Mary Ellen Schneider

The federal government has awarded $162 million in grants to states to aid in the secure exchange of health information across different proprietary systems.

The grants will go to 16 states and qualified state-designated entities. The money was set aside for states under the American Recovery and Reinvestment Act of 2009. This final round of grants follows the release of $385 million to 40 states and qualified state-designed entities in February.

“What these awards will do is strengthen our health care system and speed our economic recovery,” Kathleen Sebelius, Health and Human Services Secretary, said during a press conference to announce the grants. “They help to unleash the power of health information technology to cut costs, eliminate paperwork, and best of all help doctors deliver higher quality, coordinated care.”

Despite the benefits of adopting electronic health records (EHRs), only about 20% of physicians and 10% of hospitals have implemented even a basic EHR system, Ms. Sebelius said. The goal in awarding these grants is that the states will be able to develop policies and frameworks based on nationally approved technical standards, which will allow physicians and hospitals to securely share information regardless of what type of EHR system they have.

States will need to begin by bringing all the parties to the table—from physicians and hospitals to health insurers and lawyers, said Dr. David Blumenthal, the national coordinator for health information technology. These groups will need to agree on the strategic and operational plans for creating health-information exchange in each state, he said.

Health IT officials at the federal level will be working closely with the states on their plans for exchanging health data. But the states are in the best position to identify and credential physicians and hospitals that should be getting and sending secure health information transmissions, he said.

The states are currently at different points in their implementation timeline based on their past work on health information exchange, Dr. Blumenthal added. But he said he expects that many states will have the technology and governance structures in place by 2013 to allow physicians and hospitals to meet the requirements of the federal incentive program for EHR implementation. Created under the Recovery Act, that program calls for physicians and hospitals to show the ability to exchange information by 2011, but more robust exchange requirements do not phase in until 2013.

The federal government has awarded $162 million in grants to states to aid in the secure exchange of health information across different proprietary systems.

The grants will go to 16 states and qualified state-designated entities. The money was set aside for states under the American Recovery and Reinvestment Act of 2009. This final round of grants follows the release of $385 million to 40 states and qualified state-designed entities in February.

“What these awards will do is strengthen our health care system and speed our economic recovery,” Kathleen Sebelius, Health and Human Services Secretary, said during a press conference to announce the grants. “They help to unleash the power of health information technology to cut costs, eliminate paperwork, and best of all help doctors deliver higher quality, coordinated care.”

Despite the benefits of adopting electronic health records (EHRs), only about 20% of physicians and 10% of hospitals have implemented even a basic EHR system, Ms. Sebelius said. The goal in awarding these grants is that the states will be able to develop policies and frameworks based on nationally approved technical standards, which will allow physicians and hospitals to securely share information regardless of what type of EHR system they have.

States will need to begin by bringing all the parties to the table—from physicians and hospitals to health insurers and lawyers, said Dr. David Blumenthal, the national coordinator for health information technology. These groups will need to agree on the strategic and operational plans for creating health-information exchange in each state, he said.

Health IT officials at the federal level will be working closely with the states on their plans for exchanging health data. But the states are in the best position to identify and credential physicians and hospitals that should be getting and sending secure health information transmissions, he said.

The states are currently at different points in their implementation timeline based on their past work on health information exchange, Dr. Blumenthal added. But he said he expects that many states will have the technology and governance structures in place by 2013 to allow physicians and hospitals to meet the requirements of the federal incentive program for EHR implementation. Created under the Recovery Act, that program calls for physicians and hospitals to show the ability to exchange information by 2011, but more robust exchange requirements do not phase in until 2013.

The federal government has awarded $162 million in grants to states to aid in the secure exchange of health information across different proprietary systems.

The grants will go to 16 states and qualified state-designated entities. The money was set aside for states under the American Recovery and Reinvestment Act of 2009. This final round of grants follows the release of $385 million to 40 states and qualified state-designed entities in February.

“What these awards will do is strengthen our health care system and speed our economic recovery,” Kathleen Sebelius, Health and Human Services Secretary, said during a press conference to announce the grants. “They help to unleash the power of health information technology to cut costs, eliminate paperwork, and best of all help doctors deliver higher quality, coordinated care.”

Despite the benefits of adopting electronic health records (EHRs), only about 20% of physicians and 10% of hospitals have implemented even a basic EHR system, Ms. Sebelius said. The goal in awarding these grants is that the states will be able to develop policies and frameworks based on nationally approved technical standards, which will allow physicians and hospitals to securely share information regardless of what type of EHR system they have.

States will need to begin by bringing all the parties to the table—from physicians and hospitals to health insurers and lawyers, said Dr. David Blumenthal, the national coordinator for health information technology. These groups will need to agree on the strategic and operational plans for creating health-information exchange in each state, he said.

Health IT officials at the federal level will be working closely with the states on their plans for exchanging health data. But the states are in the best position to identify and credential physicians and hospitals that should be getting and sending secure health information transmissions, he said.

The states are currently at different points in their implementation timeline based on their past work on health information exchange, Dr. Blumenthal added. But he said he expects that many states will have the technology and governance structures in place by 2013 to allow physicians and hospitals to meet the requirements of the federal incentive program for EHR implementation. Created under the Recovery Act, that program calls for physicians and hospitals to show the ability to exchange information by 2011, but more robust exchange requirements do not phase in until 2013.

The federal government will begin its incentive program for the use of electronic health record systems in less than a year, but many physician organizations say the Medicare timeline is just too aggressive and runs the risk of turning some physicians away from the technology.

In contrast, the Medicaid incentive program offers more time for physicians to gear up. Pediatricians can start using electronic health record (EHR) technology as late as 2016 and still earn the maximum payments under the program. Those pediatricians who have a volume of at least 20% Medicaid patients in their practice are eligible to receive up to $42,500 over a period of 6 years for adopting or updating certified EHR technology, and for the “meaningful use” of that technology. For those with a 30% Medicaid volume, the maximum payment is $63,750.

Under a proposed rule issued by the Centers for Medicare and Medicaid Services in December, during the first year, pediatricians only need to show that they have installed or upgraded to a certified EHR. In the following years, they must demonstrate so-called meaningful use of the technology.

The proposed rule also outlined the requirements to achieve meaningful use. The requirements are phased in with minimum standards early on. Additional criteria are added in 2013 and 2015. Under stage 1, physicians must meet 25 objectives including the use of computerized provider order entry, electronic prescribing, reporting on quality measures, and checking insurance eligibility electronically.

In a letter to Centers for Medicare and Medicaid Services officials, sent last month, a coalition of more than 95 national and state physician organizations, including the American Academy of Pediatrics, voiced their concerns about the stage 1 requirements. Although the coalition supports the phased-in approach to meaningful use, they said there is too much being asked of physicians in the first stage of the program.

One concern is that if physicians rapidly install EHR systems without addressing the many workflow changes that EHRs create, the new systems could be more dangerous in some cases than the paper systems the electronic records replace, said Dr. Joseph H. Schneider, chief medical information officer at Baylor Health Care System in Dallas, and chair of the Council on Clinical Information Technology for the American Academy of Pediatrics.

Some of the requirements in the proposed rule also seem impractical, he said. For example, CMS proposed that as one of the requirements for achieving meaningful use, at least 75% of all permissible prescriptions written must be transmitted electronically using certified EHR technology.

That requirement overlooks the fact that in many areas there are large numbers of pharmacies that still don't accept electronic prescriptions. That figure is around 30% in Texas, he said.

But pediatricians don't need to worry about getting to meaningful use as quickly as some other specialties, Dr. Schneider said. While the Medicare incentive program requires physicians to achieve meaningful use before 2013 to qualify for the full complement of incentive payments, pediatricians under the Medicaid program can achieve meaningful use as late as 2017 and still collect all of the incentive payments.

“Most pediatricians don't need to rush to the store to get their EHRs,” Dr. Schneider said.

For one, there is discussion within the health IT community about a next generation of EHRs that may be coming in the next few years. Also, the AAP will soon be releasing better tools to help pediatricians assess their readiness, as well as tools for selecting and implementing products. Local Regional Extension Centers will also be providing support to pediatricians within the next year, Dr. Schneider said.

But depending on where you practice, you might want to think about EHRs sooner rather than later, Dr. Schneider said. That's because family physicians, who are likely to qualify for incentives under Medicare, will need to adopt sooner. If there are several family physicians in your area treating children, you don't want to be the only practice still working with paper records.

Also, pediatricians working in growth areas with lots of new families coming to the community may have a competitive edge if they adopt an EHR. Families choosing a physician in a new area may want to pick a practice that has already made the conversion to electronic records, he said.

Other factors include the ability to attract new pediatricians from residency programs, as many of these physicians expect to use an EHR.

“All of these factors, and many more, have to be weighed,” Dr. Schneider commented.

“Take your time in making this important decision and get help. We're hearing more cases of the long-term horrors of choosing the wrong EHR and you don't want to be one of them.”

The federal government will begin its incentive program for the use of electronic health record systems in less than a year, but many physician organizations say the Medicare timeline is just too aggressive and runs the risk of turning some physicians away from the technology.

In contrast, the Medicaid incentive program offers more time for physicians to gear up. Pediatricians can start using electronic health record (EHR) technology as late as 2016 and still earn the maximum payments under the program. Those pediatricians who have a volume of at least 20% Medicaid patients in their practice are eligible to receive up to $42,500 over a period of 6 years for adopting or updating certified EHR technology, and for the “meaningful use” of that technology. For those with a 30% Medicaid volume, the maximum payment is $63,750.

Under a proposed rule issued by the Centers for Medicare and Medicaid Services in December, during the first year, pediatricians only need to show that they have installed or upgraded to a certified EHR. In the following years, they must demonstrate so-called meaningful use of the technology.

The proposed rule also outlined the requirements to achieve meaningful use. The requirements are phased in with minimum standards early on. Additional criteria are added in 2013 and 2015. Under stage 1, physicians must meet 25 objectives including the use of computerized provider order entry, electronic prescribing, reporting on quality measures, and checking insurance eligibility electronically.

In a letter to Centers for Medicare and Medicaid Services officials, sent last month, a coalition of more than 95 national and state physician organizations, including the American Academy of Pediatrics, voiced their concerns about the stage 1 requirements. Although the coalition supports the phased-in approach to meaningful use, they said there is too much being asked of physicians in the first stage of the program.

One concern is that if physicians rapidly install EHR systems without addressing the many workflow changes that EHRs create, the new systems could be more dangerous in some cases than the paper systems the electronic records replace, said Dr. Joseph H. Schneider, chief medical information officer at Baylor Health Care System in Dallas, and chair of the Council on Clinical Information Technology for the American Academy of Pediatrics.

Some of the requirements in the proposed rule also seem impractical, he said. For example, CMS proposed that as one of the requirements for achieving meaningful use, at least 75% of all permissible prescriptions written must be transmitted electronically using certified EHR technology.

That requirement overlooks the fact that in many areas there are large numbers of pharmacies that still don't accept electronic prescriptions. That figure is around 30% in Texas, he said.

But pediatricians don't need to worry about getting to meaningful use as quickly as some other specialties, Dr. Schneider said. While the Medicare incentive program requires physicians to achieve meaningful use before 2013 to qualify for the full complement of incentive payments, pediatricians under the Medicaid program can achieve meaningful use as late as 2017 and still collect all of the incentive payments.

“Most pediatricians don't need to rush to the store to get their EHRs,” Dr. Schneider said.

For one, there is discussion within the health IT community about a next generation of EHRs that may be coming in the next few years. Also, the AAP will soon be releasing better tools to help pediatricians assess their readiness, as well as tools for selecting and implementing products. Local Regional Extension Centers will also be providing support to pediatricians within the next year, Dr. Schneider said.

But depending on where you practice, you might want to think about EHRs sooner rather than later, Dr. Schneider said. That's because family physicians, who are likely to qualify for incentives under Medicare, will need to adopt sooner. If there are several family physicians in your area treating children, you don't want to be the only practice still working with paper records.

Also, pediatricians working in growth areas with lots of new families coming to the community may have a competitive edge if they adopt an EHR. Families choosing a physician in a new area may want to pick a practice that has already made the conversion to electronic records, he said.

Other factors include the ability to attract new pediatricians from residency programs, as many of these physicians expect to use an EHR.

“All of these factors, and many more, have to be weighed,” Dr. Schneider commented.

“Take your time in making this important decision and get help. We're hearing more cases of the long-term horrors of choosing the wrong EHR and you don't want to be one of them.”

The federal government will begin its incentive program for the use of electronic health record systems in less than a year, but many physician organizations say the Medicare timeline is just too aggressive and runs the risk of turning some physicians away from the technology.

In contrast, the Medicaid incentive program offers more time for physicians to gear up. Pediatricians can start using electronic health record (EHR) technology as late as 2016 and still earn the maximum payments under the program. Those pediatricians who have a volume of at least 20% Medicaid patients in their practice are eligible to receive up to $42,500 over a period of 6 years for adopting or updating certified EHR technology, and for the “meaningful use” of that technology. For those with a 30% Medicaid volume, the maximum payment is $63,750.

Under a proposed rule issued by the Centers for Medicare and Medicaid Services in December, during the first year, pediatricians only need to show that they have installed or upgraded to a certified EHR. In the following years, they must demonstrate so-called meaningful use of the technology.

The proposed rule also outlined the requirements to achieve meaningful use. The requirements are phased in with minimum standards early on. Additional criteria are added in 2013 and 2015. Under stage 1, physicians must meet 25 objectives including the use of computerized provider order entry, electronic prescribing, reporting on quality measures, and checking insurance eligibility electronically.

In a letter to Centers for Medicare and Medicaid Services officials, sent last month, a coalition of more than 95 national and state physician organizations, including the American Academy of Pediatrics, voiced their concerns about the stage 1 requirements. Although the coalition supports the phased-in approach to meaningful use, they said there is too much being asked of physicians in the first stage of the program.

One concern is that if physicians rapidly install EHR systems without addressing the many workflow changes that EHRs create, the new systems could be more dangerous in some cases than the paper systems the electronic records replace, said Dr. Joseph H. Schneider, chief medical information officer at Baylor Health Care System in Dallas, and chair of the Council on Clinical Information Technology for the American Academy of Pediatrics.

Some of the requirements in the proposed rule also seem impractical, he said. For example, CMS proposed that as one of the requirements for achieving meaningful use, at least 75% of all permissible prescriptions written must be transmitted electronically using certified EHR technology.

That requirement overlooks the fact that in many areas there are large numbers of pharmacies that still don't accept electronic prescriptions. That figure is around 30% in Texas, he said.

But pediatricians don't need to worry about getting to meaningful use as quickly as some other specialties, Dr. Schneider said. While the Medicare incentive program requires physicians to achieve meaningful use before 2013 to qualify for the full complement of incentive payments, pediatricians under the Medicaid program can achieve meaningful use as late as 2017 and still collect all of the incentive payments.

“Most pediatricians don't need to rush to the store to get their EHRs,” Dr. Schneider said.

For one, there is discussion within the health IT community about a next generation of EHRs that may be coming in the next few years. Also, the AAP will soon be releasing better tools to help pediatricians assess their readiness, as well as tools for selecting and implementing products. Local Regional Extension Centers will also be providing support to pediatricians within the next year, Dr. Schneider said.

But depending on where you practice, you might want to think about EHRs sooner rather than later, Dr. Schneider said. That's because family physicians, who are likely to qualify for incentives under Medicare, will need to adopt sooner. If there are several family physicians in your area treating children, you don't want to be the only practice still working with paper records.

Also, pediatricians working in growth areas with lots of new families coming to the community may have a competitive edge if they adopt an EHR. Families choosing a physician in a new area may want to pick a practice that has already made the conversion to electronic records, he said.

Other factors include the ability to attract new pediatricians from residency programs, as many of these physicians expect to use an EHR.

“All of these factors, and many more, have to be weighed,” Dr. Schneider commented.

“Take your time in making this important decision and get help. We're hearing more cases of the long-term horrors of choosing the wrong EHR and you don't want to be one of them.”

Dr. Steve Narang, a pediatric hospitalist in Baton Rouge, La., has a deceptively simple philosophy about delivering care to his patients: He wants them to get the best care available, even if that isn't the latest and supposedly greatest therapy.

Over the last decade, he has worked with his colleagues to apply that philosophy in hospitals in the Baton Rouge area, and he has watched quality of care improve while costs decline. Now he is working with other pediatric hospitalists to spread his quality-improvement approach to hospitals around the country.

“There's a lot of emphasis in our health care system on what is the newest drug, the newest technology,” but very little comparative effectiveness data can be tapped to help physicians judge “what makes something better to use than something else,” said Dr. Narang, who serves as the medical director for quality and safety at Our Lady of the Lake Regional Medical Center in Baton Rouge.

About 2 years ago, Dr. Narang joined forces with four other pediatric hospitalists to launch the Value in Inpatient Pediatrics (VIP) Network. The small, informal steering committee included Dr. Narang, Dr. Matthew D. Garber of the University of South Carolina in Columbia, Dr. Brian M. Pate of the University of Missouri–Kansas City, Dr. Shawn Ralston of the University of Texas Health Science Center in San Antonio, and Dr. Mark Shen of Dell Children's Medical Center of Central Texas in Austin.

The grassroots project had no funding source, but it did have a straightforward goal: “Let's ask people to share their secrets” was how Dr. Narang and the other VIP Network members expressed their intent.

They began by asking hospitals around the country that care for children to report benchmark data on one of the most common diagnoses in hospitalized children—bronchiolitis. They invited the hospitals to provide a mix of process and outcome data about such patients. They sought information on length of stay, utilization of therapies, readmission rates within 72 hours, and variable direct costs for the treatment of children with bronchiolitis.

The VIP Network members also asked hospitals to report on the percentage of such patients receiving bronchodilators, steroids, chest x-rays, respiratory syncytial virus antigen testing, and chest physiotherapy.

The project, which is now in its second year, so far has collected data on about 7,000 patients who were treated for bronchiolitis at about 30 hospitals.

The hospitals participating in the VIP Network can compare their performance with that of other institutions on a quarterly and annual basis.

But the more exciting part, Dr. Narang said, is that hospitals are beginning to form collaboratives within the network, and the best-performing hospitals are sharing how they achieved success. Dr. Narang said that he hopes that the VIP Network will be able to obtain funding and thereby continue to grow.

The network founders are applying for a grant from the Agency for Healthcare Research and Quality, which they would use to hire a paid staff member who could automate and validate the data coming from the hospitals in the network.

Although other organizations are also performing this type of benchmarking work, Dr. Narang said that the VIP Network offers something unique because it does not focus only on freestanding children's hospitals.

Approximately 75% of children are cared for outside of freestanding children's hospitals, he noted, so quality data from general hospitals are needed to find the quality gaps.

The other characteristic that makes the VIP Network stand out is that it links process and outcome data, while most databases contain information only on outcomes.

“I think the key thing that we're learning in health care is not only do you need outcome measures, you need performance drivers,” Dr. Narang said. “How and why did these things occur?”

There is very little data to help physicians judge 'what makes something better to use than something else.'

Source DR. NARANG

Dr. Steve Narang, a pediatric hospitalist in Baton Rouge, La., has a deceptively simple philosophy about delivering care to his patients: He wants them to get the best care available, even if that isn't the latest and supposedly greatest therapy.

Over the last decade, he has worked with his colleagues to apply that philosophy in hospitals in the Baton Rouge area, and he has watched quality of care improve while costs decline. Now he is working with other pediatric hospitalists to spread his quality-improvement approach to hospitals around the country.

“There's a lot of emphasis in our health care system on what is the newest drug, the newest technology,” but very little comparative effectiveness data can be tapped to help physicians judge “what makes something better to use than something else,” said Dr. Narang, who serves as the medical director for quality and safety at Our Lady of the Lake Regional Medical Center in Baton Rouge.

About 2 years ago, Dr. Narang joined forces with four other pediatric hospitalists to launch the Value in Inpatient Pediatrics (VIP) Network. The small, informal steering committee included Dr. Narang, Dr. Matthew D. Garber of the University of South Carolina in Columbia, Dr. Brian M. Pate of the University of Missouri–Kansas City, Dr. Shawn Ralston of the University of Texas Health Science Center in San Antonio, and Dr. Mark Shen of Dell Children's Medical Center of Central Texas in Austin.

The grassroots project had no funding source, but it did have a straightforward goal: “Let's ask people to share their secrets” was how Dr. Narang and the other VIP Network members expressed their intent.

They began by asking hospitals around the country that care for children to report benchmark data on one of the most common diagnoses in hospitalized children—bronchiolitis. They invited the hospitals to provide a mix of process and outcome data about such patients. They sought information on length of stay, utilization of therapies, readmission rates within 72 hours, and variable direct costs for the treatment of children with bronchiolitis.

The VIP Network members also asked hospitals to report on the percentage of such patients receiving bronchodilators, steroids, chest x-rays, respiratory syncytial virus antigen testing, and chest physiotherapy.

The project, which is now in its second year, so far has collected data on about 7,000 patients who were treated for bronchiolitis at about 30 hospitals.

The hospitals participating in the VIP Network can compare their performance with that of other institutions on a quarterly and annual basis.

But the more exciting part, Dr. Narang said, is that hospitals are beginning to form collaboratives within the network, and the best-performing hospitals are sharing how they achieved success. Dr. Narang said that he hopes that the VIP Network will be able to obtain funding and thereby continue to grow.

The network founders are applying for a grant from the Agency for Healthcare Research and Quality, which they would use to hire a paid staff member who could automate and validate the data coming from the hospitals in the network.

Although other organizations are also performing this type of benchmarking work, Dr. Narang said that the VIP Network offers something unique because it does not focus only on freestanding children's hospitals.

Approximately 75% of children are cared for outside of freestanding children's hospitals, he noted, so quality data from general hospitals are needed to find the quality gaps.

The other characteristic that makes the VIP Network stand out is that it links process and outcome data, while most databases contain information only on outcomes.

“I think the key thing that we're learning in health care is not only do you need outcome measures, you need performance drivers,” Dr. Narang said. “How and why did these things occur?”

There is very little data to help physicians judge 'what makes something better to use than something else.'

Source DR. NARANG

Dr. Steve Narang, a pediatric hospitalist in Baton Rouge, La., has a deceptively simple philosophy about delivering care to his patients: He wants them to get the best care available, even if that isn't the latest and supposedly greatest therapy.

Over the last decade, he has worked with his colleagues to apply that philosophy in hospitals in the Baton Rouge area, and he has watched quality of care improve while costs decline. Now he is working with other pediatric hospitalists to spread his quality-improvement approach to hospitals around the country.

“There's a lot of emphasis in our health care system on what is the newest drug, the newest technology,” but very little comparative effectiveness data can be tapped to help physicians judge “what makes something better to use than something else,” said Dr. Narang, who serves as the medical director for quality and safety at Our Lady of the Lake Regional Medical Center in Baton Rouge.

About 2 years ago, Dr. Narang joined forces with four other pediatric hospitalists to launch the Value in Inpatient Pediatrics (VIP) Network. The small, informal steering committee included Dr. Narang, Dr. Matthew D. Garber of the University of South Carolina in Columbia, Dr. Brian M. Pate of the University of Missouri–Kansas City, Dr. Shawn Ralston of the University of Texas Health Science Center in San Antonio, and Dr. Mark Shen of Dell Children's Medical Center of Central Texas in Austin.

The grassroots project had no funding source, but it did have a straightforward goal: “Let's ask people to share their secrets” was how Dr. Narang and the other VIP Network members expressed their intent.

They began by asking hospitals around the country that care for children to report benchmark data on one of the most common diagnoses in hospitalized children—bronchiolitis. They invited the hospitals to provide a mix of process and outcome data about such patients. They sought information on length of stay, utilization of therapies, readmission rates within 72 hours, and variable direct costs for the treatment of children with bronchiolitis.

The VIP Network members also asked hospitals to report on the percentage of such patients receiving bronchodilators, steroids, chest x-rays, respiratory syncytial virus antigen testing, and chest physiotherapy.

The project, which is now in its second year, so far has collected data on about 7,000 patients who were treated for bronchiolitis at about 30 hospitals.

The hospitals participating in the VIP Network can compare their performance with that of other institutions on a quarterly and annual basis.

But the more exciting part, Dr. Narang said, is that hospitals are beginning to form collaboratives within the network, and the best-performing hospitals are sharing how they achieved success. Dr. Narang said that he hopes that the VIP Network will be able to obtain funding and thereby continue to grow.

The network founders are applying for a grant from the Agency for Healthcare Research and Quality, which they would use to hire a paid staff member who could automate and validate the data coming from the hospitals in the network.

Although other organizations are also performing this type of benchmarking work, Dr. Narang said that the VIP Network offers something unique because it does not focus only on freestanding children's hospitals.

Approximately 75% of children are cared for outside of freestanding children's hospitals, he noted, so quality data from general hospitals are needed to find the quality gaps.

The other characteristic that makes the VIP Network stand out is that it links process and outcome data, while most databases contain information only on outcomes.

“I think the key thing that we're learning in health care is not only do you need outcome measures, you need performance drivers,” Dr. Narang said. “How and why did these things occur?”

There is very little data to help physicians judge 'what makes something better to use than something else.'

Source DR. NARANG

At Beth Israel Deaconess Medical Center in Boston, Dr. Joseph M. Li and his team of 33 hospitalists are expanding the traditional role of the specialty, taking on more teaching opportunities and providing limited outpatient care.

Dr. Li, who founded the program in 1998 and serves as the director of hospital medicine, has been pushing the hospitalist team to do more than just the usual inpatient care duties. About 5 years ago, the hospital medicine program launched a procedure service. Now bedside procedures performed by house staff are supervised by a hospitalist, Dr. Li said.

“It's been a wonderful opportunity for us to teach the procedure and to supervise and make sure our patients get quality care,” Dr. Li said. “We've found that it's also a wonderful opportunity for us to interact with house staff.”

With the implementation of the procedure service a success, the hospital medicine program attempted to tackle the thorny issues of avoidable readmissions and continuity of care at discharge.

Last September, Dr. Li and his team launched a postdischarge clinic at the hospital. Due to the shortage of primary care physicians in the Boston area, Dr. Li and his colleagues found that after being discharged from the hospital, patients were waiting 4-6 weeks on average to get follow-up care with their regular physician. That's far from the 2 weeks Dr. Li said is the ideal window for follow-up care. And he has seen some patients return to the hospital with problems that might have been avoided if they had been seen earlier by their primary care physician.

The goal in setting up the postdischarge clinic was not to create outpatient work for hospitalists, he said. In fact, the hospital's call center books the first available appointment with the patient's primary care physician as part of the discharge process. But when that appointment isn't timely, the call center staff sets up an interim visit in the hospitalist-run postdischarge clinic.

The experience has been a bit like looking in a mirror for the hospitalists, Dr. Li said. Now that they hand off their patients to one of their colleagues, they've learned that they don't always do as good a job in the transition of care as they previously thought, he said.

The launch of the clinic has created some confusion for patients, requiring some extra explanation from both the nurse and the inpatient hospitalist. It's also caused some confusion for primary care providers, some of whom initially wondered if the hospitalists were trying to poach their patients, Dr. Li said. “We had to make it very clear that we're going to make every attempt to have that patient follow up with you before we send the patient to the postdischarge clinic,” he said. “That continues to be a work in process.”

But some primary care physicians have been very receptive to the notion that someone can help provide the transition after hospitalization and potentially improve the care for patients. Primary care physicians “are awfully busy today trying to provide timely access for all their patients,” Dr. Li said.

It's too early to tell if the effort is accomplishing the ultimate goal—to reduce unnecessary readmissions and improve quality of care. Dr. Li said they are reviewing data on the readmission rates of each of the hospitalists. However, it's complicated to tease out the impact of having a sicker patient population, as well as to determine the appropriate balance between the patients' length of stay and their chances for readmission. “I think that you can't look just simply at the readmission rate,” he said.

When evaluating improvements in quality of care, 'you can't look just simply at the readmission rate.'

At Beth Israel Deaconess Medical Center in Boston, Dr. Joseph M. Li and his team of 33 hospitalists are expanding the traditional role of the specialty, taking on more teaching opportunities and providing limited outpatient care.

Dr. Li, who founded the program in 1998 and serves as the director of hospital medicine, has been pushing the hospitalist team to do more than just the usual inpatient care duties. About 5 years ago, the hospital medicine program launched a procedure service. Now bedside procedures performed by house staff are supervised by a hospitalist, Dr. Li said.

“It's been a wonderful opportunity for us to teach the procedure and to supervise and make sure our patients get quality care,” Dr. Li said. “We've found that it's also a wonderful opportunity for us to interact with house staff.”

With the implementation of the procedure service a success, the hospital medicine program attempted to tackle the thorny issues of avoidable readmissions and continuity of care at discharge.

Last September, Dr. Li and his team launched a postdischarge clinic at the hospital. Due to the shortage of primary care physicians in the Boston area, Dr. Li and his colleagues found that after being discharged from the hospital, patients were waiting 4-6 weeks on average to get follow-up care with their regular physician. That's far from the 2 weeks Dr. Li said is the ideal window for follow-up care. And he has seen some patients return to the hospital with problems that might have been avoided if they had been seen earlier by their primary care physician.

The goal in setting up the postdischarge clinic was not to create outpatient work for hospitalists, he said. In fact, the hospital's call center books the first available appointment with the patient's primary care physician as part of the discharge process. But when that appointment isn't timely, the call center staff sets up an interim visit in the hospitalist-run postdischarge clinic.

The experience has been a bit like looking in a mirror for the hospitalists, Dr. Li said. Now that they hand off their patients to one of their colleagues, they've learned that they don't always do as good a job in the transition of care as they previously thought, he said.

The launch of the clinic has created some confusion for patients, requiring some extra explanation from both the nurse and the inpatient hospitalist. It's also caused some confusion for primary care providers, some of whom initially wondered if the hospitalists were trying to poach their patients, Dr. Li said. “We had to make it very clear that we're going to make every attempt to have that patient follow up with you before we send the patient to the postdischarge clinic,” he said. “That continues to be a work in process.”

But some primary care physicians have been very receptive to the notion that someone can help provide the transition after hospitalization and potentially improve the care for patients. Primary care physicians “are awfully busy today trying to provide timely access for all their patients,” Dr. Li said.

It's too early to tell if the effort is accomplishing the ultimate goal—to reduce unnecessary readmissions and improve quality of care. Dr. Li said they are reviewing data on the readmission rates of each of the hospitalists. However, it's complicated to tease out the impact of having a sicker patient population, as well as to determine the appropriate balance between the patients' length of stay and their chances for readmission. “I think that you can't look just simply at the readmission rate,” he said.

When evaluating improvements in quality of care, 'you can't look just simply at the readmission rate.'

At Beth Israel Deaconess Medical Center in Boston, Dr. Joseph M. Li and his team of 33 hospitalists are expanding the traditional role of the specialty, taking on more teaching opportunities and providing limited outpatient care.

Dr. Li, who founded the program in 1998 and serves as the director of hospital medicine, has been pushing the hospitalist team to do more than just the usual inpatient care duties. About 5 years ago, the hospital medicine program launched a procedure service. Now bedside procedures performed by house staff are supervised by a hospitalist, Dr. Li said.

“It's been a wonderful opportunity for us to teach the procedure and to supervise and make sure our patients get quality care,” Dr. Li said. “We've found that it's also a wonderful opportunity for us to interact with house staff.”

With the implementation of the procedure service a success, the hospital medicine program attempted to tackle the thorny issues of avoidable readmissions and continuity of care at discharge.

Last September, Dr. Li and his team launched a postdischarge clinic at the hospital. Due to the shortage of primary care physicians in the Boston area, Dr. Li and his colleagues found that after being discharged from the hospital, patients were waiting 4-6 weeks on average to get follow-up care with their regular physician. That's far from the 2 weeks Dr. Li said is the ideal window for follow-up care. And he has seen some patients return to the hospital with problems that might have been avoided if they had been seen earlier by their primary care physician.

The goal in setting up the postdischarge clinic was not to create outpatient work for hospitalists, he said. In fact, the hospital's call center books the first available appointment with the patient's primary care physician as part of the discharge process. But when that appointment isn't timely, the call center staff sets up an interim visit in the hospitalist-run postdischarge clinic.

The experience has been a bit like looking in a mirror for the hospitalists, Dr. Li said. Now that they hand off their patients to one of their colleagues, they've learned that they don't always do as good a job in the transition of care as they previously thought, he said.

The launch of the clinic has created some confusion for patients, requiring some extra explanation from both the nurse and the inpatient hospitalist. It's also caused some confusion for primary care providers, some of whom initially wondered if the hospitalists were trying to poach their patients, Dr. Li said. “We had to make it very clear that we're going to make every attempt to have that patient follow up with you before we send the patient to the postdischarge clinic,” he said. “That continues to be a work in process.”

But some primary care physicians have been very receptive to the notion that someone can help provide the transition after hospitalization and potentially improve the care for patients. Primary care physicians “are awfully busy today trying to provide timely access for all their patients,” Dr. Li said.

It's too early to tell if the effort is accomplishing the ultimate goal—to reduce unnecessary readmissions and improve quality of care. Dr. Li said they are reviewing data on the readmission rates of each of the hospitalists. However, it's complicated to tease out the impact of having a sicker patient population, as well as to determine the appropriate balance between the patients' length of stay and their chances for readmission. “I think that you can't look just simply at the readmission rate,” he said.

When evaluating improvements in quality of care, 'you can't look just simply at the readmission rate.'

LAS VEGAS — The federal government is stepping up its audit activities in Medicare, and that could mean greater scrutiny of billing practices.

One development that physicians should keep a close eye on is the recent nationwide rollout of Medicare's Recovery Audit Contractor program, said Edward R. Gaines III, vice president and chief compliance officer at CBIZ Medical Management Professionals Inc.

The program, which is known as the RAC, began as a demonstration project in New York, California, and Florida.

Under the program, private contractors are given contingency fees for identifying improper Medicare payments to health care providers, including over- and underpayments.

But Mr. Gaines said that the experience in the demonstration project showed that the contractors concentrated much more on detecting overpayments made to providers.

Now that the RAC program has been rolled out nationwide, four private contractors, each assigned to different regions of the country, will use data mining, outlier analysis, and referrals to root out improper payments. The RAC contractors will earn contingency fees for finding errors, with fees that vary from around 9% to 12%.

Physicians need to be aware of the RAC activities and do their own outlier analyses so they can be ready to defend against an audit, Mr. Gaines advised during a meeting on reimbursement sponsored by the American College of Emergency Physicians.

The RACs will look at evaluation and management services. During the demonstration project, evaluation and management services were exempt from audit, but that is not the case now that the RAC is a permanent program.

Medicare is raising the bar for audits because the program is in a financial squeeze, Mr. Gaines said.

Right now, Medicare receives more than 1.2 billion medical claims a year—and that's before the bulk of the baby boomer generation has entered the program. Add to that recent news reports that the Medicare and Medicaid programs are hemorrhaging tens of billions of dollars to fraud, and the federal government is in a position in which it needs to act to contain costs.

During the pilot phase of the program, the RACs collected $1 for every 20 cents spent by the government. “So, if you can get five times the rate of return and you're the federal government, this is a no-brainer,” Mr. Gaines said.

One area of specific concern with the RACs is that they have the power, at least in certain limited circumstances, to extrapolate an error rate across a larger number of Medicare claims. For example, if an RAC finds a 10% error rate on 50 medical records, extrapolation would allow the contractor to apply that error rate across all of a physician's Medicare patients over multiple years—potentially dramatically increasing the penalty.

There are restrictions to that power. For example, it can't be applied during the initial audit phase, and officials at the Centers for Medicare and Medicaid Services have stated that it can only be employed in cases where there is a sustained or a high level of payment error, or a failure to correct the error. In addition, penalties cannot be applied to claims before Oct. 1, 2007.

But the ability to perform extrapolation at all is making physicians uneasy. Although there are restrictions on when extrapolation could be applied, Mr. Gaines said, it's unclear how the CMS would put it into practice. And the fact that the RACs would earn contingency fees on extrapolated claims seems to increase the likelihood that the method would be used, he said. “That's where the money is,” he said.

Physicians who are audited by the RAC and have errors in 1 out of 50 charts would likely be at low risk for extrapolation, he said. However, the risk likely is higher for a physician or group that has been subject to audits in the past or been subject to corrective action.

LAS VEGAS — The federal government is stepping up its audit activities in Medicare, and that could mean greater scrutiny of billing practices.

One development that physicians should keep a close eye on is the recent nationwide rollout of Medicare's Recovery Audit Contractor program, said Edward R. Gaines III, vice president and chief compliance officer at CBIZ Medical Management Professionals Inc.

The program, which is known as the RAC, began as a demonstration project in New York, California, and Florida.

Under the program, private contractors are given contingency fees for identifying improper Medicare payments to health care providers, including over- and underpayments.

But Mr. Gaines said that the experience in the demonstration project showed that the contractors concentrated much more on detecting overpayments made to providers.

Now that the RAC program has been rolled out nationwide, four private contractors, each assigned to different regions of the country, will use data mining, outlier analysis, and referrals to root out improper payments. The RAC contractors will earn contingency fees for finding errors, with fees that vary from around 9% to 12%.

Physicians need to be aware of the RAC activities and do their own outlier analyses so they can be ready to defend against an audit, Mr. Gaines advised during a meeting on reimbursement sponsored by the American College of Emergency Physicians.

The RACs will look at evaluation and management services. During the demonstration project, evaluation and management services were exempt from audit, but that is not the case now that the RAC is a permanent program.

Medicare is raising the bar for audits because the program is in a financial squeeze, Mr. Gaines said.

Right now, Medicare receives more than 1.2 billion medical claims a year—and that's before the bulk of the baby boomer generation has entered the program. Add to that recent news reports that the Medicare and Medicaid programs are hemorrhaging tens of billions of dollars to fraud, and the federal government is in a position in which it needs to act to contain costs.

During the pilot phase of the program, the RACs collected $1 for every 20 cents spent by the government. “So, if you can get five times the rate of return and you're the federal government, this is a no-brainer,” Mr. Gaines said.

One area of specific concern with the RACs is that they have the power, at least in certain limited circumstances, to extrapolate an error rate across a larger number of Medicare claims. For example, if an RAC finds a 10% error rate on 50 medical records, extrapolation would allow the contractor to apply that error rate across all of a physician's Medicare patients over multiple years—potentially dramatically increasing the penalty.

There are restrictions to that power. For example, it can't be applied during the initial audit phase, and officials at the Centers for Medicare and Medicaid Services have stated that it can only be employed in cases where there is a sustained or a high level of payment error, or a failure to correct the error. In addition, penalties cannot be applied to claims before Oct. 1, 2007.

But the ability to perform extrapolation at all is making physicians uneasy. Although there are restrictions on when extrapolation could be applied, Mr. Gaines said, it's unclear how the CMS would put it into practice. And the fact that the RACs would earn contingency fees on extrapolated claims seems to increase the likelihood that the method would be used, he said. “That's where the money is,” he said.

Physicians who are audited by the RAC and have errors in 1 out of 50 charts would likely be at low risk for extrapolation, he said. However, the risk likely is higher for a physician or group that has been subject to audits in the past or been subject to corrective action.

LAS VEGAS — The federal government is stepping up its audit activities in Medicare, and that could mean greater scrutiny of billing practices.

One development that physicians should keep a close eye on is the recent nationwide rollout of Medicare's Recovery Audit Contractor program, said Edward R. Gaines III, vice president and chief compliance officer at CBIZ Medical Management Professionals Inc.

The program, which is known as the RAC, began as a demonstration project in New York, California, and Florida.

Under the program, private contractors are given contingency fees for identifying improper Medicare payments to health care providers, including over- and underpayments.

But Mr. Gaines said that the experience in the demonstration project showed that the contractors concentrated much more on detecting overpayments made to providers.

Now that the RAC program has been rolled out nationwide, four private contractors, each assigned to different regions of the country, will use data mining, outlier analysis, and referrals to root out improper payments. The RAC contractors will earn contingency fees for finding errors, with fees that vary from around 9% to 12%.

Physicians need to be aware of the RAC activities and do their own outlier analyses so they can be ready to defend against an audit, Mr. Gaines advised during a meeting on reimbursement sponsored by the American College of Emergency Physicians.

The RACs will look at evaluation and management services. During the demonstration project, evaluation and management services were exempt from audit, but that is not the case now that the RAC is a permanent program.

Medicare is raising the bar for audits because the program is in a financial squeeze, Mr. Gaines said.

Right now, Medicare receives more than 1.2 billion medical claims a year—and that's before the bulk of the baby boomer generation has entered the program. Add to that recent news reports that the Medicare and Medicaid programs are hemorrhaging tens of billions of dollars to fraud, and the federal government is in a position in which it needs to act to contain costs.

During the pilot phase of the program, the RACs collected $1 for every 20 cents spent by the government. “So, if you can get five times the rate of return and you're the federal government, this is a no-brainer,” Mr. Gaines said.

One area of specific concern with the RACs is that they have the power, at least in certain limited circumstances, to extrapolate an error rate across a larger number of Medicare claims. For example, if an RAC finds a 10% error rate on 50 medical records, extrapolation would allow the contractor to apply that error rate across all of a physician's Medicare patients over multiple years—potentially dramatically increasing the penalty.

There are restrictions to that power. For example, it can't be applied during the initial audit phase, and officials at the Centers for Medicare and Medicaid Services have stated that it can only be employed in cases where there is a sustained or a high level of payment error, or a failure to correct the error. In addition, penalties cannot be applied to claims before Oct. 1, 2007.

But the ability to perform extrapolation at all is making physicians uneasy. Although there are restrictions on when extrapolation could be applied, Mr. Gaines said, it's unclear how the CMS would put it into practice. And the fact that the RACs would earn contingency fees on extrapolated claims seems to increase the likelihood that the method would be used, he said. “That's where the money is,” he said.

Physicians who are audited by the RAC and have errors in 1 out of 50 charts would likely be at low risk for extrapolation, he said. However, the risk likely is higher for a physician or group that has been subject to audits in the past or been subject to corrective action.

NEW YORK — Building on the work in developing a clinical definition of remission in rheumatoid arthritis, a group of clinicians and researchers is interested in creating a complementary patient term called “absence of disease.”

Rheumatologists from around the world will begin discussing how to develop this patient-centered definition in Malaysian Borneo in May at the next meeting of OMERACT (Outcome Measures in Rheumatology), an international network aimed at improving outcomes assessment in rheumatology.

It's important to ask patients for their view of the “absence of disease” because they see “remission” so differently from physicians, Dr. Maarten Boers, a member of the OMERACT executive committee, said at a rheumatology course sponsored by New York University. The current remission term is a classic physician-centric definition that is largely based on inflammation, he said.

“If you talk to patients, they talk about totally different things than we talk about in terms of disease,” Dr. Boers, a professor at VU University Medical Center in Amsterdam, said in an interview.

Although patients were involved in developing the remission definition by OMERACT, that dimension wasn't fully studied. This time around, the organization plans to spend about 2 years performing qualitative work.

The effort won't have to start from scratch, though, Dr. Boers said, because there has already been qualitative work done on a related issue: the impact of disease, which could be interpreted as the opposite of the “absence of disease” concept.

NEW YORK — Building on the work in developing a clinical definition of remission in rheumatoid arthritis, a group of clinicians and researchers is interested in creating a complementary patient term called “absence of disease.”

Rheumatologists from around the world will begin discussing how to develop this patient-centered definition in Malaysian Borneo in May at the next meeting of OMERACT (Outcome Measures in Rheumatology), an international network aimed at improving outcomes assessment in rheumatology.

It's important to ask patients for their view of the “absence of disease” because they see “remission” so differently from physicians, Dr. Maarten Boers, a member of the OMERACT executive committee, said at a rheumatology course sponsored by New York University. The current remission term is a classic physician-centric definition that is largely based on inflammation, he said.

“If you talk to patients, they talk about totally different things than we talk about in terms of disease,” Dr. Boers, a professor at VU University Medical Center in Amsterdam, said in an interview.

Although patients were involved in developing the remission definition by OMERACT, that dimension wasn't fully studied. This time around, the organization plans to spend about 2 years performing qualitative work.

The effort won't have to start from scratch, though, Dr. Boers said, because there has already been qualitative work done on a related issue: the impact of disease, which could be interpreted as the opposite of the “absence of disease” concept.

NEW YORK — Building on the work in developing a clinical definition of remission in rheumatoid arthritis, a group of clinicians and researchers is interested in creating a complementary patient term called “absence of disease.”

Rheumatologists from around the world will begin discussing how to develop this patient-centered definition in Malaysian Borneo in May at the next meeting of OMERACT (Outcome Measures in Rheumatology), an international network aimed at improving outcomes assessment in rheumatology.

It's important to ask patients for their view of the “absence of disease” because they see “remission” so differently from physicians, Dr. Maarten Boers, a member of the OMERACT executive committee, said at a rheumatology course sponsored by New York University. The current remission term is a classic physician-centric definition that is largely based on inflammation, he said.

“If you talk to patients, they talk about totally different things than we talk about in terms of disease,” Dr. Boers, a professor at VU University Medical Center in Amsterdam, said in an interview.

Although patients were involved in developing the remission definition by OMERACT, that dimension wasn't fully studied. This time around, the organization plans to spend about 2 years performing qualitative work.

The effort won't have to start from scratch, though, Dr. Boers said, because there has already been qualitative work done on a related issue: the impact of disease, which could be interpreted as the opposite of the “absence of disease” concept.

Early results from two small studies show that the long-term use of oral bisphosphonates could harm bone quality and potentially lead to an increased risk for femur fractures, but the Food and Drug Administration is advising patients to stay on their medication unless advised by their physicians to stop.

The studies showed an association between the use of bisphosphonate treatments for 4 or more years and decreasing bone quality, possibly because the bisphosphonates altered the material properties of the bone. The two studies were presented at the annual meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

“Although bisphosphonates have demonstrated an improvement in bone quantity, little if anything is known about the effects of these drugs on bone quality,” Brian Gladnick, one of the researchers from the Hospital for Special Surgery in New York, said in a statement.

Researchers at the Hospital for Special Surgery conducted a prospective pilot study in which they evaluated the bone composition of 21 postmenopausal women who presented to the emergency department with proximal femoral fractures. Of the patients enrolled in the study, 12 had a history of bisphosphonate use for an average of 8.5 years. Nine of the women had never been treated with bisphosphonates.

The researchers performed bone core biopsies for each patient and analyzed both the micro-architecture and material properties of the bone. No difference was seen in the bone micro-architecture, but the patients who had been treated with bisphosphonates had reduced bone tissue heterogeneity, with reduced mineral content and crystal size, compared with the control group. The study was supported by a grant from the National Institutes of Health.

In a second study, researchers at Columbia University in New York evaluated the bone structure of 111 postmenopausal women with primary osteoporosis. Of that group, 61 had been taking bisphosphonates for at least 4 years. The other 50 women had been taking calcium and vitamin D supplements.

The researchers at Columbia saw improved structural integrity early in the bisphosphonate treatment. However, the trends began to reverse after 4 years of treatment. After that point, continued treatment was associated with decreased axial strength and structural integrity. The researchers received no compensation for this study.

Both groups of investigators called for more research to gauge the effectiveness of long-term clinical use of bisphosphonates for osteoporosis treatment. However, they did not expect the findings to affect clinical practice anytime soon.

“The message here is bisphosphonates are not bad drugs, but perhaps we need to know more about the long-term effects,” Dr. Melvin Rosenwasser, professor of orthopaedic surgery at Columbia University and one of the investigators on the Columbia study.

Further research could shed light on the best treatment approaches in women who have been taking bisphosphonates for more than 4 years. For example, it would be helpful for physicians to know the effects of a bisphosphonate drug holiday on bone quality, Dr. Rosenwasser said in an interview.

The FDA advised physicians to be aware of the possible risk of atypical subtrochanteric femur fractures in patients taking bisphosphonates, but said that at this point they saw no “clear connection” between bisphosphonate use and the risk of these fractures.

“FDA is working closely with outside experts, including members of the recently convened American Society of Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force, to gather additional information that may provide more insight into this issue,” the agency said in a statement issued on March 10.

The agency has been following the issue since 2008, when case reports were published showing that atypical subtrochanteric femur fractures were occurring in women with osteoporosis who were using bisphosphonates. In June 2008, the FDA requested information from all bisphosphonate drug manufacturers about this potential safety issue. But the agency's review of the information did not show an increased risk for women using bisphosphonates.

Some manufacturers of bisphosphonate therapies (Fosamax, Actonel, Boniva, and Reclast) issued statements pledging to monitor reports of atypical fractures, but standing by the benefits of the therapies.

The best information available to date indicates that atypical subtrochanteric fractures are rare, said Dr. Elizabeth Shane, an endocrinologist and professor of medicine at Columbia University who also co-chairs the American Society for Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force. Preliminary estimates are that fewer than 1 in 10,000 patients taking bisphosphonates suffers from this type of fracture, she said. Contrast that with the fact that treating 1,000 women for 3 years with bisphosphonates can prevent 100 fractures, and the benefit of taking these drugs far outweighs the risks, said Dr. Shane, who receives research support from Eli Lilly, Merck, and Novartis.

“Every drug has side effects,” Dr. Shane said in an interview. “It may well be that this type of fracture is associated with bisphosphonates, but we don't yet know who is vulnerable and we need more information and more research in order to determine that.”

One goal of the task force convened by the American Society of Bone and Mineral Research will be to guide future research. The group, which began meeting last year, also is working to establish a case definition, review the literature, compare imaging techniques, and consider the best management of patients with these fractures.

The task force expects to wrap up its work in the next few months, Dr. Shane said. Once completed, a report will be submitted to the Journal of Bone and Mineral Research and to the FDA. The task force is likely to recommend establishment of an international registry, allowing researchers to better study the rare fractures, she said.

The FDA statement is at www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm203891.htm

“We don't yet know who is vulnerable” to rare instances of atypical subtrochanteric fracture, Dr. Elizabeth Shane said.

Source: Courtesy Columbia University Medical Center

A typical osteoporosis fracture (left), is contrasted with an atypical fracture in a patient after many years of bisphosphonate therapy.

Source Images courtesy Dr. Melvin Rosenwasser, Columbia University

My Take

Risk, Benefit Merit Discussion With Patients

Shortly after these two small case studies were presented at the American Academy of Orthopedic Surgeons meeting, ABC World News Tonight reported on the potential hazards of prolonged bisphosphonate therapy. Three days later, these studies appeared on the front page of USA Today. The reporting included some dramatic images of proximal femoral fractures, and newcaster Diane Sawyer highlighted the extensive prescribing of oral bisphosphonates by primary care physicians. She even wondered whether they (we) had any knowledge of these problems.

Although the findings were newsworthy, the two studies found nothing conclusive as to the effects of long-term use of antiresorptive therapy and these unique fractures. Moreover, the FDA has no plans to change its recommendations regarding drug labeling of oral bisphosphonates in light of these reports. It may be all noise with no signal, but there are plans to further investigate the issue.

To return to Ms. Sawyer's musings, as a primary care physician I have long questioned the use of oral bisphosphonates beyond the 5-year mark, and many of my colleagues are in the same camp. The data beyond 5 years do support continuing use, but are not as robust as for the first 5 years of therapy. We all know that bisphosphonates make for denser bones; the question raised once again is all about bone quality.

Physicians who prescribe oral bisphosphonates should talk about risk versus benefit with these patients. They should address these questions not only in the first year, but also in the 5th year and 10th year, should these drugs be used for that length of time.

Early results from two small studies show that the long-term use of oral bisphosphonates could harm bone quality and potentially lead to an increased risk for femur fractures, but the Food and Drug Administration is advising patients to stay on their medication unless advised by their physicians to stop.

The studies showed an association between the use of bisphosphonate treatments for 4 or more years and decreasing bone quality, possibly because the bisphosphonates altered the material properties of the bone. The two studies were presented at the annual meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

“Although bisphosphonates have demonstrated an improvement in bone quantity, little if anything is known about the effects of these drugs on bone quality,” Brian Gladnick, one of the researchers from the Hospital for Special Surgery in New York, said in a statement.

Researchers at the Hospital for Special Surgery conducted a prospective pilot study in which they evaluated the bone composition of 21 postmenopausal women who presented to the emergency department with proximal femoral fractures. Of the patients enrolled in the study, 12 had a history of bisphosphonate use for an average of 8.5 years. Nine of the women had never been treated with bisphosphonates.

The researchers performed bone core biopsies for each patient and analyzed both the micro-architecture and material properties of the bone. No difference was seen in the bone micro-architecture, but the patients who had been treated with bisphosphonates had reduced bone tissue heterogeneity, with reduced mineral content and crystal size, compared with the control group. The study was supported by a grant from the National Institutes of Health.

In a second study, researchers at Columbia University in New York evaluated the bone structure of 111 postmenopausal women with primary osteoporosis. Of that group, 61 had been taking bisphosphonates for at least 4 years. The other 50 women had been taking calcium and vitamin D supplements.

The researchers at Columbia saw improved structural integrity early in the bisphosphonate treatment. However, the trends began to reverse after 4 years of treatment. After that point, continued treatment was associated with decreased axial strength and structural integrity. The researchers received no compensation for this study.

Both groups of investigators called for more research to gauge the effectiveness of long-term clinical use of bisphosphonates for osteoporosis treatment. However, they did not expect the findings to affect clinical practice anytime soon.

“The message here is bisphosphonates are not bad drugs, but perhaps we need to know more about the long-term effects,” Dr. Melvin Rosenwasser, professor of orthopaedic surgery at Columbia University and one of the investigators on the Columbia study.

Further research could shed light on the best treatment approaches in women who have been taking bisphosphonates for more than 4 years. For example, it would be helpful for physicians to know the effects of a bisphosphonate drug holiday on bone quality, Dr. Rosenwasser said in an interview.

The FDA advised physicians to be aware of the possible risk of atypical subtrochanteric femur fractures in patients taking bisphosphonates, but said that at this point they saw no “clear connection” between bisphosphonate use and the risk of these fractures.

“FDA is working closely with outside experts, including members of the recently convened American Society of Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force, to gather additional information that may provide more insight into this issue,” the agency said in a statement issued on March 10.

The agency has been following the issue since 2008, when case reports were published showing that atypical subtrochanteric femur fractures were occurring in women with osteoporosis who were using bisphosphonates. In June 2008, the FDA requested information from all bisphosphonate drug manufacturers about this potential safety issue. But the agency's review of the information did not show an increased risk for women using bisphosphonates.

Some manufacturers of bisphosphonate therapies (Fosamax, Actonel, Boniva, and Reclast) issued statements pledging to monitor reports of atypical fractures, but standing by the benefits of the therapies.

The best information available to date indicates that atypical subtrochanteric fractures are rare, said Dr. Elizabeth Shane, an endocrinologist and professor of medicine at Columbia University who also co-chairs the American Society for Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force. Preliminary estimates are that fewer than 1 in 10,000 patients taking bisphosphonates suffers from this type of fracture, she said. Contrast that with the fact that treating 1,000 women for 3 years with bisphosphonates can prevent 100 fractures, and the benefit of taking these drugs far outweighs the risks, said Dr. Shane, who receives research support from Eli Lilly, Merck, and Novartis.

“Every drug has side effects,” Dr. Shane said in an interview. “It may well be that this type of fracture is associated with bisphosphonates, but we don't yet know who is vulnerable and we need more information and more research in order to determine that.”

One goal of the task force convened by the American Society of Bone and Mineral Research will be to guide future research. The group, which began meeting last year, also is working to establish a case definition, review the literature, compare imaging techniques, and consider the best management of patients with these fractures.

The task force expects to wrap up its work in the next few months, Dr. Shane said. Once completed, a report will be submitted to the Journal of Bone and Mineral Research and to the FDA. The task force is likely to recommend establishment of an international registry, allowing researchers to better study the rare fractures, she said.

The FDA statement is at www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm203891.htm

“We don't yet know who is vulnerable” to rare instances of atypical subtrochanteric fracture, Dr. Elizabeth Shane said.

Source: Courtesy Columbia University Medical Center

A typical osteoporosis fracture (left), is contrasted with an atypical fracture in a patient after many years of bisphosphonate therapy.

Source Images courtesy Dr. Melvin Rosenwasser, Columbia University

My Take

Risk, Benefit Merit Discussion With Patients

Shortly after these two small case studies were presented at the American Academy of Orthopedic Surgeons meeting, ABC World News Tonight reported on the potential hazards of prolonged bisphosphonate therapy. Three days later, these studies appeared on the front page of USA Today. The reporting included some dramatic images of proximal femoral fractures, and newcaster Diane Sawyer highlighted the extensive prescribing of oral bisphosphonates by primary care physicians. She even wondered whether they (we) had any knowledge of these problems.

Although the findings were newsworthy, the two studies found nothing conclusive as to the effects of long-term use of antiresorptive therapy and these unique fractures. Moreover, the FDA has no plans to change its recommendations regarding drug labeling of oral bisphosphonates in light of these reports. It may be all noise with no signal, but there are plans to further investigate the issue.

To return to Ms. Sawyer's musings, as a primary care physician I have long questioned the use of oral bisphosphonates beyond the 5-year mark, and many of my colleagues are in the same camp. The data beyond 5 years do support continuing use, but are not as robust as for the first 5 years of therapy. We all know that bisphosphonates make for denser bones; the question raised once again is all about bone quality.

Physicians who prescribe oral bisphosphonates should talk about risk versus benefit with these patients. They should address these questions not only in the first year, but also in the 5th year and 10th year, should these drugs be used for that length of time.

Early results from two small studies show that the long-term use of oral bisphosphonates could harm bone quality and potentially lead to an increased risk for femur fractures, but the Food and Drug Administration is advising patients to stay on their medication unless advised by their physicians to stop.

The studies showed an association between the use of bisphosphonate treatments for 4 or more years and decreasing bone quality, possibly because the bisphosphonates altered the material properties of the bone. The two studies were presented at the annual meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

“Although bisphosphonates have demonstrated an improvement in bone quantity, little if anything is known about the effects of these drugs on bone quality,” Brian Gladnick, one of the researchers from the Hospital for Special Surgery in New York, said in a statement.

Researchers at the Hospital for Special Surgery conducted a prospective pilot study in which they evaluated the bone composition of 21 postmenopausal women who presented to the emergency department with proximal femoral fractures. Of the patients enrolled in the study, 12 had a history of bisphosphonate use for an average of 8.5 years. Nine of the women had never been treated with bisphosphonates.

The researchers performed bone core biopsies for each patient and analyzed both the micro-architecture and material properties of the bone. No difference was seen in the bone micro-architecture, but the patients who had been treated with bisphosphonates had reduced bone tissue heterogeneity, with reduced mineral content and crystal size, compared with the control group. The study was supported by a grant from the National Institutes of Health.

In a second study, researchers at Columbia University in New York evaluated the bone structure of 111 postmenopausal women with primary osteoporosis. Of that group, 61 had been taking bisphosphonates for at least 4 years. The other 50 women had been taking calcium and vitamin D supplements.

The researchers at Columbia saw improved structural integrity early in the bisphosphonate treatment. However, the trends began to reverse after 4 years of treatment. After that point, continued treatment was associated with decreased axial strength and structural integrity. The researchers received no compensation for this study.

Both groups of investigators called for more research to gauge the effectiveness of long-term clinical use of bisphosphonates for osteoporosis treatment. However, they did not expect the findings to affect clinical practice anytime soon.

“The message here is bisphosphonates are not bad drugs, but perhaps we need to know more about the long-term effects,” Dr. Melvin Rosenwasser, professor of orthopaedic surgery at Columbia University and one of the investigators on the Columbia study.

Further research could shed light on the best treatment approaches in women who have been taking bisphosphonates for more than 4 years. For example, it would be helpful for physicians to know the effects of a bisphosphonate drug holiday on bone quality, Dr. Rosenwasser said in an interview.

The FDA advised physicians to be aware of the possible risk of atypical subtrochanteric femur fractures in patients taking bisphosphonates, but said that at this point they saw no “clear connection” between bisphosphonate use and the risk of these fractures.

“FDA is working closely with outside experts, including members of the recently convened American Society of Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force, to gather additional information that may provide more insight into this issue,” the agency said in a statement issued on March 10.

The agency has been following the issue since 2008, when case reports were published showing that atypical subtrochanteric femur fractures were occurring in women with osteoporosis who were using bisphosphonates. In June 2008, the FDA requested information from all bisphosphonate drug manufacturers about this potential safety issue. But the agency's review of the information did not show an increased risk for women using bisphosphonates.

Some manufacturers of bisphosphonate therapies (Fosamax, Actonel, Boniva, and Reclast) issued statements pledging to monitor reports of atypical fractures, but standing by the benefits of the therapies.

The best information available to date indicates that atypical subtrochanteric fractures are rare, said Dr. Elizabeth Shane, an endocrinologist and professor of medicine at Columbia University who also co-chairs the American Society for Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force. Preliminary estimates are that fewer than 1 in 10,000 patients taking bisphosphonates suffers from this type of fracture, she said. Contrast that with the fact that treating 1,000 women for 3 years with bisphosphonates can prevent 100 fractures, and the benefit of taking these drugs far outweighs the risks, said Dr. Shane, who receives research support from Eli Lilly, Merck, and Novartis.

“Every drug has side effects,” Dr. Shane said in an interview. “It may well be that this type of fracture is associated with bisphosphonates, but we don't yet know who is vulnerable and we need more information and more research in order to determine that.”

One goal of the task force convened by the American Society of Bone and Mineral Research will be to guide future research. The group, which began meeting last year, also is working to establish a case definition, review the literature, compare imaging techniques, and consider the best management of patients with these fractures.

The task force expects to wrap up its work in the next few months, Dr. Shane said. Once completed, a report will be submitted to the Journal of Bone and Mineral Research and to the FDA. The task force is likely to recommend establishment of an international registry, allowing researchers to better study the rare fractures, she said.

The FDA statement is at www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm203891.htm

“We don't yet know who is vulnerable” to rare instances of atypical subtrochanteric fracture, Dr. Elizabeth Shane said.

Source: Courtesy Columbia University Medical Center

A typical osteoporosis fracture (left), is contrasted with an atypical fracture in a patient after many years of bisphosphonate therapy.

Source Images courtesy Dr. Melvin Rosenwasser, Columbia University

My Take

Risk, Benefit Merit Discussion With Patients

Shortly after these two small case studies were presented at the American Academy of Orthopedic Surgeons meeting, ABC World News Tonight reported on the potential hazards of prolonged bisphosphonate therapy. Three days later, these studies appeared on the front page of USA Today. The reporting included some dramatic images of proximal femoral fractures, and newcaster Diane Sawyer highlighted the extensive prescribing of oral bisphosphonates by primary care physicians. She even wondered whether they (we) had any knowledge of these problems.

Although the findings were newsworthy, the two studies found nothing conclusive as to the effects of long-term use of antiresorptive therapy and these unique fractures. Moreover, the FDA has no plans to change its recommendations regarding drug labeling of oral bisphosphonates in light of these reports. It may be all noise with no signal, but there are plans to further investigate the issue.

To return to Ms. Sawyer's musings, as a primary care physician I have long questioned the use of oral bisphosphonates beyond the 5-year mark, and many of my colleagues are in the same camp. The data beyond 5 years do support continuing use, but are not as robust as for the first 5 years of therapy. We all know that bisphosphonates make for denser bones; the question raised once again is all about bone quality.

Physicians who prescribe oral bisphosphonates should talk about risk versus benefit with these patients. They should address these questions not only in the first year, but also in the 5th year and 10th year, should these drugs be used for that length of time.

More U.S. medical students are choosing primary care residencies, according to new data from the National Resident Matching Program.

Interest in family medicine saw a spike in this year's resident match, with 9% more U.S. medical school seniors choosing that specialty than last year. Overall, 2,608 family medicine residency positions were offered this year. Of those, 91.4% were filled, with 44.8% filled by U.S. medical school graduates. The overall fill rate is a record for family medicine and the percentage of U.S. medical graduates matching to the specialty is the highest since 2002, according to the American Academy of Family Physicians.

But the number of U.S. seniors who matched in internal medicine rose only slightly over 2009. This year, 4,999 positions were offered and 99% were filled, 54.5% by U.S. medical graduates. In 2009, 4,922 slots were offered, 98.6% were filled, and 53.5% went to U.S. graduates.

Officials at the American College of Physicians said the small increase is not enough to make a dent in the shortage of primary care physicians. In a statement, the ACP called for reforms to make primary care more attractive to medical students, including increasing Medicare and Medicaid payments to primary care physicians and increased support for primary care training programs.

For family medicine, the upsurge in this year's resident match could signal a turnaround, said Dr. Lori Heim, president of the AAFP. During the past decade, the number of U.S. medical school graduates choosing family medicine fell by half.

Dr. Heim attributed this year's increase in part to the spotlight on family medicine during the debate on health care reform. “In virtually every discussion about improving quality of care, people pointed to the need to rebalance our system on a foundation of primary care,” she said in a statement. “Add in the heightened awareness of the patient-centered medical home, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.”

But this is just a first step, she said. In order to close the primary care physician gap, schools need to train twice as many family physicians as they are today.

Pediatrics and obstetrics-gynecology both retained their popularity. More than 70% of pediatrics positions were filled by U.S. graduates. In obstetrics-gynecology, more than 77% of slots were filled by U.S. graduates, up from 74% in 2009.

U.S. medical students maintain a strong interest in specialties with a heavy procedural focus, such as neurological surgery, orthopedic surgery, and otolaryngology.

Overall, this was the largest Match Day in the program's history, with 30,543 applicants, up 655 from last year, according to the National Resident Matching Program. The increase included 432 more U.S. medical school seniors than last year. There were more students with osteopathic degrees in this year's match, and more physicians who had previously graduated from medical school.

More U.S. medical students are choosing primary care residencies, according to new data from the National Resident Matching Program.

Interest in family medicine saw a spike in this year's resident match, with 9% more U.S. medical school seniors choosing that specialty than last year. Overall, 2,608 family medicine residency positions were offered this year. Of those, 91.4% were filled, with 44.8% filled by U.S. medical school graduates. The overall fill rate is a record for family medicine and the percentage of U.S. medical graduates matching to the specialty is the highest since 2002, according to the American Academy of Family Physicians.

But the number of U.S. seniors who matched in internal medicine rose only slightly over 2009. This year, 4,999 positions were offered and 99% were filled, 54.5% by U.S. medical graduates. In 2009, 4,922 slots were offered, 98.6% were filled, and 53.5% went to U.S. graduates.

Officials at the American College of Physicians said the small increase is not enough to make a dent in the shortage of primary care physicians. In a statement, the ACP called for reforms to make primary care more attractive to medical students, including increasing Medicare and Medicaid payments to primary care physicians and increased support for primary care training programs.

For family medicine, the upsurge in this year's resident match could signal a turnaround, said Dr. Lori Heim, president of the AAFP. During the past decade, the number of U.S. medical school graduates choosing family medicine fell by half.

Dr. Heim attributed this year's increase in part to the spotlight on family medicine during the debate on health care reform. “In virtually every discussion about improving quality of care, people pointed to the need to rebalance our system on a foundation of primary care,” she said in a statement. “Add in the heightened awareness of the patient-centered medical home, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.”

But this is just a first step, she said. In order to close the primary care physician gap, schools need to train twice as many family physicians as they are today.

Pediatrics and obstetrics-gynecology both retained their popularity. More than 70% of pediatrics positions were filled by U.S. graduates. In obstetrics-gynecology, more than 77% of slots were filled by U.S. graduates, up from 74% in 2009.

U.S. medical students maintain a strong interest in specialties with a heavy procedural focus, such as neurological surgery, orthopedic surgery, and otolaryngology.

Overall, this was the largest Match Day in the program's history, with 30,543 applicants, up 655 from last year, according to the National Resident Matching Program. The increase included 432 more U.S. medical school seniors than last year. There were more students with osteopathic degrees in this year's match, and more physicians who had previously graduated from medical school.

More U.S. medical students are choosing primary care residencies, according to new data from the National Resident Matching Program.

Interest in family medicine saw a spike in this year's resident match, with 9% more U.S. medical school seniors choosing that specialty than last year. Overall, 2,608 family medicine residency positions were offered this year. Of those, 91.4% were filled, with 44.8% filled by U.S. medical school graduates. The overall fill rate is a record for family medicine and the percentage of U.S. medical graduates matching to the specialty is the highest since 2002, according to the American Academy of Family Physicians.

But the number of U.S. seniors who matched in internal medicine rose only slightly over 2009. This year, 4,999 positions were offered and 99% were filled, 54.5% by U.S. medical graduates. In 2009, 4,922 slots were offered, 98.6% were filled, and 53.5% went to U.S. graduates.

Officials at the American College of Physicians said the small increase is not enough to make a dent in the shortage of primary care physicians. In a statement, the ACP called for reforms to make primary care more attractive to medical students, including increasing Medicare and Medicaid payments to primary care physicians and increased support for primary care training programs.

For family medicine, the upsurge in this year's resident match could signal a turnaround, said Dr. Lori Heim, president of the AAFP. During the past decade, the number of U.S. medical school graduates choosing family medicine fell by half.

Dr. Heim attributed this year's increase in part to the spotlight on family medicine during the debate on health care reform. “In virtually every discussion about improving quality of care, people pointed to the need to rebalance our system on a foundation of primary care,” she said in a statement. “Add in the heightened awareness of the patient-centered medical home, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.”

But this is just a first step, she said. In order to close the primary care physician gap, schools need to train twice as many family physicians as they are today.

Pediatrics and obstetrics-gynecology both retained their popularity. More than 70% of pediatrics positions were filled by U.S. graduates. In obstetrics-gynecology, more than 77% of slots were filled by U.S. graduates, up from 74% in 2009.

U.S. medical students maintain a strong interest in specialties with a heavy procedural focus, such as neurological surgery, orthopedic surgery, and otolaryngology.

Overall, this was the largest Match Day in the program's history, with 30,543 applicants, up 655 from last year, according to the National Resident Matching Program. The increase included 432 more U.S. medical school seniors than last year. There were more students with osteopathic degrees in this year's match, and more physicians who had previously graduated from medical school.

After more than a year of heated debate on the merits of health reform, policy makers and physicians are switching gears, assessing the impact of the new law and considering how to improve it in the future.

“This legislation improves the chance that our patients can see doctors,” said Dr. Frederick E. Turton, chair of the board of regents of the American College of Physicians. “When patients see their doctors, they live longer and live happier lives.”

Dr. Turton also lauded the law's provisions on preventive services, which will allow patients with Medicare, Medicaid, and private insurance to get many preventive services without incurring out-of-pocket costs. But the legislation does not go far enough in supporting primary care, he said. The 10% Medicare bonus payment to primary care physicians over 5 years is a positive feature of the new law, but much more is needed. “We're facing a crisis shortfall of primary care doctors, and 10% is not enough to make any difference whatsoever,” said Dr. Turton, a general internist in Sarasota, Fla.

President Obama signed most of the health reform provisions into law on March 23. On March 30, the president signed a smaller bill—known as the reconciliation bill—that Congress had passed to make adjustments to the original package, including the addition of more subsidies for purchasing insurance, and removal from the law of some of the more controversial political deals.

The new law clears the way for about 32 million previously uninsured Americans to have access to health insurance in the next few years. The law requires individuals to obtain health coverage and creates a health insurance exchange where individuals can shop for policies that meet minimum coverage standards. The law also bars insurers from discriminating against people based on gender or preexisting medical conditions.

Of special interest to primary care physicians, Medicaid payments will be increased to the level of Medicare payments for primary care physicians delivering primary care services in 2013 and 2014. And in 2011-2016, Medicare bonus payments of 10% will go to family physicians, general internists, geriatricians, and pediatricians whose Medicare charges for office, nursing home, and home visits make up at least 60% of their total Medicare charges. The law also increases funding for community health centers.

The law's emphasis on primary care is a good start, said Dr. Neil Calman, president and CEO of the Institute for Family Health and a clinical professor of family medicine at Albert Einstein College of Medicine, both in New York.

The new focus on prevention and wellness is a much better way to advance primary care, he said, compared with the gatekeeper model that was tried over a decade ago. “That was a model where primary care was getting a boost from something that flew in the face of what consumers wanted,” Dr. Calman said. The new approach is “completely consistent with what consumers want, which is well-coordinated, comprehensive care.”

The new law will help Medicare beneficiaries who fall into the Medicare part D prescription drug “doughnut hole.” This year, beneficiaries who enter the doughnut hole will get a $250 rebate. Next year, drug companies will be required to provide a 50% discount on brand-name drugs paid for while the patient is in the doughnut hole, rising to 75% on both brand-name and generic drugs by 2020.

“That doughnut hole is something that you talk about every day with your patients,” Dr. Turton noted.

The law also includes additional insurance protections. The federal government will require health plans to provide coverage for nondependent children up to age 26 years within 6 months of the law's enactment. The law also bars group health plans from excluding adult patients on the basis of preexisting conditions starting in 2014; for children, plans are barred from imposing such exclusions 6 months after enactment.

The law also aims to bring transparency to relationships between pharmaceutical companies and physicians and hospitals.

Under the incorporated Physician Payments Sunshine Act, sponsored by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), makers of medical supplies, pharmaceuticals, biologicals, and devices must report any payments or transfers of value worth more than $100/year that they make to physicians and hospitals, starting in 2013. Manufacturers will also have to report any and all physician ownership stakes. The Health and Human Services department will be required to make this information available to the public.

Finally, starting in 2012, manufacturers will also have to report to the HHS all the drug samples they give to physicians, if the drugs are covered by Medicare or Medicaid.

During the course of final debate, no Republican member of Congress voted in favor of passing the bills. Republicans railed against the package as bloated and unaffordable at the Congressional Budget Office estimated price tag of $940 billion over 10 years, despite CBO assurance that the legislation also would reduce the deficit by $143 billion over the same period.

Republican opponents also said the legislation gave the federal government too great a role and would interfere with the relationship between patients and their doctors.

The bills were supported by the American Medical Association and other physician organizations. AMA president Dr. J. James Rohack said that the legislation would do many good things, such as improve health by expanding coverage to millions of uninsured Americans, eliminate denials based on preexisting conditions, provide bonus payments to primary care physicians and general surgeons, and fund pilot projects on ways to resolve medical liability claims.

However, Congress still has work to do on some provisions, especially the one that establishes an Independent Payment Advisory Board (IPAB), the AMA said. The 15-member IPAB, which is set to begin its work in 2014, is charged with presenting proposals to Congress that would slow the growth of Medicare and private health care spending and improve the quality of care.

The AMA said that this board needs to be overseen by Congress and have input from physicians. “The current IPAB framework could result in misguided payment cuts that undermine access to care and destabilize health care delivery,” Dr. Rohack warned in a statement.

The board should be truly independent and include adequate representation from the cognitive specialties, Dr. Turton said.

My Take

Facing the Challenge of Changing a Fragmented System

Given the unsustainable nature of the U.S. health care system, change was inevitable. The reform legislation starts a process of rethinking how health care can be more effective, efficient, and sustainable.

Change, however, is and will be disruptive and disconcerting. Managing the reform process will not be easy as patients, providers, and advocates deal with uncertainty and resource allocation in an era of financial limitations. The key issue to keep in mind is that doing nothing would soon bring on similar stress, but with somewhat different variables.

How we harmonize professional activities in a fragmented health care system may turn out to be the predominant theme during the next few years.

After more than a year of heated debate on the merits of health reform, policy makers and physicians are switching gears, assessing the impact of the new law and considering how to improve it in the future.

“This legislation improves the chance that our patients can see doctors,” said Dr. Frederick E. Turton, chair of the board of regents of the American College of Physicians. “When patients see their doctors, they live longer and live happier lives.”

Dr. Turton also lauded the law's provisions on preventive services, which will allow patients with Medicare, Medicaid, and private insurance to get many preventive services without incurring out-of-pocket costs. But the legislation does not go far enough in supporting primary care, he said. The 10% Medicare bonus payment to primary care physicians over 5 years is a positive feature of the new law, but much more is needed. “We're facing a crisis shortfall of primary care doctors, and 10% is not enough to make any difference whatsoever,” said Dr. Turton, a general internist in Sarasota, Fla.

President Obama signed most of the health reform provisions into law on March 23. On March 30, the president signed a smaller bill—known as the reconciliation bill—that Congress had passed to make adjustments to the original package, including the addition of more subsidies for purchasing insurance, and removal from the law of some of the more controversial political deals.

The new law clears the way for about 32 million previously uninsured Americans to have access to health insurance in the next few years. The law requires individuals to obtain health coverage and creates a health insurance exchange where individuals can shop for policies that meet minimum coverage standards. The law also bars insurers from discriminating against people based on gender or preexisting medical conditions.

Of special interest to primary care physicians, Medicaid payments will be increased to the level of Medicare payments for primary care physicians delivering primary care services in 2013 and 2014. And in 2011-2016, Medicare bonus payments of 10% will go to family physicians, general internists, geriatricians, and pediatricians whose Medicare charges for office, nursing home, and home visits make up at least 60% of their total Medicare charges. The law also increases funding for community health centers.

The law's emphasis on primary care is a good start, said Dr. Neil Calman, president and CEO of the Institute for Family Health and a clinical professor of family medicine at Albert Einstein College of Medicine, both in New York.

The new focus on prevention and wellness is a much better way to advance primary care, he said, compared with the gatekeeper model that was tried over a decade ago. “That was a model where primary care was getting a boost from something that flew in the face of what consumers wanted,” Dr. Calman said. The new approach is “completely consistent with what consumers want, which is well-coordinated, comprehensive care.”

The new law will help Medicare beneficiaries who fall into the Medicare part D prescription drug “doughnut hole.” This year, beneficiaries who enter the doughnut hole will get a $250 rebate. Next year, drug companies will be required to provide a 50% discount on brand-name drugs paid for while the patient is in the doughnut hole, rising to 75% on both brand-name and generic drugs by 2020.

“That doughnut hole is something that you talk about every day with your patients,” Dr. Turton noted.

The law also includes additional insurance protections. The federal government will require health plans to provide coverage for nondependent children up to age 26 years within 6 months of the law's enactment. The law also bars group health plans from excluding adult patients on the basis of preexisting conditions starting in 2014; for children, plans are barred from imposing such exclusions 6 months after enactment.

The law also aims to bring transparency to relationships between pharmaceutical companies and physicians and hospitals.

Under the incorporated Physician Payments Sunshine Act, sponsored by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), makers of medical supplies, pharmaceuticals, biologicals, and devices must report any payments or transfers of value worth more than $100/year that they make to physicians and hospitals, starting in 2013. Manufacturers will also have to report any and all physician ownership stakes. The Health and Human Services department will be required to make this information available to the public.

Finally, starting in 2012, manufacturers will also have to report to the HHS all the drug samples they give to physicians, if the drugs are covered by Medicare or Medicaid.

During the course of final debate, no Republican member of Congress voted in favor of passing the bills. Republicans railed against the package as bloated and unaffordable at the Congressional Budget Office estimated price tag of $940 billion over 10 years, despite CBO assurance that the legislation also would reduce the deficit by $143 billion over the same period.

Republican opponents also said the legislation gave the federal government too great a role and would interfere with the relationship between patients and their doctors.

The bills were supported by the American Medical Association and other physician organizations. AMA president Dr. J. James Rohack said that the legislation would do many good things, such as improve health by expanding coverage to millions of uninsured Americans, eliminate denials based on preexisting conditions, provide bonus payments to primary care physicians and general surgeons, and fund pilot projects on ways to resolve medical liability claims.

However, Congress still has work to do on some provisions, especially the one that establishes an Independent Payment Advisory Board (IPAB), the AMA said. The 15-member IPAB, which is set to begin its work in 2014, is charged with presenting proposals to Congress that would slow the growth of Medicare and private health care spending and improve the quality of care.

The AMA said that this board needs to be overseen by Congress and have input from physicians. “The current IPAB framework could result in misguided payment cuts that undermine access to care and destabilize health care delivery,” Dr. Rohack warned in a statement.

The board should be truly independent and include adequate representation from the cognitive specialties, Dr. Turton said.

My Take

Facing the Challenge of Changing a Fragmented System

Given the unsustainable nature of the U.S. health care system, change was inevitable. The reform legislation starts a process of rethinking how health care can be more effective, efficient, and sustainable.

Change, however, is and will be disruptive and disconcerting. Managing the reform process will not be easy as patients, providers, and advocates deal with uncertainty and resource allocation in an era of financial limitations. The key issue to keep in mind is that doing nothing would soon bring on similar stress, but with somewhat different variables.

How we harmonize professional activities in a fragmented health care system may turn out to be the predominant theme during the next few years.

After more than a year of heated debate on the merits of health reform, policy makers and physicians are switching gears, assessing the impact of the new law and considering how to improve it in the future.

“This legislation improves the chance that our patients can see doctors,” said Dr. Frederick E. Turton, chair of the board of regents of the American College of Physicians. “When patients see their doctors, they live longer and live happier lives.”

Dr. Turton also lauded the law's provisions on preventive services, which will allow patients with Medicare, Medicaid, and private insurance to get many preventive services without incurring out-of-pocket costs. But the legislation does not go far enough in supporting primary care, he said. The 10% Medicare bonus payment to primary care physicians over 5 years is a positive feature of the new law, but much more is needed. “We're facing a crisis shortfall of primary care doctors, and 10% is not enough to make any difference whatsoever,” said Dr. Turton, a general internist in Sarasota, Fla.

President Obama signed most of the health reform provisions into law on March 23. On March 30, the president signed a smaller bill—known as the reconciliation bill—that Congress had passed to make adjustments to the original package, including the addition of more subsidies for purchasing insurance, and removal from the law of some of the more controversial political deals.

The new law clears the way for about 32 million previously uninsured Americans to have access to health insurance in the next few years. The law requires individuals to obtain health coverage and creates a health insurance exchange where individuals can shop for policies that meet minimum coverage standards. The law also bars insurers from discriminating against people based on gender or preexisting medical conditions.

Of special interest to primary care physicians, Medicaid payments will be increased to the level of Medicare payments for primary care physicians delivering primary care services in 2013 and 2014. And in 2011-2016, Medicare bonus payments of 10% will go to family physicians, general internists, geriatricians, and pediatricians whose Medicare charges for office, nursing home, and home visits make up at least 60% of their total Medicare charges. The law also increases funding for community health centers.

The law's emphasis on primary care is a good start, said Dr. Neil Calman, president and CEO of the Institute for Family Health and a clinical professor of family medicine at Albert Einstein College of Medicine, both in New York.

The new focus on prevention and wellness is a much better way to advance primary care, he said, compared with the gatekeeper model that was tried over a decade ago. “That was a model where primary care was getting a boost from something that flew in the face of what consumers wanted,” Dr. Calman said. The new approach is “completely consistent with what consumers want, which is well-coordinated, comprehensive care.”

The new law will help Medicare beneficiaries who fall into the Medicare part D prescription drug “doughnut hole.” This year, beneficiaries who enter the doughnut hole will get a $250 rebate. Next year, drug companies will be required to provide a 50% discount on brand-name drugs paid for while the patient is in the doughnut hole, rising to 75% on both brand-name and generic drugs by 2020.

“That doughnut hole is something that you talk about every day with your patients,” Dr. Turton noted.

The law also includes additional insurance protections. The federal government will require health plans to provide coverage for nondependent children up to age 26 years within 6 months of the law's enactment. The law also bars group health plans from excluding adult patients on the basis of preexisting conditions starting in 2014; for children, plans are barred from imposing such exclusions 6 months after enactment.

The law also aims to bring transparency to relationships between pharmaceutical companies and physicians and hospitals.

Under the incorporated Physician Payments Sunshine Act, sponsored by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.), makers of medical supplies, pharmaceuticals, biologicals, and devices must report any payments or transfers of value worth more than $100/year that they make to physicians and hospitals, starting in 2013. Manufacturers will also have to report any and all physician ownership stakes. The Health and Human Services department will be required to make this information available to the public.

Finally, starting in 2012, manufacturers will also have to report to the HHS all the drug samples they give to physicians, if the drugs are covered by Medicare or Medicaid.

During the course of final debate, no Republican member of Congress voted in favor of passing the bills. Republicans railed against the package as bloated and unaffordable at the Congressional Budget Office estimated price tag of $940 billion over 10 years, despite CBO assurance that the legislation also would reduce the deficit by $143 billion over the same period.

Republican opponents also said the legislation gave the federal government too great a role and would interfere with the relationship between patients and their doctors.

The bills were supported by the American Medical Association and other physician organizations. AMA president Dr. J. James Rohack said that the legislation would do many good things, such as improve health by expanding coverage to millions of uninsured Americans, eliminate denials based on preexisting conditions, provide bonus payments to primary care physicians and general surgeons, and fund pilot projects on ways to resolve medical liability claims.

However, Congress still has work to do on some provisions, especially the one that establishes an Independent Payment Advisory Board (IPAB), the AMA said. The 15-member IPAB, which is set to begin its work in 2014, is charged with presenting proposals to Congress that would slow the growth of Medicare and private health care spending and improve the quality of care.

The AMA said that this board needs to be overseen by Congress and have input from physicians. “The current IPAB framework could result in misguided payment cuts that undermine access to care and destabilize health care delivery,” Dr. Rohack warned in a statement.

The board should be truly independent and include adequate representation from the cognitive specialties, Dr. Turton said.

My Take

Facing the Challenge of Changing a Fragmented System

Given the unsustainable nature of the U.S. health care system, change was inevitable. The reform legislation starts a process of rethinking how health care can be more effective, efficient, and sustainable.

Change, however, is and will be disruptive and disconcerting. Managing the reform process will not be easy as patients, providers, and advocates deal with uncertainty and resource allocation in an era of financial limitations. The key issue to keep in mind is that doing nothing would soon bring on similar stress, but with somewhat different variables.

How we harmonize professional activities in a fragmented health care system may turn out to be the predominant theme during the next few years.

The federal government will begin its incentive program for the use of electronic health record information systems in less than a year, but many physician organizations say the timeline is just too aggressive and runs the risk of turning some physicians away from the technology.

Starting next year, physicians who demonstrate “meaningful use” of certified electronic health record (EHR) technology will be eligible to receive bonus payments of up to $18,000 from the Medicare program. Those bonuses continue for 5 years, with physicians eligible to earn up to a total of $44,000.

Physicians can still receive bonuses if they begin their meaningful use of the technology later, but they must start before 2013 to get all the available incentives.

A similar program is in place under the Medicaid program, with physicians eligible to receive nearly $64,000 over 6 years for the adoption and use of certified EHR technology.

Last December, officials at the Centers for Medicare and Medicaid Services released a proposal outlining the requirements to achieve meaningful use of EHRs. The requirements are phased in with minimum standards taking effect in 2011 and 2012, and stricter criteria phasing in over time.

Under Stage 1, physicians must meet 25 objectives including the use of computerized provider order entry, electronic prescribing, reporting on quality measures, and checking insurance eligibility electronically, among others.

In a letter to CMS officials, sent last month, a coalition of more than 95 national and state physician organizations voiced their concerns about the Stage 1 requirements. Though the coalition supports the phased-in approach to meaningful use, they said there is too much being asked of physicians in the first stage of the program.

The Medical Group Management Association, which signed on to the letter to CMS, said it has survey data suggesting that requiring practices to meet all 25 meaningful use objectives would actually lead to decreased productivity. Nearly 68% of respondents to a recent survey predicted that physician productivity would drop if all of the meaningful use objectives were implemented. That drop would be separate from the temporary decline expected with implementation of a new EHR, MGMA said.

Survey respondents said they would have a particularly hard time meeting the requirement that at least 80% of all patient requests for an electronic copy of their health information be fulfilled within 48 hours and the requirement that at least 10% of all patients be given timely electronic access to their health information. The survey, which was conducted in February, included responses from 445 providers in medical group practices.

The federal government will begin its incentive program for the use of electronic health record information systems in less than a year, but many physician organizations say the timeline is just too aggressive and runs the risk of turning some physicians away from the technology.

Starting next year, physicians who demonstrate “meaningful use” of certified electronic health record (EHR) technology will be eligible to receive bonus payments of up to $18,000 from the Medicare program. Those bonuses continue for 5 years, with physicians eligible to earn up to a total of $44,000.

Physicians can still receive bonuses if they begin their meaningful use of the technology later, but they must start before 2013 to get all the available incentives.

A similar program is in place under the Medicaid program, with physicians eligible to receive nearly $64,000 over 6 years for the adoption and use of certified EHR technology.

Last December, officials at the Centers for Medicare and Medicaid Services released a proposal outlining the requirements to achieve meaningful use of EHRs. The requirements are phased in with minimum standards taking effect in 2011 and 2012, and stricter criteria phasing in over time.

Under Stage 1, physicians must meet 25 objectives including the use of computerized provider order entry, electronic prescribing, reporting on quality measures, and checking insurance eligibility electronically, among others.

In a letter to CMS officials, sent last month, a coalition of more than 95 national and state physician organizations voiced their concerns about the Stage 1 requirements. Though the coalition supports the phased-in approach to meaningful use, they said there is too much being asked of physicians in the first stage of the program.

The Medical Group Management Association, which signed on to the letter to CMS, said it has survey data suggesting that requiring practices to meet all 25 meaningful use objectives would actually lead to decreased productivity. Nearly 68% of respondents to a recent survey predicted that physician productivity would drop if all of the meaningful use objectives were implemented. That drop would be separate from the temporary decline expected with implementation of a new EHR, MGMA said.

Survey respondents said they would have a particularly hard time meeting the requirement that at least 80% of all patient requests for an electronic copy of their health information be fulfilled within 48 hours and the requirement that at least 10% of all patients be given timely electronic access to their health information. The survey, which was conducted in February, included responses from 445 providers in medical group practices.

The federal government will begin its incentive program for the use of electronic health record information systems in less than a year, but many physician organizations say the timeline is just too aggressive and runs the risk of turning some physicians away from the technology.

Starting next year, physicians who demonstrate “meaningful use” of certified electronic health record (EHR) technology will be eligible to receive bonus payments of up to $18,000 from the Medicare program. Those bonuses continue for 5 years, with physicians eligible to earn up to a total of $44,000.

Physicians can still receive bonuses if they begin their meaningful use of the technology later, but they must start before 2013 to get all the available incentives.

A similar program is in place under the Medicaid program, with physicians eligible to receive nearly $64,000 over 6 years for the adoption and use of certified EHR technology.

Last December, officials at the Centers for Medicare and Medicaid Services released a proposal outlining the requirements to achieve meaningful use of EHRs. The requirements are phased in with minimum standards taking effect in 2011 and 2012, and stricter criteria phasing in over time.

Under Stage 1, physicians must meet 25 objectives including the use of computerized provider order entry, electronic prescribing, reporting on quality measures, and checking insurance eligibility electronically, among others.

In a letter to CMS officials, sent last month, a coalition of more than 95 national and state physician organizations voiced their concerns about the Stage 1 requirements. Though the coalition supports the phased-in approach to meaningful use, they said there is too much being asked of physicians in the first stage of the program.

The Medical Group Management Association, which signed on to the letter to CMS, said it has survey data suggesting that requiring practices to meet all 25 meaningful use objectives would actually lead to decreased productivity. Nearly 68% of respondents to a recent survey predicted that physician productivity would drop if all of the meaningful use objectives were implemented. That drop would be separate from the temporary decline expected with implementation of a new EHR, MGMA said.

Survey respondents said they would have a particularly hard time meeting the requirement that at least 80% of all patient requests for an electronic copy of their health information be fulfilled within 48 hours and the requirement that at least 10% of all patients be given timely electronic access to their health information. The survey, which was conducted in February, included responses from 445 providers in medical group practices.