payments to providers, and once the ECR has been negotiated, physicians would be free to manage the patient in any way they deem appropriate.

"The amount of the payment is derived from taking a good clinical practice guideline and deriving from it the amount of money it would take to deliver care," she said.

Providers negotiate which part of the care budget they can cover, she said. Obviously, a one- or two-physician practice would be able to handle less of the "global care budget" than would a large, integrated delivery system, she said.

"The evidence-informed case rate encompasses all providers treating the patient for that condition and is allocated among them in accordance with that portion of the clinical practice guideline they negotiate to deliver," she said.

Although this may sound like capitation, Ms. Gosfield said it differs in several ways. First, the payment model avoids the problems inherent in capitation by constructing the payment rates in a way that reflects the cost of what is clinically relevant to the patient's condition, and, second, by adjusting ECRs to account for relative severity of patients' cases, she said.

WASHINGTON — Prometheus Payment Inc., a nonprofit group seeking to implement a better way to pay providers, intends to launch pilot projects this year that will test a new form of payment featuring a negotiated flat fee for guideline-based care of patients with specific conditions.

The program, supported by a 3-year, $6-million Robert Wood Johnson Foundation grant, will be piloted in Minneapolis, Rockford, Ill., as well as at two other sites that have not yet been announced by Prometheus.

The developers believe that it could represent the basis of a payment system that moves beyond pay for performance to integrate evidence-based medicine, said Alice Gosfield, a Philadelphia-based attorney and a past chairwoman of the National Committee for Quality Assurance, who heads the effort.

The intent of the Prometheus payment system is to get beyond pay for performance, "which is not going to be sustainable," Ms. Gosfield said at the annual meeting of the American College of Physicians.

Pay for performance "is not sustainable because if the whole class gets an A in diabetes, what happens next? Do we take that money and put it on asthma? If so, what happens to diabetes performance?" Ms. Gosfield asked. "If we add more money for asthma, how is that going to keep costs down?"

She also said that physicians are suspicious of where pay-for-performance money comes from. "They believe that either the money comes from what could be paid to other doctors, or it is money that isn't being paid to increase fee schedules," she said.

In addition, some of the documentation required for pay for performance wastes time.

Dr. Keith Michl, a general internist in Manchester Center, Vt., who has been involved in the development of Prometheus, said that the system would reward primary care physicians for saving money by keeping people healthier.

Under the Prometheus system, he said, case rates are standardized, and physicians who provide good care consistently will see a profit.

"This provides a powerful incentive to develop new systems of cost-effective care with much more validation than is provided by current pay-for-performance methods," he added.

The Prometheus group held its first meeting in December 2004 and has met monthly since. The Commonwealth Fund provided some of the initial funding to develop the group's evidence-informed case rates (ECRs), which are used as the foundation of the payment system.

The system aims to create regionally adjusted ECRs for patients with specific conditions, such as controlled diabetes. Providers will be asked to take responsibility for well-defined parts of the care for such patients.

For example, if a provider group agrees to be responsible for 70% of a patient's care, that group would receive 70% of the ECR, Ms. Gosfield said.

The ECRs would replace any other payments to providers, and once the ECR has been negotiated, physicians would be free to manage the patient in any way they deem appropriate.

"The amount of the payment is derived from taking a good clinical practice guideline and deriving from it the amount of money it would take to deliver care," she said.

Providers negotiate which part of the care budget they can cover, she said. Obviously, a one- or two-physician practice would be able to handle less of the "global care budget" than would a large, integrated delivery system, she said.

"The evidence-informed case rate encompasses all providers treating the patient for that condition and is allocated among them in accordance with that portion of the clinical practice guideline they negotiate to deliver," she said.

Although this may sound like capitation, Ms. Gosfield said it differs in several ways. First, the payment model avoids the problems inherent in capitation by constructing the payment rates in a way that reflects the cost of what is clinically relevant to the patient's condition, and, second, by adjusting ECRs to account for relative severity of patients' cases, she said.

WASHINGTON — Prometheus Payment Inc., a nonprofit group seeking to implement a better way to pay providers, intends to launch pilot projects this year that will test a new form of payment featuring a negotiated flat fee for guideline-based care of patients with specific conditions.

The program, supported by a 3-year, $6-million Robert Wood Johnson Foundation grant, will be piloted in Minneapolis, Rockford, Ill., as well as at two other sites that have not yet been announced by Prometheus.

The developers believe that it could represent the basis of a payment system that moves beyond pay for performance to integrate evidence-based medicine, said Alice Gosfield, a Philadelphia-based attorney and a past chairwoman of the National Committee for Quality Assurance, who heads the effort.

The intent of the Prometheus payment system is to get beyond pay for performance, "which is not going to be sustainable," Ms. Gosfield said at the annual meeting of the American College of Physicians.

Pay for performance "is not sustainable because if the whole class gets an A in diabetes, what happens next? Do we take that money and put it on asthma? If so, what happens to diabetes performance?" Ms. Gosfield asked. "If we add more money for asthma, how is that going to keep costs down?"

She also said that physicians are suspicious of where pay-for-performance money comes from. "They believe that either the money comes from what could be paid to other doctors, or it is money that isn't being paid to increase fee schedules," she said.

In addition, some of the documentation required for pay for performance wastes time.

Dr. Keith Michl, a general internist in Manchester Center, Vt., who has been involved in the development of Prometheus, said that the system would reward primary care physicians for saving money by keeping people healthier.

Under the Prometheus system, he said, case rates are standardized, and physicians who provide good care consistently will see a profit.

"This provides a powerful incentive to develop new systems of cost-effective care with much more validation than is provided by current pay-for-performance methods," he added.

The Prometheus group held its first meeting in December 2004 and has met monthly since. The Commonwealth Fund provided some of the initial funding to develop the group's evidence-informed case rates (ECRs), which are used as the foundation of the payment system.

The system aims to create regionally adjusted ECRs for patients with specific conditions, such as controlled diabetes. Providers will be asked to take responsibility for well-defined parts of the care for such patients.

For example, if a provider group agrees to be responsible for 70% of a patient's care, that group would receive 70% of the ECR, Ms. Gosfield said.

The ECRs would replace any other payments to providers, and once the ECR has been negotiated, physicians would be free to manage the patient in any way they deem appropriate.

"The amount of the payment is derived from taking a good clinical practice guideline and deriving from it the amount of money it would take to deliver care," she said.

Providers negotiate which part of the care budget they can cover, she said. Obviously, a one- or two-physician practice would be able to handle less of the "global care budget" than would a large, integrated delivery system, she said.

"The evidence-informed case rate encompasses all providers treating the patient for that condition and is allocated among them in accordance with that portion of the clinical practice guideline they negotiate to deliver," she said.

Although this may sound like capitation, Ms. Gosfield said it differs in several ways. First, the payment model avoids the problems inherent in capitation by constructing the payment rates in a way that reflects the cost of what is clinically relevant to the patient's condition, and, second, by adjusting ECRs to account for relative severity of patients' cases, she said.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned from health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, and Japan) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, "High-Performance Health Care System with Universal Access."

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

"Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care," the ACP position paper noted.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. "Patients need to have some stake in the system themselves," he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those found in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. "Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients."

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper noted.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned from health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, and Japan) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, "High-Performance Health Care System with Universal Access."

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

"Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care," the ACP position paper noted.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. "Patients need to have some stake in the system themselves," he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those found in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. "Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients."

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper noted.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. health care system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned from health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Primary care is the foundation of high-performing systems. Societal investment in medical education, as found in France, Germany, and the United Kingdom, can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, and Japan) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, "High-Performance Health Care System with Universal Access."

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts. In 2005, the average debt was $105,000 for graduates of public institutions and $135,000 for those who attended private institutions.

"Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care," the ACP position paper noted.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. "Patients need to have some stake in the system themselves," he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those found in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors, improving health outcomes, and creating responsible utilization, without punishing people who fail to adopt recommended behaviors or lifestyles, he said.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Meanwhile, an interoperable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision making and can enhance electronic communications among treating health professionals, he said. Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools, according to the ACP's position paper. "Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients."

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness.

Many other countries that have national health insurance programs, such as the United Kingdom and Australia, perform evidence-based evaluations of new drugs and technology, the position paper noted.

WASHINGTON — When Dr. David Gregory worked to open a health clinic for the uninsured in Nashville in 1991, he thought that he would be treating residents from the nearby housing projects. But Siloam Clinic is the treatment center of choice for a large population of refugees and immigrants from some 100 nations, ranging from Afghanistan to Vietnam.

“One morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” said Dr. Gregory, of the division of infectious diseases at Vanderbilt University, Nashville, Tenn. “It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge—and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building with 12 exam rooms and a chapel.

The need for this type of community service has soared since 1991 as the population of uninsured and underinsured has grown, Dr. Gregory said. He offered some advice for physicians who want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked.

The first thing Dr. Gregory suggested for physicians who want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks. Developing a mission statement is critical “to avoid institutional drift,” Dr. Gregory said.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. And depending entirely or almost entirely on volunteers can be chancy, because they don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

As Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5.00 'donation.' The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees—for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

But the patients make it worthwhile.

Dr. Gregory spoke of one, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham—a Tennessee resident for 4 years—recently had returned from a 1-month stay in Uganda, where he was searching for family members.

Physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said, adding the young man subsequently found a better job.

Another patient was a young Vietnamese woman, who arrived at the clinic unable to speak any English, Dr. Gregory said. “We didn't then have a translator—we have lots of them now—but we finally figured out that what she wanted was a Pap smear.”

It turned out that the woman had had a Pap smear in Vietnam and had been told she had cervical cancer. But the repeat Pap was clear. “She was so, so grateful” to know she did not have cancer, he said.

Dr. David Gregory talks with an Asian immigrant patient. Today, 80% of his patients are refugees or immigrants. Joicelyn Gregory

Dr. Gregory's clinic receives funding from Medicaid, federal grants, donations, and foundations. Nancy West/Siloam Clinic

WASHINGTON — When Dr. David Gregory worked to open a health clinic for the uninsured in Nashville in 1991, he thought that he would be treating residents from the nearby housing projects. But Siloam Clinic is the treatment center of choice for a large population of refugees and immigrants from some 100 nations, ranging from Afghanistan to Vietnam.

“One morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” said Dr. Gregory, of the division of infectious diseases at Vanderbilt University, Nashville, Tenn. “It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge—and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building with 12 exam rooms and a chapel.

The need for this type of community service has soared since 1991 as the population of uninsured and underinsured has grown, Dr. Gregory said. He offered some advice for physicians who want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked.

The first thing Dr. Gregory suggested for physicians who want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks. Developing a mission statement is critical “to avoid institutional drift,” Dr. Gregory said.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. And depending entirely or almost entirely on volunteers can be chancy, because they don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

As Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5.00 'donation.' The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees—for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

But the patients make it worthwhile.

Dr. Gregory spoke of one, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham—a Tennessee resident for 4 years—recently had returned from a 1-month stay in Uganda, where he was searching for family members.

Physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said, adding the young man subsequently found a better job.

Another patient was a young Vietnamese woman, who arrived at the clinic unable to speak any English, Dr. Gregory said. “We didn't then have a translator—we have lots of them now—but we finally figured out that what she wanted was a Pap smear.”

It turned out that the woman had had a Pap smear in Vietnam and had been told she had cervical cancer. But the repeat Pap was clear. “She was so, so grateful” to know she did not have cancer, he said.

Dr. David Gregory talks with an Asian immigrant patient. Today, 80% of his patients are refugees or immigrants. Joicelyn Gregory

Dr. Gregory's clinic receives funding from Medicaid, federal grants, donations, and foundations. Nancy West/Siloam Clinic

WASHINGTON — When Dr. David Gregory worked to open a health clinic for the uninsured in Nashville in 1991, he thought that he would be treating residents from the nearby housing projects. But Siloam Clinic is the treatment center of choice for a large population of refugees and immigrants from some 100 nations, ranging from Afghanistan to Vietnam.

“One morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” said Dr. Gregory, of the division of infectious diseases at Vanderbilt University, Nashville, Tenn. “It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge—and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building with 12 exam rooms and a chapel.

The need for this type of community service has soared since 1991 as the population of uninsured and underinsured has grown, Dr. Gregory said. He offered some advice for physicians who want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked.

The first thing Dr. Gregory suggested for physicians who want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks. Developing a mission statement is critical “to avoid institutional drift,” Dr. Gregory said.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. And depending entirely or almost entirely on volunteers can be chancy, because they don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

As Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5.00 'donation.' The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees—for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

But the patients make it worthwhile.

Dr. Gregory spoke of one, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham—a Tennessee resident for 4 years—recently had returned from a 1-month stay in Uganda, where he was searching for family members.

Physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said, adding the young man subsequently found a better job.

Another patient was a young Vietnamese woman, who arrived at the clinic unable to speak any English, Dr. Gregory said. “We didn't then have a translator—we have lots of them now—but we finally figured out that what she wanted was a Pap smear.”

It turned out that the woman had had a Pap smear in Vietnam and had been told she had cervical cancer. But the repeat Pap was clear. “She was so, so grateful” to know she did not have cancer, he said.

Dr. David Gregory talks with an Asian immigrant patient. Today, 80% of his patients are refugees or immigrants. Joicelyn Gregory

Dr. Gregory's clinic receives funding from Medicaid, federal grants, donations, and foundations. Nancy West/Siloam Clinic

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned in looking closely at health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Societal investment in medical education can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so that students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those found in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

In Denmark, for example, primary care physicians receive a capitated payment for providing care coordination and case management by telephone or e-mail, in addition to receiving fee-for-service payments for office visits.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology result in reliance on outdated technologies and medical equipment, and delay patients' access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

The goal in applying these lessons should be to identify approaches that the evidence shows are more likely to be effective and determine if they can be adapted to the unique circumstances in the U.S., Mr. Doherty said.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned in looking closely at health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Societal investment in medical education can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so that students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those found in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

In Denmark, for example, primary care physicians receive a capitated payment for providing care coordination and case management by telephone or e-mail, in addition to receiving fee-for-service payments for office visits.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology result in reliance on outdated technologies and medical equipment, and delay patients' access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

The goal in applying these lessons should be to identify approaches that the evidence shows are more likely to be effective and determine if they can be adapted to the unique circumstances in the U.S., Mr. Doherty said.

WASHINGTON — Analysis of other countries' health care systems has pointed out what might work—and what won't work—in efforts to reform the U.S. system.

At the annual meeting of the American College of Physicians, ACP senior vice president of governmental affairs and public policy Robert Doherty outlined seven key lessons the college learned in looking closely at health care systems around the globe:

▸ Lesson No. 1. Global budgets and price controls can restrain costs, but they can also lead to negative consequences. Canada, Germany, New Zealand, Taiwan, and the United Kingdom all use global budgets, Mr. Doherty said. In the United Kingdom, for example, annual per capita health expenditures totaled $2,546 in 2004 versus $6,012 in the United States that year.

Nevertheless, global budgets do not provide incentives for improved efficiency unless the annual expense budget is reasonable and the target region is small enough to motivate individual providers to avoid the overuse of services, he said.

▸ Lesson No. 2. Societal investment in medical education can help achieve a well-trained workforce that has the right proportion of primary care physicians and specialists and is large enough to ensure access, he said.

Many countries finance medical school education with public funds, so that students pay little (as in the Netherlands) or no (as in Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for books and fees, the ACP reported earlier this year in a position paper, “High-Performance Health Care System with Universal Access.”

In contrast, the average U.S. tuition in 2005 was $20,370 for public medical schools and $38,190 at private medical schools, according to the paper. As a result, 85% of graduating medical students begin their careers with substantial debts.

▸ Lesson No. 3. High-performing systems encourage patients to be prudent purchasers and to engage in healthy behavior, Mr. Doherty said. “Patients need to have some stake in the system themselves,” he said. For example, in Belgium, France, Japan, New Zealand, and Switzerland, patients share costs with copayment schedules based on income, and that can help restrain costs while ensuring that poorer individuals have access, he said.

In addition, incentives to encourage personal responsibility—such as those found in Australia, Belgium, Japan, and other countries—can be effective in influencing healthy behaviors.

▸ Lesson No. 4. The best payment systems recognize the value of care coordinated by primary care doctors, Mr. Doherty said. Effective payment systems provide adequate payment for primary care services, create incentives for quality improvement and reporting (as in Belgium and the United Kingdom), recognize geographic or local payment differences (as in Canada, Denmark, Germany, and the United Kingdom), and provide incentives for care coordination (as in Denmark and the Netherlands), he said.

In Denmark, for example, primary care physicians receive a capitated payment for providing care coordination and case management by telephone or e-mail, in addition to receiving fee-for-service payments for office visits.

▸ Lesson No. 5. High-performing systems measure their own performance. Countries such as Australia, New Zealand, and the United Kingdom, along with the U.S. Veterans Health Administration, have implemented performance measures linked to quality, he said.

▸ Lesson No. 6. High-performing systems invest in health information technology, and have uniform billing and lower administrative costs, Mr. Doherty said. The adoption of uniform billing and electronic processing of claims—as has been done in Germany, Canada, and Taiwan, among others—improves efficiency and reduces administrative expenses, he said.

Denmark, Taiwan, and the Netherlands have interoperable health information infrastructures that incorporate decision-support tools. “Systems like these will enable physicians to obtain instantaneous information at the point of medical decision making and will enhance electronic communications among physicians, hospitals, pharmacies, diagnostic testing laboratories, and patients.”

▸ Lesson No. 7. High-performing systems invest in research and comparative effectiveness. Insufficient investments in research and medical technology result in reliance on outdated technologies and medical equipment, and delay patients' access to advances in medical care, he said. This has occurred in Canada and the United Kingdom, according to the position paper.

The goal in applying these lessons should be to identify approaches that the evidence shows are more likely to be effective and determine if they can be adapted to the unique circumstances in the U.S., Mr. Doherty said.

WASHINGTON — Physicians generally believe that medical errors—especially those that cause an adverse event—should be disclosed to patients, but some question whether patients should be told all the details or just the basic facts about what happened, said an internist who has studied the issue.

Dr. Thomas Gallagher, associate professor of medicine at the University of Washington, Seattle, told attendees at the annual meeting of the American College of Physicians that physicians are unsure about what to include when they disclose a medical error. But he added that physicians are actively debating the best way to proceed.

“Over the next 5 years, we're going to see very exciting changes,” Dr. Gallagher said. “I think physicians as a profession will be leading the way to set some standards as to how these difficult conversations should go.”

Patients conceive of errors broadly and desire full disclosure of harmful errors, while at the same time worrying that health care workers might hide them, Dr. Gallagher said. In disclosure, they want “an explicit statement that an error occurred,” details of what happened and the implications for their health, why it happened, and how recurrences will be prevented, he said. In addition, they want an apology, he said, adding, “That really mattered very much to the patient.”

Physicians define errors more narrowly than patients do, he said. They agree in principle with full disclosure and want to be truthful, but perceive barriers to disclosure, he said. “Physicians feared that disclosure could be harmful to the patient, and physicians saw disclosure as akin to admitting personal failure,” Dr. Gallagher said, adding that most physicians haven't had any formal training in disclosure.

The University of Washington recently surveyed 4,000 physicians about communication with patients, colleagues, and health care institutions about medical errors.

According to Dr. Gallagher, the survey on error disclosure was sent to 2,000 physicians in Washington State and 2,000 Canadian physicians. The survey, which asked about general attitudes regarding disclosure, had a response rate of 63%.

Respondents were randomized to one of four specialty-specific disclosure scenarios and answered five questions to measure the content of their disclosure. Each question offered actual disclosure language that contained no information, a little information, or full disclosure.

When asked about general attitudes regarding disclosure, 98% of U.S. physicians said serious errors should be disclosed, and more than three-quarters said minor errors should be disclosed to patients. Less than one-third, however, said near misses should be disclosed, he said.

But when asked for answers in the specific scenarios, physicians didn't always want to admit that a medical error occurred. For example, one fictitious scenario involved an inpatient insulin overdose: A physician wrote an order for the patient to receive “10 U” of insulin, but the “U” in the order looked like a “0,” and the following morning the patient received 100 units of insulin. The patient later was found unresponsive, with a blood glucose level of 35 mg/dL, was resuscitated and transferred to the intensive care unit, and is expected to make a full recovery.

Nearly 65% of physicians said they would “definitely” disclose the error, and about 32% said they “probably” would disclose the error, Dr. Gallagher said. When asked how they would explain the situation, 1% said they would tell the patient, “Your blood sugar went too low and you passed out”; 28% said they would say, “Your blood sugar went too low because you received more insulin than you needed”; and 71% said they would tell the patient, “Your blood sugar went too low because an error happened and you received too much insulin.”

When asked how much detail they would provide, 11% said they would not volunteer specific details about the error unless asked by the patient; 36% said they'd tell the patient, “You received more insulin than you needed”; and 54% said they'd tell the patient, “You received 100 units rather than your usual 10 units of insulin.”

There were 3% who said they would not volunteer that they were sorry or apologize; 54% would say, “I am sorry about what happened”; and 43% would say, “I am so sorry that you were harmed by this error.”

Preliminary conclusions show that physicians support the concept of disclosure, but are uncertain about the core content of any disclosure. Most would disclose less information about errors that would not be apparent to the patient, Dr. Gallagher said, adding that medical and surgical specialties may approach disclosure differently.

There is accelerating interest in disclosure and growing experimentation with disclosure approaches among health care organizations and malpractice insurers. This goes hand-in-hand with the increased emphasis on transparency in health care, he said.

A “disclosure performance gap” also is increasingly evident, and harmful errors often are not disclosed. “When disclosure does take place, it often falls short of meeting patient expectations for what these conversations should be about,” he said.

In addition, little prospective evidence exists regarding what types of disclosure strategies are effective, Dr. Gallagher said. “That makes it difficult to know not [only] whether to disclose or not, but [also] what to say to the patient. Effective disclosure ought to have a positive effect on quality.”

There are multiple rationales for disclosing errors to patients, Dr. Gallagher said. Error disclosure can be considered a part of informed consent, he added, saying, however, “This is an area where doctors and patients appear to be on somewhat different pages. Physicians focus on informed consent, while patients see it as truth-telling.”

WASHINGTON — Physicians generally believe that medical errors—especially those that cause an adverse event—should be disclosed to patients, but some question whether patients should be told all the details or just the basic facts about what happened, said an internist who has studied the issue.

Dr. Thomas Gallagher, associate professor of medicine at the University of Washington, Seattle, told attendees at the annual meeting of the American College of Physicians that physicians are unsure about what to include when they disclose a medical error. But he added that physicians are actively debating the best way to proceed.

“Over the next 5 years, we're going to see very exciting changes,” Dr. Gallagher said. “I think physicians as a profession will be leading the way to set some standards as to how these difficult conversations should go.”

Patients conceive of errors broadly and desire full disclosure of harmful errors, while at the same time worrying that health care workers might hide them, Dr. Gallagher said. In disclosure, they want “an explicit statement that an error occurred,” details of what happened and the implications for their health, why it happened, and how recurrences will be prevented, he said. In addition, they want an apology, he said, adding, “That really mattered very much to the patient.”

Physicians define errors more narrowly than patients do, he said. They agree in principle with full disclosure and want to be truthful, but perceive barriers to disclosure, he said. “Physicians feared that disclosure could be harmful to the patient, and physicians saw disclosure as akin to admitting personal failure,” Dr. Gallagher said, adding that most physicians haven't had any formal training in disclosure.

The University of Washington recently surveyed 4,000 physicians about communication with patients, colleagues, and health care institutions about medical errors.

According to Dr. Gallagher, the survey on error disclosure was sent to 2,000 physicians in Washington State and 2,000 Canadian physicians. The survey, which asked about general attitudes regarding disclosure, had a response rate of 63%.

Respondents were randomized to one of four specialty-specific disclosure scenarios and answered five questions to measure the content of their disclosure. Each question offered actual disclosure language that contained no information, a little information, or full disclosure.

When asked about general attitudes regarding disclosure, 98% of U.S. physicians said serious errors should be disclosed, and more than three-quarters said minor errors should be disclosed to patients. Less than one-third, however, said near misses should be disclosed, he said.

But when asked for answers in the specific scenarios, physicians didn't always want to admit that a medical error occurred. For example, one fictitious scenario involved an inpatient insulin overdose: A physician wrote an order for the patient to receive “10 U” of insulin, but the “U” in the order looked like a “0,” and the following morning the patient received 100 units of insulin. The patient later was found unresponsive, with a blood glucose level of 35 mg/dL, was resuscitated and transferred to the intensive care unit, and is expected to make a full recovery.

Nearly 65% of physicians said they would “definitely” disclose the error, and about 32% said they “probably” would disclose the error, Dr. Gallagher said. When asked how they would explain the situation, 1% said they would tell the patient, “Your blood sugar went too low and you passed out”; 28% said they would say, “Your blood sugar went too low because you received more insulin than you needed”; and 71% said they would tell the patient, “Your blood sugar went too low because an error happened and you received too much insulin.”

When asked how much detail they would provide, 11% said they would not volunteer specific details about the error unless asked by the patient; 36% said they'd tell the patient, “You received more insulin than you needed”; and 54% said they'd tell the patient, “You received 100 units rather than your usual 10 units of insulin.”

There were 3% who said they would not volunteer that they were sorry or apologize; 54% would say, “I am sorry about what happened”; and 43% would say, “I am so sorry that you were harmed by this error.”

Preliminary conclusions show that physicians support the concept of disclosure, but are uncertain about the core content of any disclosure. Most would disclose less information about errors that would not be apparent to the patient, Dr. Gallagher said, adding that medical and surgical specialties may approach disclosure differently.

There is accelerating interest in disclosure and growing experimentation with disclosure approaches among health care organizations and malpractice insurers. This goes hand-in-hand with the increased emphasis on transparency in health care, he said.

A “disclosure performance gap” also is increasingly evident, and harmful errors often are not disclosed. “When disclosure does take place, it often falls short of meeting patient expectations for what these conversations should be about,” he said.

In addition, little prospective evidence exists regarding what types of disclosure strategies are effective, Dr. Gallagher said. “That makes it difficult to know not [only] whether to disclose or not, but [also] what to say to the patient. Effective disclosure ought to have a positive effect on quality.”

There are multiple rationales for disclosing errors to patients, Dr. Gallagher said. Error disclosure can be considered a part of informed consent, he added, saying, however, “This is an area where doctors and patients appear to be on somewhat different pages. Physicians focus on informed consent, while patients see it as truth-telling.”

WASHINGTON — Physicians generally believe that medical errors—especially those that cause an adverse event—should be disclosed to patients, but some question whether patients should be told all the details or just the basic facts about what happened, said an internist who has studied the issue.

Dr. Thomas Gallagher, associate professor of medicine at the University of Washington, Seattle, told attendees at the annual meeting of the American College of Physicians that physicians are unsure about what to include when they disclose a medical error. But he added that physicians are actively debating the best way to proceed.

“Over the next 5 years, we're going to see very exciting changes,” Dr. Gallagher said. “I think physicians as a profession will be leading the way to set some standards as to how these difficult conversations should go.”

Patients conceive of errors broadly and desire full disclosure of harmful errors, while at the same time worrying that health care workers might hide them, Dr. Gallagher said. In disclosure, they want “an explicit statement that an error occurred,” details of what happened and the implications for their health, why it happened, and how recurrences will be prevented, he said. In addition, they want an apology, he said, adding, “That really mattered very much to the patient.”

Physicians define errors more narrowly than patients do, he said. They agree in principle with full disclosure and want to be truthful, but perceive barriers to disclosure, he said. “Physicians feared that disclosure could be harmful to the patient, and physicians saw disclosure as akin to admitting personal failure,” Dr. Gallagher said, adding that most physicians haven't had any formal training in disclosure.

The University of Washington recently surveyed 4,000 physicians about communication with patients, colleagues, and health care institutions about medical errors.

According to Dr. Gallagher, the survey on error disclosure was sent to 2,000 physicians in Washington State and 2,000 Canadian physicians. The survey, which asked about general attitudes regarding disclosure, had a response rate of 63%.

Respondents were randomized to one of four specialty-specific disclosure scenarios and answered five questions to measure the content of their disclosure. Each question offered actual disclosure language that contained no information, a little information, or full disclosure.

When asked about general attitudes regarding disclosure, 98% of U.S. physicians said serious errors should be disclosed, and more than three-quarters said minor errors should be disclosed to patients. Less than one-third, however, said near misses should be disclosed, he said.

But when asked for answers in the specific scenarios, physicians didn't always want to admit that a medical error occurred. For example, one fictitious scenario involved an inpatient insulin overdose: A physician wrote an order for the patient to receive “10 U” of insulin, but the “U” in the order looked like a “0,” and the following morning the patient received 100 units of insulin. The patient later was found unresponsive, with a blood glucose level of 35 mg/dL, was resuscitated and transferred to the intensive care unit, and is expected to make a full recovery.

Nearly 65% of physicians said they would “definitely” disclose the error, and about 32% said they “probably” would disclose the error, Dr. Gallagher said. When asked how they would explain the situation, 1% said they would tell the patient, “Your blood sugar went too low and you passed out”; 28% said they would say, “Your blood sugar went too low because you received more insulin than you needed”; and 71% said they would tell the patient, “Your blood sugar went too low because an error happened and you received too much insulin.”

When asked how much detail they would provide, 11% said they would not volunteer specific details about the error unless asked by the patient; 36% said they'd tell the patient, “You received more insulin than you needed”; and 54% said they'd tell the patient, “You received 100 units rather than your usual 10 units of insulin.”

There were 3% who said they would not volunteer that they were sorry or apologize; 54% would say, “I am sorry about what happened”; and 43% would say, “I am so sorry that you were harmed by this error.”

Preliminary conclusions show that physicians support the concept of disclosure, but are uncertain about the core content of any disclosure. Most would disclose less information about errors that would not be apparent to the patient, Dr. Gallagher said, adding that medical and surgical specialties may approach disclosure differently.

There is accelerating interest in disclosure and growing experimentation with disclosure approaches among health care organizations and malpractice insurers. This goes hand-in-hand with the increased emphasis on transparency in health care, he said.

A “disclosure performance gap” also is increasingly evident, and harmful errors often are not disclosed. “When disclosure does take place, it often falls short of meeting patient expectations for what these conversations should be about,” he said.

In addition, little prospective evidence exists regarding what types of disclosure strategies are effective, Dr. Gallagher said. “That makes it difficult to know not [only] whether to disclose or not, but [also] what to say to the patient. Effective disclosure ought to have a positive effect on quality.”

There are multiple rationales for disclosing errors to patients, Dr. Gallagher said. Error disclosure can be considered a part of informed consent, he added, saying, however, “This is an area where doctors and patients appear to be on somewhat different pages. Physicians focus on informed consent, while patients see it as truth-telling.”

WASHINGTON — Prometheus Payment Inc., a nonprofit group seeking to implement a better way to pay providers, intends to launch pilot projects this year that will test a new form of payment featuring a negotiated flat fee for guideline-based care of patients with specific conditions.

Supported by a 3-year, $6-million Robert Wood Johnson Foundation grant, the program will be piloted in Minneapolis, Rockford, Ill., and two other sites that have not yet been announced. The developers believe that it could represent the basis of a payment system that moves beyond pay for performance to integrate evidence-based medicine, said Alice Gosfield, a Philadelphia-based attorney and a past chairwoman of the National Committee for Quality Assurance, who heads the effort.

The intent of the Prometheus payment system is to get beyond pay for performance, “which is not going to be sustainable,” Ms. Gosfield said at the annual meeting of the American College of Physicians. Pay for performance “is not sustainable because if the whole class gets an A in diabetes, what happens next? Do we take that money and put it on asthma? If so, what happens to diabetes performance?” Ms. Gosfield asked. “If we add more money for asthma, how is that going to keep costs down?”

She also said that physicians are suspicious of where pay for performance money comes from. “They believe that either the money comes from what could be paid to other doctors, or it is money that isn't being paid to increase fee schedules,” she said.

In addition, some of the documentation required for pay for performance wastes time. “You have to write down why you're doing liver function studies on a patient taking Lipitor, when it would pretty much be malpractice to not do liver function studies on a patient on Lipitor,” Ms. Gosfield said.

Dr. Keith Michl, a general internist in Manchester Center, Vt., who has been involved in the development of Prometheus, said that the system would reward primary care physicians for saving money by keeping people healthier.

“Primary care, when done properly, is comprehensive care that is organized into systems of care. It is expensive to provide this care,” Dr. Michl said in an interview. “We can no longer expect primary care physicians to provide time-consuming, innovative care and not be compensated.”

Under the Prometheus system, he said, case rates are standardized, and physicians who provide good care consistently will see a profit. “This provides a powerful incentive to develop new systems of cost-effective care with much more validation than is provided by current pay-for-performance methods,” he added.

The Prometheus group held its first meeting in December 2004 and has met monthly since. The Commonwealth Fund provided some initial funding to develop the group's evidence-informed case rates (ECRs), which are used as the foundation of the payment system.

The system aims to create regionally adjusted ECRs for patients with specific conditions, such as diabetes. Providers will be asked to take responsibility for well-defined parts of the care for such patients. For example, if a provider group agrees to be responsible for 70% of a patient's care, that group would receive 70% of the ECR, Ms. Gosfield said. The ECRs would replace any other payments to providers, and once the ECR has been negotiated, physicians would be free to manage the patient in any way they deem appropriate. “The amount of the payment is derived from taking a good clinical practice guideline and deriving from it the amount of money it would take to deliver care,” she said.

Providers who volunteer to participate in the pilot program negotiate which part of the care budget they can cover, she said. Obviously, a one- or two-physician practice would be able to handle less of the “global care budget” than would a large, integrated delivery system, she said.

“The evidence-informed case rate encompasses all providers treating the patient for that condition and is allocated among them in accordance with that portion of the clinical practice guideline they negotiate to deliver,” she said.

Although this may sound like capitation, Ms. Gosfield said it differs in several ways. The payment model avoids the problems inherent in capitation by constructing the payment rates in a way that reflects the cost of what is clinically relevant to the patient's condition, and by adjusting ECRs to account for relative severity of cases.

Diabetes and acute MI will be the first two conditions piloted under the Prometheus system, Ms. Gosfield said.

For diabetes, “we tried to define what would be a typical diabetes case. Then we defined hospitalization, strokes, amputation, and retinal procedures as potentially avoidable complications,” she said. To make the system fair, “we decided to take half the money we'd be spending on those preventable complications and give it back to providers anyway.” For example, in the system, a primary care physician caring for a patient with controlled type 2 diabetes might receive $2,300 per year. With enough of these patients, the physician could hire a nurse practitioner to serve as a patient educator and coach, Ms. Gosfield said.

If the cost of care exceeds the flat rate payment, the physician must make up the difference—providing a powerful incentive to manage the patient carefully, she said.

The Prometheus system is risk adjusted and sustainable as a business model, Ms. Gosfield said. In addition, it provides certainty in payment, is transparent and easy to administer, reduces malpractice liability, improves clinical guideline quality, and gives physicians more control, she said.

Gosfield cautioned that the system is complicated and will incur transitional costs, especially if it becomes widely adopted while other payment systems remain in place at the same time.

WASHINGTON — Prometheus Payment Inc., a nonprofit group seeking to implement a better way to pay providers, intends to launch pilot projects this year that will test a new form of payment featuring a negotiated flat fee for guideline-based care of patients with specific conditions.

Supported by a 3-year, $6-million Robert Wood Johnson Foundation grant, the program will be piloted in Minneapolis, Rockford, Ill., and two other sites that have not yet been announced. The developers believe that it could represent the basis of a payment system that moves beyond pay for performance to integrate evidence-based medicine, said Alice Gosfield, a Philadelphia-based attorney and a past chairwoman of the National Committee for Quality Assurance, who heads the effort.

The intent of the Prometheus payment system is to get beyond pay for performance, “which is not going to be sustainable,” Ms. Gosfield said at the annual meeting of the American College of Physicians. Pay for performance “is not sustainable because if the whole class gets an A in diabetes, what happens next? Do we take that money and put it on asthma? If so, what happens to diabetes performance?” Ms. Gosfield asked. “If we add more money for asthma, how is that going to keep costs down?”

She also said that physicians are suspicious of where pay for performance money comes from. “They believe that either the money comes from what could be paid to other doctors, or it is money that isn't being paid to increase fee schedules,” she said.

In addition, some of the documentation required for pay for performance wastes time. “You have to write down why you're doing liver function studies on a patient taking Lipitor, when it would pretty much be malpractice to not do liver function studies on a patient on Lipitor,” Ms. Gosfield said.

Dr. Keith Michl, a general internist in Manchester Center, Vt., who has been involved in the development of Prometheus, said that the system would reward primary care physicians for saving money by keeping people healthier.

“Primary care, when done properly, is comprehensive care that is organized into systems of care. It is expensive to provide this care,” Dr. Michl said in an interview. “We can no longer expect primary care physicians to provide time-consuming, innovative care and not be compensated.”

Under the Prometheus system, he said, case rates are standardized, and physicians who provide good care consistently will see a profit. “This provides a powerful incentive to develop new systems of cost-effective care with much more validation than is provided by current pay-for-performance methods,” he added.

The Prometheus group held its first meeting in December 2004 and has met monthly since. The Commonwealth Fund provided some initial funding to develop the group's evidence-informed case rates (ECRs), which are used as the foundation of the payment system.

The system aims to create regionally adjusted ECRs for patients with specific conditions, such as diabetes. Providers will be asked to take responsibility for well-defined parts of the care for such patients. For example, if a provider group agrees to be responsible for 70% of a patient's care, that group would receive 70% of the ECR, Ms. Gosfield said. The ECRs would replace any other payments to providers, and once the ECR has been negotiated, physicians would be free to manage the patient in any way they deem appropriate. “The amount of the payment is derived from taking a good clinical practice guideline and deriving from it the amount of money it would take to deliver care,” she said.

Providers who volunteer to participate in the pilot program negotiate which part of the care budget they can cover, she said. Obviously, a one- or two-physician practice would be able to handle less of the “global care budget” than would a large, integrated delivery system, she said.

“The evidence-informed case rate encompasses all providers treating the patient for that condition and is allocated among them in accordance with that portion of the clinical practice guideline they negotiate to deliver,” she said.

Although this may sound like capitation, Ms. Gosfield said it differs in several ways. The payment model avoids the problems inherent in capitation by constructing the payment rates in a way that reflects the cost of what is clinically relevant to the patient's condition, and by adjusting ECRs to account for relative severity of cases.

Diabetes and acute MI will be the first two conditions piloted under the Prometheus system, Ms. Gosfield said.

For diabetes, “we tried to define what would be a typical diabetes case. Then we defined hospitalization, strokes, amputation, and retinal procedures as potentially avoidable complications,” she said. To make the system fair, “we decided to take half the money we'd be spending on those preventable complications and give it back to providers anyway.” For example, in the system, a primary care physician caring for a patient with controlled type 2 diabetes might receive $2,300 per year. With enough of these patients, the physician could hire a nurse practitioner to serve as a patient educator and coach, Ms. Gosfield said.

If the cost of care exceeds the flat rate payment, the physician must make up the difference—providing a powerful incentive to manage the patient carefully, she said.

The Prometheus system is risk adjusted and sustainable as a business model, Ms. Gosfield said. In addition, it provides certainty in payment, is transparent and easy to administer, reduces malpractice liability, improves clinical guideline quality, and gives physicians more control, she said.

Gosfield cautioned that the system is complicated and will incur transitional costs, especially if it becomes widely adopted while other payment systems remain in place at the same time.

WASHINGTON — Prometheus Payment Inc., a nonprofit group seeking to implement a better way to pay providers, intends to launch pilot projects this year that will test a new form of payment featuring a negotiated flat fee for guideline-based care of patients with specific conditions.

Supported by a 3-year, $6-million Robert Wood Johnson Foundation grant, the program will be piloted in Minneapolis, Rockford, Ill., and two other sites that have not yet been announced. The developers believe that it could represent the basis of a payment system that moves beyond pay for performance to integrate evidence-based medicine, said Alice Gosfield, a Philadelphia-based attorney and a past chairwoman of the National Committee for Quality Assurance, who heads the effort.

The intent of the Prometheus payment system is to get beyond pay for performance, “which is not going to be sustainable,” Ms. Gosfield said at the annual meeting of the American College of Physicians. Pay for performance “is not sustainable because if the whole class gets an A in diabetes, what happens next? Do we take that money and put it on asthma? If so, what happens to diabetes performance?” Ms. Gosfield asked. “If we add more money for asthma, how is that going to keep costs down?”

She also said that physicians are suspicious of where pay for performance money comes from. “They believe that either the money comes from what could be paid to other doctors, or it is money that isn't being paid to increase fee schedules,” she said.

In addition, some of the documentation required for pay for performance wastes time. “You have to write down why you're doing liver function studies on a patient taking Lipitor, when it would pretty much be malpractice to not do liver function studies on a patient on Lipitor,” Ms. Gosfield said.

Dr. Keith Michl, a general internist in Manchester Center, Vt., who has been involved in the development of Prometheus, said that the system would reward primary care physicians for saving money by keeping people healthier.

“Primary care, when done properly, is comprehensive care that is organized into systems of care. It is expensive to provide this care,” Dr. Michl said in an interview. “We can no longer expect primary care physicians to provide time-consuming, innovative care and not be compensated.”

Under the Prometheus system, he said, case rates are standardized, and physicians who provide good care consistently will see a profit. “This provides a powerful incentive to develop new systems of cost-effective care with much more validation than is provided by current pay-for-performance methods,” he added.

The Prometheus group held its first meeting in December 2004 and has met monthly since. The Commonwealth Fund provided some initial funding to develop the group's evidence-informed case rates (ECRs), which are used as the foundation of the payment system.

The system aims to create regionally adjusted ECRs for patients with specific conditions, such as diabetes. Providers will be asked to take responsibility for well-defined parts of the care for such patients. For example, if a provider group agrees to be responsible for 70% of a patient's care, that group would receive 70% of the ECR, Ms. Gosfield said. The ECRs would replace any other payments to providers, and once the ECR has been negotiated, physicians would be free to manage the patient in any way they deem appropriate. “The amount of the payment is derived from taking a good clinical practice guideline and deriving from it the amount of money it would take to deliver care,” she said.

Providers who volunteer to participate in the pilot program negotiate which part of the care budget they can cover, she said. Obviously, a one- or two-physician practice would be able to handle less of the “global care budget” than would a large, integrated delivery system, she said.

“The evidence-informed case rate encompasses all providers treating the patient for that condition and is allocated among them in accordance with that portion of the clinical practice guideline they negotiate to deliver,” she said.

Although this may sound like capitation, Ms. Gosfield said it differs in several ways. The payment model avoids the problems inherent in capitation by constructing the payment rates in a way that reflects the cost of what is clinically relevant to the patient's condition, and by adjusting ECRs to account for relative severity of cases.

Diabetes and acute MI will be the first two conditions piloted under the Prometheus system, Ms. Gosfield said.

For diabetes, “we tried to define what would be a typical diabetes case. Then we defined hospitalization, strokes, amputation, and retinal procedures as potentially avoidable complications,” she said. To make the system fair, “we decided to take half the money we'd be spending on those preventable complications and give it back to providers anyway.” For example, in the system, a primary care physician caring for a patient with controlled type 2 diabetes might receive $2,300 per year. With enough of these patients, the physician could hire a nurse practitioner to serve as a patient educator and coach, Ms. Gosfield said.

If the cost of care exceeds the flat rate payment, the physician must make up the difference—providing a powerful incentive to manage the patient carefully, she said.

The Prometheus system is risk adjusted and sustainable as a business model, Ms. Gosfield said. In addition, it provides certainty in payment, is transparent and easy to administer, reduces malpractice liability, improves clinical guideline quality, and gives physicians more control, she said.

Gosfield cautioned that the system is complicated and will incur transitional costs, especially if it becomes widely adopted while other payment systems remain in place at the same time.

WASHINGTON — Physicians generally believe that medical errors—especially those that cause an adverse event—should be disclosed to patients, but there is disagreement about the level of detail that should be provided, according to a physician who has studied the issue.

Dr. Thomas Gallagher, associate professor of medicine at the University of Washington, Seattle, told attendees at the annual meeting of the American College of Physicians that physicians are unsure about what to include when they disclose a medical error. But he added that physicians are actively debating the best way to proceed.

"Over the next 5 years, we're going to see very exciting changes," he said. "I think physicians as a profession will be leading the way to set some standards as to how these difficult conversations should go."

Patients conceive of errors broadly and desire full disclosure of harmful errors, while at the same time worrying that health care workers might hide them. In disclosure, they want "an explicit statement that an error occurred," details of what happened, and the implications for their health, he said.

Physicians define errors more narrowly than patients do. They agree in principle with full disclosure and want to be truthful, but perceive barriers to disclosure. "Physicians feared that disclosure could be harmful to the patient," Dr. Gallagher said.

The University of Washington recently surveyed 4,000 physicians about communication with patients, colleagues, and health care institutions about errors.

According to Dr. Gallagher, the survey on error disclosure was sent to 2,000 physicians in Washington State and 2,000 Canadian physicians. The survey, which asked about general attitudes regarding disclosure, had a response rate of 63%.

Respondents were randomized to one of four specialty-specific disclosure scenarios and answered five questions to measure the content of their disclosure. Each question offered actual disclosure language that contained no information, a little information, or full disclosure.

When asked about general attitudes regarding disclosure, 98% of U.S. physicians said serious errors should be disclosed, and more than three-quarters said minor errors should be disclosed to patients. Less than one-third, however, said near misses should be disclosed, Dr. Gallagher said.

But when asked for answers in the specific scenarios, physicians didn't always want to admit that a medical error occurred, he said.

For example, one fictitious scenario involved an inpatient insulin overdose. In the example, a physician wrote an order for the patient to receive "10 U" of insulin, but the "U" in the order looked like a "0," and the following morning the patient received 100 units of insulin. The patient, found unresponsive with a blood glucose level of 35 mg/dL, was resuscitated and transferred to the intensive care unit and is expected to make a full recovery.

Nearly 65% of physicians said they would "definitely" disclose the error, and about 32% said they "probably" would disclose the error, Dr. Gallagher said. When asked how they would explain the situation, 1% said they would tell the patient, "Your blood sugar went too low and you passed out"; 28% said they would say, "Your blood sugar went too low because you received more insulin than you needed"; and 71% said they would tell the patient, "Your blood sugar went too low because an error happened and you received too much insulin."

When asked how much detail they would provide, 11% said they would not volunteer any specific information about the details of the error unless asked by the patient; 36% said they'd tell the patient, "You received more insulin than you needed"; and 54% said they'd tell the patient, "You received 100 units rather than your usual 10 units of insulin."

Dr. Gallagher said that preliminary survey conclusions show that physicians support the concept of disclosure, but are uncertain about the core content of any disclosure. Most would disclose less information about errors that would not be apparent to the patient, he said.

There is accelerating interest in disclosure and growing experimentation with disclosure approaches among health care organizations and malpractice insurers, Dr. Gallagher said, and this goes hand-in-hand with the increased emphasis on transparency in health care generally.

WASHINGTON — Physicians generally believe that medical errors—especially those that cause an adverse event—should be disclosed to patients, but there is disagreement about the level of detail that should be provided, according to a physician who has studied the issue.

Dr. Thomas Gallagher, associate professor of medicine at the University of Washington, Seattle, told attendees at the annual meeting of the American College of Physicians that physicians are unsure about what to include when they disclose a medical error. But he added that physicians are actively debating the best way to proceed.

"Over the next 5 years, we're going to see very exciting changes," he said. "I think physicians as a profession will be leading the way to set some standards as to how these difficult conversations should go."

Patients conceive of errors broadly and desire full disclosure of harmful errors, while at the same time worrying that health care workers might hide them. In disclosure, they want "an explicit statement that an error occurred," details of what happened, and the implications for their health, he said.

Physicians define errors more narrowly than patients do. They agree in principle with full disclosure and want to be truthful, but perceive barriers to disclosure. "Physicians feared that disclosure could be harmful to the patient," Dr. Gallagher said.

The University of Washington recently surveyed 4,000 physicians about communication with patients, colleagues, and health care institutions about errors.

According to Dr. Gallagher, the survey on error disclosure was sent to 2,000 physicians in Washington State and 2,000 Canadian physicians. The survey, which asked about general attitudes regarding disclosure, had a response rate of 63%.

Respondents were randomized to one of four specialty-specific disclosure scenarios and answered five questions to measure the content of their disclosure. Each question offered actual disclosure language that contained no information, a little information, or full disclosure.

When asked about general attitudes regarding disclosure, 98% of U.S. physicians said serious errors should be disclosed, and more than three-quarters said minor errors should be disclosed to patients. Less than one-third, however, said near misses should be disclosed, Dr. Gallagher said.

But when asked for answers in the specific scenarios, physicians didn't always want to admit that a medical error occurred, he said.

For example, one fictitious scenario involved an inpatient insulin overdose. In the example, a physician wrote an order for the patient to receive "10 U" of insulin, but the "U" in the order looked like a "0," and the following morning the patient received 100 units of insulin. The patient, found unresponsive with a blood glucose level of 35 mg/dL, was resuscitated and transferred to the intensive care unit and is expected to make a full recovery.

Nearly 65% of physicians said they would "definitely" disclose the error, and about 32% said they "probably" would disclose the error, Dr. Gallagher said. When asked how they would explain the situation, 1% said they would tell the patient, "Your blood sugar went too low and you passed out"; 28% said they would say, "Your blood sugar went too low because you received more insulin than you needed"; and 71% said they would tell the patient, "Your blood sugar went too low because an error happened and you received too much insulin."

When asked how much detail they would provide, 11% said they would not volunteer any specific information about the details of the error unless asked by the patient; 36% said they'd tell the patient, "You received more insulin than you needed"; and 54% said they'd tell the patient, "You received 100 units rather than your usual 10 units of insulin."

Dr. Gallagher said that preliminary survey conclusions show that physicians support the concept of disclosure, but are uncertain about the core content of any disclosure. Most would disclose less information about errors that would not be apparent to the patient, he said.

There is accelerating interest in disclosure and growing experimentation with disclosure approaches among health care organizations and malpractice insurers, Dr. Gallagher said, and this goes hand-in-hand with the increased emphasis on transparency in health care generally.

WASHINGTON — Physicians generally believe that medical errors—especially those that cause an adverse event—should be disclosed to patients, but there is disagreement about the level of detail that should be provided, according to a physician who has studied the issue.

Dr. Thomas Gallagher, associate professor of medicine at the University of Washington, Seattle, told attendees at the annual meeting of the American College of Physicians that physicians are unsure about what to include when they disclose a medical error. But he added that physicians are actively debating the best way to proceed.

"Over the next 5 years, we're going to see very exciting changes," he said. "I think physicians as a profession will be leading the way to set some standards as to how these difficult conversations should go."

Patients conceive of errors broadly and desire full disclosure of harmful errors, while at the same time worrying that health care workers might hide them. In disclosure, they want "an explicit statement that an error occurred," details of what happened, and the implications for their health, he said.

Physicians define errors more narrowly than patients do. They agree in principle with full disclosure and want to be truthful, but perceive barriers to disclosure. "Physicians feared that disclosure could be harmful to the patient," Dr. Gallagher said.

The University of Washington recently surveyed 4,000 physicians about communication with patients, colleagues, and health care institutions about errors.

According to Dr. Gallagher, the survey on error disclosure was sent to 2,000 physicians in Washington State and 2,000 Canadian physicians. The survey, which asked about general attitudes regarding disclosure, had a response rate of 63%.

Respondents were randomized to one of four specialty-specific disclosure scenarios and answered five questions to measure the content of their disclosure. Each question offered actual disclosure language that contained no information, a little information, or full disclosure.

When asked about general attitudes regarding disclosure, 98% of U.S. physicians said serious errors should be disclosed, and more than three-quarters said minor errors should be disclosed to patients. Less than one-third, however, said near misses should be disclosed, Dr. Gallagher said.

But when asked for answers in the specific scenarios, physicians didn't always want to admit that a medical error occurred, he said.

For example, one fictitious scenario involved an inpatient insulin overdose. In the example, a physician wrote an order for the patient to receive "10 U" of insulin, but the "U" in the order looked like a "0," and the following morning the patient received 100 units of insulin. The patient, found unresponsive with a blood glucose level of 35 mg/dL, was resuscitated and transferred to the intensive care unit and is expected to make a full recovery.

Nearly 65% of physicians said they would "definitely" disclose the error, and about 32% said they "probably" would disclose the error, Dr. Gallagher said. When asked how they would explain the situation, 1% said they would tell the patient, "Your blood sugar went too low and you passed out"; 28% said they would say, "Your blood sugar went too low because you received more insulin than you needed"; and 71% said they would tell the patient, "Your blood sugar went too low because an error happened and you received too much insulin."

When asked how much detail they would provide, 11% said they would not volunteer any specific information about the details of the error unless asked by the patient; 36% said they'd tell the patient, "You received more insulin than you needed"; and 54% said they'd tell the patient, "You received 100 units rather than your usual 10 units of insulin."

Dr. Gallagher said that preliminary survey conclusions show that physicians support the concept of disclosure, but are uncertain about the core content of any disclosure. Most would disclose less information about errors that would not be apparent to the patient, he said.

There is accelerating interest in disclosure and growing experimentation with disclosure approaches among health care organizations and malpractice insurers, Dr. Gallagher said, and this goes hand-in-hand with the increased emphasis on transparency in health care generally.