Mary Ellen Schneider

NEW YORK – Juvenile bipolar disorder is a controversial diagnosis, and broad disagreement exists among both clinicians and researchers about how the diagnosis should be made, according to Dr. Jennifer Harris, of the department of psychiatry at Harvard Medical School, Boston.

Making the diagnosis is further complicated by the fact that the research literature includes three different major approaches to the diagnosis of the condition, Dr. Harris reported at the annual meeting of the American Society for Adolescent Psychiatry.

There appears to be agreement on how to interpret the presence of category B symptoms as described in the DSM-IV criteria for mania, but there is little agreement on the category A symptoms, which are defined as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood,” lasting at least 7 days for mania or 4 days for hypomania.

The first diagnostic approach that is detailed in the literature is a narrow phenotype in which clinicians apply strict adult criteria for bipolar disorder, looking for distinct manic episodes of long duration.

This definition doesn't require the presence of euphoria or grandiosity, just irritability alone. However, the mood symptoms must occur only during a distinct time frame and they cannot be chronic.

The second approach is marked by the expression of cardinal symptoms and brief frequent cycles. These patients demonstrate very rapid mood changes and complicated cycling patterns with about three cycles per day. This definition uses strict criteria for the quality of mood symptoms, requiring not only irritability, but grandiosity or euphoria.

The third approach focuses on patients with persistent, impairing irritability. This diagnostic approach does not require the cardinal symptoms of grandiosity or euphoria and does not focus on distinct episodes. Severe, persistent, impairing irritability is considered sufficient to meet criteria for mania, even if it is not a change from the patient's baseline.

A consensus is starting to develop that the narrow phenotype group should be called bipolar disorder I or II, because it reflects the classic bipolar disorder, Dr. Harris said.

She noted that there are some children whose symptoms meet this strict set of criteria.

More controversy exists about whether or not patients who present with the cardinal symptoms and rapid cycling should be categorized as bipolar not otherwise specified (NOS), but included in the spectrum, she said.

Finally, the best way in which to categorize patients who fall into the persistent irritability group remains an open question, Dr. Harris said, although she added that there is some support for diagnosing these patients with severe mood dysregulation.

In practice, Dr. Harris recommends that clinicians diagnose juvenile bipolar disorder “judiciously,” using narrow phenotype criteria and looking for distinct episodes.

If a case doesn't meet the narrow phenotype criteria, Dr. Harris said she wouldn't be convinced that the patient should be treated the same way as an adult with classic bipolar disorder.

However, she cautioned that it's important not to be completely skeptical about the diagnosis of juvenile bipolar disorder.

“These are challenging kids to treat and kids who have really significant problems,” Dr. Harris said. “You can make mistakes either way.”

NEW YORK – Juvenile bipolar disorder is a controversial diagnosis, and broad disagreement exists among both clinicians and researchers about how the diagnosis should be made, according to Dr. Jennifer Harris, of the department of psychiatry at Harvard Medical School, Boston.

Making the diagnosis is further complicated by the fact that the research literature includes three different major approaches to the diagnosis of the condition, Dr. Harris reported at the annual meeting of the American Society for Adolescent Psychiatry.

There appears to be agreement on how to interpret the presence of category B symptoms as described in the DSM-IV criteria for mania, but there is little agreement on the category A symptoms, which are defined as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood,” lasting at least 7 days for mania or 4 days for hypomania.

The first diagnostic approach that is detailed in the literature is a narrow phenotype in which clinicians apply strict adult criteria for bipolar disorder, looking for distinct manic episodes of long duration.

This definition doesn't require the presence of euphoria or grandiosity, just irritability alone. However, the mood symptoms must occur only during a distinct time frame and they cannot be chronic.

The second approach is marked by the expression of cardinal symptoms and brief frequent cycles. These patients demonstrate very rapid mood changes and complicated cycling patterns with about three cycles per day. This definition uses strict criteria for the quality of mood symptoms, requiring not only irritability, but grandiosity or euphoria.

The third approach focuses on patients with persistent, impairing irritability. This diagnostic approach does not require the cardinal symptoms of grandiosity or euphoria and does not focus on distinct episodes. Severe, persistent, impairing irritability is considered sufficient to meet criteria for mania, even if it is not a change from the patient's baseline.

A consensus is starting to develop that the narrow phenotype group should be called bipolar disorder I or II, because it reflects the classic bipolar disorder, Dr. Harris said.

She noted that there are some children whose symptoms meet this strict set of criteria.

More controversy exists about whether or not patients who present with the cardinal symptoms and rapid cycling should be categorized as bipolar not otherwise specified (NOS), but included in the spectrum, she said.

Finally, the best way in which to categorize patients who fall into the persistent irritability group remains an open question, Dr. Harris said, although she added that there is some support for diagnosing these patients with severe mood dysregulation.

In practice, Dr. Harris recommends that clinicians diagnose juvenile bipolar disorder “judiciously,” using narrow phenotype criteria and looking for distinct episodes.

If a case doesn't meet the narrow phenotype criteria, Dr. Harris said she wouldn't be convinced that the patient should be treated the same way as an adult with classic bipolar disorder.

However, she cautioned that it's important not to be completely skeptical about the diagnosis of juvenile bipolar disorder.

“These are challenging kids to treat and kids who have really significant problems,” Dr. Harris said. “You can make mistakes either way.”

NEW YORK – Juvenile bipolar disorder is a controversial diagnosis, and broad disagreement exists among both clinicians and researchers about how the diagnosis should be made, according to Dr. Jennifer Harris, of the department of psychiatry at Harvard Medical School, Boston.

Making the diagnosis is further complicated by the fact that the research literature includes three different major approaches to the diagnosis of the condition, Dr. Harris reported at the annual meeting of the American Society for Adolescent Psychiatry.

There appears to be agreement on how to interpret the presence of category B symptoms as described in the DSM-IV criteria for mania, but there is little agreement on the category A symptoms, which are defined as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood,” lasting at least 7 days for mania or 4 days for hypomania.

The first diagnostic approach that is detailed in the literature is a narrow phenotype in which clinicians apply strict adult criteria for bipolar disorder, looking for distinct manic episodes of long duration.

This definition doesn't require the presence of euphoria or grandiosity, just irritability alone. However, the mood symptoms must occur only during a distinct time frame and they cannot be chronic.

The second approach is marked by the expression of cardinal symptoms and brief frequent cycles. These patients demonstrate very rapid mood changes and complicated cycling patterns with about three cycles per day. This definition uses strict criteria for the quality of mood symptoms, requiring not only irritability, but grandiosity or euphoria.

The third approach focuses on patients with persistent, impairing irritability. This diagnostic approach does not require the cardinal symptoms of grandiosity or euphoria and does not focus on distinct episodes. Severe, persistent, impairing irritability is considered sufficient to meet criteria for mania, even if it is not a change from the patient's baseline.

A consensus is starting to develop that the narrow phenotype group should be called bipolar disorder I or II, because it reflects the classic bipolar disorder, Dr. Harris said.

She noted that there are some children whose symptoms meet this strict set of criteria.

More controversy exists about whether or not patients who present with the cardinal symptoms and rapid cycling should be categorized as bipolar not otherwise specified (NOS), but included in the spectrum, she said.

Finally, the best way in which to categorize patients who fall into the persistent irritability group remains an open question, Dr. Harris said, although she added that there is some support for diagnosing these patients with severe mood dysregulation.

In practice, Dr. Harris recommends that clinicians diagnose juvenile bipolar disorder “judiciously,” using narrow phenotype criteria and looking for distinct episodes.

If a case doesn't meet the narrow phenotype criteria, Dr. Harris said she wouldn't be convinced that the patient should be treated the same way as an adult with classic bipolar disorder.

However, she cautioned that it's important not to be completely skeptical about the diagnosis of juvenile bipolar disorder.

“These are challenging kids to treat and kids who have really significant problems,” Dr. Harris said. “You can make mistakes either way.”

In just a few weeks, the three hospitals at the University of Utah will go live with a computerized provider order entry system that includes medications, lab orders, and radiology.

“It's kind of a clinician-centric system,” said Dr. Michael Strong, the University of Utah's chief medical information officer and founder and director of the hospitalist program there in Salt Lake City.

Dr. Strong has been involved in development of the CPOE system for several years. Going forward, he and his hospitalist colleagues have signed on to be “super users” who will receive additional training and then help other hospital clinicians begin using the system.

Implementing such health IT systems has been a challenge for many hospitals. Only about 17% of nonfederal U.S. hospitals use CPOE for medications in all their major clinical units, according to a survey of nearly 3,000 hospitals sponsored by the U.S. Office of the National Coordinator for Health Information Technology (N. Engl. J. Med. 2009 Mar. 25; doi:10.1056/NEJMsa0900592). Cost is the overriding barrier, but physician resistance has also played a role, the survey found.

By getting involved on the ground floor in the CPOE discussions at his institution, Dr. Strong said, he was able to help customize the order sets so that the CPOE system helped clinical workflow. Another clinician-centric feature of the CPOE system is that it includes links to current practice guidelines. That feature makes for an excellent teaching tool that lets residents learn more about a disease when they order medications, he said.

For Dr. Strong, the next step will be to use his role as chief medical information officer to advance another IT project with important clinical implications for hospitalists. Over the next 2 years, the University of Utah plans to develop a Web-based physician portal that referring physicians can use to securely access clinical data on patients at the hospital. This will “enhance the link” between hospitalists and community physicians, he said.

Working on the CPOE project was just one way that he and his hospitalist colleagues have tried to focus on quality improvement and patient safety activities. Aside from the clinical care benefits, investing time in quality improvement enabled Dr. Strong's hospitalist group to cement their position within the hospital and make themselves more valuable to the administration, he said.

Over time, as his group showed improvements in quality and efficiency through measures such as decreased length of stay, they gained enough bargaining power to move some hospitalists into seats on key administration councils.

Building a partnership with the hospital administration can also soften some of the pressure that hospitalist programs can feel to make a dent in the bottom line. “The bottom line is important and certainly we have accountability for it, but I don't feel our hospital administration hammers us on that,” Dr. Strong said. “They see value that extends beyond dollars-and-cents items.”

And the working partnership with the hospital administration has created a better working environment for the hospitalist group, which in turn has resulted in limited staff turnover—an advantage for house staff programs, residency programs, and research activities.

Another role for hospitalists in academic settings is as researchers on topics such as patient flow and process improvement. “Hospitalists are in a wonderful position to be able to further knowledge about how hospitals work and how we can do it better and safer,” he said. “Hospitalists have taken up the clarion call.”

A Web-based physician portal will 'enhance the link' between hospitalists and community physicians. DR. STRONG

In just a few weeks, the three hospitals at the University of Utah will go live with a computerized provider order entry system that includes medications, lab orders, and radiology.

“It's kind of a clinician-centric system,” said Dr. Michael Strong, the University of Utah's chief medical information officer and founder and director of the hospitalist program there in Salt Lake City.

Dr. Strong has been involved in development of the CPOE system for several years. Going forward, he and his hospitalist colleagues have signed on to be “super users” who will receive additional training and then help other hospital clinicians begin using the system.

Implementing such health IT systems has been a challenge for many hospitals. Only about 17% of nonfederal U.S. hospitals use CPOE for medications in all their major clinical units, according to a survey of nearly 3,000 hospitals sponsored by the U.S. Office of the National Coordinator for Health Information Technology (N. Engl. J. Med. 2009 Mar. 25; doi:10.1056/NEJMsa0900592). Cost is the overriding barrier, but physician resistance has also played a role, the survey found.

By getting involved on the ground floor in the CPOE discussions at his institution, Dr. Strong said, he was able to help customize the order sets so that the CPOE system helped clinical workflow. Another clinician-centric feature of the CPOE system is that it includes links to current practice guidelines. That feature makes for an excellent teaching tool that lets residents learn more about a disease when they order medications, he said.

For Dr. Strong, the next step will be to use his role as chief medical information officer to advance another IT project with important clinical implications for hospitalists. Over the next 2 years, the University of Utah plans to develop a Web-based physician portal that referring physicians can use to securely access clinical data on patients at the hospital. This will “enhance the link” between hospitalists and community physicians, he said.

Working on the CPOE project was just one way that he and his hospitalist colleagues have tried to focus on quality improvement and patient safety activities. Aside from the clinical care benefits, investing time in quality improvement enabled Dr. Strong's hospitalist group to cement their position within the hospital and make themselves more valuable to the administration, he said.

Over time, as his group showed improvements in quality and efficiency through measures such as decreased length of stay, they gained enough bargaining power to move some hospitalists into seats on key administration councils.

Building a partnership with the hospital administration can also soften some of the pressure that hospitalist programs can feel to make a dent in the bottom line. “The bottom line is important and certainly we have accountability for it, but I don't feel our hospital administration hammers us on that,” Dr. Strong said. “They see value that extends beyond dollars-and-cents items.”

And the working partnership with the hospital administration has created a better working environment for the hospitalist group, which in turn has resulted in limited staff turnover—an advantage for house staff programs, residency programs, and research activities.

Another role for hospitalists in academic settings is as researchers on topics such as patient flow and process improvement. “Hospitalists are in a wonderful position to be able to further knowledge about how hospitals work and how we can do it better and safer,” he said. “Hospitalists have taken up the clarion call.”

A Web-based physician portal will 'enhance the link' between hospitalists and community physicians. DR. STRONG

In just a few weeks, the three hospitals at the University of Utah will go live with a computerized provider order entry system that includes medications, lab orders, and radiology.

“It's kind of a clinician-centric system,” said Dr. Michael Strong, the University of Utah's chief medical information officer and founder and director of the hospitalist program there in Salt Lake City.

Dr. Strong has been involved in development of the CPOE system for several years. Going forward, he and his hospitalist colleagues have signed on to be “super users” who will receive additional training and then help other hospital clinicians begin using the system.

Implementing such health IT systems has been a challenge for many hospitals. Only about 17% of nonfederal U.S. hospitals use CPOE for medications in all their major clinical units, according to a survey of nearly 3,000 hospitals sponsored by the U.S. Office of the National Coordinator for Health Information Technology (N. Engl. J. Med. 2009 Mar. 25; doi:10.1056/NEJMsa0900592). Cost is the overriding barrier, but physician resistance has also played a role, the survey found.

By getting involved on the ground floor in the CPOE discussions at his institution, Dr. Strong said, he was able to help customize the order sets so that the CPOE system helped clinical workflow. Another clinician-centric feature of the CPOE system is that it includes links to current practice guidelines. That feature makes for an excellent teaching tool that lets residents learn more about a disease when they order medications, he said.

For Dr. Strong, the next step will be to use his role as chief medical information officer to advance another IT project with important clinical implications for hospitalists. Over the next 2 years, the University of Utah plans to develop a Web-based physician portal that referring physicians can use to securely access clinical data on patients at the hospital. This will “enhance the link” between hospitalists and community physicians, he said.

Working on the CPOE project was just one way that he and his hospitalist colleagues have tried to focus on quality improvement and patient safety activities. Aside from the clinical care benefits, investing time in quality improvement enabled Dr. Strong's hospitalist group to cement their position within the hospital and make themselves more valuable to the administration, he said.

Over time, as his group showed improvements in quality and efficiency through measures such as decreased length of stay, they gained enough bargaining power to move some hospitalists into seats on key administration councils.

Building a partnership with the hospital administration can also soften some of the pressure that hospitalist programs can feel to make a dent in the bottom line. “The bottom line is important and certainly we have accountability for it, but I don't feel our hospital administration hammers us on that,” Dr. Strong said. “They see value that extends beyond dollars-and-cents items.”

And the working partnership with the hospital administration has created a better working environment for the hospitalist group, which in turn has resulted in limited staff turnover—an advantage for house staff programs, residency programs, and research activities.

Another role for hospitalists in academic settings is as researchers on topics such as patient flow and process improvement. “Hospitalists are in a wonderful position to be able to further knowledge about how hospitals work and how we can do it better and safer,” he said. “Hospitalists have taken up the clarion call.”

A Web-based physician portal will 'enhance the link' between hospitalists and community physicians. DR. STRONG

Medicare officials have validated the use of certain home-based tests to diagnose obstructive sleep apnea.

The Centers for Medicare and Medicaid Services had previously established a national policy of covering continuous positive airway pressure treatment for beneficiaries with obstructive sleep apnea (OSA) if they are diagnosed using certain home sleep tests. But coverage for the tests themselves had been left to the discretion of the local contractor.

In the current decision memo, CMS officials noted that the evidence is “sufficient” to find that in appropriately selected patients, certain home testing monitors can identify a significant proportion of OSA patients who are likely to respond to treatment.

Under the final coverage decision, officials at the CMS opted to cover four categories of sleep testing devices when they are used to establish a diagnosis of OSA in a symptomatic patient.

Type I tests must be performed in a sleep lab facility with an attendant. The other tests can be done either in or out of a sleep lab facility.

The nationally covered tests include:

▸ Type I polysomnography.

▸ Type II or type III sleep testing devices.

▸ Type IV sleep testing devices measuring three or more channels, one of which is airflow.

▸ Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone.

“Medicare beneficiaries who have obstructive sleep apnea face significant risks for cardiovascular disease and other ailments,” said Charlene Frizzera, CMS acting administrator. “This coverage decision establishes nationally consistent coverage and assures that beneficiaries who have sleep apnea can be appropriately diagnosed and referred for treatment.”

Obstructive sleep apnea is a commonly underdiagnosed condition that occurs in about 4% of men and 2% of women. But the prevalence increases with age, rising to 10% among Medicare-age individuals, according to the CMS.

The CMS decision to cover home sleep testing devices is likely to improve access to testing over the next 3–5 years, said Phillip Porte, executive director of the Sleep Manufacturers Alliance. But more time will be needed for the public and physicians to grow more comfortable with at-home sleep testing, he said. Patient acceptance of the technology will depend in large part on what they hear from a trusted physician, he said.

The coverage decision is good news for the millions of Americans with undiagnosed and untreated sleep apnea, said Edward Grandi, executive director of the American Sleep Apnea Association. The coverage of home sleep testing devices will give more options to patients who have not been able to get into a sleep lab, are not comfortable in a laboratory setting, or cannot afford the cost of an evaluation in a sleep lab, he said.

The memo is available at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=227

Medicare officials have validated the use of certain home-based tests to diagnose obstructive sleep apnea.

The Centers for Medicare and Medicaid Services had previously established a national policy of covering continuous positive airway pressure treatment for beneficiaries with obstructive sleep apnea (OSA) if they are diagnosed using certain home sleep tests. But coverage for the tests themselves had been left to the discretion of the local contractor.

In the current decision memo, CMS officials noted that the evidence is “sufficient” to find that in appropriately selected patients, certain home testing monitors can identify a significant proportion of OSA patients who are likely to respond to treatment.

Under the final coverage decision, officials at the CMS opted to cover four categories of sleep testing devices when they are used to establish a diagnosis of OSA in a symptomatic patient.

Type I tests must be performed in a sleep lab facility with an attendant. The other tests can be done either in or out of a sleep lab facility.

The nationally covered tests include:

▸ Type I polysomnography.

▸ Type II or type III sleep testing devices.

▸ Type IV sleep testing devices measuring three or more channels, one of which is airflow.

▸ Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone.

“Medicare beneficiaries who have obstructive sleep apnea face significant risks for cardiovascular disease and other ailments,” said Charlene Frizzera, CMS acting administrator. “This coverage decision establishes nationally consistent coverage and assures that beneficiaries who have sleep apnea can be appropriately diagnosed and referred for treatment.”

Obstructive sleep apnea is a commonly underdiagnosed condition that occurs in about 4% of men and 2% of women. But the prevalence increases with age, rising to 10% among Medicare-age individuals, according to the CMS.

The CMS decision to cover home sleep testing devices is likely to improve access to testing over the next 3–5 years, said Phillip Porte, executive director of the Sleep Manufacturers Alliance. But more time will be needed for the public and physicians to grow more comfortable with at-home sleep testing, he said. Patient acceptance of the technology will depend in large part on what they hear from a trusted physician, he said.

The coverage decision is good news for the millions of Americans with undiagnosed and untreated sleep apnea, said Edward Grandi, executive director of the American Sleep Apnea Association. The coverage of home sleep testing devices will give more options to patients who have not been able to get into a sleep lab, are not comfortable in a laboratory setting, or cannot afford the cost of an evaluation in a sleep lab, he said.

The memo is available at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=227

Medicare officials have validated the use of certain home-based tests to diagnose obstructive sleep apnea.

The Centers for Medicare and Medicaid Services had previously established a national policy of covering continuous positive airway pressure treatment for beneficiaries with obstructive sleep apnea (OSA) if they are diagnosed using certain home sleep tests. But coverage for the tests themselves had been left to the discretion of the local contractor.

In the current decision memo, CMS officials noted that the evidence is “sufficient” to find that in appropriately selected patients, certain home testing monitors can identify a significant proportion of OSA patients who are likely to respond to treatment.

Under the final coverage decision, officials at the CMS opted to cover four categories of sleep testing devices when they are used to establish a diagnosis of OSA in a symptomatic patient.

Type I tests must be performed in a sleep lab facility with an attendant. The other tests can be done either in or out of a sleep lab facility.

The nationally covered tests include:

▸ Type I polysomnography.

▸ Type II or type III sleep testing devices.

▸ Type IV sleep testing devices measuring three or more channels, one of which is airflow.

▸ Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone.

“Medicare beneficiaries who have obstructive sleep apnea face significant risks for cardiovascular disease and other ailments,” said Charlene Frizzera, CMS acting administrator. “This coverage decision establishes nationally consistent coverage and assures that beneficiaries who have sleep apnea can be appropriately diagnosed and referred for treatment.”

Obstructive sleep apnea is a commonly underdiagnosed condition that occurs in about 4% of men and 2% of women. But the prevalence increases with age, rising to 10% among Medicare-age individuals, according to the CMS.

The CMS decision to cover home sleep testing devices is likely to improve access to testing over the next 3–5 years, said Phillip Porte, executive director of the Sleep Manufacturers Alliance. But more time will be needed for the public and physicians to grow more comfortable with at-home sleep testing, he said. Patient acceptance of the technology will depend in large part on what they hear from a trusted physician, he said.

The coverage decision is good news for the millions of Americans with undiagnosed and untreated sleep apnea, said Edward Grandi, executive director of the American Sleep Apnea Association. The coverage of home sleep testing devices will give more options to patients who have not been able to get into a sleep lab, are not comfortable in a laboratory setting, or cannot afford the cost of an evaluation in a sleep lab, he said.

The memo is available at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=227

President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding coverage to all Americans.

The proposed "reserve fund" for health care would get half of its funding from new revenue and half from savings proposals. For example, the Obama administration wants to introduce a competitive bidding process to the Medicare Advantage program, a move estimated to save more than $175 billion over 10 years.

However, in its budget proposal, the administration acknowledged that even $634 billion would not be enough to fully fund a comprehensive reform of the health care system and that administration officials would need to work with Congress to find even more money.

President Obama delivered the 140-page outline of his fiscal year 2010 budget proposal to Congress on Feb. 26. "With this budget we are making a historic commitment to comprehensive health care reform," President Obama said.

The budget proposal contains a set of eight principles the president plans to use to guide his health reform efforts: reducing premiums and other costs for American families and businesses; reducing costs from unnecessary tests and services; putting the nation on a path to universal health care coverage; providing portability to health care insurance; providing individuals with a choice of health plans and physicians; investing in prevention and wellness; improving patient safety and quality of care; and ensuring the long-term fiscal sustainability of the system.

Key among the reforms identified by the Obama administration is the need to change the Medicare physician payment formula. The President supports "comprehensive, but fiscally responsible" changes to the current payment system. "The Administration believes Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care."

The budget proposal also contains good news for physicians who have been bracing for a deep Medicare pay cut next January. In what the administration calls a "return to honest budgeting," the FY 2010 budget proposal will account for the fact that payments to physicians under Medicare will not be significantly cut as called for under current law.

The American Medical Association applauded the administration's willingness to address Medicare physician payment issues. "President Obama's budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40% over the next decade," AMA President Nancy H. Nielsen said in a statement.

The investment in health reform was praised by health care advocates. Ron Pollack, executive director of Families USA, a national organization for health care consumers, said the FY 2010 budget proposal bodes well for achieving health care reform this year. "The fiscal investment proposed by the President is a critical first step towards two related and important objectives—bending the health care cost growth curve and ensuring that everyone has access to high-quality, affordable health coverage and care," he said in a statement.

America's Health Insurance Plans also praised the President's commitment to health reform. However, the group criticized the proposal to make Medicare Advantage plans engage in a competitive bidding process, saying that significant cuts to Medicare Advantage would "jeopardize the health security of more than 10 million seniors" enrolled in the program and reverse payment incentives designed to improve quality of care.

The FY 2010 budget proposal also includes $76.8 billion in discretionary funding for the Health and Human Services department. The budget proposal for HHS includes more than $6 billion in cancer research funding at the National Institutes of Health, on top of the $10 billion in NIH funding that was included as part of the American Recovery and Reinvestment Act, enacted in February.

The administration's budget proposal also aims to address physician shortages by spending $330 million to expand loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas.

Finally, the proposal aims to reduce drug prices by accelerating access to generic versions of biologic drugs.

The administration's FY 2010 budget proposal is available at www.whitehouse.gov/omb/budget/

President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding coverage to all Americans.

The proposed "reserve fund" for health care would get half of its funding from new revenue and half from savings proposals. For example, the Obama administration wants to introduce a competitive bidding process to the Medicare Advantage program, a move estimated to save more than $175 billion over 10 years.

However, in its budget proposal, the administration acknowledged that even $634 billion would not be enough to fully fund a comprehensive reform of the health care system and that administration officials would need to work with Congress to find even more money.

President Obama delivered the 140-page outline of his fiscal year 2010 budget proposal to Congress on Feb. 26. "With this budget we are making a historic commitment to comprehensive health care reform," President Obama said.

The budget proposal contains a set of eight principles the president plans to use to guide his health reform efforts: reducing premiums and other costs for American families and businesses; reducing costs from unnecessary tests and services; putting the nation on a path to universal health care coverage; providing portability to health care insurance; providing individuals with a choice of health plans and physicians; investing in prevention and wellness; improving patient safety and quality of care; and ensuring the long-term fiscal sustainability of the system.

Key among the reforms identified by the Obama administration is the need to change the Medicare physician payment formula. The President supports "comprehensive, but fiscally responsible" changes to the current payment system. "The Administration believes Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care."

The budget proposal also contains good news for physicians who have been bracing for a deep Medicare pay cut next January. In what the administration calls a "return to honest budgeting," the FY 2010 budget proposal will account for the fact that payments to physicians under Medicare will not be significantly cut as called for under current law.

The American Medical Association applauded the administration's willingness to address Medicare physician payment issues. "President Obama's budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40% over the next decade," AMA President Nancy H. Nielsen said in a statement.

The investment in health reform was praised by health care advocates. Ron Pollack, executive director of Families USA, a national organization for health care consumers, said the FY 2010 budget proposal bodes well for achieving health care reform this year. "The fiscal investment proposed by the President is a critical first step towards two related and important objectives—bending the health care cost growth curve and ensuring that everyone has access to high-quality, affordable health coverage and care," he said in a statement.

America's Health Insurance Plans also praised the President's commitment to health reform. However, the group criticized the proposal to make Medicare Advantage plans engage in a competitive bidding process, saying that significant cuts to Medicare Advantage would "jeopardize the health security of more than 10 million seniors" enrolled in the program and reverse payment incentives designed to improve quality of care.

The FY 2010 budget proposal also includes $76.8 billion in discretionary funding for the Health and Human Services department. The budget proposal for HHS includes more than $6 billion in cancer research funding at the National Institutes of Health, on top of the $10 billion in NIH funding that was included as part of the American Recovery and Reinvestment Act, enacted in February.

The administration's budget proposal also aims to address physician shortages by spending $330 million to expand loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas.

Finally, the proposal aims to reduce drug prices by accelerating access to generic versions of biologic drugs.

The administration's FY 2010 budget proposal is available at www.whitehouse.gov/omb/budget/

President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding coverage to all Americans.

The proposed "reserve fund" for health care would get half of its funding from new revenue and half from savings proposals. For example, the Obama administration wants to introduce a competitive bidding process to the Medicare Advantage program, a move estimated to save more than $175 billion over 10 years.

However, in its budget proposal, the administration acknowledged that even $634 billion would not be enough to fully fund a comprehensive reform of the health care system and that administration officials would need to work with Congress to find even more money.

President Obama delivered the 140-page outline of his fiscal year 2010 budget proposal to Congress on Feb. 26. "With this budget we are making a historic commitment to comprehensive health care reform," President Obama said.

The budget proposal contains a set of eight principles the president plans to use to guide his health reform efforts: reducing premiums and other costs for American families and businesses; reducing costs from unnecessary tests and services; putting the nation on a path to universal health care coverage; providing portability to health care insurance; providing individuals with a choice of health plans and physicians; investing in prevention and wellness; improving patient safety and quality of care; and ensuring the long-term fiscal sustainability of the system.

Key among the reforms identified by the Obama administration is the need to change the Medicare physician payment formula. The President supports "comprehensive, but fiscally responsible" changes to the current payment system. "The Administration believes Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care."

The budget proposal also contains good news for physicians who have been bracing for a deep Medicare pay cut next January. In what the administration calls a "return to honest budgeting," the FY 2010 budget proposal will account for the fact that payments to physicians under Medicare will not be significantly cut as called for under current law.

The American Medical Association applauded the administration's willingness to address Medicare physician payment issues. "President Obama's budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40% over the next decade," AMA President Nancy H. Nielsen said in a statement.

The investment in health reform was praised by health care advocates. Ron Pollack, executive director of Families USA, a national organization for health care consumers, said the FY 2010 budget proposal bodes well for achieving health care reform this year. "The fiscal investment proposed by the President is a critical first step towards two related and important objectives—bending the health care cost growth curve and ensuring that everyone has access to high-quality, affordable health coverage and care," he said in a statement.

America's Health Insurance Plans also praised the President's commitment to health reform. However, the group criticized the proposal to make Medicare Advantage plans engage in a competitive bidding process, saying that significant cuts to Medicare Advantage would "jeopardize the health security of more than 10 million seniors" enrolled in the program and reverse payment incentives designed to improve quality of care.

The FY 2010 budget proposal also includes $76.8 billion in discretionary funding for the Health and Human Services department. The budget proposal for HHS includes more than $6 billion in cancer research funding at the National Institutes of Health, on top of the $10 billion in NIH funding that was included as part of the American Recovery and Reinvestment Act, enacted in February.

The administration's budget proposal also aims to address physician shortages by spending $330 million to expand loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas.

Finally, the proposal aims to reduce drug prices by accelerating access to generic versions of biologic drugs.

The administration's FY 2010 budget proposal is available at www.whitehouse.gov/omb/budget/

By next fall, dermatologists will have a chance to purchase electronic medical record systems that have been certified specifically for use in dermatology practices.

The Certification Commission for Healthcare Information Technology (CCHIT) will give vendors the option to certify their office-based EMR products as having additional functions specific to dermatology. The CCHIT already offers optional add-on certification in cardiovascular medicine and child health.

Certification for dermatology will begin in July 2010, and certified products should be out in the marketplace by fall 2010, according to Dr. Mark Leavitt, chair of the CCHIT.

The dermatology certification option will help to address one of the biggest reasons that dermatologists have failed to widely adopt EMRs—their fear that they will get the wrong system, said Dr. Mark D. Kaufmann of the department of dermatology at Mount Sinai School of Medicine in New York and a member of the American Academy of Dermatology's Practice Management Task Force.

The AAD urged the CCHIT to establish this certification pathway with the goal of spurring greater adoption of EMRs among dermatologists, said Dr. Girish Munavalli of the department of dermatology at Johns Hopkins University in Baltimore and a member of the AAD's Medical Informatics Committee.

Adoption levels are estimated to be between 7.5% and 11% in dermatology, according to the AAD, putting dermatologists on the lower end of adoption rates among medical specialties.

With dermatology-specific functions now being certified by the CCHIT, dermatologists can know there are EMR products in the marketplace that will be able to meet their documentation needs, Dr. Munavalli said. “There is also an added layer of protection for practicing dermatologists to help protect against fly-by-night vendors, because there is a level of cost and commitment required on the part of vendors who seek the CCHIT certification.”

But dermatologists who plan to purchase a certified EMR product still need to do their due diligence, he said. The certification process is an important first step in assessing a system, but it won't give physicians a full picture of whether a system will address their workflow issues, he said.

Dr. Kaufmann advised physicians to test EMR systems in real-world situations and not to rely on Webinars and other product demos offered by vendors.

Although dermatologists will have to wait more than a year if they want to purchase an EMR that has been specifically certified for office-based dermatology practice, that should not keep them from adopting an EMR sooner, Dr. Leavitt said.

The financial incentives for adopting EMRs that were spelled out in the American Recovery and Reinvestment Act will be available only to physicians who demonstrate “meaningful” use of these systems over the next few years. That means that dermatologists will have to spend about a year implementing their EMR system before the first year of the incentives begins in 2011 if they want to receive the maximum bonus payments, Dr. Leavitt said.

Under the law, Medicare providers who are “meaningful” users of EMRs will be eligible to earn about $44,000 over a period of 5 years. But the payments are front loaded and phase out over time. In addition, the law includes penalties for lack of adoption beginning in 2015.

Dermatologists who want to begin adoption now can look for vendors who have products that have been certified for general care and offer dermatology features. Another option is to purchase a system but make a portion of the payment contingent on updating the system once the dermatology functions have been certified.

The AAD urged the CCHIT to establish this certification with the goal of spurring greater adoption among dermatologists. DR. MUNAVALLI

By next fall, dermatologists will have a chance to purchase electronic medical record systems that have been certified specifically for use in dermatology practices.

The Certification Commission for Healthcare Information Technology (CCHIT) will give vendors the option to certify their office-based EMR products as having additional functions specific to dermatology. The CCHIT already offers optional add-on certification in cardiovascular medicine and child health.

Certification for dermatology will begin in July 2010, and certified products should be out in the marketplace by fall 2010, according to Dr. Mark Leavitt, chair of the CCHIT.

The dermatology certification option will help to address one of the biggest reasons that dermatologists have failed to widely adopt EMRs—their fear that they will get the wrong system, said Dr. Mark D. Kaufmann of the department of dermatology at Mount Sinai School of Medicine in New York and a member of the American Academy of Dermatology's Practice Management Task Force.

The AAD urged the CCHIT to establish this certification pathway with the goal of spurring greater adoption of EMRs among dermatologists, said Dr. Girish Munavalli of the department of dermatology at Johns Hopkins University in Baltimore and a member of the AAD's Medical Informatics Committee.

Adoption levels are estimated to be between 7.5% and 11% in dermatology, according to the AAD, putting dermatologists on the lower end of adoption rates among medical specialties.

With dermatology-specific functions now being certified by the CCHIT, dermatologists can know there are EMR products in the marketplace that will be able to meet their documentation needs, Dr. Munavalli said. “There is also an added layer of protection for practicing dermatologists to help protect against fly-by-night vendors, because there is a level of cost and commitment required on the part of vendors who seek the CCHIT certification.”

But dermatologists who plan to purchase a certified EMR product still need to do their due diligence, he said. The certification process is an important first step in assessing a system, but it won't give physicians a full picture of whether a system will address their workflow issues, he said.

Dr. Kaufmann advised physicians to test EMR systems in real-world situations and not to rely on Webinars and other product demos offered by vendors.

Although dermatologists will have to wait more than a year if they want to purchase an EMR that has been specifically certified for office-based dermatology practice, that should not keep them from adopting an EMR sooner, Dr. Leavitt said.

The financial incentives for adopting EMRs that were spelled out in the American Recovery and Reinvestment Act will be available only to physicians who demonstrate “meaningful” use of these systems over the next few years. That means that dermatologists will have to spend about a year implementing their EMR system before the first year of the incentives begins in 2011 if they want to receive the maximum bonus payments, Dr. Leavitt said.

Under the law, Medicare providers who are “meaningful” users of EMRs will be eligible to earn about $44,000 over a period of 5 years. But the payments are front loaded and phase out over time. In addition, the law includes penalties for lack of adoption beginning in 2015.

Dermatologists who want to begin adoption now can look for vendors who have products that have been certified for general care and offer dermatology features. Another option is to purchase a system but make a portion of the payment contingent on updating the system once the dermatology functions have been certified.

The AAD urged the CCHIT to establish this certification with the goal of spurring greater adoption among dermatologists. DR. MUNAVALLI

By next fall, dermatologists will have a chance to purchase electronic medical record systems that have been certified specifically for use in dermatology practices.

The Certification Commission for Healthcare Information Technology (CCHIT) will give vendors the option to certify their office-based EMR products as having additional functions specific to dermatology. The CCHIT already offers optional add-on certification in cardiovascular medicine and child health.

Certification for dermatology will begin in July 2010, and certified products should be out in the marketplace by fall 2010, according to Dr. Mark Leavitt, chair of the CCHIT.

The dermatology certification option will help to address one of the biggest reasons that dermatologists have failed to widely adopt EMRs—their fear that they will get the wrong system, said Dr. Mark D. Kaufmann of the department of dermatology at Mount Sinai School of Medicine in New York and a member of the American Academy of Dermatology's Practice Management Task Force.

The AAD urged the CCHIT to establish this certification pathway with the goal of spurring greater adoption of EMRs among dermatologists, said Dr. Girish Munavalli of the department of dermatology at Johns Hopkins University in Baltimore and a member of the AAD's Medical Informatics Committee.

Adoption levels are estimated to be between 7.5% and 11% in dermatology, according to the AAD, putting dermatologists on the lower end of adoption rates among medical specialties.

With dermatology-specific functions now being certified by the CCHIT, dermatologists can know there are EMR products in the marketplace that will be able to meet their documentation needs, Dr. Munavalli said. “There is also an added layer of protection for practicing dermatologists to help protect against fly-by-night vendors, because there is a level of cost and commitment required on the part of vendors who seek the CCHIT certification.”

But dermatologists who plan to purchase a certified EMR product still need to do their due diligence, he said. The certification process is an important first step in assessing a system, but it won't give physicians a full picture of whether a system will address their workflow issues, he said.

Dr. Kaufmann advised physicians to test EMR systems in real-world situations and not to rely on Webinars and other product demos offered by vendors.

Although dermatologists will have to wait more than a year if they want to purchase an EMR that has been specifically certified for office-based dermatology practice, that should not keep them from adopting an EMR sooner, Dr. Leavitt said.

The financial incentives for adopting EMRs that were spelled out in the American Recovery and Reinvestment Act will be available only to physicians who demonstrate “meaningful” use of these systems over the next few years. That means that dermatologists will have to spend about a year implementing their EMR system before the first year of the incentives begins in 2011 if they want to receive the maximum bonus payments, Dr. Leavitt said.

Under the law, Medicare providers who are “meaningful” users of EMRs will be eligible to earn about $44,000 over a period of 5 years. But the payments are front loaded and phase out over time. In addition, the law includes penalties for lack of adoption beginning in 2015.

Dermatologists who want to begin adoption now can look for vendors who have products that have been certified for general care and offer dermatology features. Another option is to purchase a system but make a portion of the payment contingent on updating the system once the dermatology functions have been certified.

The AAD urged the CCHIT to establish this certification with the goal of spurring greater adoption among dermatologists. DR. MUNAVALLI

The controversial Medicare Recovery Audit Contractor program is continuing as planned after federal officials cleared up some contracting disputes.

The rollout of the permanent, national Recovery Audit Contractor (RAC) program is now proceeding, with the full implementation of the program expected across the country by Jan. 1, 2010.

Under the program, Medicare contracts with private companies to identify and correct improper payments—both over- and underpayments—made through the Medicare fee-for-service program. The contractors will be paid on a contingency fee basis for both the over- and underpayments that they identify. In addition, each RAC must employ a full-time medical director to assist in claims review.

During its demonstration phase, the RAC program came under fire from physician testers who said it added administrative hassles and placed the burden on physicians to prove that payments they received were correct.

Last November, officials at the Centers for Medicare and Medicaid Services imposed an automatic stay on the program due to protests filed by two contractors who bid unsuccessfully to be part of the program. Under federal statute, the disputes were reviewed by the Government Accountability Office and a decision was issued in early February. As part of the settlement, two subcontractors have been retained to work with the four RACs announced last October.

With the RAC program back on track, the CMS will resume provider outreach activities over the next few months.

The controversial Medicare Recovery Audit Contractor program is continuing as planned after federal officials cleared up some contracting disputes.

The rollout of the permanent, national Recovery Audit Contractor (RAC) program is now proceeding, with the full implementation of the program expected across the country by Jan. 1, 2010.

Under the program, Medicare contracts with private companies to identify and correct improper payments—both over- and underpayments—made through the Medicare fee-for-service program. The contractors will be paid on a contingency fee basis for both the over- and underpayments that they identify. In addition, each RAC must employ a full-time medical director to assist in claims review.

During its demonstration phase, the RAC program came under fire from physician testers who said it added administrative hassles and placed the burden on physicians to prove that payments they received were correct.

Last November, officials at the Centers for Medicare and Medicaid Services imposed an automatic stay on the program due to protests filed by two contractors who bid unsuccessfully to be part of the program. Under federal statute, the disputes were reviewed by the Government Accountability Office and a decision was issued in early February. As part of the settlement, two subcontractors have been retained to work with the four RACs announced last October.

With the RAC program back on track, the CMS will resume provider outreach activities over the next few months.

The controversial Medicare Recovery Audit Contractor program is continuing as planned after federal officials cleared up some contracting disputes.

The rollout of the permanent, national Recovery Audit Contractor (RAC) program is now proceeding, with the full implementation of the program expected across the country by Jan. 1, 2010.

Under the program, Medicare contracts with private companies to identify and correct improper payments—both over- and underpayments—made through the Medicare fee-for-service program. The contractors will be paid on a contingency fee basis for both the over- and underpayments that they identify. In addition, each RAC must employ a full-time medical director to assist in claims review.

During its demonstration phase, the RAC program came under fire from physician testers who said it added administrative hassles and placed the burden on physicians to prove that payments they received were correct.

Last November, officials at the Centers for Medicare and Medicaid Services imposed an automatic stay on the program due to protests filed by two contractors who bid unsuccessfully to be part of the program. Under federal statute, the disputes were reviewed by the Government Accountability Office and a decision was issued in early February. As part of the settlement, two subcontractors have been retained to work with the four RACs announced last October.

With the RAC program back on track, the CMS will resume provider outreach activities over the next few months.

A national health insurance exchange that would allow individuals to choose among private plans or a new nationwide public plan is the cornerstone of an expert panel's proposal to cover nearly all Americans within 2 years and slow the growth of health care spending by nearly $3 trillion over the next decade.

The health reform proposal unveiled by the Commonwealth Fund is similar to plans outlined by President Barack Obama and Senate Finance Chairman Max Baucus (D-Mont.). It was developed by the fund's Commission on a High Performance Health System, a 19-member panel formed in April 2005.

The difference between the Commonwealth Fund's plan and other proposals is that it provides the details on how to implement these broad policies, as well as the financial and clinical consequences, said Karen Davis, president of the Commonwealth Fund. Modeling and estimates outlined in the report were performed by the Lewin Group.

Under the proposal, individuals could keep their own coverage or obtain new coverage through the insurance exchange. The public plan would initially be available to those seeking insurance on the individual market and those working for small employers, but by 2014 it would be available to the entire under-65 population, including individuals working for large employers. It would offer benefits similar to the standard option available to federal employees, but at premiums at least 20% lower than those of private plans offered in small group markets.

Private plans would be required to guarantee the issue and renewal of policies regardless of health status and provide community-rate premiums, but they would be able to stay competitive with the public plan, according to Cathy Schoen, lead author of the report and senior vice president of the Commonwealth Fund, because they would be able to reduce costs such as underwriting and marketing.

“The report's central message is that we all stand to gain by taking bold action,” Ms. Schoen said at a press briefing to release the report. “With middle- and low-income families at risk, and businesses struggling to provide insurance for their employees, there is broad public support for significant reforms.”

The Commonwealth Fund proposal would impose an individual insurance mandate but would cap premiums at 5% of income for low-income individuals and 10% for those in higher brackets. It would also require employers to either offer coverage or contribute about 7% of payroll into a coverage trust fund.

On the payment side, the Commonwealth Fund endorses moving away from the fee-for-service system now in use for Medicare and Medicaid and replacing it with a number of reforms, including bundling payments for acute care episodes, increasing payment for primary care while decreasing payment for specialty and procedural care, and providing additional payments for practices that provide a patient-centered medical home.

Under the proposal, all payment reforms would apply to Medicare, Medicaid, and the new public health plan. The proposal would also raise Medicaid rates to Medicare levels and invest in health information technology, population health, and comparative effectiveness research.

The proposal would not lower current costs but could slow the rate of health care spending, according to the Commonwealth Fund. Instead of spending rising 6.7% each year over the next 11 years, as predicted by current trends, the increase in spending would slow to about 5.5% per year if the reforms were implemented in 2010. The combination of the proposed insurance and payment system reforms could slow spending by nearly $3 trillion by 2020.

A national health insurance exchange that would allow individuals to choose among private plans or a new nationwide public plan is the cornerstone of an expert panel's proposal to cover nearly all Americans within 2 years and slow the growth of health care spending by nearly $3 trillion over the next decade.

The health reform proposal unveiled by the Commonwealth Fund is similar to plans outlined by President Barack Obama and Senate Finance Chairman Max Baucus (D-Mont.). It was developed by the fund's Commission on a High Performance Health System, a 19-member panel formed in April 2005.

The difference between the Commonwealth Fund's plan and other proposals is that it provides the details on how to implement these broad policies, as well as the financial and clinical consequences, said Karen Davis, president of the Commonwealth Fund. Modeling and estimates outlined in the report were performed by the Lewin Group.

Under the proposal, individuals could keep their own coverage or obtain new coverage through the insurance exchange. The public plan would initially be available to those seeking insurance on the individual market and those working for small employers, but by 2014 it would be available to the entire under-65 population, including individuals working for large employers. It would offer benefits similar to the standard option available to federal employees, but at premiums at least 20% lower than those of private plans offered in small group markets.

Private plans would be required to guarantee the issue and renewal of policies regardless of health status and provide community-rate premiums, but they would be able to stay competitive with the public plan, according to Cathy Schoen, lead author of the report and senior vice president of the Commonwealth Fund, because they would be able to reduce costs such as underwriting and marketing.

“The report's central message is that we all stand to gain by taking bold action,” Ms. Schoen said at a press briefing to release the report. “With middle- and low-income families at risk, and businesses struggling to provide insurance for their employees, there is broad public support for significant reforms.”

The Commonwealth Fund proposal would impose an individual insurance mandate but would cap premiums at 5% of income for low-income individuals and 10% for those in higher brackets. It would also require employers to either offer coverage or contribute about 7% of payroll into a coverage trust fund.

On the payment side, the Commonwealth Fund endorses moving away from the fee-for-service system now in use for Medicare and Medicaid and replacing it with a number of reforms, including bundling payments for acute care episodes, increasing payment for primary care while decreasing payment for specialty and procedural care, and providing additional payments for practices that provide a patient-centered medical home.

Under the proposal, all payment reforms would apply to Medicare, Medicaid, and the new public health plan. The proposal would also raise Medicaid rates to Medicare levels and invest in health information technology, population health, and comparative effectiveness research.

The proposal would not lower current costs but could slow the rate of health care spending, according to the Commonwealth Fund. Instead of spending rising 6.7% each year over the next 11 years, as predicted by current trends, the increase in spending would slow to about 5.5% per year if the reforms were implemented in 2010. The combination of the proposed insurance and payment system reforms could slow spending by nearly $3 trillion by 2020.

A national health insurance exchange that would allow individuals to choose among private plans or a new nationwide public plan is the cornerstone of an expert panel's proposal to cover nearly all Americans within 2 years and slow the growth of health care spending by nearly $3 trillion over the next decade.

The health reform proposal unveiled by the Commonwealth Fund is similar to plans outlined by President Barack Obama and Senate Finance Chairman Max Baucus (D-Mont.). It was developed by the fund's Commission on a High Performance Health System, a 19-member panel formed in April 2005.

The difference between the Commonwealth Fund's plan and other proposals is that it provides the details on how to implement these broad policies, as well as the financial and clinical consequences, said Karen Davis, president of the Commonwealth Fund. Modeling and estimates outlined in the report were performed by the Lewin Group.

Under the proposal, individuals could keep their own coverage or obtain new coverage through the insurance exchange. The public plan would initially be available to those seeking insurance on the individual market and those working for small employers, but by 2014 it would be available to the entire under-65 population, including individuals working for large employers. It would offer benefits similar to the standard option available to federal employees, but at premiums at least 20% lower than those of private plans offered in small group markets.

Private plans would be required to guarantee the issue and renewal of policies regardless of health status and provide community-rate premiums, but they would be able to stay competitive with the public plan, according to Cathy Schoen, lead author of the report and senior vice president of the Commonwealth Fund, because they would be able to reduce costs such as underwriting and marketing.

“The report's central message is that we all stand to gain by taking bold action,” Ms. Schoen said at a press briefing to release the report. “With middle- and low-income families at risk, and businesses struggling to provide insurance for their employees, there is broad public support for significant reforms.”

The Commonwealth Fund proposal would impose an individual insurance mandate but would cap premiums at 5% of income for low-income individuals and 10% for those in higher brackets. It would also require employers to either offer coverage or contribute about 7% of payroll into a coverage trust fund.

On the payment side, the Commonwealth Fund endorses moving away from the fee-for-service system now in use for Medicare and Medicaid and replacing it with a number of reforms, including bundling payments for acute care episodes, increasing payment for primary care while decreasing payment for specialty and procedural care, and providing additional payments for practices that provide a patient-centered medical home.

Under the proposal, all payment reforms would apply to Medicare, Medicaid, and the new public health plan. The proposal would also raise Medicaid rates to Medicare levels and invest in health information technology, population health, and comparative effectiveness research.

The proposal would not lower current costs but could slow the rate of health care spending, according to the Commonwealth Fund. Instead of spending rising 6.7% each year over the next 11 years, as predicted by current trends, the increase in spending would slow to about 5.5% per year if the reforms were implemented in 2010. The combination of the proposed insurance and payment system reforms could slow spending by nearly $3 trillion by 2020.

The FY 2010 budget proposal is available at www.whitehouse.gov/omb/budget

President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding health care coverage to all Americans.

The proposed “reserve fund” for health care would get half of its funding from new revenue and half from savings proposals. For example, the Obama administration wants to introduce a competitive bidding process to the Medicare Advantage program, a move estimated to save more than $175 billion over 10 years.

However, in its budget proposal, the administration acknowledged that even $634 billion would not be enough to fully fund a comprehensive reform of the health care system and that administration officials would need to work with Congress to find even more money.

President Obama delivered the 140-page outline of his fiscal year 2010 budget proposal to Congress on Feb. 26; complete documents will be submitted to Congress in April.

“With this budget we are making an historic commitment to comprehensive health care reform,” President Obama said. “It's a step that will not only make families healthier and companies more competitive, but over the long term, it will also help us bring down our deficit.”

The budget proposal contains a set of eight principles the president plans to use to guide his health reform efforts: reducing premiums and other costs for American families and businesses, reducing costs from unnecessary tests and services, putting the nation on a path to universal health care coverage, providing portability to health care insurance, providing individuals with a choice of health plans and physicians, investing in prevention and wellness; improving patient safety and quality of care, and ensuring the long-term fiscal sustainability of the system.

Key among the reforms identified by the Obama administration is the need to change the Medicare physician payment formula. The president supports “comprehensive, but fiscally responsible” changes to the current payment system, according to the budget proposal. “The Administration believes Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care rather than simply more care.”

The budget proposal also contains good news for physicians who have been bracing for a deep Medicare pay cut next January. In what the administration calls a “return to honest budgeting,” the FY 2010 budget proposal will account for the fact that payments to physicians under Medicare will not be significantly cut as called for under current law.

The American Medical Association applauded the administration's willingness to address Medicare physician payment issues. “President Obama's budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40% over the next decade,” AMA president Nancy H. Nielsen said in a statement. “Looming widespread physician shortages coupled with aging baby boomers highlight the urgent need for permanent Medicare physician payment system reform to preserve seniors' access to health care.”

The investment in health reform was praised by health care advocates. Ron Pollack, executive director of Families USA, a national organization for health care consumers, said the FY 2010 budget proposal bodes well for achieving health care reform this year. It “is a critical first step towards two related and important objectives—bending the health care cost growth curve and ensuring that everyone has access to high-quality, affordable health coverage and care,” he said in a statement.

America's Health Insurance Plans also praised the president's commitment to health reform. However, the group criticized the proposal to make Medicare Advantage plans engage in a competitive bidding process, saying that significant cuts to Medicare Advantage would “jeopardize the health security of more than 10 million seniors” enrolled in the program and reverse payment incentives designed to improve quality of care.

The FY 2010 budget proposal also includes $76.8 billion in discretionary funding for the Health and Human Services department. At press time, Congress was still finishing up work on the FY 2009 budget for the HHS.

The FY 2010 budget proposal for the HHS includes more than $6 billion in cancer research funding at the National Institutes of Health, on top of the $10 billion in NIH funding that was included as part of the American Recovery and Reinvestment Act, enacted earlier this month.

The administration's budget proposal also aims to address physician shortages by spending $330 million to expand loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas.

Finally, the proposal aims to reduce drug prices by accelerating access to generic versions of biologic drugs.

The FY 2010 budget proposal is available at www.whitehouse.gov/omb/budget

President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding health care coverage to all Americans.

The proposed “reserve fund” for health care would get half of its funding from new revenue and half from savings proposals. For example, the Obama administration wants to introduce a competitive bidding process to the Medicare Advantage program, a move estimated to save more than $175 billion over 10 years.

However, in its budget proposal, the administration acknowledged that even $634 billion would not be enough to fully fund a comprehensive reform of the health care system and that administration officials would need to work with Congress to find even more money.

President Obama delivered the 140-page outline of his fiscal year 2010 budget proposal to Congress on Feb. 26; complete documents will be submitted to Congress in April.

“With this budget we are making an historic commitment to comprehensive health care reform,” President Obama said. “It's a step that will not only make families healthier and companies more competitive, but over the long term, it will also help us bring down our deficit.”

The budget proposal contains a set of eight principles the president plans to use to guide his health reform efforts: reducing premiums and other costs for American families and businesses, reducing costs from unnecessary tests and services, putting the nation on a path to universal health care coverage, providing portability to health care insurance, providing individuals with a choice of health plans and physicians, investing in prevention and wellness; improving patient safety and quality of care, and ensuring the long-term fiscal sustainability of the system.

Key among the reforms identified by the Obama administration is the need to change the Medicare physician payment formula. The president supports “comprehensive, but fiscally responsible” changes to the current payment system, according to the budget proposal. “The Administration believes Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care rather than simply more care.”

The budget proposal also contains good news for physicians who have been bracing for a deep Medicare pay cut next January. In what the administration calls a “return to honest budgeting,” the FY 2010 budget proposal will account for the fact that payments to physicians under Medicare will not be significantly cut as called for under current law.

The American Medical Association applauded the administration's willingness to address Medicare physician payment issues. “President Obama's budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40% over the next decade,” AMA president Nancy H. Nielsen said in a statement. “Looming widespread physician shortages coupled with aging baby boomers highlight the urgent need for permanent Medicare physician payment system reform to preserve seniors' access to health care.”

The investment in health reform was praised by health care advocates. Ron Pollack, executive director of Families USA, a national organization for health care consumers, said the FY 2010 budget proposal bodes well for achieving health care reform this year. It “is a critical first step towards two related and important objectives—bending the health care cost growth curve and ensuring that everyone has access to high-quality, affordable health coverage and care,” he said in a statement.

America's Health Insurance Plans also praised the president's commitment to health reform. However, the group criticized the proposal to make Medicare Advantage plans engage in a competitive bidding process, saying that significant cuts to Medicare Advantage would “jeopardize the health security of more than 10 million seniors” enrolled in the program and reverse payment incentives designed to improve quality of care.

The FY 2010 budget proposal also includes $76.8 billion in discretionary funding for the Health and Human Services department. At press time, Congress was still finishing up work on the FY 2009 budget for the HHS.

The FY 2010 budget proposal for the HHS includes more than $6 billion in cancer research funding at the National Institutes of Health, on top of the $10 billion in NIH funding that was included as part of the American Recovery and Reinvestment Act, enacted earlier this month.

The administration's budget proposal also aims to address physician shortages by spending $330 million to expand loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas.

Finally, the proposal aims to reduce drug prices by accelerating access to generic versions of biologic drugs.

The FY 2010 budget proposal is available at www.whitehouse.gov/omb/budget

President Barack Obama has made health care a top priority in his first budget proposal by setting aside $634 billion over the next decade to begin reforming the health care system and expanding health care coverage to all Americans.

The proposed “reserve fund” for health care would get half of its funding from new revenue and half from savings proposals. For example, the Obama administration wants to introduce a competitive bidding process to the Medicare Advantage program, a move estimated to save more than $175 billion over 10 years.

However, in its budget proposal, the administration acknowledged that even $634 billion would not be enough to fully fund a comprehensive reform of the health care system and that administration officials would need to work with Congress to find even more money.

President Obama delivered the 140-page outline of his fiscal year 2010 budget proposal to Congress on Feb. 26; complete documents will be submitted to Congress in April.

“With this budget we are making an historic commitment to comprehensive health care reform,” President Obama said. “It's a step that will not only make families healthier and companies more competitive, but over the long term, it will also help us bring down our deficit.”

The budget proposal contains a set of eight principles the president plans to use to guide his health reform efforts: reducing premiums and other costs for American families and businesses, reducing costs from unnecessary tests and services, putting the nation on a path to universal health care coverage, providing portability to health care insurance, providing individuals with a choice of health plans and physicians, investing in prevention and wellness; improving patient safety and quality of care, and ensuring the long-term fiscal sustainability of the system.

Key among the reforms identified by the Obama administration is the need to change the Medicare physician payment formula. The president supports “comprehensive, but fiscally responsible” changes to the current payment system, according to the budget proposal. “The Administration believes Medicare and the country need to move toward a system in which doctors face better incentives for high-quality care rather than simply more care.”

The budget proposal also contains good news for physicians who have been bracing for a deep Medicare pay cut next January. In what the administration calls a “return to honest budgeting,” the FY 2010 budget proposal will account for the fact that payments to physicians under Medicare will not be significantly cut as called for under current law.

The American Medical Association applauded the administration's willingness to address Medicare physician payment issues. “President Obama's budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40% over the next decade,” AMA president Nancy H. Nielsen said in a statement. “Looming widespread physician shortages coupled with aging baby boomers highlight the urgent need for permanent Medicare physician payment system reform to preserve seniors' access to health care.”

The investment in health reform was praised by health care advocates. Ron Pollack, executive director of Families USA, a national organization for health care consumers, said the FY 2010 budget proposal bodes well for achieving health care reform this year. It “is a critical first step towards two related and important objectives—bending the health care cost growth curve and ensuring that everyone has access to high-quality, affordable health coverage and care,” he said in a statement.

America's Health Insurance Plans also praised the president's commitment to health reform. However, the group criticized the proposal to make Medicare Advantage plans engage in a competitive bidding process, saying that significant cuts to Medicare Advantage would “jeopardize the health security of more than 10 million seniors” enrolled in the program and reverse payment incentives designed to improve quality of care.

The FY 2010 budget proposal also includes $76.8 billion in discretionary funding for the Health and Human Services department. At press time, Congress was still finishing up work on the FY 2009 budget for the HHS.

The FY 2010 budget proposal for the HHS includes more than $6 billion in cancer research funding at the National Institutes of Health, on top of the $10 billion in NIH funding that was included as part of the American Recovery and Reinvestment Act, enacted earlier this month.

The administration's budget proposal also aims to address physician shortages by spending $330 million to expand loan repayment programs for physicians, nurses, and dentists who agree to practice in medically underserved areas.

Finally, the proposal aims to reduce drug prices by accelerating access to generic versions of biologic drugs.

The controversial Medicare Recovery Audit Contractor program is continuing as planned after federal officials cleared up contracting disputes.

The rollout of the permanent, national Recovery Audit Contractor (RAC) program is proceeding, with the full implementation of the program expected across the country by Jan. 1, 2010.

Under the program, Medicare contracts with private companies to identify and correct improper payments—both over- and underpayments—made through the Medicare fee-for-service program. The contractors will be paid on a contingency fee basis for the errors they identify. Also, each RAC must employ a full-time medical director to assist in claims review.

During its demonstration phase, the RAC program came under fire from physician testers who said it added administrative hassles and placed the burden on physicians to prove that payments they received were correct.

Last November, officials at the Centers for Medicare and Medicaid Services imposed an automatic stay on the program due to protests filed by two contractors who bid unsuccessfully to be part of the program. The disputes were reviewed by the Government Accountability Office, and as part of the settlement, two subcontractors have been retained to work with the four RACs.

The RAC program was mandated by Congress as part of the Medicare Modernization Act of 2003 and began as a demonstration project in six states. The project resulted in the return of more than $900 million in overpayments in 2005-2008 and nearly $38 million in underpayments, according to the CMS.

The controversial Medicare Recovery Audit Contractor program is continuing as planned after federal officials cleared up contracting disputes.

The rollout of the permanent, national Recovery Audit Contractor (RAC) program is proceeding, with the full implementation of the program expected across the country by Jan. 1, 2010.

Under the program, Medicare contracts with private companies to identify and correct improper payments—both over- and underpayments—made through the Medicare fee-for-service program. The contractors will be paid on a contingency fee basis for the errors they identify. Also, each RAC must employ a full-time medical director to assist in claims review.

During its demonstration phase, the RAC program came under fire from physician testers who said it added administrative hassles and placed the burden on physicians to prove that payments they received were correct.

Last November, officials at the Centers for Medicare and Medicaid Services imposed an automatic stay on the program due to protests filed by two contractors who bid unsuccessfully to be part of the program. The disputes were reviewed by the Government Accountability Office, and as part of the settlement, two subcontractors have been retained to work with the four RACs.

The RAC program was mandated by Congress as part of the Medicare Modernization Act of 2003 and began as a demonstration project in six states. The project resulted in the return of more than $900 million in overpayments in 2005-2008 and nearly $38 million in underpayments, according to the CMS.

The controversial Medicare Recovery Audit Contractor program is continuing as planned after federal officials cleared up contracting disputes.

The rollout of the permanent, national Recovery Audit Contractor (RAC) program is proceeding, with the full implementation of the program expected across the country by Jan. 1, 2010.

Under the program, Medicare contracts with private companies to identify and correct improper payments—both over- and underpayments—made through the Medicare fee-for-service program. The contractors will be paid on a contingency fee basis for the errors they identify. Also, each RAC must employ a full-time medical director to assist in claims review.

During its demonstration phase, the RAC program came under fire from physician testers who said it added administrative hassles and placed the burden on physicians to prove that payments they received were correct.

Last November, officials at the Centers for Medicare and Medicaid Services imposed an automatic stay on the program due to protests filed by two contractors who bid unsuccessfully to be part of the program. The disputes were reviewed by the Government Accountability Office, and as part of the settlement, two subcontractors have been retained to work with the four RACs.

The RAC program was mandated by Congress as part of the Medicare Modernization Act of 2003 and began as a demonstration project in six states. The project resulted in the return of more than $900 million in overpayments in 2005-2008 and nearly $38 million in underpayments, according to the CMS.

A national health insurance exchange that would allow individuals to choose among private plans or a new nationwide public plan is the cornerstone of an expert panel's proposal to cover nearly all Americans within 2 years and slow the growth of health care spending by nearly $3 trillion over the next decade.

The health reform proposal is similar to plans outlined by President Barack Obama and Senate Finance Chairman Max Baucus (D-Mont.). It was developed by the Commonwealth Fund's Commission on a High Performance Health System, a 19-member panel formed in April 2005 to study possible changes to the delivery and financing of health care.

The difference between the Commonwealth Fund's plan and other policy proposals under consideration is that it provides the details on how to implement these broad policies, as well as the financial and clinical consequences of the policies, said Karen Davis, president of the Commonwealth Fund.

Under the proposal, individuals could choose to keep their own coverage or obtain coverage through the insurance exchange. The public plan would initially be available to those seeking insurance on the individual market and those working for small employers, but by 2014 it would be available to the entire under-65 population, including those working for large employers. The public plan would offer benefits similar to the standard option available to federal employees and members of Congress, but at premiums about 20% lower than those of private plans.

Private plans would be required to guarantee the issue and renewal of policies regardless of health status, and to provide community-rate premiums, said Cathy Schoen, lead author of the report and senior vice president of the Commonwealth Fund. “With middle- and low-income families at risk, and businesses struggling to provide insurance for their employees, there is broad public support for significant reforms,” Ms. Schoen said at a press briefing to release the report.

The Commonwealth Fund proposal would impose an individual insurance mandate, but would cap premiums at 5% of income for low-income individuals and 10% for those in higher-income tax brackets. It would also require employers to either offer coverage or contribute about 7% of payroll into a coverage trust fund.

The Commonwealth Fund proposal endorses moving away from the fee-for-service system currently in use for Medicare and Medicaid and replacing it with a number of reforms, including bundling payments for acute care episodes, increasing payment for primary care, and adding payments for providing a patient-centered medical home.

Under the proposal, all payment reforms would apply to Medicare, Medicaid, and the new public health plan. The proposal would also raise Medicaid rates to Medicare levels and invest in health information technology, population health, and comparative effectiveness research.

The proposal would not lower current costs but could slow the rate of health care spending, according to the Commonwealth Fund. Instead of health care spending rising 6.7% each year over the next 11 years, as predicted by current trends, the increase in spending would slow to about 5.5% per year if the reforms were implemented in 2010. The combination of the proposed insurance and payment system reforms could slow spending by nearly $3 trillion by 2020.

Costs incurred by the federal government would climb sharply during the first years of implementing these changes, but could be largely recouped by 2020, according to the report.

Under the proposal, the number of uninsured would drop from about 48 million to about 4 million by 2012.

A national health insurance exchange that would allow individuals to choose among private plans or a new nationwide public plan is the cornerstone of an expert panel's proposal to cover nearly all Americans within 2 years and slow the growth of health care spending by nearly $3 trillion over the next decade.

The health reform proposal is similar to plans outlined by President Barack Obama and Senate Finance Chairman Max Baucus (D-Mont.). It was developed by the Commonwealth Fund's Commission on a High Performance Health System, a 19-member panel formed in April 2005 to study possible changes to the delivery and financing of health care.

The difference between the Commonwealth Fund's plan and other policy proposals under consideration is that it provides the details on how to implement these broad policies, as well as the financial and clinical consequences of the policies, said Karen Davis, president of the Commonwealth Fund.

Under the proposal, individuals could choose to keep their own coverage or obtain coverage through the insurance exchange. The public plan would initially be available to those seeking insurance on the individual market and those working for small employers, but by 2014 it would be available to the entire under-65 population, including those working for large employers. The public plan would offer benefits similar to the standard option available to federal employees and members of Congress, but at premiums about 20% lower than those of private plans.

Private plans would be required to guarantee the issue and renewal of policies regardless of health status, and to provide community-rate premiums, said Cathy Schoen, lead author of the report and senior vice president of the Commonwealth Fund. “With middle- and low-income families at risk, and businesses struggling to provide insurance for their employees, there is broad public support for significant reforms,” Ms. Schoen said at a press briefing to release the report.

The Commonwealth Fund proposal would impose an individual insurance mandate, but would cap premiums at 5% of income for low-income individuals and 10% for those in higher-income tax brackets. It would also require employers to either offer coverage or contribute about 7% of payroll into a coverage trust fund.

The Commonwealth Fund proposal endorses moving away from the fee-for-service system currently in use for Medicare and Medicaid and replacing it with a number of reforms, including bundling payments for acute care episodes, increasing payment for primary care, and adding payments for providing a patient-centered medical home.

Under the proposal, all payment reforms would apply to Medicare, Medicaid, and the new public health plan. The proposal would also raise Medicaid rates to Medicare levels and invest in health information technology, population health, and comparative effectiveness research.

The proposal would not lower current costs but could slow the rate of health care spending, according to the Commonwealth Fund. Instead of health care spending rising 6.7% each year over the next 11 years, as predicted by current trends, the increase in spending would slow to about 5.5% per year if the reforms were implemented in 2010. The combination of the proposed insurance and payment system reforms could slow spending by nearly $3 trillion by 2020.

Costs incurred by the federal government would climb sharply during the first years of implementing these changes, but could be largely recouped by 2020, according to the report.

Under the proposal, the number of uninsured would drop from about 48 million to about 4 million by 2012.

A national health insurance exchange that would allow individuals to choose among private plans or a new nationwide public plan is the cornerstone of an expert panel's proposal to cover nearly all Americans within 2 years and slow the growth of health care spending by nearly $3 trillion over the next decade.

The health reform proposal is similar to plans outlined by President Barack Obama and Senate Finance Chairman Max Baucus (D-Mont.). It was developed by the Commonwealth Fund's Commission on a High Performance Health System, a 19-member panel formed in April 2005 to study possible changes to the delivery and financing of health care.

The difference between the Commonwealth Fund's plan and other policy proposals under consideration is that it provides the details on how to implement these broad policies, as well as the financial and clinical consequences of the policies, said Karen Davis, president of the Commonwealth Fund.

Under the proposal, individuals could choose to keep their own coverage or obtain coverage through the insurance exchange. The public plan would initially be available to those seeking insurance on the individual market and those working for small employers, but by 2014 it would be available to the entire under-65 population, including those working for large employers. The public plan would offer benefits similar to the standard option available to federal employees and members of Congress, but at premiums about 20% lower than those of private plans.

Private plans would be required to guarantee the issue and renewal of policies regardless of health status, and to provide community-rate premiums, said Cathy Schoen, lead author of the report and senior vice president of the Commonwealth Fund. “With middle- and low-income families at risk, and businesses struggling to provide insurance for their employees, there is broad public support for significant reforms,” Ms. Schoen said at a press briefing to release the report.

The Commonwealth Fund proposal would impose an individual insurance mandate, but would cap premiums at 5% of income for low-income individuals and 10% for those in higher-income tax brackets. It would also require employers to either offer coverage or contribute about 7% of payroll into a coverage trust fund.

The Commonwealth Fund proposal endorses moving away from the fee-for-service system currently in use for Medicare and Medicaid and replacing it with a number of reforms, including bundling payments for acute care episodes, increasing payment for primary care, and adding payments for providing a patient-centered medical home.

Under the proposal, all payment reforms would apply to Medicare, Medicaid, and the new public health plan. The proposal would also raise Medicaid rates to Medicare levels and invest in health information technology, population health, and comparative effectiveness research.

The proposal would not lower current costs but could slow the rate of health care spending, according to the Commonwealth Fund. Instead of health care spending rising 6.7% each year over the next 11 years, as predicted by current trends, the increase in spending would slow to about 5.5% per year if the reforms were implemented in 2010. The combination of the proposed insurance and payment system reforms could slow spending by nearly $3 trillion by 2020.

Costs incurred by the federal government would climb sharply during the first years of implementing these changes, but could be largely recouped by 2020, according to the report.

Under the proposal, the number of uninsured would drop from about 48 million to about 4 million by 2012.