Mary Ellen Schneider

When treating rosacea and acne, pay close attention to the potential for adverse effects ranging from skin irritation to drug resistance, according to Dr. Joseph F. Fowler Jr.

Irritation is especially common in rosacea patients, and there can be significant adverse effects from systemic treatments of both rosacea and acne. Fortunately, newer formulations of both topical and systemic drugs have been created to reduce the adverse effects and increase the efficacy of these treatments, said Dr. Fowler of the University of Louisville (Ky.).

At the Caribeean Dermatology Symposium, he outlined a treatment plan for acne and rosacea patients with sensitive skin and reviewed the adverse effects of current treatments. Dr. Fowler disclosed being a consultant and conducting clinical studies for a number of pharmaceutical companies that produce rosacea and acne treatments.

Rosacea patients tend to have more sensitive skin, Dr. Fowler said in an interview, so topical medications need to be carefully chosen. Data suggest that metronidazole 1% (MetroGel, Galderma) is the least irritating. Another topical option is azelaic acid gel 15% (Finacea), which has been shown to be somewhat more irritating, but slightly more efficacious. Both of these options cause less irritation than do many of the generic products on the market.

“From a topical standpoint, it is fairly difficult to find products that are both highly effective and nonirritating,” Dr. Fowler said. “We probably don't have a topical agent that is tremendously efficacious, especially in more severe rosacea.”

When a topical therapy is efficacious but is causing irritation, Dr. Fowler recommends using an adjunctive therapy such as calcineurin inhibitors, antifungal treatments, and moisturizers. The treatments may not do much alone, but they can be added to the regimen to allow tolerance of the first topical agent.

For patients with moderate to severe rosacea or even mild cases where an oral agent is preferred, systemic treatment may be appropriate. However, Dr. Fowler tries to use the lowest doses possible because of concerns about oral antibiotics' adverse effects, such as gastrointestinal symptoms, vertigo, photosensitivity, autoimmune disease, and antibiotic resistance.

For example, he tries to avoid using higher doses (the levels used in acne treatment) when treating chronic rosacea. Dr. Fowler recommends using sub-antimicrobial-dose doxycycline generic 20 mg/twice a day or Oracea delayed release. He said that he prefers to use Oracea delayed release because the once-a-day formulation is better for patient compliance. In addition, the delayed release probably gives more of an anti-inflammatory effect, he noted.

In acne, watch out for irritation from topical retinoids, he said. Generally, the irritation tends to increase as the efficacy increases. When using a topical retinoid, Dr. Fowler recommends slowly stepping up treatment from a mild retinoid such as low-dose adapalene to one with a higher strength.

When treating rosacea and acne, pay close attention to the potential for adverse effects ranging from skin irritation to drug resistance, according to Dr. Joseph F. Fowler Jr.

Irritation is especially common in rosacea patients, and there can be significant adverse effects from systemic treatments of both rosacea and acne. Fortunately, newer formulations of both topical and systemic drugs have been created to reduce the adverse effects and increase the efficacy of these treatments, said Dr. Fowler of the University of Louisville (Ky.).

At the Caribeean Dermatology Symposium, he outlined a treatment plan for acne and rosacea patients with sensitive skin and reviewed the adverse effects of current treatments. Dr. Fowler disclosed being a consultant and conducting clinical studies for a number of pharmaceutical companies that produce rosacea and acne treatments.

Rosacea patients tend to have more sensitive skin, Dr. Fowler said in an interview, so topical medications need to be carefully chosen. Data suggest that metronidazole 1% (MetroGel, Galderma) is the least irritating. Another topical option is azelaic acid gel 15% (Finacea), which has been shown to be somewhat more irritating, but slightly more efficacious. Both of these options cause less irritation than do many of the generic products on the market.

“From a topical standpoint, it is fairly difficult to find products that are both highly effective and nonirritating,” Dr. Fowler said. “We probably don't have a topical agent that is tremendously efficacious, especially in more severe rosacea.”

When a topical therapy is efficacious but is causing irritation, Dr. Fowler recommends using an adjunctive therapy such as calcineurin inhibitors, antifungal treatments, and moisturizers. The treatments may not do much alone, but they can be added to the regimen to allow tolerance of the first topical agent.

For patients with moderate to severe rosacea or even mild cases where an oral agent is preferred, systemic treatment may be appropriate. However, Dr. Fowler tries to use the lowest doses possible because of concerns about oral antibiotics' adverse effects, such as gastrointestinal symptoms, vertigo, photosensitivity, autoimmune disease, and antibiotic resistance.

For example, he tries to avoid using higher doses (the levels used in acne treatment) when treating chronic rosacea. Dr. Fowler recommends using sub-antimicrobial-dose doxycycline generic 20 mg/twice a day or Oracea delayed release. He said that he prefers to use Oracea delayed release because the once-a-day formulation is better for patient compliance. In addition, the delayed release probably gives more of an anti-inflammatory effect, he noted.

In acne, watch out for irritation from topical retinoids, he said. Generally, the irritation tends to increase as the efficacy increases. When using a topical retinoid, Dr. Fowler recommends slowly stepping up treatment from a mild retinoid such as low-dose adapalene to one with a higher strength.

When treating rosacea and acne, pay close attention to the potential for adverse effects ranging from skin irritation to drug resistance, according to Dr. Joseph F. Fowler Jr.

Irritation is especially common in rosacea patients, and there can be significant adverse effects from systemic treatments of both rosacea and acne. Fortunately, newer formulations of both topical and systemic drugs have been created to reduce the adverse effects and increase the efficacy of these treatments, said Dr. Fowler of the University of Louisville (Ky.).

At the Caribeean Dermatology Symposium, he outlined a treatment plan for acne and rosacea patients with sensitive skin and reviewed the adverse effects of current treatments. Dr. Fowler disclosed being a consultant and conducting clinical studies for a number of pharmaceutical companies that produce rosacea and acne treatments.

Rosacea patients tend to have more sensitive skin, Dr. Fowler said in an interview, so topical medications need to be carefully chosen. Data suggest that metronidazole 1% (MetroGel, Galderma) is the least irritating. Another topical option is azelaic acid gel 15% (Finacea), which has been shown to be somewhat more irritating, but slightly more efficacious. Both of these options cause less irritation than do many of the generic products on the market.

“From a topical standpoint, it is fairly difficult to find products that are both highly effective and nonirritating,” Dr. Fowler said. “We probably don't have a topical agent that is tremendously efficacious, especially in more severe rosacea.”

When a topical therapy is efficacious but is causing irritation, Dr. Fowler recommends using an adjunctive therapy such as calcineurin inhibitors, antifungal treatments, and moisturizers. The treatments may not do much alone, but they can be added to the regimen to allow tolerance of the first topical agent.

For patients with moderate to severe rosacea or even mild cases where an oral agent is preferred, systemic treatment may be appropriate. However, Dr. Fowler tries to use the lowest doses possible because of concerns about oral antibiotics' adverse effects, such as gastrointestinal symptoms, vertigo, photosensitivity, autoimmune disease, and antibiotic resistance.

For example, he tries to avoid using higher doses (the levels used in acne treatment) when treating chronic rosacea. Dr. Fowler recommends using sub-antimicrobial-dose doxycycline generic 20 mg/twice a day or Oracea delayed release. He said that he prefers to use Oracea delayed release because the once-a-day formulation is better for patient compliance. In addition, the delayed release probably gives more of an anti-inflammatory effect, he noted.

In acne, watch out for irritation from topical retinoids, he said. Generally, the irritation tends to increase as the efficacy increases. When using a topical retinoid, Dr. Fowler recommends slowly stepping up treatment from a mild retinoid such as low-dose adapalene to one with a higher strength.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register last month, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement them.

The HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to the HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. A spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to the HHS, to replace the outdated ICD-9. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

“These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology,” Mike Leavitt, HHS Secretary, said in a statement. “The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities.”

The final rule gives providers and plans almost 2 years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. The costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to the ACP.

The ACP is urging the HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop an implementation assistance program to help physicians, especially those in small practices and rural communities. If the value to the health system is as significant as the HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at the MGMA.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register last month, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement them.

The HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to the HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. A spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to the HHS, to replace the outdated ICD-9. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

“These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology,” Mike Leavitt, HHS Secretary, said in a statement. “The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities.”

The final rule gives providers and plans almost 2 years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. The costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to the ACP.

The ACP is urging the HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop an implementation assistance program to help physicians, especially those in small practices and rural communities. If the value to the health system is as significant as the HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at the MGMA.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register last month, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement them.

The HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to the HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. A spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to the HHS, to replace the outdated ICD-9. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

“These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology,” Mike Leavitt, HHS Secretary, said in a statement. “The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities.”

The final rule gives providers and plans almost 2 years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. The costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to the ACP.

The ACP is urging the HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop an implementation assistance program to help physicians, especially those in small practices and rural communities. If the value to the health system is as significant as the HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at the MGMA.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with a significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement the new code sets.

In addition, HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. However, a spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to HHS, to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

"These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology," Mike Leavitt, HHS Secretary, said in a statement. "The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities."

The final rule gives health care providers and plans almost 2 extra years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10, compared with the timeline originally proposed last year. HHS officials said they decided to allow extra time for implementation in response to concerns that a short implementation phase would result in high implementation costs and inadequate time for training.

Physician groups praised HHS for providing additional time for implementation but said other issues persist.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. The costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to ACP.

ACP is urging HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop an implementation assistance program to help physicians. If the value to the health system is as significant as HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at MGMA.

HHS also should extend its outreach to the vendor community, Mr. Tennant said, since they will be the ones to provide updates to the practice management software. HHS also needs to work with private health plans to ensure there is no disruption in payments.

Mr. Tennant advised physician practices to get started by becoming familiar with the requirements and compliance dates. Next, reach out to vendors of practice management software and find out their plans for updating the software, including the timeline and costs, he said.

ICD-10 'will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities.' MR. LEAVITT

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with a significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement the new code sets.

In addition, HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. However, a spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to HHS, to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

"These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology," Mike Leavitt, HHS Secretary, said in a statement. "The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities."

The final rule gives health care providers and plans almost 2 extra years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10, compared with the timeline originally proposed last year. HHS officials said they decided to allow extra time for implementation in response to concerns that a short implementation phase would result in high implementation costs and inadequate time for training.

Physician groups praised HHS for providing additional time for implementation but said other issues persist.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. The costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to ACP.

ACP is urging HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop an implementation assistance program to help physicians. If the value to the health system is as significant as HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at MGMA.

HHS also should extend its outreach to the vendor community, Mr. Tennant said, since they will be the ones to provide updates to the practice management software. HHS also needs to work with private health plans to ensure there is no disruption in payments.

Mr. Tennant advised physician practices to get started by becoming familiar with the requirements and compliance dates. Next, reach out to vendors of practice management software and find out their plans for updating the software, including the timeline and costs, he said.

ICD-10 'will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities.' MR. LEAVITT

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with a significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement the new code sets.

In addition, HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. However, a spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to HHS, to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

"These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology," Mike Leavitt, HHS Secretary, said in a statement. "The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities."

The final rule gives health care providers and plans almost 2 extra years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10, compared with the timeline originally proposed last year. HHS officials said they decided to allow extra time for implementation in response to concerns that a short implementation phase would result in high implementation costs and inadequate time for training.

Physician groups praised HHS for providing additional time for implementation but said other issues persist.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. The costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to ACP.

ACP is urging HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop an implementation assistance program to help physicians. If the value to the health system is as significant as HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at MGMA.

HHS also should extend its outreach to the vendor community, Mr. Tennant said, since they will be the ones to provide updates to the practice management software. HHS also needs to work with private health plans to ensure there is no disruption in payments.

Mr. Tennant advised physician practices to get started by becoming familiar with the requirements and compliance dates. Next, reach out to vendors of practice management software and find out their plans for updating the software, including the timeline and costs, he said.

ICD-10 'will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities.' MR. LEAVITT

As part of an agreement with New York Attorney General Andrew Cuomo, UnitedHealth Group has agreed to shut down a national billing database used by health plans to determine reimbursements to members who use out-of-network physician services.

The billing database, which is operated by the UnitedHealth Group (UHG) subsidiary Ingenix Inc., will be replaced with a new, independent database run by a qualified nonprofit organization. Under the terms of the agreement, UHG will pay $50 million to help establish the new database. In addition, the nonprofit organization will develop a public Web site where consumers can research—before seeking services—how much they may be reimbursed for common out-of-network medical services in their area.

Aetna, the nation's third largest insurer, also has entered into an agreement with the New York attorney general to abandon its use of the Ingenix database in favor of the new one. Aetna also will contribute $20 million over 5 years for the creation of the new database.

In February 2009, Aetna reached an agreement with the New York Attorney General's office to pay $5.1 million to reimburse patients and physicians for claims involving out-of-network care. The settlement addresses charges that Aetna underpaid college student health insurance claims between 1998 and 2008 by more than $5 million. Aetna will now pay back the students, and in some cases their physicians, for the underpayments plus interest and penalties as calculated under state law. The agreement reached with the New York Attorney General will affect underpayments made to students across the country.

The agreements follow an investigation by Mr. Cuomo's office into allegations that insurers were systematically underpaying consumers for their out-of-network medical expenses by saying that physician charges were higher than the “usual, customary, and reasonable” rates as calculated by the Ingenix database. As a result, insurers would only pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill.

The investigation found that insurers were underpaying consumers for out-of-network expenses by 10%–28% for medical services across the state.

According to UHG officials, the agreement with the New York attorney general will help increase the transparency of information related to physician fees for out-of-network services.

Just days after reaching an agreement with Mr. Cuomo's office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA.

The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for out-of-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient.

But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won't be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, president of the AMA.

When UHG and other insurers refused to pay the physician's charge, they were telling patients that the charge was unreasonable, creating tension between the patient and physician, said Dr. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA's class action lawsuit. “This was always a wedge between patients and physicians.”

As part of an agreement with New York Attorney General Andrew Cuomo, UnitedHealth Group has agreed to shut down a national billing database used by health plans to determine reimbursements to members who use out-of-network physician services.

The billing database, which is operated by the UnitedHealth Group (UHG) subsidiary Ingenix Inc., will be replaced with a new, independent database run by a qualified nonprofit organization. Under the terms of the agreement, UHG will pay $50 million to help establish the new database. In addition, the nonprofit organization will develop a public Web site where consumers can research—before seeking services—how much they may be reimbursed for common out-of-network medical services in their area.

Aetna, the nation's third largest insurer, also has entered into an agreement with the New York attorney general to abandon its use of the Ingenix database in favor of the new one. Aetna also will contribute $20 million over 5 years for the creation of the new database.

In February 2009, Aetna reached an agreement with the New York Attorney General's office to pay $5.1 million to reimburse patients and physicians for claims involving out-of-network care. The settlement addresses charges that Aetna underpaid college student health insurance claims between 1998 and 2008 by more than $5 million. Aetna will now pay back the students, and in some cases their physicians, for the underpayments plus interest and penalties as calculated under state law. The agreement reached with the New York Attorney General will affect underpayments made to students across the country.

The agreements follow an investigation by Mr. Cuomo's office into allegations that insurers were systematically underpaying consumers for their out-of-network medical expenses by saying that physician charges were higher than the “usual, customary, and reasonable” rates as calculated by the Ingenix database. As a result, insurers would only pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill.

The investigation found that insurers were underpaying consumers for out-of-network expenses by 10%–28% for medical services across the state.

According to UHG officials, the agreement with the New York attorney general will help increase the transparency of information related to physician fees for out-of-network services.

Just days after reaching an agreement with Mr. Cuomo's office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA.

The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for out-of-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient.

But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won't be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, president of the AMA.

When UHG and other insurers refused to pay the physician's charge, they were telling patients that the charge was unreasonable, creating tension between the patient and physician, said Dr. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA's class action lawsuit. “This was always a wedge between patients and physicians.”

As part of an agreement with New York Attorney General Andrew Cuomo, UnitedHealth Group has agreed to shut down a national billing database used by health plans to determine reimbursements to members who use out-of-network physician services.

The billing database, which is operated by the UnitedHealth Group (UHG) subsidiary Ingenix Inc., will be replaced with a new, independent database run by a qualified nonprofit organization. Under the terms of the agreement, UHG will pay $50 million to help establish the new database. In addition, the nonprofit organization will develop a public Web site where consumers can research—before seeking services—how much they may be reimbursed for common out-of-network medical services in their area.

Aetna, the nation's third largest insurer, also has entered into an agreement with the New York attorney general to abandon its use of the Ingenix database in favor of the new one. Aetna also will contribute $20 million over 5 years for the creation of the new database.

In February 2009, Aetna reached an agreement with the New York Attorney General's office to pay $5.1 million to reimburse patients and physicians for claims involving out-of-network care. The settlement addresses charges that Aetna underpaid college student health insurance claims between 1998 and 2008 by more than $5 million. Aetna will now pay back the students, and in some cases their physicians, for the underpayments plus interest and penalties as calculated under state law. The agreement reached with the New York Attorney General will affect underpayments made to students across the country.

The agreements follow an investigation by Mr. Cuomo's office into allegations that insurers were systematically underpaying consumers for their out-of-network medical expenses by saying that physician charges were higher than the “usual, customary, and reasonable” rates as calculated by the Ingenix database. As a result, insurers would only pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill.

The investigation found that insurers were underpaying consumers for out-of-network expenses by 10%–28% for medical services across the state.

According to UHG officials, the agreement with the New York attorney general will help increase the transparency of information related to physician fees for out-of-network services.

Just days after reaching an agreement with Mr. Cuomo's office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA.

The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for out-of-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient.

But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won't be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, president of the AMA.

When UHG and other insurers refused to pay the physician's charge, they were telling patients that the charge was unreasonable, creating tension between the patient and physician, said Dr. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA's class action lawsuit. “This was always a wedge between patients and physicians.”

Women, Minorities Bear STD Burden

Women continue to be disproportionately affected by sexually transmitted diseases, according to 2007 surveillance figures from the Centers for Disease Control and Prevention. The chlamydia rate among women was nearly three times that of men in 2007 with 543.6 cases per 100,000 women, compared with 190 cases per 100,000 men. More women also suffer from gonorrhea, the CDC reported, with 123.5 cases per 100,000 women, versus 113.7 cases per 100,000 men. The consequences of untreated chlamydia and gonorrhea infections are high for women, the report reminded: infertility, ectopic pregnancy, and chronic pelvic pain. The CDC report, Sexually Transmitted Disease Surveillance, 2007, also highlighted racial disparities in chlamydia, gonorrhea, and syphilis. Young African American women (aged 15–19 years) had the highest rates of chlamydia and gonorrhea. The full report is available online at

www.cdc.gov/std/stats07

ACOG Supports Same-Sex Couples

The American College of Obstetricians and Gynecologists supports the right of same-sex couples to the same federal and state legal protections afforded heterosexual married couples. In a new position statement written by ACOG's Committee on Health Care for Underserved Women, committee members pointed out that lesbian women and their families face obstacles in accessing health care. These obstacles range from discriminatory attitudes and treatment to limited access to health insurance. For example, a lesbian woman might have a medical power of attorney but might still be prevented from seeing her partner in the hospital. Many women in same-sex relationships are unable to take leave under the Family Medical Leave Act to care for a sick partner. ACOG published its policy statement in the February issue of Obstetrics & Gynecology.

Misoprostol Urged After Abortion

The availability and use of misoprostol should be increased as a first-line method of immediate postabortion care in outpatient settings, according to another new opinion from ACOG. “Women need an option within their communities that will allow for immediate medical attention,” Dr. Laura Castleman, a member of ACOG's Committee on International Affairs. “A woman who is sick and in pain, poor, or otherwise unable to travel may not receive care she needs in time to preserve her health or save her life.” Misoprostol is a safe, low-cost alternative to vacuum aspiration, according to ACOG. The college also advised that nurses and midwives can safely provide postabortion care in outpatient settings, provided they received appropriate training and support. The ACOG policy statement was also published in the February issue of Obstetrics & Gynecology.

Reproductive Rights Report Card

Reproductive rights made some advances and had some setbacks in 2008, according to a report from the NARAL Pro-Choice American Foundation. Twenty-three states enacted 39 “prochoice” measures, such as policies to prevent unintended pregnancy. Colorado, Indiana, Minnesota, and Wisconsin each enacted measures to improve access to contraceptives and provide comprehensive sex education to teens. Wisconsin also enacted legislation that ensures that sexual assault victims receive information about and access to emergency contraception in hospital emergency departments. On the other hand, 16 states enacted 24 “antichoice” measures. For example, Oklahoma passed omnibus legislation that allows certain individuals and organizations to refuse to provide abortion services and requires women seeking abortions to view ultrasound images. The report provides grades for each state as well as an assessment of federal actions in this area.

Seeking Low-Cost Contraceptives

Legislation in the House of Representatives would restore discounts for contraceptives purchased by college health centers and safety-net clinics for low-income people. The “Prevention Through Affordable Access Act” (H.R. 398) would reinstate the health centers' access to the Medicaid discount drug prices, which they lost with the enactment of the Deficit Reduction Act of 2005. Since January 2008, women getting contraceptives at these clinics have seen the average price of a prescription increase from about $5 to almost $50, according to Rep. Joseph Crowley (D-N.Y.), who reintroduced the legislation last month after it failed to pass in the last session of Congress. The bill is supported by the Planned Parenthood Federation of America and Physicians for Reproductive Choice and Health.

Women, Minorities Bear STD Burden

Women continue to be disproportionately affected by sexually transmitted diseases, according to 2007 surveillance figures from the Centers for Disease Control and Prevention. The chlamydia rate among women was nearly three times that of men in 2007 with 543.6 cases per 100,000 women, compared with 190 cases per 100,000 men. More women also suffer from gonorrhea, the CDC reported, with 123.5 cases per 100,000 women, versus 113.7 cases per 100,000 men. The consequences of untreated chlamydia and gonorrhea infections are high for women, the report reminded: infertility, ectopic pregnancy, and chronic pelvic pain. The CDC report, Sexually Transmitted Disease Surveillance, 2007, also highlighted racial disparities in chlamydia, gonorrhea, and syphilis. Young African American women (aged 15–19 years) had the highest rates of chlamydia and gonorrhea. The full report is available online at

www.cdc.gov/std/stats07

ACOG Supports Same-Sex Couples

The American College of Obstetricians and Gynecologists supports the right of same-sex couples to the same federal and state legal protections afforded heterosexual married couples. In a new position statement written by ACOG's Committee on Health Care for Underserved Women, committee members pointed out that lesbian women and their families face obstacles in accessing health care. These obstacles range from discriminatory attitudes and treatment to limited access to health insurance. For example, a lesbian woman might have a medical power of attorney but might still be prevented from seeing her partner in the hospital. Many women in same-sex relationships are unable to take leave under the Family Medical Leave Act to care for a sick partner. ACOG published its policy statement in the February issue of Obstetrics & Gynecology.

Misoprostol Urged After Abortion

The availability and use of misoprostol should be increased as a first-line method of immediate postabortion care in outpatient settings, according to another new opinion from ACOG. “Women need an option within their communities that will allow for immediate medical attention,” Dr. Laura Castleman, a member of ACOG's Committee on International Affairs. “A woman who is sick and in pain, poor, or otherwise unable to travel may not receive care she needs in time to preserve her health or save her life.” Misoprostol is a safe, low-cost alternative to vacuum aspiration, according to ACOG. The college also advised that nurses and midwives can safely provide postabortion care in outpatient settings, provided they received appropriate training and support. The ACOG policy statement was also published in the February issue of Obstetrics & Gynecology.

Reproductive Rights Report Card

Reproductive rights made some advances and had some setbacks in 2008, according to a report from the NARAL Pro-Choice American Foundation. Twenty-three states enacted 39 “prochoice” measures, such as policies to prevent unintended pregnancy. Colorado, Indiana, Minnesota, and Wisconsin each enacted measures to improve access to contraceptives and provide comprehensive sex education to teens. Wisconsin also enacted legislation that ensures that sexual assault victims receive information about and access to emergency contraception in hospital emergency departments. On the other hand, 16 states enacted 24 “antichoice” measures. For example, Oklahoma passed omnibus legislation that allows certain individuals and organizations to refuse to provide abortion services and requires women seeking abortions to view ultrasound images. The report provides grades for each state as well as an assessment of federal actions in this area.

Seeking Low-Cost Contraceptives

Legislation in the House of Representatives would restore discounts for contraceptives purchased by college health centers and safety-net clinics for low-income people. The “Prevention Through Affordable Access Act” (H.R. 398) would reinstate the health centers' access to the Medicaid discount drug prices, which they lost with the enactment of the Deficit Reduction Act of 2005. Since January 2008, women getting contraceptives at these clinics have seen the average price of a prescription increase from about $5 to almost $50, according to Rep. Joseph Crowley (D-N.Y.), who reintroduced the legislation last month after it failed to pass in the last session of Congress. The bill is supported by the Planned Parenthood Federation of America and Physicians for Reproductive Choice and Health.

Women, Minorities Bear STD Burden

Women continue to be disproportionately affected by sexually transmitted diseases, according to 2007 surveillance figures from the Centers for Disease Control and Prevention. The chlamydia rate among women was nearly three times that of men in 2007 with 543.6 cases per 100,000 women, compared with 190 cases per 100,000 men. More women also suffer from gonorrhea, the CDC reported, with 123.5 cases per 100,000 women, versus 113.7 cases per 100,000 men. The consequences of untreated chlamydia and gonorrhea infections are high for women, the report reminded: infertility, ectopic pregnancy, and chronic pelvic pain. The CDC report, Sexually Transmitted Disease Surveillance, 2007, also highlighted racial disparities in chlamydia, gonorrhea, and syphilis. Young African American women (aged 15–19 years) had the highest rates of chlamydia and gonorrhea. The full report is available online at

www.cdc.gov/std/stats07

ACOG Supports Same-Sex Couples

The American College of Obstetricians and Gynecologists supports the right of same-sex couples to the same federal and state legal protections afforded heterosexual married couples. In a new position statement written by ACOG's Committee on Health Care for Underserved Women, committee members pointed out that lesbian women and their families face obstacles in accessing health care. These obstacles range from discriminatory attitudes and treatment to limited access to health insurance. For example, a lesbian woman might have a medical power of attorney but might still be prevented from seeing her partner in the hospital. Many women in same-sex relationships are unable to take leave under the Family Medical Leave Act to care for a sick partner. ACOG published its policy statement in the February issue of Obstetrics & Gynecology.

Misoprostol Urged After Abortion

The availability and use of misoprostol should be increased as a first-line method of immediate postabortion care in outpatient settings, according to another new opinion from ACOG. “Women need an option within their communities that will allow for immediate medical attention,” Dr. Laura Castleman, a member of ACOG's Committee on International Affairs. “A woman who is sick and in pain, poor, or otherwise unable to travel may not receive care she needs in time to preserve her health or save her life.” Misoprostol is a safe, low-cost alternative to vacuum aspiration, according to ACOG. The college also advised that nurses and midwives can safely provide postabortion care in outpatient settings, provided they received appropriate training and support. The ACOG policy statement was also published in the February issue of Obstetrics & Gynecology.

Reproductive Rights Report Card

Reproductive rights made some advances and had some setbacks in 2008, according to a report from the NARAL Pro-Choice American Foundation. Twenty-three states enacted 39 “prochoice” measures, such as policies to prevent unintended pregnancy. Colorado, Indiana, Minnesota, and Wisconsin each enacted measures to improve access to contraceptives and provide comprehensive sex education to teens. Wisconsin also enacted legislation that ensures that sexual assault victims receive information about and access to emergency contraception in hospital emergency departments. On the other hand, 16 states enacted 24 “antichoice” measures. For example, Oklahoma passed omnibus legislation that allows certain individuals and organizations to refuse to provide abortion services and requires women seeking abortions to view ultrasound images. The report provides grades for each state as well as an assessment of federal actions in this area.

Seeking Low-Cost Contraceptives

Legislation in the House of Representatives would restore discounts for contraceptives purchased by college health centers and safety-net clinics for low-income people. The “Prevention Through Affordable Access Act” (H.R. 398) would reinstate the health centers' access to the Medicaid discount drug prices, which they lost with the enactment of the Deficit Reduction Act of 2005. Since January 2008, women getting contraceptives at these clinics have seen the average price of a prescription increase from about $5 to almost $50, according to Rep. Joseph Crowley (D-N.Y.), who reintroduced the legislation last month after it failed to pass in the last session of Congress. The bill is supported by the Planned Parenthood Federation of America and Physicians for Reproductive Choice and Health.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register last month, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with a significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement the new code sets.

In addition, HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. However, a spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to HHS, to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

“These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology,” Mike Leavitt, HHS Secretary, said in a statement.

“The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities,” Mr. Leavitt continued.

The final rule gives health care providers and plans almost 2 extra years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10, compared with the timeline originally proposed last year. HHS officials said they decided to allow extra time for implementation in response to concerns that a short implementation phase would result in high implementation costs and inadequate time for training and testing.

Physician groups praised HHS for providing additional time for implementation but said other issues persist.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. In fact, the costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to ACP.

ACP is urging HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop some type of implementation assistance program to help physicians, especially those in small practices and rural communities. If the value to the health system is as significant as HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at MGMA.

HHS also should extend its outreach to the vendor community, Mr. Tennant said, since they will be the ones to provide updates to the practice management software. HHS also needs to work with private health plans to ensure there is no disruption in payments.

For their part, Mr. Tennant advised physician practices to get started by becoming familiar with the requirements and the compliance dates. Next, reach out to vendors of practice management software and find out their plans for updating the software, including the timeline and costs. With that information in hand, practices can formulate a budget for implementation that includes training and testing, he said.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register last month, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with a significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement the new code sets.

In addition, HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. However, a spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to HHS, to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

“These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology,” Mike Leavitt, HHS Secretary, said in a statement.

“The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities,” Mr. Leavitt continued.

The final rule gives health care providers and plans almost 2 extra years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10, compared with the timeline originally proposed last year. HHS officials said they decided to allow extra time for implementation in response to concerns that a short implementation phase would result in high implementation costs and inadequate time for training and testing.

Physician groups praised HHS for providing additional time for implementation but said other issues persist.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. In fact, the costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to ACP.

ACP is urging HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop some type of implementation assistance program to help physicians, especially those in small practices and rural communities. If the value to the health system is as significant as HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at MGMA.

HHS also should extend its outreach to the vendor community, Mr. Tennant said, since they will be the ones to provide updates to the practice management software. HHS also needs to work with private health plans to ensure there is no disruption in payments.

For their part, Mr. Tennant advised physician practices to get started by becoming familiar with the requirements and the compliance dates. Next, reach out to vendors of practice management software and find out their plans for updating the software, including the timeline and costs. With that information in hand, practices can formulate a budget for implementation that includes training and testing, he said.

In less than 5 years, physicians and other health care providers will be required to begin using a new system of code sets to report health care diagnoses and procedures.

Under a final rule published in the Federal Register last month, the Health and Human Services department is replacing the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) code sets now used with a significantly expanded ICD-10 code sets. Providers and health plans will have until Oct. 1, 2013, to implement the new code sets.

In addition, HHS also issued a final rule adopting new standards for certain electronic health care transactions. The rule requires health care providers to come into compliance with the updated X12 standard, Version 5010, which includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Use of the updated standard is necessary to use the ICD-10 code sets, according to HHS. Providers and health plans must be in compliance with the updated transaction standard by Jan. 1, 2012.

At press time, the Obama administration was in the process of reviewing and approving all new and pending regulations written under the previous administration, including the ICD-10 rules. However, a spokesman for the Centers for Medicare and Medicaid Services said that until the review is complete, it is not possible to determine which regulations are affected.

The move to the new code sets was necessary, according to HHS, to replace the outdated ICD-9 code sets. The ICD-9-CM contains about 17,000 codes, compared with 155,000 codes in the ICD-10 code sets.

“These regulations will move the nation toward a more efficient, quality-focused health care system by helping accelerate the widespread adoption of health information technology,” Mike Leavitt, HHS Secretary, said in a statement.

“The greatly expanded ICD-10 code sets will fully support quality reporting, pay-for-performance, biosurveillance, and other critical activities,” Mr. Leavitt continued.

The final rule gives health care providers and plans almost 2 extra years to implement the Version 5010 transaction standard and a full 2 years to switch to ICD-10, compared with the timeline originally proposed last year. HHS officials said they decided to allow extra time for implementation in response to concerns that a short implementation phase would result in high implementation costs and inadequate time for training and testing.

Physician groups praised HHS for providing additional time for implementation but said other issues persist.

Officials at the American College of Physicians said that they believe that the benefits of switching to the ICD-10 code sets in the ambulatory setting do not outweigh the collective costs, said Brett Baker, director of regulatory affairs. In fact, the costs and administrative burdens related to adopting ICD-10 could slow adoption of health information technology and make it more difficult for physicians to engage in quality improvement efforts, according to ACP.

ACP is urging HHS to explore alternatives to the implementation plan outlined in the final rule. For example, the department could delay implementation of ICD-10 in the outpatient setting until a certain percentage of physicians adopted interoperable electronic health record systems. Since EHRs would ease the adoption burden for physicians, it makes sense to wait until adoption of health information technology reaches a certain threshold point, Mr. Baker said.

The Medical Group Management Association also expressed concern that physician practices will struggle to implement the new code sets. The association is calling on the federal government to develop some type of implementation assistance program to help physicians, especially those in small practices and rural communities. If the value to the health system is as significant as HHS estimates, government officials should be prepared to invest that savings early on to ensure implementation runs smoothly, said Robert Tennant, senior policy adviser at MGMA.

HHS also should extend its outreach to the vendor community, Mr. Tennant said, since they will be the ones to provide updates to the practice management software. HHS also needs to work with private health plans to ensure there is no disruption in payments.

For their part, Mr. Tennant advised physician practices to get started by becoming familiar with the requirements and the compliance dates. Next, reach out to vendors of practice management software and find out their plans for updating the software, including the timeline and costs. With that information in hand, practices can formulate a budget for implementation that includes training and testing, he said.

Federal officials are seeking significant reductions in some of the most common health care-associated infections over the next 5 years.

In an “action plan” issued in January, Department of Health and Human Services officials outlined goals related to six categories of health care-associated infections: central line-associated bloodstream infections, Clostridium difficile infections, catheter-associated urinary tract infections, methicillin-resistant Staphylococcus aureus (MRSA) infections, surgical-site infections, and ventilator-associated pneumonia.

The seven national prevention targets identified in the plan call for:

▸ Reducing the number of central line-associated bloodstream infections per 1,000 device days to below the current 25th percentile set by the National Healthcare Safety Network by location type.

▸ Achieving full compliance with the central line bundle in nonemergent insertions.

▸ Reducing by 30% the case rate per patient days and administrative/discharge data for ICD-9-CM-coded C. difficile infections.

▸ Reducing the median deep-incision and organ-space infection rate for each procedure/risk group to at or below the current National Healthcare Safety Network 25th percentile.

▸ Reducing by 25% the number of symptomatic urinary tract infections per 1,000 urinary catheter days.

▸ Reducing by half the incidence rate of all health care-associated invasive MRSA infections.

▸ Achieving 95% adherence rates for each Surgical Care Improvement Project/National Quality Forum infection process measure for surgical-site infections.

Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology, said the goals are “reasonable.”

Dr. Patrick J. Brennan, chairman of the Healthcare Infection Control Practices Advisory Committee, said it also addresses concerns about a lack of coordination among the federal agencies and departments that have some responsibility for health care-associated infections. Dr. Brennan served on the steering committee that prepared the report.

The plan is online at www.hhs.gov/ophs/initiatives/hai

Federal officials are seeking significant reductions in some of the most common health care-associated infections over the next 5 years.

In an “action plan” issued in January, Department of Health and Human Services officials outlined goals related to six categories of health care-associated infections: central line-associated bloodstream infections, Clostridium difficile infections, catheter-associated urinary tract infections, methicillin-resistant Staphylococcus aureus (MRSA) infections, surgical-site infections, and ventilator-associated pneumonia.

The seven national prevention targets identified in the plan call for:

▸ Reducing the number of central line-associated bloodstream infections per 1,000 device days to below the current 25th percentile set by the National Healthcare Safety Network by location type.

▸ Achieving full compliance with the central line bundle in nonemergent insertions.

▸ Reducing by 30% the case rate per patient days and administrative/discharge data for ICD-9-CM-coded C. difficile infections.

▸ Reducing the median deep-incision and organ-space infection rate for each procedure/risk group to at or below the current National Healthcare Safety Network 25th percentile.

▸ Reducing by 25% the number of symptomatic urinary tract infections per 1,000 urinary catheter days.

▸ Reducing by half the incidence rate of all health care-associated invasive MRSA infections.

▸ Achieving 95% adherence rates for each Surgical Care Improvement Project/National Quality Forum infection process measure for surgical-site infections.

Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology, said the goals are “reasonable.”

Dr. Patrick J. Brennan, chairman of the Healthcare Infection Control Practices Advisory Committee, said it also addresses concerns about a lack of coordination among the federal agencies and departments that have some responsibility for health care-associated infections. Dr. Brennan served on the steering committee that prepared the report.

The plan is online at www.hhs.gov/ophs/initiatives/hai

Federal officials are seeking significant reductions in some of the most common health care-associated infections over the next 5 years.

In an “action plan” issued in January, Department of Health and Human Services officials outlined goals related to six categories of health care-associated infections: central line-associated bloodstream infections, Clostridium difficile infections, catheter-associated urinary tract infections, methicillin-resistant Staphylococcus aureus (MRSA) infections, surgical-site infections, and ventilator-associated pneumonia.

The seven national prevention targets identified in the plan call for:

▸ Reducing the number of central line-associated bloodstream infections per 1,000 device days to below the current 25th percentile set by the National Healthcare Safety Network by location type.

▸ Achieving full compliance with the central line bundle in nonemergent insertions.

▸ Reducing by 30% the case rate per patient days and administrative/discharge data for ICD-9-CM-coded C. difficile infections.

▸ Reducing the median deep-incision and organ-space infection rate for each procedure/risk group to at or below the current National Healthcare Safety Network 25th percentile.

▸ Reducing by 25% the number of symptomatic urinary tract infections per 1,000 urinary catheter days.

▸ Reducing by half the incidence rate of all health care-associated invasive MRSA infections.

▸ Achieving 95% adherence rates for each Surgical Care Improvement Project/National Quality Forum infection process measure for surgical-site infections.

Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology, said the goals are “reasonable.”

Dr. Patrick J. Brennan, chairman of the Healthcare Infection Control Practices Advisory Committee, said it also addresses concerns about a lack of coordination among the federal agencies and departments that have some responsibility for health care-associated infections. Dr. Brennan served on the steering committee that prepared the report.

The plan is online at www.hhs.gov/ophs/initiatives/hai

Nearly 11 million low-income children will receive health coverage under the reauthorization and expansion of the State Children's Health Insurance Program, which was recently signed into law by President Barack Obama.

The legislation (H.R. 2), which received broad support in both the House and Senate, was signed on Feb. 4. SCHIP is now reauthorized through September 2013 and will provide coverage to the approximately 6.7 million children currently covered by the program, as well as 4.1 million new children.

“But this bill is only a first step,” President Obama said at a signing ceremony for the SCHIP law. “The way I see it, providing coverage to 11 million children through [SCHIP] is a down payment on my commitment to cover every single American. And it is just one component of a much broader effort to finally bring our health care system into the 21st century.”

On the same day he signed the SCHIP law, President Obama directed the Centers for Medicare and Medicaid Services to rescind a Bush administration directive that limited the flexibility of states to set higher income eligibility standards for their SCHIP programs.

Under the newly enacted SCHIP law, states are allowed to cover children in families up to 300% of the federal poverty level while retaining access to full federal matching funds. It also gives states the option to cover prenatal care for pregnant women. However, it requires states to phase out coverage of low-income parents and childless adults currently covered under the program. The new law eliminates the 5-year waiting period for legal immigrant children and pregnant women to gain access to SCHIP benefits.

States now will have the option to provide dental-only coverage to children who have private insurance, which often has limited coverage for dental services.

In an effort to measure and improve health care quality, the law calls for development of an initial core set of child health quality measures for children enrolled in SCHIP and Medicaid by Jan. 1, 2010. The measures would be designed to assess the effectiveness and availability of preventive services, prenatal care, and treatments for acute and chronic conditions.

Although SCHIP has enjoyed wide support in Congress, members of the House and Senate vigorously debated last month whether such a significant expansion of the program was appropriate. Some Republicans in the House objected to the legislation, saying that it would undermine the original intent of the SCHIP legislation by expanding the program to adults, illegal immigrants, and families with higher incomes. The legislation bars the coverage of illegal immigrants, but Republicans who spoke out against the legislation said that the lack of an adequate system to verify citizenship status would result in illegal immigrants gaining access to coverage.

But the law signed by the president has been widely praised by children's health advocates as necessary during the current economic downturn.

“Sharp increases in unemployment have likely added more children to the ranks of the uninsured and put increasing pressure on state health care programs,” Dr. Nancy Nielsen, president of the American Medical Association, said in a statement. “This new law will enable states to extend health care coverage to more children whose parents cannot afford it, but earn too much to qualify for Medicaid.”

The SCHIP law will be paid for in large part through a 62-cent-per-pack increase in the federal tax on cigarettes, with proportional increases for other tobacco products. The AMA praised the increase in the tobacco tax, saying the move will help fund health care for more children and act as a deterrent to young smokers and potential smokers.

Attempts to reauthorize the program during the last session of Congress were unsuccessful when Congress twice failed to override vetoes from President George W. Bush.

Nearly 11 million low-income children will receive health coverage under the reauthorization and expansion of the State Children's Health Insurance Program, which was recently signed into law by President Barack Obama.

The legislation (H.R. 2), which received broad support in both the House and Senate, was signed on Feb. 4. SCHIP is now reauthorized through September 2013 and will provide coverage to the approximately 6.7 million children currently covered by the program, as well as 4.1 million new children.

“But this bill is only a first step,” President Obama said at a signing ceremony for the SCHIP law. “The way I see it, providing coverage to 11 million children through [SCHIP] is a down payment on my commitment to cover every single American. And it is just one component of a much broader effort to finally bring our health care system into the 21st century.”

On the same day he signed the SCHIP law, President Obama directed the Centers for Medicare and Medicaid Services to rescind a Bush administration directive that limited the flexibility of states to set higher income eligibility standards for their SCHIP programs.

Under the newly enacted SCHIP law, states are allowed to cover children in families up to 300% of the federal poverty level while retaining access to full federal matching funds. It also gives states the option to cover prenatal care for pregnant women. However, it requires states to phase out coverage of low-income parents and childless adults currently covered under the program. The new law eliminates the 5-year waiting period for legal immigrant children and pregnant women to gain access to SCHIP benefits.

States now will have the option to provide dental-only coverage to children who have private insurance, which often has limited coverage for dental services.

In an effort to measure and improve health care quality, the law calls for development of an initial core set of child health quality measures for children enrolled in SCHIP and Medicaid by Jan. 1, 2010. The measures would be designed to assess the effectiveness and availability of preventive services, prenatal care, and treatments for acute and chronic conditions.

Although SCHIP has enjoyed wide support in Congress, members of the House and Senate vigorously debated last month whether such a significant expansion of the program was appropriate. Some Republicans in the House objected to the legislation, saying that it would undermine the original intent of the SCHIP legislation by expanding the program to adults, illegal immigrants, and families with higher incomes. The legislation bars the coverage of illegal immigrants, but Republicans who spoke out against the legislation said that the lack of an adequate system to verify citizenship status would result in illegal immigrants gaining access to coverage.

But the law signed by the president has been widely praised by children's health advocates as necessary during the current economic downturn.

“Sharp increases in unemployment have likely added more children to the ranks of the uninsured and put increasing pressure on state health care programs,” Dr. Nancy Nielsen, president of the American Medical Association, said in a statement. “This new law will enable states to extend health care coverage to more children whose parents cannot afford it, but earn too much to qualify for Medicaid.”

The SCHIP law will be paid for in large part through a 62-cent-per-pack increase in the federal tax on cigarettes, with proportional increases for other tobacco products. The AMA praised the increase in the tobacco tax, saying the move will help fund health care for more children and act as a deterrent to young smokers and potential smokers.

Attempts to reauthorize the program during the last session of Congress were unsuccessful when Congress twice failed to override vetoes from President George W. Bush.

Nearly 11 million low-income children will receive health coverage under the reauthorization and expansion of the State Children's Health Insurance Program, which was recently signed into law by President Barack Obama.

The legislation (H.R. 2), which received broad support in both the House and Senate, was signed on Feb. 4. SCHIP is now reauthorized through September 2013 and will provide coverage to the approximately 6.7 million children currently covered by the program, as well as 4.1 million new children.

“But this bill is only a first step,” President Obama said at a signing ceremony for the SCHIP law. “The way I see it, providing coverage to 11 million children through [SCHIP] is a down payment on my commitment to cover every single American. And it is just one component of a much broader effort to finally bring our health care system into the 21st century.”

On the same day he signed the SCHIP law, President Obama directed the Centers for Medicare and Medicaid Services to rescind a Bush administration directive that limited the flexibility of states to set higher income eligibility standards for their SCHIP programs.

Under the newly enacted SCHIP law, states are allowed to cover children in families up to 300% of the federal poverty level while retaining access to full federal matching funds. It also gives states the option to cover prenatal care for pregnant women. However, it requires states to phase out coverage of low-income parents and childless adults currently covered under the program. The new law eliminates the 5-year waiting period for legal immigrant children and pregnant women to gain access to SCHIP benefits.

States now will have the option to provide dental-only coverage to children who have private insurance, which often has limited coverage for dental services.

In an effort to measure and improve health care quality, the law calls for development of an initial core set of child health quality measures for children enrolled in SCHIP and Medicaid by Jan. 1, 2010. The measures would be designed to assess the effectiveness and availability of preventive services, prenatal care, and treatments for acute and chronic conditions.

Although SCHIP has enjoyed wide support in Congress, members of the House and Senate vigorously debated last month whether such a significant expansion of the program was appropriate. Some Republicans in the House objected to the legislation, saying that it would undermine the original intent of the SCHIP legislation by expanding the program to adults, illegal immigrants, and families with higher incomes. The legislation bars the coverage of illegal immigrants, but Republicans who spoke out against the legislation said that the lack of an adequate system to verify citizenship status would result in illegal immigrants gaining access to coverage.

But the law signed by the president has been widely praised by children's health advocates as necessary during the current economic downturn.

“Sharp increases in unemployment have likely added more children to the ranks of the uninsured and put increasing pressure on state health care programs,” Dr. Nancy Nielsen, president of the American Medical Association, said in a statement. “This new law will enable states to extend health care coverage to more children whose parents cannot afford it, but earn too much to qualify for Medicaid.”

The SCHIP law will be paid for in large part through a 62-cent-per-pack increase in the federal tax on cigarettes, with proportional increases for other tobacco products. The AMA praised the increase in the tobacco tax, saying the move will help fund health care for more children and act as a deterrent to young smokers and potential smokers.

Attempts to reauthorize the program during the last session of Congress were unsuccessful when Congress twice failed to override vetoes from President George W. Bush.

As part of an agreement with New York Attorney General Andrew Cuomo, UnitedHealth Group has agreed to shut down a national billing database used by health plans to determine reimbursements to members who use out-of-network physician services.

The billing database, which is operated by the UnitedHealth Group (UHG) subsidiary Ingenix Inc., will be replaced with a new, independent database run by a qualified nonprofit organization. Under the terms of the agreement, UHG will pay $50 million to help establish the new database. The nonprofit organization will develop a public Web site where consumers can research how much they may be reimbursed for common out-of-network medical services in their area.

Aetna, the nation's third largest insurer, also has entered into an agreement with the New York attorney general to abandon its use of the Ingenix database in favor of the new one. Aetna will contribute $20 million over 5 years for the creation of the new database.

In February 2009, Aetna reached an agreement with the New York Attorney General's office to pay $5.1 million to reimburse patients and physicians for claims involving out-of-network care. The agreement will affect underpayments made to students across the country.

The agreements follow an investigation by Mr. Cuomo's office into allegations that insurers were systematically underpaying consumers for out-of-network medical expenses by saying that physician charges were higher than the “usual, customary, and reasonable” rates as calculated by the Ingenix database. As a result, insurers would pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill.

The investigation found that insurers were underpaying consumers for out-of-network expenses by 10%-28% for medical services across the state. “For the past 10 years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry,” Mr. Cuomo said in a statement. “This agreement marks the end of that flawed system.”

“We are committed to increasing the amount of useful information available in the health care marketplace so that people can make informed decisions, and this agreement is consistent with that approach and philosophy,” Thomas L. Strickland, executive vice president and chief legal officer for UnitedHealth Group, said in a statement. “We are pleased that an independent not-for-profit entity will play this important role for the marketplace.”

Just days after reaching an agreement with Mr. Cuomo's office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA.

The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for out-of-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient.

But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won't be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, AMA president.

When UHG and other insurers refused to pay the physician's charge, they were telling patients that the charge was unreasonable, creating “a wedge between patients and physicians,” said Dr. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA's class action lawsuit.

Regardless of who calculates the usual rates, there is still a wide discrepancy between the in-network rates available to most patients and the out-of-network rates paid by some, said Robert Laszewski, president of Health Policy and Strategy Associates LLC, a Washington-based consulting firm. Increased transparency would benefit the insurance industry if it shows physicians charging out-of-network patients significantly more.

“I think the insurance industry has won,” Mr. Laszewski said.

“This agreement marks the end of that flawed system,” N.Y. Attorney General Andrew Cuomo said. Office of the N.Y. Attorney General

As part of an agreement with New York Attorney General Andrew Cuomo, UnitedHealth Group has agreed to shut down a national billing database used by health plans to determine reimbursements to members who use out-of-network physician services.

The billing database, which is operated by the UnitedHealth Group (UHG) subsidiary Ingenix Inc., will be replaced with a new, independent database run by a qualified nonprofit organization. Under the terms of the agreement, UHG will pay $50 million to help establish the new database. The nonprofit organization will develop a public Web site where consumers can research how much they may be reimbursed for common out-of-network medical services in their area.

Aetna, the nation's third largest insurer, also has entered into an agreement with the New York attorney general to abandon its use of the Ingenix database in favor of the new one. Aetna will contribute $20 million over 5 years for the creation of the new database.

In February 2009, Aetna reached an agreement with the New York Attorney General's office to pay $5.1 million to reimburse patients and physicians for claims involving out-of-network care. The agreement will affect underpayments made to students across the country.

The agreements follow an investigation by Mr. Cuomo's office into allegations that insurers were systematically underpaying consumers for out-of-network medical expenses by saying that physician charges were higher than the “usual, customary, and reasonable” rates as calculated by the Ingenix database. As a result, insurers would pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill.

The investigation found that insurers were underpaying consumers for out-of-network expenses by 10%-28% for medical services across the state. “For the past 10 years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry,” Mr. Cuomo said in a statement. “This agreement marks the end of that flawed system.”

“We are committed to increasing the amount of useful information available in the health care marketplace so that people can make informed decisions, and this agreement is consistent with that approach and philosophy,” Thomas L. Strickland, executive vice president and chief legal officer for UnitedHealth Group, said in a statement. “We are pleased that an independent not-for-profit entity will play this important role for the marketplace.”

Just days after reaching an agreement with Mr. Cuomo's office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA.

The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for out-of-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient.

But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won't be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, AMA president.

When UHG and other insurers refused to pay the physician's charge, they were telling patients that the charge was unreasonable, creating “a wedge between patients and physicians,” said Dr. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA's class action lawsuit.

Regardless of who calculates the usual rates, there is still a wide discrepancy between the in-network rates available to most patients and the out-of-network rates paid by some, said Robert Laszewski, president of Health Policy and Strategy Associates LLC, a Washington-based consulting firm. Increased transparency would benefit the insurance industry if it shows physicians charging out-of-network patients significantly more.

“I think the insurance industry has won,” Mr. Laszewski said.

“This agreement marks the end of that flawed system,” N.Y. Attorney General Andrew Cuomo said. Office of the N.Y. Attorney General

As part of an agreement with New York Attorney General Andrew Cuomo, UnitedHealth Group has agreed to shut down a national billing database used by health plans to determine reimbursements to members who use out-of-network physician services.

The billing database, which is operated by the UnitedHealth Group (UHG) subsidiary Ingenix Inc., will be replaced with a new, independent database run by a qualified nonprofit organization. Under the terms of the agreement, UHG will pay $50 million to help establish the new database. The nonprofit organization will develop a public Web site where consumers can research how much they may be reimbursed for common out-of-network medical services in their area.

Aetna, the nation's third largest insurer, also has entered into an agreement with the New York attorney general to abandon its use of the Ingenix database in favor of the new one. Aetna will contribute $20 million over 5 years for the creation of the new database.

In February 2009, Aetna reached an agreement with the New York Attorney General's office to pay $5.1 million to reimburse patients and physicians for claims involving out-of-network care. The agreement will affect underpayments made to students across the country.

The agreements follow an investigation by Mr. Cuomo's office into allegations that insurers were systematically underpaying consumers for out-of-network medical expenses by saying that physician charges were higher than the “usual, customary, and reasonable” rates as calculated by the Ingenix database. As a result, insurers would pay a percentage of the lower “usual, customary, and reasonable” rate, leaving consumers to pay their own portion plus the balance of the bill.

The investigation found that insurers were underpaying consumers for out-of-network expenses by 10%-28% for medical services across the state. “For the past 10 years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry,” Mr. Cuomo said in a statement. “This agreement marks the end of that flawed system.”

“We are committed to increasing the amount of useful information available in the health care marketplace so that people can make informed decisions, and this agreement is consistent with that approach and philosophy,” Thomas L. Strickland, executive vice president and chief legal officer for UnitedHealth Group, said in a statement. “We are pleased that an independent not-for-profit entity will play this important role for the marketplace.”

Just days after reaching an agreement with Mr. Cuomo's office, UHG also settled a lawsuit with the American Medical Association and two state medical associations over the use of the Ingenix database. The $350 million settlement is the largest monetary settlement of a class action lawsuit against a single health insurer in the United States, according to the AMA.

The suit, which has been pending since 2000, alleged that UHG had been understating the “usual, customary, and reasonable” charges in payments to physicians and in reimbursing patients for out-of-network expenses. Under the class action settlement, UHG subscribers who submitted a claim for out-of-network services and were not properly reimbursed are eligible to receive part of the settlement. Physicians also could be eligible to receive payment under the settlement if they were underpaid by UHG and did not receive the balance from the patient.

But the biggest gain for physicians under both the AMA settlement and the agreement with the New York attorney general won't be money, but the rebuilding of the trust lost between patients and physicians, said Dr. Nancy H. Nielsen, AMA president.

When UHG and other insurers refused to pay the physician's charge, they were telling patients that the charge was unreasonable, creating “a wedge between patients and physicians,” said Dr. Michael H. Rosenberg, president of the Medical Society of the State of New York, which was part of the AMA's class action lawsuit.

Regardless of who calculates the usual rates, there is still a wide discrepancy between the in-network rates available to most patients and the out-of-network rates paid by some, said Robert Laszewski, president of Health Policy and Strategy Associates LLC, a Washington-based consulting firm. Increased transparency would benefit the insurance industry if it shows physicians charging out-of-network patients significantly more.

“I think the insurance industry has won,” Mr. Laszewski said.

“This agreement marks the end of that flawed system,” N.Y. Attorney General Andrew Cuomo said. Office of the N.Y. Attorney General

About 38% of adults and nearly 12% of children in the United States used some type of complementary or alternative medicine therapy in 2007, according to survey data released by the Centers for Disease Control and Prevention and the National Institutes of Health.

Adults primarily reported using complementary and alternative medicine (CAM) to help manage chronic pain such as back, neck, or joint pain, as well as arthritis. Among children, the most common reason for using CAM was back or neck pain. However, children had a greater variety of conditions being treated with CAM than did adults, including head and chest colds, anxiety and stress, insomnia, attention-deficit/hyperactivity disorder, and musculoskeletal complaints.

“While both children and adults are using CAM at high rates, the types of therapies they use and the conditions for which they are using these therapies vary between children and adults,” Richard Nahin, Ph.D., acting director of the division of extramural research at the National Center for Complementary and Alternative Medicine, part of NIH, said at a press briefing.

The survey data come from the 2007 National Health Interview Survey and include information on the use of CAM from more than 23,000 adults and 9,400 children. Officials at CDC, which administers the survey, first collected data on CAM use in adults in 2002. This is the first time that information was collected about use by children.

The percentage of adults using CAM appears to be holding steady, said Dr. Nahin, who coauthored the report on the survey data. The rate was about 36% in 2002 and about 38% in 2007. Adults are much more likely than children to use CAM, probably because adults have more health care needs, he said.

Natural products, including herbal medicines and dietary supplements, were the most commonly used CAM therapies. For adults, some of the most common natural products were fish oil, glucosamine, echinacea, flaxseed oil or pills, and ginseng. Other popular CAM therapies used by adults were deep breathing exercises, chiropractic manipulation, massage, and yoga. For children, the most common natural product was echinacea, followed by fish oil, combination herb pills, and flaxseed oil or pills. Other common CAM therapies used by children included chiropractic manipulation, deep breathing exercises, yoga, and homeopathic treatment.

Natural products, including herbal medicines and dietary supplements, are the most commonly used CAM therapies. ©Bob Stockfield/National Center for Complementary and Alternative Medicine

About 38% of adults and nearly 12% of children in the United States used some type of complementary or alternative medicine therapy in 2007, according to survey data released by the Centers for Disease Control and Prevention and the National Institutes of Health.

Adults primarily reported using complementary and alternative medicine (CAM) to help manage chronic pain such as back, neck, or joint pain, as well as arthritis. Among children, the most common reason for using CAM was back or neck pain. However, children had a greater variety of conditions being treated with CAM than did adults, including head and chest colds, anxiety and stress, insomnia, attention-deficit/hyperactivity disorder, and musculoskeletal complaints.

“While both children and adults are using CAM at high rates, the types of therapies they use and the conditions for which they are using these therapies vary between children and adults,” Richard Nahin, Ph.D., acting director of the division of extramural research at the National Center for Complementary and Alternative Medicine, part of NIH, said at a press briefing.

The survey data come from the 2007 National Health Interview Survey and include information on the use of CAM from more than 23,000 adults and 9,400 children. Officials at CDC, which administers the survey, first collected data on CAM use in adults in 2002. This is the first time that information was collected about use by children.

The percentage of adults using CAM appears to be holding steady, said Dr. Nahin, who coauthored the report on the survey data. The rate was about 36% in 2002 and about 38% in 2007. Adults are much more likely than children to use CAM, probably because adults have more health care needs, he said.

Natural products, including herbal medicines and dietary supplements, were the most commonly used CAM therapies. For adults, some of the most common natural products were fish oil, glucosamine, echinacea, flaxseed oil or pills, and ginseng. Other popular CAM therapies used by adults were deep breathing exercises, chiropractic manipulation, massage, and yoga. For children, the most common natural product was echinacea, followed by fish oil, combination herb pills, and flaxseed oil or pills. Other common CAM therapies used by children included chiropractic manipulation, deep breathing exercises, yoga, and homeopathic treatment.

Natural products, including herbal medicines and dietary supplements, are the most commonly used CAM therapies. ©Bob Stockfield/National Center for Complementary and Alternative Medicine

About 38% of adults and nearly 12% of children in the United States used some type of complementary or alternative medicine therapy in 2007, according to survey data released by the Centers for Disease Control and Prevention and the National Institutes of Health.

Adults primarily reported using complementary and alternative medicine (CAM) to help manage chronic pain such as back, neck, or joint pain, as well as arthritis. Among children, the most common reason for using CAM was back or neck pain. However, children had a greater variety of conditions being treated with CAM than did adults, including head and chest colds, anxiety and stress, insomnia, attention-deficit/hyperactivity disorder, and musculoskeletal complaints.

“While both children and adults are using CAM at high rates, the types of therapies they use and the conditions for which they are using these therapies vary between children and adults,” Richard Nahin, Ph.D., acting director of the division of extramural research at the National Center for Complementary and Alternative Medicine, part of NIH, said at a press briefing.

The survey data come from the 2007 National Health Interview Survey and include information on the use of CAM from more than 23,000 adults and 9,400 children. Officials at CDC, which administers the survey, first collected data on CAM use in adults in 2002. This is the first time that information was collected about use by children.

The percentage of adults using CAM appears to be holding steady, said Dr. Nahin, who coauthored the report on the survey data. The rate was about 36% in 2002 and about 38% in 2007. Adults are much more likely than children to use CAM, probably because adults have more health care needs, he said.

Natural products, including herbal medicines and dietary supplements, were the most commonly used CAM therapies. For adults, some of the most common natural products were fish oil, glucosamine, echinacea, flaxseed oil or pills, and ginseng. Other popular CAM therapies used by adults were deep breathing exercises, chiropractic manipulation, massage, and yoga. For children, the most common natural product was echinacea, followed by fish oil, combination herb pills, and flaxseed oil or pills. Other common CAM therapies used by children included chiropractic manipulation, deep breathing exercises, yoga, and homeopathic treatment.

Natural products, including herbal medicines and dietary supplements, are the most commonly used CAM therapies. ©Bob Stockfield/National Center for Complementary and Alternative Medicine