Mary Ellen Schneider

Nearly all U.S. hospitals have a centralized system for reporting adverse events, but only about 20% are distributing and discussing the findings widely across their organization, according to national survey data.

The survey, conducted by the RAND Corporation and the Joint Commission from September 2005 to January 2006, also found that hospitals fell short in terms of how they collected adverse event reports. Only about a third (32%) of hospitals surveyed had established an environment that fostered reporting through confidentiality, and only 13% had broad staff involvement in reporting.

The survey included responses from 1,652 U.S. hospitals, about 63% of which were general medical-surgical hospitals. The survey and the analysis were funded by the Agency for Healthcare Research and Quality with the goal of establishing baseline data on internal adverse event reporting in U.S. hospitals (Qual. Saf. Health Care 2008;17:416–23). The researchers reported no conflicts of interest.

The investigators found strong agreement among hospitals about what elements should be included in adverse event reporting systems. For example, nearly all hospitals included information on patient demographics, personnel involved, follow-up treatment, and actions taken.

However, hospitals varied widely in terms of how information was used and who reported it. Only about 20% of hospitals surveyed reported that they distributed summary reports of adverse events broadly to nurses, physicians, and hospital administrators, and that the reports were discussed by the hospital board and medical executive committee. Hospitals with patient safety programs were more likely to discuss adverse events. In contrast, critical access hospitals, teaching hospitals, and hospitals with computer-only reporting systems were less likely to discuss adverse event findings within hospital board and medical executive committees.

It will take time for something as complex as adverse event reporting to become part of the culture, just as new medical therapies take 10–15 years to be adopted into routine clinical practice, said Dr. Peter Lindenauer, director of the Center for Quality and Safety Research at Baystate Medical Center in Springfield, Mass.; he was not involved in the analysis.

“Engaging physicians is difficult because they already feel stressed for time, and because they may not sense that there are direct benefits to them from reporting,” said Dr. Lindenauer, who also is an associate professor of medicine at Tufts University in Boston.

A recent report from the Department of Health and Human Services Office of Inspector General found similar trends. Hospital staff may fail to report adverse events because they don't believe action will be taken, they lack time to complete documentation, they assume another staff member will report the incident, or they fear punitive action, the report said.

The key to making an adverse event reporting system successful is similar to making any other major organization change, Dr. Lindenauer said. Hospitals must establish a rationale for change, ensure readiness, and communicate a clear vision as to why the event reporting system is an improvement over the status quo. Hospital leaders must also promote participation and develop a clear and consistent communication plan, he said.

“Safety reporting represents one of the best ways for organizations to discover opportunities to enhance the safety and quality of care,” he added.

Nearly all U.S. hospitals have a centralized system for reporting adverse events, but only about 20% are distributing and discussing the findings widely across their organization, according to national survey data.

The survey, conducted by the RAND Corporation and the Joint Commission from September 2005 to January 2006, also found that hospitals fell short in terms of how they collected adverse event reports. Only about a third (32%) of hospitals surveyed had established an environment that fostered reporting through confidentiality, and only 13% had broad staff involvement in reporting.

The survey included responses from 1,652 U.S. hospitals, about 63% of which were general medical-surgical hospitals. The survey and the analysis were funded by the Agency for Healthcare Research and Quality with the goal of establishing baseline data on internal adverse event reporting in U.S. hospitals (Qual. Saf. Health Care 2008;17:416–23). The researchers reported no conflicts of interest.

The investigators found strong agreement among hospitals about what elements should be included in adverse event reporting systems. For example, nearly all hospitals included information on patient demographics, personnel involved, follow-up treatment, and actions taken.

However, hospitals varied widely in terms of how information was used and who reported it. Only about 20% of hospitals surveyed reported that they distributed summary reports of adverse events broadly to nurses, physicians, and hospital administrators, and that the reports were discussed by the hospital board and medical executive committee. Hospitals with patient safety programs were more likely to discuss adverse events. In contrast, critical access hospitals, teaching hospitals, and hospitals with computer-only reporting systems were less likely to discuss adverse event findings within hospital board and medical executive committees.

It will take time for something as complex as adverse event reporting to become part of the culture, just as new medical therapies take 10–15 years to be adopted into routine clinical practice, said Dr. Peter Lindenauer, director of the Center for Quality and Safety Research at Baystate Medical Center in Springfield, Mass.; he was not involved in the analysis.

“Engaging physicians is difficult because they already feel stressed for time, and because they may not sense that there are direct benefits to them from reporting,” said Dr. Lindenauer, who also is an associate professor of medicine at Tufts University in Boston.

A recent report from the Department of Health and Human Services Office of Inspector General found similar trends. Hospital staff may fail to report adverse events because they don't believe action will be taken, they lack time to complete documentation, they assume another staff member will report the incident, or they fear punitive action, the report said.

The key to making an adverse event reporting system successful is similar to making any other major organization change, Dr. Lindenauer said. Hospitals must establish a rationale for change, ensure readiness, and communicate a clear vision as to why the event reporting system is an improvement over the status quo. Hospital leaders must also promote participation and develop a clear and consistent communication plan, he said.

“Safety reporting represents one of the best ways for organizations to discover opportunities to enhance the safety and quality of care,” he added.

Nearly all U.S. hospitals have a centralized system for reporting adverse events, but only about 20% are distributing and discussing the findings widely across their organization, according to national survey data.

The survey, conducted by the RAND Corporation and the Joint Commission from September 2005 to January 2006, also found that hospitals fell short in terms of how they collected adverse event reports. Only about a third (32%) of hospitals surveyed had established an environment that fostered reporting through confidentiality, and only 13% had broad staff involvement in reporting.

The survey included responses from 1,652 U.S. hospitals, about 63% of which were general medical-surgical hospitals. The survey and the analysis were funded by the Agency for Healthcare Research and Quality with the goal of establishing baseline data on internal adverse event reporting in U.S. hospitals (Qual. Saf. Health Care 2008;17:416–23). The researchers reported no conflicts of interest.

The investigators found strong agreement among hospitals about what elements should be included in adverse event reporting systems. For example, nearly all hospitals included information on patient demographics, personnel involved, follow-up treatment, and actions taken.

However, hospitals varied widely in terms of how information was used and who reported it. Only about 20% of hospitals surveyed reported that they distributed summary reports of adverse events broadly to nurses, physicians, and hospital administrators, and that the reports were discussed by the hospital board and medical executive committee. Hospitals with patient safety programs were more likely to discuss adverse events. In contrast, critical access hospitals, teaching hospitals, and hospitals with computer-only reporting systems were less likely to discuss adverse event findings within hospital board and medical executive committees.

It will take time for something as complex as adverse event reporting to become part of the culture, just as new medical therapies take 10–15 years to be adopted into routine clinical practice, said Dr. Peter Lindenauer, director of the Center for Quality and Safety Research at Baystate Medical Center in Springfield, Mass.; he was not involved in the analysis.

“Engaging physicians is difficult because they already feel stressed for time, and because they may not sense that there are direct benefits to them from reporting,” said Dr. Lindenauer, who also is an associate professor of medicine at Tufts University in Boston.

A recent report from the Department of Health and Human Services Office of Inspector General found similar trends. Hospital staff may fail to report adverse events because they don't believe action will be taken, they lack time to complete documentation, they assume another staff member will report the incident, or they fear punitive action, the report said.

The key to making an adverse event reporting system successful is similar to making any other major organization change, Dr. Lindenauer said. Hospitals must establish a rationale for change, ensure readiness, and communicate a clear vision as to why the event reporting system is an improvement over the status quo. Hospital leaders must also promote participation and develop a clear and consistent communication plan, he said.

“Safety reporting represents one of the best ways for organizations to discover opportunities to enhance the safety and quality of care,” he added.

Senior editor Joyce Frieden contributed to this report.

Many physician and hospital groups are feeling optimistic about the chances for comprehensive health reform, in response to early signals from the incoming Obama administration.

Laura Allendorf, Washington representative for the Society of Hospital Medicine (SHM), expressed similar sentiments. “Health reform was a top priority for [then-Sen.] Obama during the campaign, and many members of Congress also made health care a key message in their campaigns,” said Laura Allendorf, Washington representative for the Society of Hospital Medicine (SHM). “Consequently, lawmakers are expected to move quickly on a health care bill when the new Congress convenes.”

The economy is one reason that health reform may have a greater chance for success now than it did during the Clinton administration, said Dr. Nancy H. Nielsen, president of the American Medical Association. As more Americans lose their jobs, they are also losing their health insurance, she said, driving policy makers to address the issue of the uninsured. “There may be more tension for change now than there has been in the past,” she said.

Mr. Obama addressed that tension head-on during a press briefing last month to announce former Sen. Tom Daschle (D-S.D.) as his choice for Health and Human Services secretary.

In a move that many agree signals how serious Mr. Obama is about health reform, he tapped Sen. Daschle for not one, but two posts. In addition to serving as HHS secretary, Sen. Daschle is slated to serve as director for a new White House Office on Health Care Reform. Sen. Daschle's HHS position must be confirmed by the Senate; however, the health care czar position does not.

Hospital-related societies also have other legislative priorities for the 2009. For example, the SHM is planning to advocate for changes in Medicare and other payment systems to reward quality and promote better outcomes. “The federal government needs to get better value for the substantial dollars it spends on health care,” Ms. Allendorf said. “SHM will advocate for new reimbursement models that align incentives across providers to improve patient care. We will support [Medicare] demonstrations that test bundling of Part A and B payments for episodes of care, [and] urge Congress to ease legal barriers that hamper the ability of hospitals and physicians to share savings from improved efficiency and quality.”

The SHM also will advocate for improved care coordination, particularly as patients transition from the hospital to the home. The SHM is urging that components of its Project BOOST (Better Outcomes for Older Adults Through Safe Transitions)—a program that uses a team approach to assess patients and develop a plan for safe hospital discharge—be incorporated into congressional health reform plans as a way to improve care transitions and reduce readmission rates, Ms. Allendorf said. Increased funding for comparative effectiveness research is another priority for SHM, she added.

The Federation for American Hospitals has its own health care reform proposal, known as Health Coverage Passport. A health reform white paper written by Sen. Max Baucus (D-Mont.) includes many elements similar to those found in the federation's plan. “Once the new administration comes in, there is going to be a lot of movement” on health reform, said Jeff Cohen, executive vice president for advocacy and political affairs.

The FAH also would like Congress to pass a law barring physicians from referring patients to hospitals in which the physician has a financial interest. The House of Representatives has passed such a ban twice and the Senate has passed it once, but the proposal has yet to become law, Cohen said.

Other legislative priorities for the federation include ensuring that hospitals receive their usual “market basket” payment increase in the Medicare program—based on the price increases for a standard list of goods and services—and pushing for rural hospitals to get their fair share of the “disproportionate share hospital” money that is given to facilities who serve a large number of low-income and uninsured patients.

Meanwhile, the AMA is pushing Congress and the administration to enact permanent Medicare physician payment reform by eliminating the sustainable growth rate formula, which ties physician payments to the gross domestic product. Without congressional action on the payment formula within the next year, physicians will be faced with a projected 21% cut in Medicare payments starting in 2010, Dr. Nielsen said.

If Congress chooses to throw out the SGR formula, legislators likely will need to authorize some fast-track pilot projects to test some of the most promising models for new payment systems such as global and bundled payments, said Robert Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians.

Senior editor Joyce Frieden contributed to this report.

Many physician and hospital groups are feeling optimistic about the chances for comprehensive health reform, in response to early signals from the incoming Obama administration.

Laura Allendorf, Washington representative for the Society of Hospital Medicine (SHM), expressed similar sentiments. “Health reform was a top priority for [then-Sen.] Obama during the campaign, and many members of Congress also made health care a key message in their campaigns,” said Laura Allendorf, Washington representative for the Society of Hospital Medicine (SHM). “Consequently, lawmakers are expected to move quickly on a health care bill when the new Congress convenes.”

The economy is one reason that health reform may have a greater chance for success now than it did during the Clinton administration, said Dr. Nancy H. Nielsen, president of the American Medical Association. As more Americans lose their jobs, they are also losing their health insurance, she said, driving policy makers to address the issue of the uninsured. “There may be more tension for change now than there has been in the past,” she said.

Mr. Obama addressed that tension head-on during a press briefing last month to announce former Sen. Tom Daschle (D-S.D.) as his choice for Health and Human Services secretary.

In a move that many agree signals how serious Mr. Obama is about health reform, he tapped Sen. Daschle for not one, but two posts. In addition to serving as HHS secretary, Sen. Daschle is slated to serve as director for a new White House Office on Health Care Reform. Sen. Daschle's HHS position must be confirmed by the Senate; however, the health care czar position does not.

Hospital-related societies also have other legislative priorities for the 2009. For example, the SHM is planning to advocate for changes in Medicare and other payment systems to reward quality and promote better outcomes. “The federal government needs to get better value for the substantial dollars it spends on health care,” Ms. Allendorf said. “SHM will advocate for new reimbursement models that align incentives across providers to improve patient care. We will support [Medicare] demonstrations that test bundling of Part A and B payments for episodes of care, [and] urge Congress to ease legal barriers that hamper the ability of hospitals and physicians to share savings from improved efficiency and quality.”

The SHM also will advocate for improved care coordination, particularly as patients transition from the hospital to the home. The SHM is urging that components of its Project BOOST (Better Outcomes for Older Adults Through Safe Transitions)—a program that uses a team approach to assess patients and develop a plan for safe hospital discharge—be incorporated into congressional health reform plans as a way to improve care transitions and reduce readmission rates, Ms. Allendorf said. Increased funding for comparative effectiveness research is another priority for SHM, she added.

The Federation for American Hospitals has its own health care reform proposal, known as Health Coverage Passport. A health reform white paper written by Sen. Max Baucus (D-Mont.) includes many elements similar to those found in the federation's plan. “Once the new administration comes in, there is going to be a lot of movement” on health reform, said Jeff Cohen, executive vice president for advocacy and political affairs.

The FAH also would like Congress to pass a law barring physicians from referring patients to hospitals in which the physician has a financial interest. The House of Representatives has passed such a ban twice and the Senate has passed it once, but the proposal has yet to become law, Cohen said.

Other legislative priorities for the federation include ensuring that hospitals receive their usual “market basket” payment increase in the Medicare program—based on the price increases for a standard list of goods and services—and pushing for rural hospitals to get their fair share of the “disproportionate share hospital” money that is given to facilities who serve a large number of low-income and uninsured patients.

Meanwhile, the AMA is pushing Congress and the administration to enact permanent Medicare physician payment reform by eliminating the sustainable growth rate formula, which ties physician payments to the gross domestic product. Without congressional action on the payment formula within the next year, physicians will be faced with a projected 21% cut in Medicare payments starting in 2010, Dr. Nielsen said.

If Congress chooses to throw out the SGR formula, legislators likely will need to authorize some fast-track pilot projects to test some of the most promising models for new payment systems such as global and bundled payments, said Robert Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians.

Senior editor Joyce Frieden contributed to this report.

Many physician and hospital groups are feeling optimistic about the chances for comprehensive health reform, in response to early signals from the incoming Obama administration.

Laura Allendorf, Washington representative for the Society of Hospital Medicine (SHM), expressed similar sentiments. “Health reform was a top priority for [then-Sen.] Obama during the campaign, and many members of Congress also made health care a key message in their campaigns,” said Laura Allendorf, Washington representative for the Society of Hospital Medicine (SHM). “Consequently, lawmakers are expected to move quickly on a health care bill when the new Congress convenes.”

The economy is one reason that health reform may have a greater chance for success now than it did during the Clinton administration, said Dr. Nancy H. Nielsen, president of the American Medical Association. As more Americans lose their jobs, they are also losing their health insurance, she said, driving policy makers to address the issue of the uninsured. “There may be more tension for change now than there has been in the past,” she said.

Mr. Obama addressed that tension head-on during a press briefing last month to announce former Sen. Tom Daschle (D-S.D.) as his choice for Health and Human Services secretary.

In a move that many agree signals how serious Mr. Obama is about health reform, he tapped Sen. Daschle for not one, but two posts. In addition to serving as HHS secretary, Sen. Daschle is slated to serve as director for a new White House Office on Health Care Reform. Sen. Daschle's HHS position must be confirmed by the Senate; however, the health care czar position does not.

Hospital-related societies also have other legislative priorities for the 2009. For example, the SHM is planning to advocate for changes in Medicare and other payment systems to reward quality and promote better outcomes. “The federal government needs to get better value for the substantial dollars it spends on health care,” Ms. Allendorf said. “SHM will advocate for new reimbursement models that align incentives across providers to improve patient care. We will support [Medicare] demonstrations that test bundling of Part A and B payments for episodes of care, [and] urge Congress to ease legal barriers that hamper the ability of hospitals and physicians to share savings from improved efficiency and quality.”

The SHM also will advocate for improved care coordination, particularly as patients transition from the hospital to the home. The SHM is urging that components of its Project BOOST (Better Outcomes for Older Adults Through Safe Transitions)—a program that uses a team approach to assess patients and develop a plan for safe hospital discharge—be incorporated into congressional health reform plans as a way to improve care transitions and reduce readmission rates, Ms. Allendorf said. Increased funding for comparative effectiveness research is another priority for SHM, she added.

The Federation for American Hospitals has its own health care reform proposal, known as Health Coverage Passport. A health reform white paper written by Sen. Max Baucus (D-Mont.) includes many elements similar to those found in the federation's plan. “Once the new administration comes in, there is going to be a lot of movement” on health reform, said Jeff Cohen, executive vice president for advocacy and political affairs.

The FAH also would like Congress to pass a law barring physicians from referring patients to hospitals in which the physician has a financial interest. The House of Representatives has passed such a ban twice and the Senate has passed it once, but the proposal has yet to become law, Cohen said.

Other legislative priorities for the federation include ensuring that hospitals receive their usual “market basket” payment increase in the Medicare program—based on the price increases for a standard list of goods and services—and pushing for rural hospitals to get their fair share of the “disproportionate share hospital” money that is given to facilities who serve a large number of low-income and uninsured patients.

Meanwhile, the AMA is pushing Congress and the administration to enact permanent Medicare physician payment reform by eliminating the sustainable growth rate formula, which ties physician payments to the gross domestic product. Without congressional action on the payment formula within the next year, physicians will be faced with a projected 21% cut in Medicare payments starting in 2010, Dr. Nielsen said.

If Congress chooses to throw out the SGR formula, legislators likely will need to authorize some fast-track pilot projects to test some of the most promising models for new payment systems such as global and bundled payments, said Robert Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians.

Physicians could face increased requirements when renewing their state medical licenses under a draft model policy being evaluated by the Federation of State Medical Boards.

Under the draft policy, relicensure would become more comprehensive and require that physicians demonstrate continuing skills and knowledge in their area of practice. As proposed, the maintenance of licensure process would closely mirror the requirements that the American Board of Medical Specialties has established for maintenance of certification. The draft policy is a model that state medical boards could use, but individual states would determine whether or how the policy would be implemented.

Over the last 5 years, the Federation of State Medical Boards (FSMB) has been considering how state medical boards could change these policies to ensure that licensees are competent. Earlier this year, the organization's House of Delegates approved guiding principles for developing maintenance of licensure and called for additional research on the impact that the new requirements would have on state medical boards and licensed physicians.

Once that research is complete, the draft maintenance of licensure policy would likely be considered by the FSMB House of Delegates at their meeting next May, said Carol Clothier, vice president of strategic planning and physician competency initiatives for the FSMB.

“Nobody wants to create more work for physicians,” she said.

The idea is to try to take advantage of activities physicians already are doing to demonstrate their competence and use those to satisfy state licensure requirements, she said.

For their part, state medical boards are feeling pressure from the public to ensure that physicians are competent in light of rapidly changing science and technology. And the current requirements, which vary but generally include some continuing medical education, don't match up with public expectations of the oversight of physicians, she said.

If the maintenance of licensure policy is accepted by the FSMB House of Delegates, it still would be a model policy only, Ms. Clothier said. It would be up to individual states and territories to decide if they wanted to adopt, revise, or ignore the model policy. And that decision and its timing is likely to vary widely based on the politics involved in each state, she said.

The American Board of Medical Specialties, the not-for-profit organization that oversees certification of physicians in the United States, said in a statement that it is supportive of FSMB's direction on maintenance of licensure and is working on ways to collaborate.

Whatever states choose to do in terms of their relicensure policies, the process should be efficient for the physician, said Dr. Lynne Kirk, president emeritus of the American College of Physicians and professor of internal medicine at the University of Texas Southwestern, Dallas.

The ACP does not have an official policy on maintenance of licensure, but Dr. Kirk said that it makes sense that relicensure requirements should follow the same guiding principles as maintenance of certification. For example, the process should have significant value to both the physician and the patient, whether that means engaging in meaningful education or examining outcomes. The cost and time away from patient care also should be minimized, she said.

Ideally, a physician should be able to walk into the office each morning and document the care he or she provides in the patient's electronic medical record and have that documentation fulfill requirements for maintenance of certification, state licensure, payers, and others, she said. While both technology and the medical community have not quite reached that point yet, the goal should be for physicians to be able to focus on delivering high-quality care to patients without having to spend a significant amount of time satisfying reporting requirements for several sources.

If maintenance of certification could be used to also satisfy requirements for relicensure, that would go a long way toward being efficient for physicians, Dr. Kirk said. However, state medical boards will still have to address what type of process would be appropriate for physicians who hold lifetime certification and those who are licensed but not board certified, she said.

Physicians could face increased requirements when renewing their state medical licenses under a draft model policy being evaluated by the Federation of State Medical Boards.

Under the draft policy, relicensure would become more comprehensive and require that physicians demonstrate continuing skills and knowledge in their area of practice. As proposed, the maintenance of licensure process would closely mirror the requirements that the American Board of Medical Specialties has established for maintenance of certification. The draft policy is a model that state medical boards could use, but individual states would determine whether or how the policy would be implemented.

Over the last 5 years, the Federation of State Medical Boards (FSMB) has been considering how state medical boards could change these policies to ensure that licensees are competent. Earlier this year, the organization's House of Delegates approved guiding principles for developing maintenance of licensure and called for additional research on the impact that the new requirements would have on state medical boards and licensed physicians.

Once that research is complete, the draft maintenance of licensure policy would likely be considered by the FSMB House of Delegates at their meeting next May, said Carol Clothier, vice president of strategic planning and physician competency initiatives for the FSMB.

“Nobody wants to create more work for physicians,” she said.

The idea is to try to take advantage of activities physicians already are doing to demonstrate their competence and use those to satisfy state licensure requirements, she said.

For their part, state medical boards are feeling pressure from the public to ensure that physicians are competent in light of rapidly changing science and technology. And the current requirements, which vary but generally include some continuing medical education, don't match up with public expectations of the oversight of physicians, she said.

If the maintenance of licensure policy is accepted by the FSMB House of Delegates, it still would be a model policy only, Ms. Clothier said. It would be up to individual states and territories to decide if they wanted to adopt, revise, or ignore the model policy. And that decision and its timing is likely to vary widely based on the politics involved in each state, she said.

The American Board of Medical Specialties, the not-for-profit organization that oversees certification of physicians in the United States, said in a statement that it is supportive of FSMB's direction on maintenance of licensure and is working on ways to collaborate.

Whatever states choose to do in terms of their relicensure policies, the process should be efficient for the physician, said Dr. Lynne Kirk, president emeritus of the American College of Physicians and professor of internal medicine at the University of Texas Southwestern, Dallas.

The ACP does not have an official policy on maintenance of licensure, but Dr. Kirk said that it makes sense that relicensure requirements should follow the same guiding principles as maintenance of certification. For example, the process should have significant value to both the physician and the patient, whether that means engaging in meaningful education or examining outcomes. The cost and time away from patient care also should be minimized, she said.

Ideally, a physician should be able to walk into the office each morning and document the care he or she provides in the patient's electronic medical record and have that documentation fulfill requirements for maintenance of certification, state licensure, payers, and others, she said. While both technology and the medical community have not quite reached that point yet, the goal should be for physicians to be able to focus on delivering high-quality care to patients without having to spend a significant amount of time satisfying reporting requirements for several sources.

If maintenance of certification could be used to also satisfy requirements for relicensure, that would go a long way toward being efficient for physicians, Dr. Kirk said. However, state medical boards will still have to address what type of process would be appropriate for physicians who hold lifetime certification and those who are licensed but not board certified, she said.

Physicians could face increased requirements when renewing their state medical licenses under a draft model policy being evaluated by the Federation of State Medical Boards.

Under the draft policy, relicensure would become more comprehensive and require that physicians demonstrate continuing skills and knowledge in their area of practice. As proposed, the maintenance of licensure process would closely mirror the requirements that the American Board of Medical Specialties has established for maintenance of certification. The draft policy is a model that state medical boards could use, but individual states would determine whether or how the policy would be implemented.

Over the last 5 years, the Federation of State Medical Boards (FSMB) has been considering how state medical boards could change these policies to ensure that licensees are competent. Earlier this year, the organization's House of Delegates approved guiding principles for developing maintenance of licensure and called for additional research on the impact that the new requirements would have on state medical boards and licensed physicians.

Once that research is complete, the draft maintenance of licensure policy would likely be considered by the FSMB House of Delegates at their meeting next May, said Carol Clothier, vice president of strategic planning and physician competency initiatives for the FSMB.

“Nobody wants to create more work for physicians,” she said.

The idea is to try to take advantage of activities physicians already are doing to demonstrate their competence and use those to satisfy state licensure requirements, she said.

For their part, state medical boards are feeling pressure from the public to ensure that physicians are competent in light of rapidly changing science and technology. And the current requirements, which vary but generally include some continuing medical education, don't match up with public expectations of the oversight of physicians, she said.

If the maintenance of licensure policy is accepted by the FSMB House of Delegates, it still would be a model policy only, Ms. Clothier said. It would be up to individual states and territories to decide if they wanted to adopt, revise, or ignore the model policy. And that decision and its timing is likely to vary widely based on the politics involved in each state, she said.

The American Board of Medical Specialties, the not-for-profit organization that oversees certification of physicians in the United States, said in a statement that it is supportive of FSMB's direction on maintenance of licensure and is working on ways to collaborate.

Whatever states choose to do in terms of their relicensure policies, the process should be efficient for the physician, said Dr. Lynne Kirk, president emeritus of the American College of Physicians and professor of internal medicine at the University of Texas Southwestern, Dallas.

The ACP does not have an official policy on maintenance of licensure, but Dr. Kirk said that it makes sense that relicensure requirements should follow the same guiding principles as maintenance of certification. For example, the process should have significant value to both the physician and the patient, whether that means engaging in meaningful education or examining outcomes. The cost and time away from patient care also should be minimized, she said.

Ideally, a physician should be able to walk into the office each morning and document the care he or she provides in the patient's electronic medical record and have that documentation fulfill requirements for maintenance of certification, state licensure, payers, and others, she said. While both technology and the medical community have not quite reached that point yet, the goal should be for physicians to be able to focus on delivering high-quality care to patients without having to spend a significant amount of time satisfying reporting requirements for several sources.

If maintenance of certification could be used to also satisfy requirements for relicensure, that would go a long way toward being efficient for physicians, Dr. Kirk said. However, state medical boards will still have to address what type of process would be appropriate for physicians who hold lifetime certification and those who are licensed but not board certified, she said.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), representing about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide “listening tour” on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, insurance premiums had gone up and individual insurance enrollment had gone down. In addition, some health plans had left the individual insurance marketplace.

The AHIP proposal also aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventive services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program.

“No one should fall through the cracks of our health care system,” Karen Ignagni, AHIP president and CEO, said in a statement. “Universal coverage is within reach and can be achieved by building on the current system.”

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. “How can you require someone to do something they simply can't achieve?”

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage.

The AHIP proposal is a “helpful step,” but some work is still needed in determining what steps can be taken to guarantee coverage if a mandate for coverage is not politically feasible, he said.

Ed Howard, executive vice president and CEO for the Alliance for Health Reform, agreed that the cost of health care will be the top priority of policy makers as they consider health care reform. Without a cost containment plan, a mandate would be hard to enforce, he said.

But he said he is somewhat optimistic that substantial health reform can be enacted, even if it is implemented in stages. “Clearly, things are getting worse,” he said, referring to the growing number of uninsured and underinsured Americans.

Although there is not a crisis pushing health care on the agenda, the economic climate gives the issue some urgency, Mr. Howard said. Add to that a new administration and senior members of Congress with an interest in health reform, and there is a possibility for action, he said.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), representing about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide “listening tour” on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, insurance premiums had gone up and individual insurance enrollment had gone down. In addition, some health plans had left the individual insurance marketplace.

The AHIP proposal also aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventive services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program.

“No one should fall through the cracks of our health care system,” Karen Ignagni, AHIP president and CEO, said in a statement. “Universal coverage is within reach and can be achieved by building on the current system.”

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. “How can you require someone to do something they simply can't achieve?”

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage.

The AHIP proposal is a “helpful step,” but some work is still needed in determining what steps can be taken to guarantee coverage if a mandate for coverage is not politically feasible, he said.

Ed Howard, executive vice president and CEO for the Alliance for Health Reform, agreed that the cost of health care will be the top priority of policy makers as they consider health care reform. Without a cost containment plan, a mandate would be hard to enforce, he said.

But he said he is somewhat optimistic that substantial health reform can be enacted, even if it is implemented in stages. “Clearly, things are getting worse,” he said, referring to the growing number of uninsured and underinsured Americans.

Although there is not a crisis pushing health care on the agenda, the economic climate gives the issue some urgency, Mr. Howard said. Add to that a new administration and senior members of Congress with an interest in health reform, and there is a possibility for action, he said.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), representing about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide “listening tour” on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, insurance premiums had gone up and individual insurance enrollment had gone down. In addition, some health plans had left the individual insurance marketplace.

The AHIP proposal also aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventive services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program.

“No one should fall through the cracks of our health care system,” Karen Ignagni, AHIP president and CEO, said in a statement. “Universal coverage is within reach and can be achieved by building on the current system.”

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. “How can you require someone to do something they simply can't achieve?”

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage.

The AHIP proposal is a “helpful step,” but some work is still needed in determining what steps can be taken to guarantee coverage if a mandate for coverage is not politically feasible, he said.

Ed Howard, executive vice president and CEO for the Alliance for Health Reform, agreed that the cost of health care will be the top priority of policy makers as they consider health care reform. Without a cost containment plan, a mandate would be hard to enforce, he said.

But he said he is somewhat optimistic that substantial health reform can be enacted, even if it is implemented in stages. “Clearly, things are getting worse,” he said, referring to the growing number of uninsured and underinsured Americans.

Although there is not a crisis pushing health care on the agenda, the economic climate gives the issue some urgency, Mr. Howard said. Add to that a new administration and senior members of Congress with an interest in health reform, and there is a possibility for action, he said.

When President-elect Barack Obama takes office this month, observers expect that one of his early moves may be to stop action on a controversial federal abortion regulation.

The regulation, issued during the final weeks of the Bush administration, withholds federal payment and funding from providers who do not certify that they do not discriminate against physicians and midlevel providers who refuse to perform abortion or sterilization procedures.

The regulation has been stirring controversy among abortion rights advocates since it was first proposed in August 2008. They contend that the regulation is overly broad and as a result would decrease access to reproductive health services, including contraception. Meanwhile, supporters, such as the Christian Medical Association, say the Bush administration's approach is balanced and helps clear up misconceptions about the conscience protections already in place under existing law.

Democrats in Congress have already indicated their willingness to act to reverse the regulation. At the end of the last session of Congress, Sen. Patty Murray (D.-Wash.) and then-Sen. Hillary Clinton (D.-N.Y.), introduced a bill that would stop all action on the regulation.

Aside from addressing the conscience refusal issue, reproductive health advocates expect that the Obama administration's health care agenda may include changes to expand access to emergency contraception, increase funding for family planning, and take a more comprehensive approach to sex education.

"We certainly have a pent up agenda," said Susan Cohen, director of government affairs at the Guttmacher Institute, a nonprofit research and education organization focused on sexual and reproductive health.

One area in which Ms. Cohen and her colleagues hope to see some action early in the Obama administration is increasing funding for Title X, which provides federal funds for family planning and preventive screening services.

Sex education is another area ripe for a change in course under a Democratic president and Congress. During the Bush administration, the federal government invested millions in abstinence-only education. However, many reproductive rights advocates say policy makers should look at evidence favoring a comprehensive sex education approach, which includes teaching teens about contraception as well as abstinence. President-elect Obama should eliminate funding for abstinence-only sex education and shift those funds to comprehensive sex education, said Dr. Suzanne T. Poppema, chairwoman of the board of Physicians for Reproductive Choice and Health.

Reproductive rights advocates also are hopeful that the new president will eliminate the Mexico City policy or "global gag rule," which bars nongovernmental organizations that receive U.S. funds from performing abortions or providing referrals for abortion overseas.

Dr. Poppema also said that the Obama administration should take action to expand access to emergency contraception. The president-elect could significantly expand the number of women who could obtain emergency contraception by directing the Department of Defense to add the medication to its formulary and instructing the Justice Department to mandate that emergency contraception be made available to all victims of sexual assault.

When President-elect Barack Obama takes office this month, observers expect that one of his early moves may be to stop action on a controversial federal abortion regulation.

The regulation, issued during the final weeks of the Bush administration, withholds federal payment and funding from providers who do not certify that they do not discriminate against physicians and midlevel providers who refuse to perform abortion or sterilization procedures.

The regulation has been stirring controversy among abortion rights advocates since it was first proposed in August 2008. They contend that the regulation is overly broad and as a result would decrease access to reproductive health services, including contraception. Meanwhile, supporters, such as the Christian Medical Association, say the Bush administration's approach is balanced and helps clear up misconceptions about the conscience protections already in place under existing law.

Democrats in Congress have already indicated their willingness to act to reverse the regulation. At the end of the last session of Congress, Sen. Patty Murray (D.-Wash.) and then-Sen. Hillary Clinton (D.-N.Y.), introduced a bill that would stop all action on the regulation.

Aside from addressing the conscience refusal issue, reproductive health advocates expect that the Obama administration's health care agenda may include changes to expand access to emergency contraception, increase funding for family planning, and take a more comprehensive approach to sex education.

"We certainly have a pent up agenda," said Susan Cohen, director of government affairs at the Guttmacher Institute, a nonprofit research and education organization focused on sexual and reproductive health.

One area in which Ms. Cohen and her colleagues hope to see some action early in the Obama administration is increasing funding for Title X, which provides federal funds for family planning and preventive screening services.

Sex education is another area ripe for a change in course under a Democratic president and Congress. During the Bush administration, the federal government invested millions in abstinence-only education. However, many reproductive rights advocates say policy makers should look at evidence favoring a comprehensive sex education approach, which includes teaching teens about contraception as well as abstinence. President-elect Obama should eliminate funding for abstinence-only sex education and shift those funds to comprehensive sex education, said Dr. Suzanne T. Poppema, chairwoman of the board of Physicians for Reproductive Choice and Health.

Reproductive rights advocates also are hopeful that the new president will eliminate the Mexico City policy or "global gag rule," which bars nongovernmental organizations that receive U.S. funds from performing abortions or providing referrals for abortion overseas.

Dr. Poppema also said that the Obama administration should take action to expand access to emergency contraception. The president-elect could significantly expand the number of women who could obtain emergency contraception by directing the Department of Defense to add the medication to its formulary and instructing the Justice Department to mandate that emergency contraception be made available to all victims of sexual assault.

When President-elect Barack Obama takes office this month, observers expect that one of his early moves may be to stop action on a controversial federal abortion regulation.

The regulation, issued during the final weeks of the Bush administration, withholds federal payment and funding from providers who do not certify that they do not discriminate against physicians and midlevel providers who refuse to perform abortion or sterilization procedures.

The regulation has been stirring controversy among abortion rights advocates since it was first proposed in August 2008. They contend that the regulation is overly broad and as a result would decrease access to reproductive health services, including contraception. Meanwhile, supporters, such as the Christian Medical Association, say the Bush administration's approach is balanced and helps clear up misconceptions about the conscience protections already in place under existing law.

Democrats in Congress have already indicated their willingness to act to reverse the regulation. At the end of the last session of Congress, Sen. Patty Murray (D.-Wash.) and then-Sen. Hillary Clinton (D.-N.Y.), introduced a bill that would stop all action on the regulation.

Aside from addressing the conscience refusal issue, reproductive health advocates expect that the Obama administration's health care agenda may include changes to expand access to emergency contraception, increase funding for family planning, and take a more comprehensive approach to sex education.

"We certainly have a pent up agenda," said Susan Cohen, director of government affairs at the Guttmacher Institute, a nonprofit research and education organization focused on sexual and reproductive health.

One area in which Ms. Cohen and her colleagues hope to see some action early in the Obama administration is increasing funding for Title X, which provides federal funds for family planning and preventive screening services.

Sex education is another area ripe for a change in course under a Democratic president and Congress. During the Bush administration, the federal government invested millions in abstinence-only education. However, many reproductive rights advocates say policy makers should look at evidence favoring a comprehensive sex education approach, which includes teaching teens about contraception as well as abstinence. President-elect Obama should eliminate funding for abstinence-only sex education and shift those funds to comprehensive sex education, said Dr. Suzanne T. Poppema, chairwoman of the board of Physicians for Reproductive Choice and Health.

Reproductive rights advocates also are hopeful that the new president will eliminate the Mexico City policy or "global gag rule," which bars nongovernmental organizations that receive U.S. funds from performing abortions or providing referrals for abortion overseas.

Dr. Poppema also said that the Obama administration should take action to expand access to emergency contraception. The president-elect could significantly expand the number of women who could obtain emergency contraception by directing the Department of Defense to add the medication to its formulary and instructing the Justice Department to mandate that emergency contraception be made available to all victims of sexual assault.

The price tag for medical assistance under Medicaid is expected to reach nearly $674 billion over the next decade, with the federal government picking up more than $383 billion of the cost, according to projections from the Centers for Medicare and Medicaid Services.

Under this estimate, which was part of the first annual actuarial report on the financial outlook of Medicaid, the program's expenditures for medical assistance are projected to grow on average 7.9% per year for the next 10 years, outpacing the 4.8% growth in the U.S. gross domestic product.

"This report should serve as an urgent reminder that the current path of Medicaid spending is unsustainable for both federal and state governments," Mike Leavitt, secretary of the Health and Human Services department, said in a statement. "If nothing is done to rein in these costs, access to health care for the nation's most vulnerable citizens could be threatened."

Medicaid spending for fiscal 2007 was about $333 billion, with the federal government paying 57% of the cost and the states picking up 43%. The average per-person spending for medical services was $6,120 in fiscal year 2007, with more spent on older and disabled enrollees and less on children. The average per-person spending was $2,435 for nondisabled children and $3,586 for nondisabled adults, compared with $14,058 for older adults and $14,858 for disabled beneficiaries.

Average Medicaid enrollment also is expected to increase over the next decade, according to the report, from 49.1 million in FY 2007 to 55.1 million by FY 2017.

The projections are no surprise given the rising cost of health care overall, said Judith Solomon, senior fellow at the Center on Budget and Policy Priorities, a research organization that analyzes state and federal budget issues.

For states, which pay a significant share of Medicaid costs, the 10-year projections are likely be mainly academic, she said, as they struggle to balance this year's budgets in a worsening economy.

The report offers an analysis of past trends in Medicaid and a 10-year projection of expenditures and enrollment, according to CMS.

The data and assumptions of the report are based largely on three sources: data submitted to CMS from the states; the boards of trustees of the Social Security and Medicare programs; and National Health Expenditure historical data and projections. The analysis is based on current law and does not make predictions of possible policy or legislative changes.

The full report is available online at http://cms.hhs.gov/ActuarialStudies/03_MedicaidReport.asp

The price tag for medical assistance under Medicaid is expected to reach nearly $674 billion over the next decade, with the federal government picking up more than $383 billion of the cost, according to projections from the Centers for Medicare and Medicaid Services.

Under this estimate, which was part of the first annual actuarial report on the financial outlook of Medicaid, the program's expenditures for medical assistance are projected to grow on average 7.9% per year for the next 10 years, outpacing the 4.8% growth in the U.S. gross domestic product.

"This report should serve as an urgent reminder that the current path of Medicaid spending is unsustainable for both federal and state governments," Mike Leavitt, secretary of the Health and Human Services department, said in a statement. "If nothing is done to rein in these costs, access to health care for the nation's most vulnerable citizens could be threatened."

Medicaid spending for fiscal 2007 was about $333 billion, with the federal government paying 57% of the cost and the states picking up 43%. The average per-person spending for medical services was $6,120 in fiscal year 2007, with more spent on older and disabled enrollees and less on children. The average per-person spending was $2,435 for nondisabled children and $3,586 for nondisabled adults, compared with $14,058 for older adults and $14,858 for disabled beneficiaries.

Average Medicaid enrollment also is expected to increase over the next decade, according to the report, from 49.1 million in FY 2007 to 55.1 million by FY 2017.

The projections are no surprise given the rising cost of health care overall, said Judith Solomon, senior fellow at the Center on Budget and Policy Priorities, a research organization that analyzes state and federal budget issues.

For states, which pay a significant share of Medicaid costs, the 10-year projections are likely be mainly academic, she said, as they struggle to balance this year's budgets in a worsening economy.

The report offers an analysis of past trends in Medicaid and a 10-year projection of expenditures and enrollment, according to CMS.

The data and assumptions of the report are based largely on three sources: data submitted to CMS from the states; the boards of trustees of the Social Security and Medicare programs; and National Health Expenditure historical data and projections. The analysis is based on current law and does not make predictions of possible policy or legislative changes.

The full report is available online at http://cms.hhs.gov/ActuarialStudies/03_MedicaidReport.asp

The price tag for medical assistance under Medicaid is expected to reach nearly $674 billion over the next decade, with the federal government picking up more than $383 billion of the cost, according to projections from the Centers for Medicare and Medicaid Services.

Under this estimate, which was part of the first annual actuarial report on the financial outlook of Medicaid, the program's expenditures for medical assistance are projected to grow on average 7.9% per year for the next 10 years, outpacing the 4.8% growth in the U.S. gross domestic product.

"This report should serve as an urgent reminder that the current path of Medicaid spending is unsustainable for both federal and state governments," Mike Leavitt, secretary of the Health and Human Services department, said in a statement. "If nothing is done to rein in these costs, access to health care for the nation's most vulnerable citizens could be threatened."

Medicaid spending for fiscal 2007 was about $333 billion, with the federal government paying 57% of the cost and the states picking up 43%. The average per-person spending for medical services was $6,120 in fiscal year 2007, with more spent on older and disabled enrollees and less on children. The average per-person spending was $2,435 for nondisabled children and $3,586 for nondisabled adults, compared with $14,058 for older adults and $14,858 for disabled beneficiaries.

Average Medicaid enrollment also is expected to increase over the next decade, according to the report, from 49.1 million in FY 2007 to 55.1 million by FY 2017.

The projections are no surprise given the rising cost of health care overall, said Judith Solomon, senior fellow at the Center on Budget and Policy Priorities, a research organization that analyzes state and federal budget issues.

For states, which pay a significant share of Medicaid costs, the 10-year projections are likely be mainly academic, she said, as they struggle to balance this year's budgets in a worsening economy.

The report offers an analysis of past trends in Medicaid and a 10-year projection of expenditures and enrollment, according to CMS.

The data and assumptions of the report are based largely on three sources: data submitted to CMS from the states; the boards of trustees of the Social Security and Medicare programs; and National Health Expenditure historical data and projections. The analysis is based on current law and does not make predictions of possible policy or legislative changes.

The full report is available online at http://cms.hhs.gov/ActuarialStudies/03_MedicaidReport.asp

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), which represents about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide "listening tour" on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, there had been a rise in insurance premiums and a reduction in individual insurance enrollment. In addition, some health plans had left the individual insurance marketplace.

Another aspect of the AHIP proposal aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventative services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program.

"No one should fall through the cracks of our health care system," Karen Ignagni, AHIP president and CEO, said in a statement. "Universal coverage is within reach and can be achieved by building on the current system."

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. "It's the ball game," he said. "How can you require someone to do something they simply can't achieve?"

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage on their own.

Ed Howard, executive vice president and CEO for the Alliance for Health Reform, agreed that the cost of health care will be the top priority of policy makers as they consider health care reform. Without a cost containment plan, a mandate would be hard to enforce.

But he said he is somewhat optimistic that substantial health reform can be enacted, even if it is implemented in stages. "Clearly, things are getting worse," he said, referring to the growing number of uninsured and underinsured Americans.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), which represents about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide "listening tour" on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, there had been a rise in insurance premiums and a reduction in individual insurance enrollment. In addition, some health plans had left the individual insurance marketplace.

Another aspect of the AHIP proposal aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventative services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program.

"No one should fall through the cracks of our health care system," Karen Ignagni, AHIP president and CEO, said in a statement. "Universal coverage is within reach and can be achieved by building on the current system."

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. "It's the ball game," he said. "How can you require someone to do something they simply can't achieve?"

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage on their own.

Ed Howard, executive vice president and CEO for the Alliance for Health Reform, agreed that the cost of health care will be the top priority of policy makers as they consider health care reform. Without a cost containment plan, a mandate would be hard to enforce.

But he said he is somewhat optimistic that substantial health reform can be enacted, even if it is implemented in stages. "Clearly, things are getting worse," he said, referring to the growing number of uninsured and underinsured Americans.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), which represents about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide "listening tour" on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, there had been a rise in insurance premiums and a reduction in individual insurance enrollment. In addition, some health plans had left the individual insurance marketplace.

Another aspect of the AHIP proposal aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventative services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program.

"No one should fall through the cracks of our health care system," Karen Ignagni, AHIP president and CEO, said in a statement. "Universal coverage is within reach and can be achieved by building on the current system."

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. "It's the ball game," he said. "How can you require someone to do something they simply can't achieve?"

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage on their own.

Ed Howard, executive vice president and CEO for the Alliance for Health Reform, agreed that the cost of health care will be the top priority of policy makers as they consider health care reform. Without a cost containment plan, a mandate would be hard to enforce.

But he said he is somewhat optimistic that substantial health reform can be enacted, even if it is implemented in stages. "Clearly, things are getting worse," he said, referring to the growing number of uninsured and underinsured Americans.

A disagreement within the house of medicine over billing for dermatopathology services has spread to state legislatures around the country.

The quarrel centers on client versus direct billing. The American Academy of Dermatology supports the continuation of client billing—which allows dermatologists to send tissue samples to the best-qualified pathologist, even if that lab does not have an agreement with the patient's insurance plan, then bill the insurance company directly. The insurance company pays based on its contract with the physician. The dermatologist may mark up the charge enough to cover the cost of billing and the risk of nonpayment or underpayment by the insurance company.

"The primary motivation should be for the patient's benefit, not profit," said Dr. Dirk Elston, director of the department of dermatology at Geisinger Medical Center in Danville, Pa., and a member of the Pennsylvania Academy of Dermatology ad hoc work group on client billing.

The College of American Pathologists, on the other hand, has argued that the markup can be abusive and can lead to arrangements with labs that are not in the patients' best interest.

To date, 14 states have established laws requiring direct billing, 6 states have antimarkup laws, and 14 states require disclosure of billing arrangements, according to the College of American Pathologists.

The AAD and state dermatology societies acknowledge the potential for abuse in client billing but there is also the potential to benefit patients through fewer payment hassles and access to the best pathology experts, Dr. Elston said.

But state legislatures need to be aware of both sides of the issue and the potential benefits to patients, he said. "You don't throw the baby out with the bathwater," Dr. Elston said.

That's almost what happened in states like Nebraska and Arkansas.

In 2007, despite a lack of abuses with the client billing system, pathologists in Arkansas sought legislation to mandate direct billing, said Dr. Scott Dinehart, a Mohs surgeon in Little Rock.

But the dermatologists, along with a coalition of other physicians, came together to help defeat the bill. One reason for the support of thousands of physicians was that, in an early draft of the bill, pathologists sought direct billing not only for anatomic pathology, but also for clinical pathology. While the language was changed early on, Dr. Dinehart said other physicians were wary that pathologists were trying to create an environment where they would be the only ones able to read slides.

The Arkansas coalition ultimately prevailed in part because the pathologists didn't have the "high ground" on the issue, said Dr. Dinehart, who was active in opposing the measure. "This is really just an economic issue for them," he said. "It's really not a patient problem."

In Nebraska, pathologists wanted to mandate direct billing for anatomic pathology. Dermatologists were concerned that this would significantly limit patient access to dermatopathologists, since many patients participate in local insurance networks that won't cover out-of-state pathology labs and there are few dermatopathologists in the state, said Dr. David Watts, a dermatologist in Omaha and immediate past president of the Nebraska Dermatology Society.

During the 2007–2008 legislative session, the dermatologists tried to work out a compromise, Dr. Watts said, but when the pathologists withdrew their support for the proposal, the legislation failed.

The Nebraska Medical Association, which represents both dermatologists and pathologists, is now crafting a legislative proposal, similar to one passed in North Carolina, that would allow for client billing but would mandate transparency of the billing process to patients, he said.

The Nebraska Dermatology Society will support legislation requiring transparent billing. "We really don't want to have a public debate that looks like a couple of groups of physicians arguing about money," Dr. Watts said. "We'd rather be in public arguing about how best to help people."

A disagreement within the house of medicine over billing for dermatopathology services has spread to state legislatures around the country.

The quarrel centers on client versus direct billing. The American Academy of Dermatology supports the continuation of client billing—which allows dermatologists to send tissue samples to the best-qualified pathologist, even if that lab does not have an agreement with the patient's insurance plan, then bill the insurance company directly. The insurance company pays based on its contract with the physician. The dermatologist may mark up the charge enough to cover the cost of billing and the risk of nonpayment or underpayment by the insurance company.

"The primary motivation should be for the patient's benefit, not profit," said Dr. Dirk Elston, director of the department of dermatology at Geisinger Medical Center in Danville, Pa., and a member of the Pennsylvania Academy of Dermatology ad hoc work group on client billing.

The College of American Pathologists, on the other hand, has argued that the markup can be abusive and can lead to arrangements with labs that are not in the patients' best interest.

To date, 14 states have established laws requiring direct billing, 6 states have antimarkup laws, and 14 states require disclosure of billing arrangements, according to the College of American Pathologists.

The AAD and state dermatology societies acknowledge the potential for abuse in client billing but there is also the potential to benefit patients through fewer payment hassles and access to the best pathology experts, Dr. Elston said.

But state legislatures need to be aware of both sides of the issue and the potential benefits to patients, he said. "You don't throw the baby out with the bathwater," Dr. Elston said.

That's almost what happened in states like Nebraska and Arkansas.

In 2007, despite a lack of abuses with the client billing system, pathologists in Arkansas sought legislation to mandate direct billing, said Dr. Scott Dinehart, a Mohs surgeon in Little Rock.

But the dermatologists, along with a coalition of other physicians, came together to help defeat the bill. One reason for the support of thousands of physicians was that, in an early draft of the bill, pathologists sought direct billing not only for anatomic pathology, but also for clinical pathology. While the language was changed early on, Dr. Dinehart said other physicians were wary that pathologists were trying to create an environment where they would be the only ones able to read slides.

The Arkansas coalition ultimately prevailed in part because the pathologists didn't have the "high ground" on the issue, said Dr. Dinehart, who was active in opposing the measure. "This is really just an economic issue for them," he said. "It's really not a patient problem."

In Nebraska, pathologists wanted to mandate direct billing for anatomic pathology. Dermatologists were concerned that this would significantly limit patient access to dermatopathologists, since many patients participate in local insurance networks that won't cover out-of-state pathology labs and there are few dermatopathologists in the state, said Dr. David Watts, a dermatologist in Omaha and immediate past president of the Nebraska Dermatology Society.

During the 2007–2008 legislative session, the dermatologists tried to work out a compromise, Dr. Watts said, but when the pathologists withdrew their support for the proposal, the legislation failed.

The Nebraska Medical Association, which represents both dermatologists and pathologists, is now crafting a legislative proposal, similar to one passed in North Carolina, that would allow for client billing but would mandate transparency of the billing process to patients, he said.

The Nebraska Dermatology Society will support legislation requiring transparent billing. "We really don't want to have a public debate that looks like a couple of groups of physicians arguing about money," Dr. Watts said. "We'd rather be in public arguing about how best to help people."

A disagreement within the house of medicine over billing for dermatopathology services has spread to state legislatures around the country.

The quarrel centers on client versus direct billing. The American Academy of Dermatology supports the continuation of client billing—which allows dermatologists to send tissue samples to the best-qualified pathologist, even if that lab does not have an agreement with the patient's insurance plan, then bill the insurance company directly. The insurance company pays based on its contract with the physician. The dermatologist may mark up the charge enough to cover the cost of billing and the risk of nonpayment or underpayment by the insurance company.

"The primary motivation should be for the patient's benefit, not profit," said Dr. Dirk Elston, director of the department of dermatology at Geisinger Medical Center in Danville, Pa., and a member of the Pennsylvania Academy of Dermatology ad hoc work group on client billing.

The College of American Pathologists, on the other hand, has argued that the markup can be abusive and can lead to arrangements with labs that are not in the patients' best interest.

To date, 14 states have established laws requiring direct billing, 6 states have antimarkup laws, and 14 states require disclosure of billing arrangements, according to the College of American Pathologists.

The AAD and state dermatology societies acknowledge the potential for abuse in client billing but there is also the potential to benefit patients through fewer payment hassles and access to the best pathology experts, Dr. Elston said.

But state legislatures need to be aware of both sides of the issue and the potential benefits to patients, he said. "You don't throw the baby out with the bathwater," Dr. Elston said.

That's almost what happened in states like Nebraska and Arkansas.

In 2007, despite a lack of abuses with the client billing system, pathologists in Arkansas sought legislation to mandate direct billing, said Dr. Scott Dinehart, a Mohs surgeon in Little Rock.

But the dermatologists, along with a coalition of other physicians, came together to help defeat the bill. One reason for the support of thousands of physicians was that, in an early draft of the bill, pathologists sought direct billing not only for anatomic pathology, but also for clinical pathology. While the language was changed early on, Dr. Dinehart said other physicians were wary that pathologists were trying to create an environment where they would be the only ones able to read slides.

The Arkansas coalition ultimately prevailed in part because the pathologists didn't have the "high ground" on the issue, said Dr. Dinehart, who was active in opposing the measure. "This is really just an economic issue for them," he said. "It's really not a patient problem."

In Nebraska, pathologists wanted to mandate direct billing for anatomic pathology. Dermatologists were concerned that this would significantly limit patient access to dermatopathologists, since many patients participate in local insurance networks that won't cover out-of-state pathology labs and there are few dermatopathologists in the state, said Dr. David Watts, a dermatologist in Omaha and immediate past president of the Nebraska Dermatology Society.

During the 2007–2008 legislative session, the dermatologists tried to work out a compromise, Dr. Watts said, but when the pathologists withdrew their support for the proposal, the legislation failed.

The Nebraska Medical Association, which represents both dermatologists and pathologists, is now crafting a legislative proposal, similar to one passed in North Carolina, that would allow for client billing but would mandate transparency of the billing process to patients, he said.

The Nebraska Dermatology Society will support legislation requiring transparent billing. "We really don't want to have a public debate that looks like a couple of groups of physicians arguing about money," Dr. Watts said. "We'd rather be in public arguing about how best to help people."

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), which represents about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide “listening tour” on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, there had been a rise in insurance premiums and a reduction in individual insurance enrollment. In addition, some health plans had left the individual insurance marketplace.

Another aspect of the AHIP proposal aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventative services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program. “No one should fall through the cracks of our health care system,” said AHIP President Karen Ignagni in a statement. “Universal coverage is within reach and can be achieved by building on the current system.”

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. “It's the ball game,” he said. “How can you require someone to do something they simply can't achieve?”

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage on their own.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), which represents about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide “listening tour” on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, there had been a rise in insurance premiums and a reduction in individual insurance enrollment. In addition, some health plans had left the individual insurance marketplace.

Another aspect of the AHIP proposal aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventative services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program. “No one should fall through the cracks of our health care system,” said AHIP President Karen Ignagni in a statement. “Universal coverage is within reach and can be achieved by building on the current system.”

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. “It's the ball game,” he said. “How can you require someone to do something they simply can't achieve?”

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage on their own.

As a new administration prepares to tackle health care reform, the health insurance industry is offering a few suggestions.

America's Health Insurance Plans (AHIP), which represents about 1,300 companies covering more than 200 million Americans, says its members would be willing to guarantee coverage for individuals with preexisting medical conditions in exchange for a government mandate that all individuals purchase health insurance.

AHIP's board of directors issued the proposal after conducting a nationwide “listening tour” on health care during which many Americans raised concerns about the lack of coverage for preexisting conditions in the individual insurance market.

But to make guaranteed coverage a reality, the federal government will need to require that individuals purchase coverage and use mechanisms such as an insurance coverage verification system, an automatic enrollment process, and some type of enforcement, the group said.

When coverage is guaranteed and there is no mandate to have insurance, individuals tend not to purchase insurance until they get sick, which drives up costs, said Robert Zirkelbach, a spokesman for AHIP. For example, a study conducted on behalf of AHIP by Milliman Inc. found that in many states that implemented guarantee issue or community rating policies in the 1990s, there had been a rise in insurance premiums and a reduction in individual insurance enrollment. In addition, some health plans had left the individual insurance marketplace.

Another aspect of the AHIP proposal aims to increase the affordability of health insurance plans on the individual market. The group suggests lowering costs for consumers through refundable tax credits. In addition, it proposes tackling the overall cost of medical services by expanding the use of preventative services, conducting comparative effectiveness trials for medications and devices, and reforming the medical liability system.

The AHIP proposal also supports expanding eligibility for Medicaid and the Children's Health Insurance Program. “No one should fall through the cracks of our health care system,” said AHIP President Karen Ignagni in a statement. “Universal coverage is within reach and can be achieved by building on the current system.”

Affordability will be critical to the success of any proposal, said Ron Pollack, executive director and vice president of Families USA, a nonprofit, nonpartisan organization focused on health care affordability. “It's the ball game,” he said. “How can you require someone to do something they simply can't achieve?”

Families USA supports the idea of a mandate for health insurance coverage, Mr. Pollack said, but only if it includes adequate subsidies and help for those who can't afford to purchase coverage on their own.

Democrats Try to Block Regs

Senate Democrats are setting up roadblocks to try to keep the Bush administration from finalizing a regulation that would tighten protections for health care providers who object to providing abortion services. Sen. Hillary Clinton (D-N.Y.) and Sen. Patty Murray (D-Wash.) recently introduced legislation (S. 20) that would block any attempt by the administration to finalize, enforce, or implement the regulation. The proposed regulation, which was issued in August, would require recipients of Health and Human Services department funding to provide written certification that they would not discriminate against health care providers for refusing to perform or participate in abortion or sterilization procedures. This regulation has been the source of controversy since July when a draft of the document first began circulating publicly. Critics of the proposal, including the American College of Obstetricians and Gynecologists, said the regulation could limit access to accurate and complete information and reproductive health services and jeopardize the doctor-patient relationship.

Poor Care Behind Most Paid Claims

Most perinatal malpractice claims that are paid are the result of substandard care that results in injury, according to a study published in the December issue of Obstetrics & Gynecology. Researchers reviewed 189 perinatal care claims paid by a large professional liability insurer between 2000 and 2005 and found that about 70% of all the closed obstetric claims involved substandard care. These cases accounted for 79% of the costs associated with all 189 claims. These findings point out that “the main key to addressing litigation costs involves improvement in practice patterns and adherence to current standards of care.” However, obstetricians may be able to take steps to minimize their malpractice risk, the researchers found. For example, in more than half of shoulder dystocia cases, payment was mainly due to poor documentation. Also, 80% of vaginal birth after cesarean cases could have been avoided if the procedure had been limited to only women with spontaneous labors progressing without augmentation and without repetitive moderate to severe variable decelerations, the researchers wrote.

Screen More for Substance Abuse

Ob.gyns. should screen for substance abuse in as many patients as possible, followed by brief intervention and referral if necessary, according to a new ACOG policy statement. While there are many barriers to universal screening—from lack of training to lack of time—physicians should make a significant effort to learn established techniques for rapid screening and intervention, treat patients with respect, and protect confidentiality whenever possible. In cases where the law requires disclosure, physicians should inform patients in advance about what will be disclosed. The new statement updates a 2004 opinion from the ACOG Committee on Ethics. “Because more women than men are hidden drinkers, and many see the obstetrician or gynecologist as their principle source of care, the opportunity to screen and intervene, with benefits to women, their children, and society, are too great to be missed,” the committee wrote. The opinion was published in the December issue of Obstetrics & Gynecology.

Unspecified Chest Pain in Women

Women are diagnosed and hospitalized for unspecified chest pain more often than men, according to the Agency for Healthcare Research and Quality. In 2006, 379,000 men were admitted for unspecified chest pain, while 477,000 women got the same diagnosis. But men are admitted much more frequently for coronary artery disease—747,000 in 2006, compared with 451,000 women. Men also account for 60% of admissions for heart attacks. Admissions for heart failure and irregular heart beat are similar for both genders. The data come from the 2006 Nationwide Inpatient Sample.

Off-Label Study Needed

Fourteen widely prescribed medications urgently require additional study to determine their off-label safety and efficacy, researchers report in the journal Pharmacotherapy. Antidepressants and antipsychotics were the top drug classes on the list, which specifically targeted drugs that have high levels of off-label use without good scientific backing, according to the researchers led by Dr. Randall Stafford of the Stanford (Calif.) University Prevention Research Center. Heading the list is quetiapine; warfarin, escitalopram, risperidone, and montelukast round out the top five. The most common off-label use for 6 of the listed 14 drugs was bipolar disorder. “This list of priority drugs might be a start for confronting the problem of off-label use with limited evidence,” Dr. Stafford said in a statement.

Special Medicare Advantage Plans

Medicare officials have identified 15 chronic conditions that would make individuals eligible for enrollment in a Chronic Care Medicare Advantage Special Needs Plan. The conditions are certain neurologic disorders, stroke, chronic alcohol and other drug dependence, certain autoimmune disorders, cancer excluding precancer conditions, certain cardiovascular disorders, chronic heart failure, dementia, diabetes mellitus, end-stage liver disease, end-stage renal disease requiring dialysis, certain severe hematologic disorders, HIV/AIDS, certain chronic lung disorders, and certain chronic and disabling mental health conditions. Medicare officials said they are trying to ensure that the plans stay focused on a specific population and do not expand their services to the larger Medicare Advantage population.

Democrats Try to Block Regs

Senate Democrats are setting up roadblocks to try to keep the Bush administration from finalizing a regulation that would tighten protections for health care providers who object to providing abortion services. Sen. Hillary Clinton (D-N.Y.) and Sen. Patty Murray (D-Wash.) recently introduced legislation (S. 20) that would block any attempt by the administration to finalize, enforce, or implement the regulation. The proposed regulation, which was issued in August, would require recipients of Health and Human Services department funding to provide written certification that they would not discriminate against health care providers for refusing to perform or participate in abortion or sterilization procedures. This regulation has been the source of controversy since July when a draft of the document first began circulating publicly. Critics of the proposal, including the American College of Obstetricians and Gynecologists, said the regulation could limit access to accurate and complete information and reproductive health services and jeopardize the doctor-patient relationship.

Poor Care Behind Most Paid Claims

Most perinatal malpractice claims that are paid are the result of substandard care that results in injury, according to a study published in the December issue of Obstetrics & Gynecology. Researchers reviewed 189 perinatal care claims paid by a large professional liability insurer between 2000 and 2005 and found that about 70% of all the closed obstetric claims involved substandard care. These cases accounted for 79% of the costs associated with all 189 claims. These findings point out that “the main key to addressing litigation costs involves improvement in practice patterns and adherence to current standards of care.” However, obstetricians may be able to take steps to minimize their malpractice risk, the researchers found. For example, in more than half of shoulder dystocia cases, payment was mainly due to poor documentation. Also, 80% of vaginal birth after cesarean cases could have been avoided if the procedure had been limited to only women with spontaneous labors progressing without augmentation and without repetitive moderate to severe variable decelerations, the researchers wrote.

Screen More for Substance Abuse

Ob.gyns. should screen for substance abuse in as many patients as possible, followed by brief intervention and referral if necessary, according to a new ACOG policy statement. While there are many barriers to universal screening—from lack of training to lack of time—physicians should make a significant effort to learn established techniques for rapid screening and intervention, treat patients with respect, and protect confidentiality whenever possible. In cases where the law requires disclosure, physicians should inform patients in advance about what will be disclosed. The new statement updates a 2004 opinion from the ACOG Committee on Ethics. “Because more women than men are hidden drinkers, and many see the obstetrician or gynecologist as their principle source of care, the opportunity to screen and intervene, with benefits to women, their children, and society, are too great to be missed,” the committee wrote. The opinion was published in the December issue of Obstetrics & Gynecology.

Unspecified Chest Pain in Women

Women are diagnosed and hospitalized for unspecified chest pain more often than men, according to the Agency for Healthcare Research and Quality. In 2006, 379,000 men were admitted for unspecified chest pain, while 477,000 women got the same diagnosis. But men are admitted much more frequently for coronary artery disease—747,000 in 2006, compared with 451,000 women. Men also account for 60% of admissions for heart attacks. Admissions for heart failure and irregular heart beat are similar for both genders. The data come from the 2006 Nationwide Inpatient Sample.

Off-Label Study Needed

Fourteen widely prescribed medications urgently require additional study to determine their off-label safety and efficacy, researchers report in the journal Pharmacotherapy. Antidepressants and antipsychotics were the top drug classes on the list, which specifically targeted drugs that have high levels of off-label use without good scientific backing, according to the researchers led by Dr. Randall Stafford of the Stanford (Calif.) University Prevention Research Center. Heading the list is quetiapine; warfarin, escitalopram, risperidone, and montelukast round out the top five. The most common off-label use for 6 of the listed 14 drugs was bipolar disorder. “This list of priority drugs might be a start for confronting the problem of off-label use with limited evidence,” Dr. Stafford said in a statement.

Special Medicare Advantage Plans

Medicare officials have identified 15 chronic conditions that would make individuals eligible for enrollment in a Chronic Care Medicare Advantage Special Needs Plan. The conditions are certain neurologic disorders, stroke, chronic alcohol and other drug dependence, certain autoimmune disorders, cancer excluding precancer conditions, certain cardiovascular disorders, chronic heart failure, dementia, diabetes mellitus, end-stage liver disease, end-stage renal disease requiring dialysis, certain severe hematologic disorders, HIV/AIDS, certain chronic lung disorders, and certain chronic and disabling mental health conditions. Medicare officials said they are trying to ensure that the plans stay focused on a specific population and do not expand their services to the larger Medicare Advantage population.

Democrats Try to Block Regs

Senate Democrats are setting up roadblocks to try to keep the Bush administration from finalizing a regulation that would tighten protections for health care providers who object to providing abortion services. Sen. Hillary Clinton (D-N.Y.) and Sen. Patty Murray (D-Wash.) recently introduced legislation (S. 20) that would block any attempt by the administration to finalize, enforce, or implement the regulation. The proposed regulation, which was issued in August, would require recipients of Health and Human Services department funding to provide written certification that they would not discriminate against health care providers for refusing to perform or participate in abortion or sterilization procedures. This regulation has been the source of controversy since July when a draft of the document first began circulating publicly. Critics of the proposal, including the American College of Obstetricians and Gynecologists, said the regulation could limit access to accurate and complete information and reproductive health services and jeopardize the doctor-patient relationship.

Poor Care Behind Most Paid Claims

Most perinatal malpractice claims that are paid are the result of substandard care that results in injury, according to a study published in the December issue of Obstetrics & Gynecology. Researchers reviewed 189 perinatal care claims paid by a large professional liability insurer between 2000 and 2005 and found that about 70% of all the closed obstetric claims involved substandard care. These cases accounted for 79% of the costs associated with all 189 claims. These findings point out that “the main key to addressing litigation costs involves improvement in practice patterns and adherence to current standards of care.” However, obstetricians may be able to take steps to minimize their malpractice risk, the researchers found. For example, in more than half of shoulder dystocia cases, payment was mainly due to poor documentation. Also, 80% of vaginal birth after cesarean cases could have been avoided if the procedure had been limited to only women with spontaneous labors progressing without augmentation and without repetitive moderate to severe variable decelerations, the researchers wrote.

Screen More for Substance Abuse

Ob.gyns. should screen for substance abuse in as many patients as possible, followed by brief intervention and referral if necessary, according to a new ACOG policy statement. While there are many barriers to universal screening—from lack of training to lack of time—physicians should make a significant effort to learn established techniques for rapid screening and intervention, treat patients with respect, and protect confidentiality whenever possible. In cases where the law requires disclosure, physicians should inform patients in advance about what will be disclosed. The new statement updates a 2004 opinion from the ACOG Committee on Ethics. “Because more women than men are hidden drinkers, and many see the obstetrician or gynecologist as their principle source of care, the opportunity to screen and intervene, with benefits to women, their children, and society, are too great to be missed,” the committee wrote. The opinion was published in the December issue of Obstetrics & Gynecology.

Unspecified Chest Pain in Women

Women are diagnosed and hospitalized for unspecified chest pain more often than men, according to the Agency for Healthcare Research and Quality. In 2006, 379,000 men were admitted for unspecified chest pain, while 477,000 women got the same diagnosis. But men are admitted much more frequently for coronary artery disease—747,000 in 2006, compared with 451,000 women. Men also account for 60% of admissions for heart attacks. Admissions for heart failure and irregular heart beat are similar for both genders. The data come from the 2006 Nationwide Inpatient Sample.

Off-Label Study Needed

Fourteen widely prescribed medications urgently require additional study to determine their off-label safety and efficacy, researchers report in the journal Pharmacotherapy. Antidepressants and antipsychotics were the top drug classes on the list, which specifically targeted drugs that have high levels of off-label use without good scientific backing, according to the researchers led by Dr. Randall Stafford of the Stanford (Calif.) University Prevention Research Center. Heading the list is quetiapine; warfarin, escitalopram, risperidone, and montelukast round out the top five. The most common off-label use for 6 of the listed 14 drugs was bipolar disorder. “This list of priority drugs might be a start for confronting the problem of off-label use with limited evidence,” Dr. Stafford said in a statement.

Special Medicare Advantage Plans

Medicare officials have identified 15 chronic conditions that would make individuals eligible for enrollment in a Chronic Care Medicare Advantage Special Needs Plan. The conditions are certain neurologic disorders, stroke, chronic alcohol and other drug dependence, certain autoimmune disorders, cancer excluding precancer conditions, certain cardiovascular disorders, chronic heart failure, dementia, diabetes mellitus, end-stage liver disease, end-stage renal disease requiring dialysis, certain severe hematologic disorders, HIV/AIDS, certain chronic lung disorders, and certain chronic and disabling mental health conditions. Medicare officials said they are trying to ensure that the plans stay focused on a specific population and do not expand their services to the larger Medicare Advantage population.