Mary Ellen Schneider

The federal government has issued rules spelling out how it intends to police the use of genetic information by health plans.

The regulations bar health insurers from increasing premiums or denying enrollment based on genetic information. The regulations implement certain provisions in the Genetic Information Nondiscrimination Act (GINA), which was signed into law by President Bush in May 2008.

Beefing up consumer protections for genetic information should help accelerate progress in genetic testing and research, said Health and Human Services secretary Kathleen Sebelius. “Consumer confidence in genetic testing can now grow and help researchers get a better handle on the genetic basis of diseases,” Ms. Sebelius said in a statement. “Genetic testing will encourage the early diagnosis and treatment of certain diseases while allowing scientists to develop new medicines, treatments, and therapies.”

In an interim final rule, federal officials provide details on how health plans can obtain and use genetic information. The regulation generally bars health plans from increasing premiums based on genetic information. They also cannot require, or even request, that individuals or family members undergo genetic testing. And health plans cannot request, require, or purchase genetic information at any time for underwriting purposes, or prior to or in connection with enrollment.

Although the rule bars insurers from charging its members more based on genetic information, it doesn't limit them from doing so because of the manifestation of a disease. However, a health plan can't use the manifestation of a disease in one of its members as genetic information for a family member and raise their premiums, according to the interim final rule.

The rule does allow plans to request limited genetic information if it's necessary to determine the “medical appropriateness” of a certain treatment.

Plans also can request that individuals participate in research in which genetic testing will be conducted. However, none of the genetic information collected during that research can be used for underwriting purposes.

The interim final rule goes into effect 60 days after publication in the Federal Register.

HHS officials also issued a proposed rule that would modify the Health Insurance Portability and Accountability Act (HIPAA) to comply with the provisions of GINA.

Like the GINA rule, the HIPAA rule bars health plans from using and disclosing genetic information for underwriting purposes. However, because HIPAA applies more broadly, the prohibition in the proposed rule also affects employee welfare benefit plans and long-term care policies. It would exclude nursing home fixed indemnity policies.

If the proposed rule is finalized, then plans would have 180 days to comply with the provisions.

The federal government has issued rules spelling out how it intends to police the use of genetic information by health plans.

The regulations bar health insurers from increasing premiums or denying enrollment based on genetic information. The regulations implement certain provisions in the Genetic Information Nondiscrimination Act (GINA), which was signed into law by President Bush in May 2008.

Beefing up consumer protections for genetic information should help accelerate progress in genetic testing and research, said Health and Human Services secretary Kathleen Sebelius. “Consumer confidence in genetic testing can now grow and help researchers get a better handle on the genetic basis of diseases,” Ms. Sebelius said in a statement. “Genetic testing will encourage the early diagnosis and treatment of certain diseases while allowing scientists to develop new medicines, treatments, and therapies.”

In an interim final rule, federal officials provide details on how health plans can obtain and use genetic information. The regulation generally bars health plans from increasing premiums based on genetic information. They also cannot require, or even request, that individuals or family members undergo genetic testing. And health plans cannot request, require, or purchase genetic information at any time for underwriting purposes, or prior to or in connection with enrollment.

Although the rule bars insurers from charging its members more based on genetic information, it doesn't limit them from doing so because of the manifestation of a disease. However, a health plan can't use the manifestation of a disease in one of its members as genetic information for a family member and raise their premiums, according to the interim final rule.

The rule does allow plans to request limited genetic information if it's necessary to determine the “medical appropriateness” of a certain treatment.

Plans also can request that individuals participate in research in which genetic testing will be conducted. However, none of the genetic information collected during that research can be used for underwriting purposes.

The interim final rule goes into effect 60 days after publication in the Federal Register.

HHS officials also issued a proposed rule that would modify the Health Insurance Portability and Accountability Act (HIPAA) to comply with the provisions of GINA.

Like the GINA rule, the HIPAA rule bars health plans from using and disclosing genetic information for underwriting purposes. However, because HIPAA applies more broadly, the prohibition in the proposed rule also affects employee welfare benefit plans and long-term care policies. It would exclude nursing home fixed indemnity policies.

If the proposed rule is finalized, then plans would have 180 days to comply with the provisions.

The federal government has issued rules spelling out how it intends to police the use of genetic information by health plans.

The regulations bar health insurers from increasing premiums or denying enrollment based on genetic information. The regulations implement certain provisions in the Genetic Information Nondiscrimination Act (GINA), which was signed into law by President Bush in May 2008.

Beefing up consumer protections for genetic information should help accelerate progress in genetic testing and research, said Health and Human Services secretary Kathleen Sebelius. “Consumer confidence in genetic testing can now grow and help researchers get a better handle on the genetic basis of diseases,” Ms. Sebelius said in a statement. “Genetic testing will encourage the early diagnosis and treatment of certain diseases while allowing scientists to develop new medicines, treatments, and therapies.”

In an interim final rule, federal officials provide details on how health plans can obtain and use genetic information. The regulation generally bars health plans from increasing premiums based on genetic information. They also cannot require, or even request, that individuals or family members undergo genetic testing. And health plans cannot request, require, or purchase genetic information at any time for underwriting purposes, or prior to or in connection with enrollment.

Although the rule bars insurers from charging its members more based on genetic information, it doesn't limit them from doing so because of the manifestation of a disease. However, a health plan can't use the manifestation of a disease in one of its members as genetic information for a family member and raise their premiums, according to the interim final rule.

The rule does allow plans to request limited genetic information if it's necessary to determine the “medical appropriateness” of a certain treatment.

Plans also can request that individuals participate in research in which genetic testing will be conducted. However, none of the genetic information collected during that research can be used for underwriting purposes.

The interim final rule goes into effect 60 days after publication in the Federal Register.

HHS officials also issued a proposed rule that would modify the Health Insurance Portability and Accountability Act (HIPAA) to comply with the provisions of GINA.

Like the GINA rule, the HIPAA rule bars health plans from using and disclosing genetic information for underwriting purposes. However, because HIPAA applies more broadly, the prohibition in the proposed rule also affects employee welfare benefit plans and long-term care policies. It would exclude nursing home fixed indemnity policies.

If the proposed rule is finalized, then plans would have 180 days to comply with the provisions.

The Federal Trade Commission once again has delayed enforcement of the Red Flags Rule, giving physicians until June 1, 2010, before they have to comply with new requirements aimed at preventing identity theft.

The rule, which was issued by the Federal Trade Commission (FTC) in 2007, most recently had been scheduled to go into effect Nov. 1. But this is not the first time that the FTC has delayed the enforcement date. The agency has been pushing back enforcement of the rule every few months for about a year. Most recently, the FTC issued a statement on Oct. 30 saying that it was again delaying enforcement at the request of members of Congress.

Congress has been working on a legislative solution to exempt some physician practices and other small businesses from the identity theft requirements. On Oct. 20, the House passed a bill (H.R. 3763) that would exempt physician practices with 20 or fewer employees—as well as small accounting and legal practices—from the Red Flags Rule. The Senate has yet to act on the bill.

Rep. John Adler (D-N.J.), one of the chief sponsors of the legislation, said the regulations would be burdensome and expensive for small businesses and that physician practices were not meant to be caught up in this regulation. “The Federal Trade Commission went too far and went beyond the intent of Congress,” he said on the House floor Oct. 20.

The rule also is being challenged in court. On Oct. 30, the U.S. District Court for the District of Columbia ruled that the FTC cannot apply the regulation to lawyers.

Under the Red Flags Rule, all creditors, including physician practices, must establish a written identity theft–prevention program to protect consumers. The Red Flags Rule requires physician offices and other health care institutions to conduct risk assessments to determine their vulnerabilities to identity theft and respond to those risks.

The rule has raised the hackles of organized medicine. Groups such as the American Medical Association have objected, saying that it is inappropriate to classify physician practices as creditors simply because they allow patients to defer payment while the practices bill insurance companies. The Red Flags Rule also would add financial and administrative burdens on practices, the AMA said, because it duplicates existing privacy and security requirements put in place under the Health Insurance Portability and Accountability Act.

“For over a year, the AMA has continued to make the case to FTC that physicians are not creditors, and the red flags rule should not apply to them—now attorneys and members of Congress are also rightly raising concern with the FTC's broad interpretation,” Dr. Cecil Wilson, the AMA's president-elect, said in a statement. “The FTC's latest delay of 7 months should give them the time they need to take a good, hard look at the rule and finally revise the list of groups to which it applies.”

Go to www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm

The Federal Trade Commission once again has delayed enforcement of the Red Flags Rule, giving physicians until June 1, 2010, before they have to comply with new requirements aimed at preventing identity theft.

The rule, which was issued by the Federal Trade Commission (FTC) in 2007, most recently had been scheduled to go into effect Nov. 1. But this is not the first time that the FTC has delayed the enforcement date. The agency has been pushing back enforcement of the rule every few months for about a year. Most recently, the FTC issued a statement on Oct. 30 saying that it was again delaying enforcement at the request of members of Congress.

Congress has been working on a legislative solution to exempt some physician practices and other small businesses from the identity theft requirements. On Oct. 20, the House passed a bill (H.R. 3763) that would exempt physician practices with 20 or fewer employees—as well as small accounting and legal practices—from the Red Flags Rule. The Senate has yet to act on the bill.

Rep. John Adler (D-N.J.), one of the chief sponsors of the legislation, said the regulations would be burdensome and expensive for small businesses and that physician practices were not meant to be caught up in this regulation. “The Federal Trade Commission went too far and went beyond the intent of Congress,” he said on the House floor Oct. 20.

The rule also is being challenged in court. On Oct. 30, the U.S. District Court for the District of Columbia ruled that the FTC cannot apply the regulation to lawyers.

Under the Red Flags Rule, all creditors, including physician practices, must establish a written identity theft–prevention program to protect consumers. The Red Flags Rule requires physician offices and other health care institutions to conduct risk assessments to determine their vulnerabilities to identity theft and respond to those risks.

The rule has raised the hackles of organized medicine. Groups such as the American Medical Association have objected, saying that it is inappropriate to classify physician practices as creditors simply because they allow patients to defer payment while the practices bill insurance companies. The Red Flags Rule also would add financial and administrative burdens on practices, the AMA said, because it duplicates existing privacy and security requirements put in place under the Health Insurance Portability and Accountability Act.

“For over a year, the AMA has continued to make the case to FTC that physicians are not creditors, and the red flags rule should not apply to them—now attorneys and members of Congress are also rightly raising concern with the FTC's broad interpretation,” Dr. Cecil Wilson, the AMA's president-elect, said in a statement. “The FTC's latest delay of 7 months should give them the time they need to take a good, hard look at the rule and finally revise the list of groups to which it applies.”

Go to www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm

The Federal Trade Commission once again has delayed enforcement of the Red Flags Rule, giving physicians until June 1, 2010, before they have to comply with new requirements aimed at preventing identity theft.

The rule, which was issued by the Federal Trade Commission (FTC) in 2007, most recently had been scheduled to go into effect Nov. 1. But this is not the first time that the FTC has delayed the enforcement date. The agency has been pushing back enforcement of the rule every few months for about a year. Most recently, the FTC issued a statement on Oct. 30 saying that it was again delaying enforcement at the request of members of Congress.

Congress has been working on a legislative solution to exempt some physician practices and other small businesses from the identity theft requirements. On Oct. 20, the House passed a bill (H.R. 3763) that would exempt physician practices with 20 or fewer employees—as well as small accounting and legal practices—from the Red Flags Rule. The Senate has yet to act on the bill.

Rep. John Adler (D-N.J.), one of the chief sponsors of the legislation, said the regulations would be burdensome and expensive for small businesses and that physician practices were not meant to be caught up in this regulation. “The Federal Trade Commission went too far and went beyond the intent of Congress,” he said on the House floor Oct. 20.

The rule also is being challenged in court. On Oct. 30, the U.S. District Court for the District of Columbia ruled that the FTC cannot apply the regulation to lawyers.

Under the Red Flags Rule, all creditors, including physician practices, must establish a written identity theft–prevention program to protect consumers. The Red Flags Rule requires physician offices and other health care institutions to conduct risk assessments to determine their vulnerabilities to identity theft and respond to those risks.

The rule has raised the hackles of organized medicine. Groups such as the American Medical Association have objected, saying that it is inappropriate to classify physician practices as creditors simply because they allow patients to defer payment while the practices bill insurance companies. The Red Flags Rule also would add financial and administrative burdens on practices, the AMA said, because it duplicates existing privacy and security requirements put in place under the Health Insurance Portability and Accountability Act.

“For over a year, the AMA has continued to make the case to FTC that physicians are not creditors, and the red flags rule should not apply to them—now attorneys and members of Congress are also rightly raising concern with the FTC's broad interpretation,” Dr. Cecil Wilson, the AMA's president-elect, said in a statement. “The FTC's latest delay of 7 months should give them the time they need to take a good, hard look at the rule and finally revise the list of groups to which it applies.”

Go to www.ftc.gov/bcp/edu/microsites/redflagsrule/faqs.shtm

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn.

The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said.

“The fact is your patients will pay $35 not to see you,” he continued.

That has been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus.

The portal also includes patient education materials. Physicians can also send links and attachments to the patient, he said.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, according to Dr. Bachman.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list.

Making online consults available can help keep the worried well out of physicians' offices, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

Patients and insurers seem willing to pay for the service, and many private insurers in Minnesota are paying part or all of the online visit charge, he said. Although Medicare won't pay for an online visit, Dr. Bachman said he thinks many Medicare patients would be willing to pay the fee themselves.

During the pilot, many uninsured patients were willing to pay for the online service, he pointed out.

Overall, the Mayo Clinic physicians billed patients for fewer than half of the online consults completed because they chose not to bill for certain services, such as medication reactions that happened in the week following the initial consult, prescription refills, or other minor questions that involved minimal time and effort on the part of the physician.

As physicians begin to adopt the online visit model using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

'The biggest problem with doctors is that we think our patients want to be there.'

Source DR. BACHMAN

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn.

The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said.

“The fact is your patients will pay $35 not to see you,” he continued.

That has been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus.

The portal also includes patient education materials. Physicians can also send links and attachments to the patient, he said.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, according to Dr. Bachman.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list.

Making online consults available can help keep the worried well out of physicians' offices, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

Patients and insurers seem willing to pay for the service, and many private insurers in Minnesota are paying part or all of the online visit charge, he said. Although Medicare won't pay for an online visit, Dr. Bachman said he thinks many Medicare patients would be willing to pay the fee themselves.

During the pilot, many uninsured patients were willing to pay for the online service, he pointed out.

Overall, the Mayo Clinic physicians billed patients for fewer than half of the online consults completed because they chose not to bill for certain services, such as medication reactions that happened in the week following the initial consult, prescription refills, or other minor questions that involved minimal time and effort on the part of the physician.

As physicians begin to adopt the online visit model using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

'The biggest problem with doctors is that we think our patients want to be there.'

Source DR. BACHMAN

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn.

The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said.

“The fact is your patients will pay $35 not to see you,” he continued.

That has been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus.

The portal also includes patient education materials. Physicians can also send links and attachments to the patient, he said.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, according to Dr. Bachman.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list.

Making online consults available can help keep the worried well out of physicians' offices, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

Patients and insurers seem willing to pay for the service, and many private insurers in Minnesota are paying part or all of the online visit charge, he said. Although Medicare won't pay for an online visit, Dr. Bachman said he thinks many Medicare patients would be willing to pay the fee themselves.

During the pilot, many uninsured patients were willing to pay for the online service, he pointed out.

Overall, the Mayo Clinic physicians billed patients for fewer than half of the online consults completed because they chose not to bill for certain services, such as medication reactions that happened in the week following the initial consult, prescription refills, or other minor questions that involved minimal time and effort on the part of the physician.

As physicians begin to adopt the online visit model using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

'The biggest problem with doctors is that we think our patients want to be there.'

Source DR. BACHMAN

Millions of unemployed workers and their families are facing the prospect of becoming uninsured or paying four-figure monthly premiums to keep their health coverage as government-funded subsidies expire, according to a new report from Families USA.

Under the Recovery Act, passed earlier this year, the federal government has been subsidizing 65% of health insurance premiums under COBRA, the government program that allows unemployed workers to retain their employer-sponsored health coverage provided they pay both the worker and employer share of the premium.

The subsidy was available from 9 months from the day unemployed worker began COBRA coverage. People who obtained the subsidy when it first became available in March, tad to begin paying the full cost for COBRA starting on Dec. 1. And starting in January 2010, the subsidy will no longer be available for newly unemployed workers.

The loss of the subsidy effectively means that most of these families won't be able to afford keep their health coverage, according to Ron Pollack, executive director of Families USA, a consumer advocacy group that focuses on health care issues. For example, the average family premium for COBRA coverage is $1,111 per month, up from about $389 with the government subsidy. Many families with an unemployed worker can't afford that cost, Mr. Pollack said, since the average unemployment check is about $1,333 a month. In nine states, the average cost of family coverage under COBRA actually exceeds the average unemployment check, according to the Families USA report.

At a news conference accompanying the release of the report, Mr. Pollack urged Congress to pass legislation that would extend the COBRA subsidies for an additional 6 months. He added that the health reform proposal being debated in the Senate now would solve the issue permanently by allowing unemployed workers to purchase insurance through a regulated insurance exchange that includes subsidies for low-income Americans.

Millions of unemployed workers and their families are facing the prospect of becoming uninsured or paying four-figure monthly premiums to keep their health coverage as government-funded subsidies expire, according to a new report from Families USA.

Under the Recovery Act, passed earlier this year, the federal government has been subsidizing 65% of health insurance premiums under COBRA, the government program that allows unemployed workers to retain their employer-sponsored health coverage provided they pay both the worker and employer share of the premium.

The subsidy was available from 9 months from the day unemployed worker began COBRA coverage. People who obtained the subsidy when it first became available in March, tad to begin paying the full cost for COBRA starting on Dec. 1. And starting in January 2010, the subsidy will no longer be available for newly unemployed workers.

The loss of the subsidy effectively means that most of these families won't be able to afford keep their health coverage, according to Ron Pollack, executive director of Families USA, a consumer advocacy group that focuses on health care issues. For example, the average family premium for COBRA coverage is $1,111 per month, up from about $389 with the government subsidy. Many families with an unemployed worker can't afford that cost, Mr. Pollack said, since the average unemployment check is about $1,333 a month. In nine states, the average cost of family coverage under COBRA actually exceeds the average unemployment check, according to the Families USA report.

At a news conference accompanying the release of the report, Mr. Pollack urged Congress to pass legislation that would extend the COBRA subsidies for an additional 6 months. He added that the health reform proposal being debated in the Senate now would solve the issue permanently by allowing unemployed workers to purchase insurance through a regulated insurance exchange that includes subsidies for low-income Americans.

Millions of unemployed workers and their families are facing the prospect of becoming uninsured or paying four-figure monthly premiums to keep their health coverage as government-funded subsidies expire, according to a new report from Families USA.

Under the Recovery Act, passed earlier this year, the federal government has been subsidizing 65% of health insurance premiums under COBRA, the government program that allows unemployed workers to retain their employer-sponsored health coverage provided they pay both the worker and employer share of the premium.

The subsidy was available from 9 months from the day unemployed worker began COBRA coverage. People who obtained the subsidy when it first became available in March, tad to begin paying the full cost for COBRA starting on Dec. 1. And starting in January 2010, the subsidy will no longer be available for newly unemployed workers.

The loss of the subsidy effectively means that most of these families won't be able to afford keep their health coverage, according to Ron Pollack, executive director of Families USA, a consumer advocacy group that focuses on health care issues. For example, the average family premium for COBRA coverage is $1,111 per month, up from about $389 with the government subsidy. Many families with an unemployed worker can't afford that cost, Mr. Pollack said, since the average unemployment check is about $1,333 a month. In nine states, the average cost of family coverage under COBRA actually exceeds the average unemployment check, according to the Families USA report.

At a news conference accompanying the release of the report, Mr. Pollack urged Congress to pass legislation that would extend the COBRA subsidies for an additional 6 months. He added that the health reform proposal being debated in the Senate now would solve the issue permanently by allowing unemployed workers to purchase insurance through a regulated insurance exchange that includes subsidies for low-income Americans.

BOSTON — Physicians can go a long way toward helping their patients successfully quit smoking by thinking about tobacco dependence as a chronic disease, according to Dr. Donald J. Brideau Jr., a family physician in Alexandria, Va.

Tobacco dependence, just like diabetes or hypertension, is a chronic problem that requires follow-up and education to prevent relapse, so physicians can use the same types of strategies and patient education techniques that they use from other chronic illnesses, said Dr. Brideau, chief medical officer at Inova Mount Vernon Hospital in Alexandria.

Dr. Brideau offered this and other tips culled from the clinical practice guidelines on smoking cessation at the annual meeting of the American Academy of Family Physicians.

Another important way to increase quitting success is to offer every tobacco user some form of therapy, whether it's a pure behavioral approach or medication. This, however, requires physicians or their staffs to systematically identify every smoker or former smoker at every visit. It doesn't matter who does it or how it is done, but it should be done at every visit, he said. Practices can use stickers on charts or make smoking a fifth vital sign.

Once the smokers have been identified, it is important to assess their readiness to quit. The amount of time spent counseling them depends on where they are on the quitting spectrum. If patients say they are not ready to quit, keep the discussion brief. Let them know that you will be there when they are ready and that you will continue to ask them about it, Dr. Brideau said.

If, however, patients say they could be ready to quit in the next 30 days, they will need information on pharmacologic therapy and advice on other ways they can prepare for their quit date.

When it comes to actually quitting, the literature supports the use of counseling, pharmacologic treatments, and the combination of the two approaches, said Dr. Brideau, who disclosed a financial relationship with Pfizer and the Candela Corp.

In terms of counseling, the evidence shows that the duration and number of sessions is important to increasing success rates. Dr. Brideau tries to get his patients to commit to coming to four office visits over 3 or 4 months to discuss their progress.

Pharmacologic intervention should be a part of the approach for most patients. Clinical practice guidelines for smoking cessation recommend that all smokers be offered some form of pharmacologic intervention, unless there is a contraindication. Patients will have the greatest chance for success, though, if they receive a combination of medication and counseling. Practically, that could mean coupling medication with a 15-minute office visit that is devoted exclusively to a discussion about smoking cessation. Even that small effort could significantly increase success in quitting, Dr. Brideau said.

Another effective approach is to recommend telephone quit lines. Multiple randomized controlled trials support the use of these hotlines in increasing success rates. It's no surprise that the quit lines are successful, because they offer individualized counseling to patients, he said.

When patients are unwilling to quit, don't give up. Instead, consider using motivational interviewing techniques. When talking to a patient about quitting, for example, focus on their feelings and why they don't want to set a quit date. Try to figure out what rewards they get from smoking and what the roadblocks are to making a cessation attempt. Many patients will resist, so don't take it personally, and continue to repeat the smoking cessation message with each visit, Dr. Brideau advised.

BOSTON — Physicians can go a long way toward helping their patients successfully quit smoking by thinking about tobacco dependence as a chronic disease, according to Dr. Donald J. Brideau Jr., a family physician in Alexandria, Va.

Tobacco dependence, just like diabetes or hypertension, is a chronic problem that requires follow-up and education to prevent relapse, so physicians can use the same types of strategies and patient education techniques that they use from other chronic illnesses, said Dr. Brideau, chief medical officer at Inova Mount Vernon Hospital in Alexandria.

Dr. Brideau offered this and other tips culled from the clinical practice guidelines on smoking cessation at the annual meeting of the American Academy of Family Physicians.

Another important way to increase quitting success is to offer every tobacco user some form of therapy, whether it's a pure behavioral approach or medication. This, however, requires physicians or their staffs to systematically identify every smoker or former smoker at every visit. It doesn't matter who does it or how it is done, but it should be done at every visit, he said. Practices can use stickers on charts or make smoking a fifth vital sign.

Once the smokers have been identified, it is important to assess their readiness to quit. The amount of time spent counseling them depends on where they are on the quitting spectrum. If patients say they are not ready to quit, keep the discussion brief. Let them know that you will be there when they are ready and that you will continue to ask them about it, Dr. Brideau said.

If, however, patients say they could be ready to quit in the next 30 days, they will need information on pharmacologic therapy and advice on other ways they can prepare for their quit date.

When it comes to actually quitting, the literature supports the use of counseling, pharmacologic treatments, and the combination of the two approaches, said Dr. Brideau, who disclosed a financial relationship with Pfizer and the Candela Corp.

In terms of counseling, the evidence shows that the duration and number of sessions is important to increasing success rates. Dr. Brideau tries to get his patients to commit to coming to four office visits over 3 or 4 months to discuss their progress.

Pharmacologic intervention should be a part of the approach for most patients. Clinical practice guidelines for smoking cessation recommend that all smokers be offered some form of pharmacologic intervention, unless there is a contraindication. Patients will have the greatest chance for success, though, if they receive a combination of medication and counseling. Practically, that could mean coupling medication with a 15-minute office visit that is devoted exclusively to a discussion about smoking cessation. Even that small effort could significantly increase success in quitting, Dr. Brideau said.

Another effective approach is to recommend telephone quit lines. Multiple randomized controlled trials support the use of these hotlines in increasing success rates. It's no surprise that the quit lines are successful, because they offer individualized counseling to patients, he said.

When patients are unwilling to quit, don't give up. Instead, consider using motivational interviewing techniques. When talking to a patient about quitting, for example, focus on their feelings and why they don't want to set a quit date. Try to figure out what rewards they get from smoking and what the roadblocks are to making a cessation attempt. Many patients will resist, so don't take it personally, and continue to repeat the smoking cessation message with each visit, Dr. Brideau advised.

BOSTON — Physicians can go a long way toward helping their patients successfully quit smoking by thinking about tobacco dependence as a chronic disease, according to Dr. Donald J. Brideau Jr., a family physician in Alexandria, Va.

Tobacco dependence, just like diabetes or hypertension, is a chronic problem that requires follow-up and education to prevent relapse, so physicians can use the same types of strategies and patient education techniques that they use from other chronic illnesses, said Dr. Brideau, chief medical officer at Inova Mount Vernon Hospital in Alexandria.

Dr. Brideau offered this and other tips culled from the clinical practice guidelines on smoking cessation at the annual meeting of the American Academy of Family Physicians.

Another important way to increase quitting success is to offer every tobacco user some form of therapy, whether it's a pure behavioral approach or medication. This, however, requires physicians or their staffs to systematically identify every smoker or former smoker at every visit. It doesn't matter who does it or how it is done, but it should be done at every visit, he said. Practices can use stickers on charts or make smoking a fifth vital sign.

Once the smokers have been identified, it is important to assess their readiness to quit. The amount of time spent counseling them depends on where they are on the quitting spectrum. If patients say they are not ready to quit, keep the discussion brief. Let them know that you will be there when they are ready and that you will continue to ask them about it, Dr. Brideau said.

If, however, patients say they could be ready to quit in the next 30 days, they will need information on pharmacologic therapy and advice on other ways they can prepare for their quit date.

When it comes to actually quitting, the literature supports the use of counseling, pharmacologic treatments, and the combination of the two approaches, said Dr. Brideau, who disclosed a financial relationship with Pfizer and the Candela Corp.

In terms of counseling, the evidence shows that the duration and number of sessions is important to increasing success rates. Dr. Brideau tries to get his patients to commit to coming to four office visits over 3 or 4 months to discuss their progress.

Pharmacologic intervention should be a part of the approach for most patients. Clinical practice guidelines for smoking cessation recommend that all smokers be offered some form of pharmacologic intervention, unless there is a contraindication. Patients will have the greatest chance for success, though, if they receive a combination of medication and counseling. Practically, that could mean coupling medication with a 15-minute office visit that is devoted exclusively to a discussion about smoking cessation. Even that small effort could significantly increase success in quitting, Dr. Brideau said.

Another effective approach is to recommend telephone quit lines. Multiple randomized controlled trials support the use of these hotlines in increasing success rates. It's no surprise that the quit lines are successful, because they offer individualized counseling to patients, he said.

When patients are unwilling to quit, don't give up. Instead, consider using motivational interviewing techniques. When talking to a patient about quitting, for example, focus on their feelings and why they don't want to set a quit date. Try to figure out what rewards they get from smoking and what the roadblocks are to making a cessation attempt. Many patients will resist, so don't take it personally, and continue to repeat the smoking cessation message with each visit, Dr. Brideau advised.

Dr. Sanjay Saint and his colleagues at the Veterans Affairs Medical Center in Ann Arbor, Mich., are turning the inpatient service there into a laboratory, trying to create the ideal hospital experience for patients.

The “Gold Service” project began over the summer and is a small part of Dr. Saint's decade-long quest to curb hospital-acquired complications and infections.

Dr. Saint, a professor of internal medicine at the University of Michigan, said he strives to bring the same type of prevention focus that general internists bring to the outpatient setting to the most vulnerable patients in the hospital. “I wanted to apply that framework to those patients who are so sick that if they actually get a complication under our watch, that could tip them over and it could mean that either they die or they never go home,” he said.

For the last 9 years, Dr. Saint has served as director of the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and the University of Michigan Health System. In this latest project, he is working to create an inpatient service that is highly efficient and effective, achieves a high level of safety, and keeps patients satisfied, while also fulfilling the research and education missions of the VA and University of Michigan.

The overall goal, Dr. Saint said, is to provide the type of care that physicians would want for their own family members.

In practice, that means translating research into practice more quickly, providing appropriate oversight of residents and medical students, and improving communications across disciplines. On his service, they provide reading lists to learners, encourage better communication between nurses and physicians, and conduct multidisciplinary rounds.

Dr. Saint also urges the hospitalists and attending physicians to practice what they preach. For example, physicians can talk about the importance of preventing nosocomial infections, but if they don't wash their hands before and after touching the patient, it doesn't matter what they say. “Learners see that,” he said.

Although there are no data from the project so far, Dr. Saint said they plan to measure their progress on several metrics and compare them to those of other services. Specifically, they hope to examine mortality, readmission rates, nosocomial infection rates, hand hygiene adherence rates, length of stay, patient and nurse satisfaction, and teaching evaluations.

The project is just getting off the ground, but Dr. Saint said they have already encountered challenges. One issue is overcoming the “outdated” mindset that physicians, nurses, and social workers should operate in separate silos, he said, rather than functioning as a true health care team. Ultimately, he hopes physicians and nurses will spend less time worrying about what's in their job descriptions and more time figuring out how to make the patient “the central focus,” Dr. Saint said.

Another challenge is balancing some of the trade-offs between quality and resource utilization. For example, keeping patients in the hospital slightly longer could increase their satisfaction and potentially decrease readmission rates, but increasing the length of stay has other drawbacks. “We have to look at all these things not in a vacuum, but at how they interrelate,” he said.

If he and his team are successful in improving patient care through the Gold Service, Dr. Saint hopes to see the lessons picked up by all kinds of hospitals, not just in the United States, but in countries all around the world. Since the research is being done at a VA facility, which is part of a large, centralized system, other countries with centralized health care systems like Canada, England, Italy, and France may be able to make similar changes, he said.

'We have to look at all these things not in a vacuum, but at how they interrelate.'

Source DR. SAINT

Dr. Sanjay Saint and his colleagues at the Veterans Affairs Medical Center in Ann Arbor, Mich., are turning the inpatient service there into a laboratory, trying to create the ideal hospital experience for patients.

The “Gold Service” project began over the summer and is a small part of Dr. Saint's decade-long quest to curb hospital-acquired complications and infections.

Dr. Saint, a professor of internal medicine at the University of Michigan, said he strives to bring the same type of prevention focus that general internists bring to the outpatient setting to the most vulnerable patients in the hospital. “I wanted to apply that framework to those patients who are so sick that if they actually get a complication under our watch, that could tip them over and it could mean that either they die or they never go home,” he said.

For the last 9 years, Dr. Saint has served as director of the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and the University of Michigan Health System. In this latest project, he is working to create an inpatient service that is highly efficient and effective, achieves a high level of safety, and keeps patients satisfied, while also fulfilling the research and education missions of the VA and University of Michigan.

The overall goal, Dr. Saint said, is to provide the type of care that physicians would want for their own family members.

In practice, that means translating research into practice more quickly, providing appropriate oversight of residents and medical students, and improving communications across disciplines. On his service, they provide reading lists to learners, encourage better communication between nurses and physicians, and conduct multidisciplinary rounds.

Dr. Saint also urges the hospitalists and attending physicians to practice what they preach. For example, physicians can talk about the importance of preventing nosocomial infections, but if they don't wash their hands before and after touching the patient, it doesn't matter what they say. “Learners see that,” he said.

Although there are no data from the project so far, Dr. Saint said they plan to measure their progress on several metrics and compare them to those of other services. Specifically, they hope to examine mortality, readmission rates, nosocomial infection rates, hand hygiene adherence rates, length of stay, patient and nurse satisfaction, and teaching evaluations.

The project is just getting off the ground, but Dr. Saint said they have already encountered challenges. One issue is overcoming the “outdated” mindset that physicians, nurses, and social workers should operate in separate silos, he said, rather than functioning as a true health care team. Ultimately, he hopes physicians and nurses will spend less time worrying about what's in their job descriptions and more time figuring out how to make the patient “the central focus,” Dr. Saint said.

Another challenge is balancing some of the trade-offs between quality and resource utilization. For example, keeping patients in the hospital slightly longer could increase their satisfaction and potentially decrease readmission rates, but increasing the length of stay has other drawbacks. “We have to look at all these things not in a vacuum, but at how they interrelate,” he said.

If he and his team are successful in improving patient care through the Gold Service, Dr. Saint hopes to see the lessons picked up by all kinds of hospitals, not just in the United States, but in countries all around the world. Since the research is being done at a VA facility, which is part of a large, centralized system, other countries with centralized health care systems like Canada, England, Italy, and France may be able to make similar changes, he said.

'We have to look at all these things not in a vacuum, but at how they interrelate.'

Source DR. SAINT

Dr. Sanjay Saint and his colleagues at the Veterans Affairs Medical Center in Ann Arbor, Mich., are turning the inpatient service there into a laboratory, trying to create the ideal hospital experience for patients.

The “Gold Service” project began over the summer and is a small part of Dr. Saint's decade-long quest to curb hospital-acquired complications and infections.

Dr. Saint, a professor of internal medicine at the University of Michigan, said he strives to bring the same type of prevention focus that general internists bring to the outpatient setting to the most vulnerable patients in the hospital. “I wanted to apply that framework to those patients who are so sick that if they actually get a complication under our watch, that could tip them over and it could mean that either they die or they never go home,” he said.

For the last 9 years, Dr. Saint has served as director of the Patient Safety Enhancement Program at the Ann Arbor VA Medical Center and the University of Michigan Health System. In this latest project, he is working to create an inpatient service that is highly efficient and effective, achieves a high level of safety, and keeps patients satisfied, while also fulfilling the research and education missions of the VA and University of Michigan.

The overall goal, Dr. Saint said, is to provide the type of care that physicians would want for their own family members.

In practice, that means translating research into practice more quickly, providing appropriate oversight of residents and medical students, and improving communications across disciplines. On his service, they provide reading lists to learners, encourage better communication between nurses and physicians, and conduct multidisciplinary rounds.

Dr. Saint also urges the hospitalists and attending physicians to practice what they preach. For example, physicians can talk about the importance of preventing nosocomial infections, but if they don't wash their hands before and after touching the patient, it doesn't matter what they say. “Learners see that,” he said.

Although there are no data from the project so far, Dr. Saint said they plan to measure their progress on several metrics and compare them to those of other services. Specifically, they hope to examine mortality, readmission rates, nosocomial infection rates, hand hygiene adherence rates, length of stay, patient and nurse satisfaction, and teaching evaluations.

The project is just getting off the ground, but Dr. Saint said they have already encountered challenges. One issue is overcoming the “outdated” mindset that physicians, nurses, and social workers should operate in separate silos, he said, rather than functioning as a true health care team. Ultimately, he hopes physicians and nurses will spend less time worrying about what's in their job descriptions and more time figuring out how to make the patient “the central focus,” Dr. Saint said.

Another challenge is balancing some of the trade-offs between quality and resource utilization. For example, keeping patients in the hospital slightly longer could increase their satisfaction and potentially decrease readmission rates, but increasing the length of stay has other drawbacks. “We have to look at all these things not in a vacuum, but at how they interrelate,” he said.

If he and his team are successful in improving patient care through the Gold Service, Dr. Saint hopes to see the lessons picked up by all kinds of hospitals, not just in the United States, but in countries all around the world. Since the research is being done at a VA facility, which is part of a large, centralized system, other countries with centralized health care systems like Canada, England, Italy, and France may be able to make similar changes, he said.

'We have to look at all these things not in a vacuum, but at how they interrelate.'

Source DR. SAINT

BOSTON — If you're struggling to help your diabetic patients stay in control, the answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

During a traditional one-on-one office visit, the physician assesses and instructs the patient. But diabetes is a self-management disease that requires patients to change their behavior, something that is not likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.

The evidence for this is in the national statistics on diabetes: Fewer than half of diabetic patients achieve recommended hemoglobin A_1c goals, and only about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.

Dr. Shahady and his colleagues at the Florida Academy of Family Physicians Foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.

Under the model, group visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2.5 hours. During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with bA_1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.

The nurse also fields questions, for which Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. Putting unrelated questions on the sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.

During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.

While each visit has a set topic, the idea is not for the visits to be lectures. Instead, patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” he said. This interaction is much more effective than getting the suggestions from the physician, Dr. Shahady said.

Sometimes the sessions can get emotional, which offers an opportunity to ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.

Ideally, groups should be kept to about 10 patients. Most of the group members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they may be able to offer advice to other group members.

If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.

BOSTON — If you're struggling to help your diabetic patients stay in control, the answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

During a traditional one-on-one office visit, the physician assesses and instructs the patient. But diabetes is a self-management disease that requires patients to change their behavior, something that is not likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.

The evidence for this is in the national statistics on diabetes: Fewer than half of diabetic patients achieve recommended hemoglobin A_1c goals, and only about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.

Dr. Shahady and his colleagues at the Florida Academy of Family Physicians Foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.

Under the model, group visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2.5 hours. During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with bA_1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.

The nurse also fields questions, for which Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. Putting unrelated questions on the sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.

During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.

While each visit has a set topic, the idea is not for the visits to be lectures. Instead, patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” he said. This interaction is much more effective than getting the suggestions from the physician, Dr. Shahady said.

Sometimes the sessions can get emotional, which offers an opportunity to ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.

Ideally, groups should be kept to about 10 patients. Most of the group members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they may be able to offer advice to other group members.

If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.

BOSTON — If you're struggling to help your diabetic patients stay in control, the answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

During a traditional one-on-one office visit, the physician assesses and instructs the patient. But diabetes is a self-management disease that requires patients to change their behavior, something that is not likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.

The evidence for this is in the national statistics on diabetes: Fewer than half of diabetic patients achieve recommended hemoglobin A_1c goals, and only about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.

Dr. Shahady and his colleagues at the Florida Academy of Family Physicians Foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.

Under the model, group visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2.5 hours. During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with bA_1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.

The nurse also fields questions, for which Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. Putting unrelated questions on the sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.

During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.

While each visit has a set topic, the idea is not for the visits to be lectures. Instead, patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” he said. This interaction is much more effective than getting the suggestions from the physician, Dr. Shahady said.

Sometimes the sessions can get emotional, which offers an opportunity to ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.

Ideally, groups should be kept to about 10 patients. Most of the group members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they may be able to offer advice to other group members.

If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn. The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said. “The fact is, your patients will pay $35 not to see you.”

That's been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus. The portal also includes patient education materials. Physicians can also send links and attachments to the patient.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, Dr. Bachman said.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list. Doing online consults can help keep the worried well out of the office, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

Many private insurers in Minnesota are paying part or all of the online visit charge, he said. Although Medicare won't pay for an online visit, Dr. Bachman said he thinks many Medicare patients would be willing to pay the fee themselves. During the pilot, many uninsured patients were willing to pay for the online service.

Overall, the Mayo Clinic physicians billed patients for fewer than half of the online consults completed because they chose not to bill for certain services, such as medication reactions that happened in the week following the initial consult, prescription refills, or other minor questions.

As physicians begin to do online visits using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

'The fact is, your patients will pay $35 not to see you.'

Source DR. BACHMAN

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn. The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said. “The fact is, your patients will pay $35 not to see you.”

That's been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus. The portal also includes patient education materials. Physicians can also send links and attachments to the patient.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, Dr. Bachman said.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list. Doing online consults can help keep the worried well out of the office, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

Many private insurers in Minnesota are paying part or all of the online visit charge, he said. Although Medicare won't pay for an online visit, Dr. Bachman said he thinks many Medicare patients would be willing to pay the fee themselves. During the pilot, many uninsured patients were willing to pay for the online service.

Overall, the Mayo Clinic physicians billed patients for fewer than half of the online consults completed because they chose not to bill for certain services, such as medication reactions that happened in the week following the initial consult, prescription refills, or other minor questions.

As physicians begin to do online visits using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

'The fact is, your patients will pay $35 not to see you.'

Source DR. BACHMAN

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn. The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said. “The fact is, your patients will pay $35 not to see you.”

That's been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus. The portal also includes patient education materials. Physicians can also send links and attachments to the patient.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, Dr. Bachman said.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list. Doing online consults can help keep the worried well out of the office, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

Many private insurers in Minnesota are paying part or all of the online visit charge, he said. Although Medicare won't pay for an online visit, Dr. Bachman said he thinks many Medicare patients would be willing to pay the fee themselves. During the pilot, many uninsured patients were willing to pay for the online service.

Overall, the Mayo Clinic physicians billed patients for fewer than half of the online consults completed because they chose not to bill for certain services, such as medication reactions that happened in the week following the initial consult, prescription refills, or other minor questions.

As physicians begin to do online visits using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

'The fact is, your patients will pay $35 not to see you.'

Source DR. BACHMAN

NEW YORK — The incidence of posttraumatic stress disorder is likely to be significantly higher in the current population of veterans because of long and repeated tours of duty, said Dr. John A. Renner Jr., associate chief of psychiatry at the VA Boston Healthcare System.

Clinicians and scientists have known since the 1960s that limiting exposure to combat to 1 year helps reduce the incidence of PTSD, but today a large cohort of troops has had repeated exposures of more than 1 year, said Dr. Renner, also a faculty member at Boston University.

“Statistically … that's going to have a major impact,” Dr. Renner said during a panel discussion on substance abuse and mental health among veterans and active duty military sponsored by the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

Veterans of the Iraq and Afghanistan conflicts are often 22- and 23-year-olds who have been deployed two, three, or four times in many cases, said Dr. Loree K. Sutton, a brigadier general in the Department of Defense Military Health System. These troops were constantly exposed to danger and improvised explosive devices, and, operated in places where they often were unable to identify the enemy, she said.

Another difference between today's combat veterans and those from other eras is the increased number of soldiers returning with chronic pain syndromes, said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health. More soldiers are able to survive combat injuries but that translates into living with more pain and the potential for abusing prescription pain medications, she said.

NEW YORK — The incidence of posttraumatic stress disorder is likely to be significantly higher in the current population of veterans because of long and repeated tours of duty, said Dr. John A. Renner Jr., associate chief of psychiatry at the VA Boston Healthcare System.

Clinicians and scientists have known since the 1960s that limiting exposure to combat to 1 year helps reduce the incidence of PTSD, but today a large cohort of troops has had repeated exposures of more than 1 year, said Dr. Renner, also a faculty member at Boston University.

“Statistically … that's going to have a major impact,” Dr. Renner said during a panel discussion on substance abuse and mental health among veterans and active duty military sponsored by the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

Veterans of the Iraq and Afghanistan conflicts are often 22- and 23-year-olds who have been deployed two, three, or four times in many cases, said Dr. Loree K. Sutton, a brigadier general in the Department of Defense Military Health System. These troops were constantly exposed to danger and improvised explosive devices, and, operated in places where they often were unable to identify the enemy, she said.

Another difference between today's combat veterans and those from other eras is the increased number of soldiers returning with chronic pain syndromes, said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health. More soldiers are able to survive combat injuries but that translates into living with more pain and the potential for abusing prescription pain medications, she said.

NEW YORK — The incidence of posttraumatic stress disorder is likely to be significantly higher in the current population of veterans because of long and repeated tours of duty, said Dr. John A. Renner Jr., associate chief of psychiatry at the VA Boston Healthcare System.

Clinicians and scientists have known since the 1960s that limiting exposure to combat to 1 year helps reduce the incidence of PTSD, but today a large cohort of troops has had repeated exposures of more than 1 year, said Dr. Renner, also a faculty member at Boston University.

“Statistically … that's going to have a major impact,” Dr. Renner said during a panel discussion on substance abuse and mental health among veterans and active duty military sponsored by the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

Veterans of the Iraq and Afghanistan conflicts are often 22- and 23-year-olds who have been deployed two, three, or four times in many cases, said Dr. Loree K. Sutton, a brigadier general in the Department of Defense Military Health System. These troops were constantly exposed to danger and improvised explosive devices, and, operated in places where they often were unable to identify the enemy, she said.

Another difference between today's combat veterans and those from other eras is the increased number of soldiers returning with chronic pain syndromes, said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health. More soldiers are able to survive combat injuries but that translates into living with more pain and the potential for abusing prescription pain medications, she said.

NEW YORK — Stigma surrounding mental illness continues to complicate treatment for veterans with symptoms of posttraumatic stress disorder, according to experts.

The stigma exists not just in the military culture but also as an issue among young men, M. David Rudd, Ph.D., chair of the department of psychology at Texas Tech University in Lubbock, said during a panel discussion on substance abuse and mental health issues among veterans and active-duty military personnel at a meeting sponsored by the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

These young men often perceive experiencing psychiatric symptoms after combat as a failure. For them, it means that they are not invulnerable and that somehow they have done something wrong because they are having problems coping with the stress, said Dr. Rudd, who is a Gulf War veteran.

“It's really a sense of this notion of guilt and shame attached to an experience of failure after having been exposed to combat and then somehow feeling like they haven't responded in the way they should have,” he said.

Many veterans actually prefer to live with the trauma than to treat it, said Dr. Alexander Neumeister, of the psychiatry department at Yale University, New Haven, Conn., and the VA Connecticut Healthcare System, who was on the panel. Part of the problem is the evaluation process generally used for patients with PTSD, he said. The evaluation can take hours, and patients have to discuss the trauma that they have been working to suppress. Dr. Neumeister said.

NEW YORK — Stigma surrounding mental illness continues to complicate treatment for veterans with symptoms of posttraumatic stress disorder, according to experts.

The stigma exists not just in the military culture but also as an issue among young men, M. David Rudd, Ph.D., chair of the department of psychology at Texas Tech University in Lubbock, said during a panel discussion on substance abuse and mental health issues among veterans and active-duty military personnel at a meeting sponsored by the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

These young men often perceive experiencing psychiatric symptoms after combat as a failure. For them, it means that they are not invulnerable and that somehow they have done something wrong because they are having problems coping with the stress, said Dr. Rudd, who is a Gulf War veteran.

“It's really a sense of this notion of guilt and shame attached to an experience of failure after having been exposed to combat and then somehow feeling like they haven't responded in the way they should have,” he said.

Many veterans actually prefer to live with the trauma than to treat it, said Dr. Alexander Neumeister, of the psychiatry department at Yale University, New Haven, Conn., and the VA Connecticut Healthcare System, who was on the panel. Part of the problem is the evaluation process generally used for patients with PTSD, he said. The evaluation can take hours, and patients have to discuss the trauma that they have been working to suppress. Dr. Neumeister said.

NEW YORK — Stigma surrounding mental illness continues to complicate treatment for veterans with symptoms of posttraumatic stress disorder, according to experts.

The stigma exists not just in the military culture but also as an issue among young men, M. David Rudd, Ph.D., chair of the department of psychology at Texas Tech University in Lubbock, said during a panel discussion on substance abuse and mental health issues among veterans and active-duty military personnel at a meeting sponsored by the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

These young men often perceive experiencing psychiatric symptoms after combat as a failure. For them, it means that they are not invulnerable and that somehow they have done something wrong because they are having problems coping with the stress, said Dr. Rudd, who is a Gulf War veteran.

“It's really a sense of this notion of guilt and shame attached to an experience of failure after having been exposed to combat and then somehow feeling like they haven't responded in the way they should have,” he said.

Many veterans actually prefer to live with the trauma than to treat it, said Dr. Alexander Neumeister, of the psychiatry department at Yale University, New Haven, Conn., and the VA Connecticut Healthcare System, who was on the panel. Part of the problem is the evaluation process generally used for patients with PTSD, he said. The evaluation can take hours, and patients have to discuss the trauma that they have been working to suppress. Dr. Neumeister said.