Mary Ellen Schneider

Physicians, even those holding permanent board certificates, could face increased requirements when renewing their state medical licenses under a draft model policy currently being evaluated by the Federation of State Medical Boards.

Under the draft policy, relicensure would become more comprehensive and would 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 in place for maintenance of certification. The draft policy is a model that state medical boards could use, but individual states would determine whether or how it would be implemented.

Over the last 5 years, the Federation of State Medical Boards (FSMB) has been considering how individual state 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 processes, and called for additional research on the effect 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's 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 that physicians already are doing to demonstrate their competence, and to 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's 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 are likely to vary widely, based on the politics involved in each state, she said.

“I think it's just inevitable that this will probably happen,” said Dr. Larry R. Faulkner, executive vice president and CEO of the American Board of Psychiatry and Neurology (ABPN).

The current state licensing requirements, which mainly involve completing a certain number of hours of continuing medical education, are unlikely to stand up to public scrutiny, said Dr. Faulkner, and that will likely drive this process. But when and how fast these changes occur is unknown. Much could depend on whether there is a case of negligence on the part of a physician that draws significant media attention and drives states to beef up requirements for relicensure. The important thing is to keep any possible maintenance-of-licensure process from being onerous. The states should develop something that promotes quality, but doesn't impose an undue burden on physicians in terms of time and money, Dr. Faulkner said.

The best way to ensure that any maintenance-of-licensure process does not impose new burdens on physicians is to align it with the existing maintenance-of-certification requirements, said Dr. Ralph F. Jozefowicz, a neurology director for ABPN and a professor of neurology and medicine at the University of Rochester (N.Y.) However, each state would still have to create a general maintenance-of-licensure process for physicians who are not board certified.

Neurologists with lifetime board certification could choose to either follow this more general relicensure route or participate in ABPN's maintenance-of-certification process. Dr. Jozefowicz, who holds a lifetime certificate, said he has taken the recertification exam and gone through the other maintenance-of-certification modules and found the experience to be “very educational and rather pleasant.”

Pursuing maintenance of certification may also be an attractive option for lifetime certificate holders in neurology because they can be tested in their area of expertise, not through a general exam that could include clinical questions on subjects they haven't studied in many years, like obstetrics and gynecology, Dr. Faulkner said.

Dr. Myles Abbott, a pediatrician in Berkeley and Orinda, Calif., who holds a time-limited certificate from the American Board of Pediatrics, said he is skeptical that the states will act quickly enough to affect many permanent certificate holders who may be considering retirement in the next several years. And because this process will play out in state legislatures for the most part, it's possible that some states could end up issuing “grandfather” exceptions for those physicians who hold permanent certificates from their boards.

However, that doesn't mean that permanent certificate holders who want to continue in practice won't need to at least consider maintenance of certification, Dr. Abbott said. It's likely that before the states tackle licensure changes, hospitals, universities, and payers may require physicians to be able to verify that they are up to date on their knowledge and skills, he said.

Physicians, even those holding permanent board certificates, could face increased requirements when renewing their state medical licenses under a draft model policy currently being evaluated by the Federation of State Medical Boards.

Under the draft policy, relicensure would become more comprehensive and would 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 in place for maintenance of certification. The draft policy is a model that state medical boards could use, but individual states would determine whether or how it would be implemented.

Over the last 5 years, the Federation of State Medical Boards (FSMB) has been considering how individual state 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 processes, and called for additional research on the effect 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's 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 that physicians already are doing to demonstrate their competence, and to 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's 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 are likely to vary widely, based on the politics involved in each state, she said.

“I think it's just inevitable that this will probably happen,” said Dr. Larry R. Faulkner, executive vice president and CEO of the American Board of Psychiatry and Neurology (ABPN).

The current state licensing requirements, which mainly involve completing a certain number of hours of continuing medical education, are unlikely to stand up to public scrutiny, said Dr. Faulkner, and that will likely drive this process. But when and how fast these changes occur is unknown. Much could depend on whether there is a case of negligence on the part of a physician that draws significant media attention and drives states to beef up requirements for relicensure. The important thing is to keep any possible maintenance-of-licensure process from being onerous. The states should develop something that promotes quality, but doesn't impose an undue burden on physicians in terms of time and money, Dr. Faulkner said.

The best way to ensure that any maintenance-of-licensure process does not impose new burdens on physicians is to align it with the existing maintenance-of-certification requirements, said Dr. Ralph F. Jozefowicz, a neurology director for ABPN and a professor of neurology and medicine at the University of Rochester (N.Y.) However, each state would still have to create a general maintenance-of-licensure process for physicians who are not board certified.

Neurologists with lifetime board certification could choose to either follow this more general relicensure route or participate in ABPN's maintenance-of-certification process. Dr. Jozefowicz, who holds a lifetime certificate, said he has taken the recertification exam and gone through the other maintenance-of-certification modules and found the experience to be “very educational and rather pleasant.”

Pursuing maintenance of certification may also be an attractive option for lifetime certificate holders in neurology because they can be tested in their area of expertise, not through a general exam that could include clinical questions on subjects they haven't studied in many years, like obstetrics and gynecology, Dr. Faulkner said.

Dr. Myles Abbott, a pediatrician in Berkeley and Orinda, Calif., who holds a time-limited certificate from the American Board of Pediatrics, said he is skeptical that the states will act quickly enough to affect many permanent certificate holders who may be considering retirement in the next several years. And because this process will play out in state legislatures for the most part, it's possible that some states could end up issuing “grandfather” exceptions for those physicians who hold permanent certificates from their boards.

However, that doesn't mean that permanent certificate holders who want to continue in practice won't need to at least consider maintenance of certification, Dr. Abbott said. It's likely that before the states tackle licensure changes, hospitals, universities, and payers may require physicians to be able to verify that they are up to date on their knowledge and skills, he said.

Physicians, even those holding permanent board certificates, could face increased requirements when renewing their state medical licenses under a draft model policy currently being evaluated by the Federation of State Medical Boards.

Under the draft policy, relicensure would become more comprehensive and would 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 in place for maintenance of certification. The draft policy is a model that state medical boards could use, but individual states would determine whether or how it would be implemented.

Over the last 5 years, the Federation of State Medical Boards (FSMB) has been considering how individual state 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 processes, and called for additional research on the effect 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's 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 that physicians already are doing to demonstrate their competence, and to 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's 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 are likely to vary widely, based on the politics involved in each state, she said.

“I think it's just inevitable that this will probably happen,” said Dr. Larry R. Faulkner, executive vice president and CEO of the American Board of Psychiatry and Neurology (ABPN).

The current state licensing requirements, which mainly involve completing a certain number of hours of continuing medical education, are unlikely to stand up to public scrutiny, said Dr. Faulkner, and that will likely drive this process. But when and how fast these changes occur is unknown. Much could depend on whether there is a case of negligence on the part of a physician that draws significant media attention and drives states to beef up requirements for relicensure. The important thing is to keep any possible maintenance-of-licensure process from being onerous. The states should develop something that promotes quality, but doesn't impose an undue burden on physicians in terms of time and money, Dr. Faulkner said.

The best way to ensure that any maintenance-of-licensure process does not impose new burdens on physicians is to align it with the existing maintenance-of-certification requirements, said Dr. Ralph F. Jozefowicz, a neurology director for ABPN and a professor of neurology and medicine at the University of Rochester (N.Y.) However, each state would still have to create a general maintenance-of-licensure process for physicians who are not board certified.

Neurologists with lifetime board certification could choose to either follow this more general relicensure route or participate in ABPN's maintenance-of-certification process. Dr. Jozefowicz, who holds a lifetime certificate, said he has taken the recertification exam and gone through the other maintenance-of-certification modules and found the experience to be “very educational and rather pleasant.”

Pursuing maintenance of certification may also be an attractive option for lifetime certificate holders in neurology because they can be tested in their area of expertise, not through a general exam that could include clinical questions on subjects they haven't studied in many years, like obstetrics and gynecology, Dr. Faulkner said.

Dr. Myles Abbott, a pediatrician in Berkeley and Orinda, Calif., who holds a time-limited certificate from the American Board of Pediatrics, said he is skeptical that the states will act quickly enough to affect many permanent certificate holders who may be considering retirement in the next several years. And because this process will play out in state legislatures for the most part, it's possible that some states could end up issuing “grandfather” exceptions for those physicians who hold permanent certificates from their boards.

However, that doesn't mean that permanent certificate holders who want to continue in practice won't need to at least consider maintenance of certification, Dr. Abbott said. It's likely that before the states tackle licensure changes, hospitals, universities, and payers may require physicians to be able to verify that they are up to date on their knowledge and skills, he said.

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, issued in October, offers an analysis of past trends in Medicaid and a 10-year projection of expenditures and enrollment. Future reports are expected to have longer-range projections and more extensive analysis, 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, issued in October, offers an analysis of past trends in Medicaid and a 10-year projection of expenditures and enrollment. Future reports are expected to have longer-range projections and more extensive analysis, 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, issued in October, offers an analysis of past trends in Medicaid and a 10-year projection of expenditures and enrollment. Future reports are expected to have longer-range projections and more extensive analysis, 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.

House Passes Arthritis Bill

Landmark arthritis legislation that would establish a National Arthritis Action Program passed the House of Representatives just before it recessed for the general election. The Arthritis Prevention, Control, and Cure Act (H.R. 1283) would promote research into the control, prevention, and surveillance of arthritis and other rheum-atic diseases. The legislation also would aim to increase the supply of pediatric rheumatologists in the United States by increasing the number and size of institutional training grants. Another part of the bill would create a loan repayment program in pediatric rheumatology. “The bill invests in the critical needs of those suffering from arthritis and in research that will help future generations of Americans who are diagnosed with the disease,” Rep. Anna G. Eshoo (D-Calif.), sponsor of the legislation, said in a statement. A companion bill (S. 626) is pending before the Senate Committee on Health, Education, Labor, and Pensions.

Florida Files Vioxx Suit

Florida Attorney General Bill McCollum has sued Merck & Co. on behalf of state agencies he said were damaged by “the company's allegedly deceptive marketing and promotion” of Vioxx. The lawsuit follows a 3-year investigation of Merck's practices in the promotion of Vioxx (rofecoxib) and alleges that, because of the company's marketing practices, numerous Florida agencies approved the inclusion of Vioxx as a covered or approved drug. Vioxx purchases by the Florida Medicaid program exceeded $80 million between 1999 and 2004, according to McCollum, who argued that if the facts about Vioxx had been known earlier, physicians and their Medicaid patients would have chosen other, less expensive prescriptions. Eight other states have filed similar lawsuits, according to Merck spokesman Ronald Rogers, who said in an interview that Merck acted responsibly on Vioxx and will defend against the suits.

Industry Groups Protest IVIg Cuts

The Biotechnology Industry Organization, the American Society of Clinical Oncology, the Association of Community Cancer Centers, and the Alliance for Plasma Therapies are urging the Centers for Medicare and Medicaid Services to preserve the preadministration fee currently paid for administering intravenous immune globulin (IVIg) therapy in hospital outpatient settings. The CMS proposed to eliminate the payment as part of its hospital outpatient prospective payment system rule for next year, which was published in July. The preadministration payment began in 2006 at a time when IVIg supplies were tight, driving up the price. CMS officials say it's not clear that supply is still an issue, but manufacturers and patient organizations say there are still difficulties. “BIO does not believe that there is stability in the [IVIg] marketplace when over 40% of the providers cannot purchase [IVIg] at or below the Medicare payment rate,” said the group in its comments. The CMS also said that it wants to cut the add-on fee because IVIg use has gone up markedly. BIO argued that increased use shows that the preadministration payment has helped providers acquire and administer the drug.

GAO: FDA Needed Broader Pool

Food and Drug Administration officials might have avoided some conflicts of interest on their scientific advisory committees by expanding recruitment efforts beyond word-of-mouth nominations, according to a report from the Government Accountability Office. The report, released last month, analyzed the recruitment and screening of FDA advisory committee members before the agency changed those processes in 2007. The FDA could have reached out beyond its usual source of experts to retired professionals, university professors, and experts in epidemiology and statistics, the GAO concluded. The evaluation was requested by members of the Senate.

Nationwide RAC Launched

The CMS has launched its national recovery audit contractor program as part of its “aggressive new steps to find and prevent waste, fraud and abuse in Medicare.” The new RACs, which will be paid on a contingency fee basis, soon will begin to contact providers, the CMS said. The 3-year RAC demonstration program in California, Florida, New York, Massachusetts, South Carolina, and Arizona collected more than $900 million in overpayments, according to the agency. But the program has drawn strong criticism from physician groups, who have maintained that RAC audits were overly burdensome. In addition to implementing the RACs, the CMS said it will begin to work directly with beneficiaries to make certain that they receive the durable medical equipment or home health services for which Medicare has been billed, and that the items or services were medically necessary.

House Passes Arthritis Bill

Landmark arthritis legislation that would establish a National Arthritis Action Program passed the House of Representatives just before it recessed for the general election. The Arthritis Prevention, Control, and Cure Act (H.R. 1283) would promote research into the control, prevention, and surveillance of arthritis and other rheum-atic diseases. The legislation also would aim to increase the supply of pediatric rheumatologists in the United States by increasing the number and size of institutional training grants. Another part of the bill would create a loan repayment program in pediatric rheumatology. “The bill invests in the critical needs of those suffering from arthritis and in research that will help future generations of Americans who are diagnosed with the disease,” Rep. Anna G. Eshoo (D-Calif.), sponsor of the legislation, said in a statement. A companion bill (S. 626) is pending before the Senate Committee on Health, Education, Labor, and Pensions.

Florida Files Vioxx Suit

Florida Attorney General Bill McCollum has sued Merck & Co. on behalf of state agencies he said were damaged by “the company's allegedly deceptive marketing and promotion” of Vioxx. The lawsuit follows a 3-year investigation of Merck's practices in the promotion of Vioxx (rofecoxib) and alleges that, because of the company's marketing practices, numerous Florida agencies approved the inclusion of Vioxx as a covered or approved drug. Vioxx purchases by the Florida Medicaid program exceeded $80 million between 1999 and 2004, according to McCollum, who argued that if the facts about Vioxx had been known earlier, physicians and their Medicaid patients would have chosen other, less expensive prescriptions. Eight other states have filed similar lawsuits, according to Merck spokesman Ronald Rogers, who said in an interview that Merck acted responsibly on Vioxx and will defend against the suits.

Industry Groups Protest IVIg Cuts

The Biotechnology Industry Organization, the American Society of Clinical Oncology, the Association of Community Cancer Centers, and the Alliance for Plasma Therapies are urging the Centers for Medicare and Medicaid Services to preserve the preadministration fee currently paid for administering intravenous immune globulin (IVIg) therapy in hospital outpatient settings. The CMS proposed to eliminate the payment as part of its hospital outpatient prospective payment system rule for next year, which was published in July. The preadministration payment began in 2006 at a time when IVIg supplies were tight, driving up the price. CMS officials say it's not clear that supply is still an issue, but manufacturers and patient organizations say there are still difficulties. “BIO does not believe that there is stability in the [IVIg] marketplace when over 40% of the providers cannot purchase [IVIg] at or below the Medicare payment rate,” said the group in its comments. The CMS also said that it wants to cut the add-on fee because IVIg use has gone up markedly. BIO argued that increased use shows that the preadministration payment has helped providers acquire and administer the drug.

GAO: FDA Needed Broader Pool

Food and Drug Administration officials might have avoided some conflicts of interest on their scientific advisory committees by expanding recruitment efforts beyond word-of-mouth nominations, according to a report from the Government Accountability Office. The report, released last month, analyzed the recruitment and screening of FDA advisory committee members before the agency changed those processes in 2007. The FDA could have reached out beyond its usual source of experts to retired professionals, university professors, and experts in epidemiology and statistics, the GAO concluded. The evaluation was requested by members of the Senate.

Nationwide RAC Launched

The CMS has launched its national recovery audit contractor program as part of its “aggressive new steps to find and prevent waste, fraud and abuse in Medicare.” The new RACs, which will be paid on a contingency fee basis, soon will begin to contact providers, the CMS said. The 3-year RAC demonstration program in California, Florida, New York, Massachusetts, South Carolina, and Arizona collected more than $900 million in overpayments, according to the agency. But the program has drawn strong criticism from physician groups, who have maintained that RAC audits were overly burdensome. In addition to implementing the RACs, the CMS said it will begin to work directly with beneficiaries to make certain that they receive the durable medical equipment or home health services for which Medicare has been billed, and that the items or services were medically necessary.

House Passes Arthritis Bill

Landmark arthritis legislation that would establish a National Arthritis Action Program passed the House of Representatives just before it recessed for the general election. The Arthritis Prevention, Control, and Cure Act (H.R. 1283) would promote research into the control, prevention, and surveillance of arthritis and other rheum-atic diseases. The legislation also would aim to increase the supply of pediatric rheumatologists in the United States by increasing the number and size of institutional training grants. Another part of the bill would create a loan repayment program in pediatric rheumatology. “The bill invests in the critical needs of those suffering from arthritis and in research that will help future generations of Americans who are diagnosed with the disease,” Rep. Anna G. Eshoo (D-Calif.), sponsor of the legislation, said in a statement. A companion bill (S. 626) is pending before the Senate Committee on Health, Education, Labor, and Pensions.

Florida Files Vioxx Suit

Florida Attorney General Bill McCollum has sued Merck & Co. on behalf of state agencies he said were damaged by “the company's allegedly deceptive marketing and promotion” of Vioxx. The lawsuit follows a 3-year investigation of Merck's practices in the promotion of Vioxx (rofecoxib) and alleges that, because of the company's marketing practices, numerous Florida agencies approved the inclusion of Vioxx as a covered or approved drug. Vioxx purchases by the Florida Medicaid program exceeded $80 million between 1999 and 2004, according to McCollum, who argued that if the facts about Vioxx had been known earlier, physicians and their Medicaid patients would have chosen other, less expensive prescriptions. Eight other states have filed similar lawsuits, according to Merck spokesman Ronald Rogers, who said in an interview that Merck acted responsibly on Vioxx and will defend against the suits.

Industry Groups Protest IVIg Cuts

The Biotechnology Industry Organization, the American Society of Clinical Oncology, the Association of Community Cancer Centers, and the Alliance for Plasma Therapies are urging the Centers for Medicare and Medicaid Services to preserve the preadministration fee currently paid for administering intravenous immune globulin (IVIg) therapy in hospital outpatient settings. The CMS proposed to eliminate the payment as part of its hospital outpatient prospective payment system rule for next year, which was published in July. The preadministration payment began in 2006 at a time when IVIg supplies were tight, driving up the price. CMS officials say it's not clear that supply is still an issue, but manufacturers and patient organizations say there are still difficulties. “BIO does not believe that there is stability in the [IVIg] marketplace when over 40% of the providers cannot purchase [IVIg] at or below the Medicare payment rate,” said the group in its comments. The CMS also said that it wants to cut the add-on fee because IVIg use has gone up markedly. BIO argued that increased use shows that the preadministration payment has helped providers acquire and administer the drug.

GAO: FDA Needed Broader Pool

Food and Drug Administration officials might have avoided some conflicts of interest on their scientific advisory committees by expanding recruitment efforts beyond word-of-mouth nominations, according to a report from the Government Accountability Office. The report, released last month, analyzed the recruitment and screening of FDA advisory committee members before the agency changed those processes in 2007. The FDA could have reached out beyond its usual source of experts to retired professionals, university professors, and experts in epidemiology and statistics, the GAO concluded. The evaluation was requested by members of the Senate.

Nationwide RAC Launched

The CMS has launched its national recovery audit contractor program as part of its “aggressive new steps to find and prevent waste, fraud and abuse in Medicare.” The new RACs, which will be paid on a contingency fee basis, soon will begin to contact providers, the CMS said. The 3-year RAC demonstration program in California, Florida, New York, Massachusetts, South Carolina, and Arizona collected more than $900 million in overpayments, according to the agency. But the program has drawn strong criticism from physician groups, who have maintained that RAC audits were overly burdensome. In addition to implementing the RACs, the CMS said it will begin to work directly with beneficiaries to make certain that they receive the durable medical equipment or home health services for which Medicare has been billed, and that the items or services were medically necessary.

They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.

Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that will go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.

“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for addressing lesser violations.

▸ Protect those who report incidents and include nonretaliation clauses into policy statements.

▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.

The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians.

Over the last decade, the system has also been adopted by a number of large academic medical centers and community medical centers.

The information is then used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improvement of communication skills. If problems continue after that, corrective action may be taken.

Overall, the Vanderbilt data suggest that about 4%–6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said.

Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders, Dr. Hickson said. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.

Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.

And this can lead to real safety issues for patients, she said. For example, during surgery a nurse may observe a physician break with sterile protocol when placing a subclavian central line. That nurse is in a position to stop the procedure but only if he or she feels comfortable to question the physician. Without a culture that allows for that action by the nurse, the patient is the one who suffers, Ms. Cohen said.

She advised hospital leadership to get started as soon as possible. It takes a lot of work to change the culture of an organization and to get at the root of why the bad behavior is occurring. “There is no easy fix,” she said.

At Centra Health in Lynchburg, Va., they have been operating with a practitioner code of conduct for more than a decade and over the years the leadership has tried to enforce it while still keeping the process collegial.

Dr. Chal Nunn, chief medical officer for Centra Health, said he encourages clinicians to confront inappropriate behavior on the front lines and have an informal conversation about it.

Under their policy, the starting point is a conversation with the offending clinician. If the problem persists, the complaint is made in writing and the clinician is informed of the consequences. “The whole point is to try to help the person,” Dr. Nunn said.

There are plenty of examples of policies out there. But get started now, he said, because, “you just can't let it slide.”

They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.

Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that will go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.

“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for addressing lesser violations.

▸ Protect those who report incidents and include nonretaliation clauses into policy statements.

▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.

The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians.

Over the last decade, the system has also been adopted by a number of large academic medical centers and community medical centers.

The information is then used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improvement of communication skills. If problems continue after that, corrective action may be taken.

Overall, the Vanderbilt data suggest that about 4%–6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said.

Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders, Dr. Hickson said. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.

Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.

And this can lead to real safety issues for patients, she said. For example, during surgery a nurse may observe a physician break with sterile protocol when placing a subclavian central line. That nurse is in a position to stop the procedure but only if he or she feels comfortable to question the physician. Without a culture that allows for that action by the nurse, the patient is the one who suffers, Ms. Cohen said.

She advised hospital leadership to get started as soon as possible. It takes a lot of work to change the culture of an organization and to get at the root of why the bad behavior is occurring. “There is no easy fix,” she said.

At Centra Health in Lynchburg, Va., they have been operating with a practitioner code of conduct for more than a decade and over the years the leadership has tried to enforce it while still keeping the process collegial.

Dr. Chal Nunn, chief medical officer for Centra Health, said he encourages clinicians to confront inappropriate behavior on the front lines and have an informal conversation about it.

Under their policy, the starting point is a conversation with the offending clinician. If the problem persists, the complaint is made in writing and the clinician is informed of the consequences. “The whole point is to try to help the person,” Dr. Nunn said.

There are plenty of examples of policies out there. But get started now, he said, because, “you just can't let it slide.”

They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.

Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that will go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.

“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for addressing lesser violations.

▸ Protect those who report incidents and include nonretaliation clauses into policy statements.

▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.

The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians.

Over the last decade, the system has also been adopted by a number of large academic medical centers and community medical centers.

The information is then used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improvement of communication skills. If problems continue after that, corrective action may be taken.

Overall, the Vanderbilt data suggest that about 4%–6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said.

Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders, Dr. Hickson said. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.

Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.

And this can lead to real safety issues for patients, she said. For example, during surgery a nurse may observe a physician break with sterile protocol when placing a subclavian central line. That nurse is in a position to stop the procedure but only if he or she feels comfortable to question the physician. Without a culture that allows for that action by the nurse, the patient is the one who suffers, Ms. Cohen said.

She advised hospital leadership to get started as soon as possible. It takes a lot of work to change the culture of an organization and to get at the root of why the bad behavior is occurring. “There is no easy fix,” she said.

At Centra Health in Lynchburg, Va., they have been operating with a practitioner code of conduct for more than a decade and over the years the leadership has tried to enforce it while still keeping the process collegial.

Dr. Chal Nunn, chief medical officer for Centra Health, said he encourages clinicians to confront inappropriate behavior on the front lines and have an informal conversation about it.

Under their policy, the starting point is a conversation with the offending clinician. If the problem persists, the complaint is made in writing and the clinician is informed of the consequences. “The whole point is to try to help the person,” Dr. Nunn said.

There are plenty of examples of policies out there. But get started now, he said, because, “you just can't let it slide.”

Veterans with amyotrophic lateral sclerosis can now receive services and equipment from the Department of Veterans Affairs without having to prove that their condition is connected to their military service.

The VA established a presumption of service connection for amyotrophic lateral sclerosis (ALS) for any veteran who develops the disease at any time after their separation from service. Veterans must have 90 days or more of continuous active service in the military to qualify for the benefits, according to an interim final regulation issued on Sept. 23.

Researchers have been studying the link between military service and ALS for years, and the evidence has been suggestive of an association but a definitive link has not been made. In 2001, the VA issued a policy giving “special consideration” to ALS claims made by veterans of the 1991 Gulf War, regardless of when the disease manifested itself.

VA Secretary James B. Peake said he based the decision to presumptively connect ALS to military service primarily on a November 2006 report from the Institute of Medicine that concluded that “there is limited and suggestive evidence of an association between military service and later development of ALS.” The IOM conclusion was based on a review of available evidence. The IOM committee that issued the study recommended further research to establish a definitive association, but Dr. Peake said he thought it was unlikely that further research would show the link given the rarity of the disease.

“There simply isn't time to develop the evidence needed to support compensation claims before many veterans become seriously ill,” Dr. Peake said in a statement. “My decision will make those claims much easier to process, and for them and their families to receive the compensation they have earned through their service to our nation.”

The new regulation will apply to all applications for benefits received by VA on or after Sept. 23, as well as those currently pending before the VA, the U.S. Court of Appeals for Veterans Claims, and the U.S. Court of Appeals for the Federal Circuit. VA officials are also planning to contact veterans with ALS whose claims were previously denied.

For neurologists working outside of the VA who are seeing veterans with ALS, its critical to get patients connected with a VA physician, said Dr. Carlayne E. Jackson, professor of neurology and otolaryngology at the University of Texas at San Antonio, and director of the South Texas ALS Clinic at the University Health Science Center. Once patients are connected to the VA system, a physician there will be able to help them get coverage for necessary equipment and services, she said.

“It's an opportunity to dramatically improve the services and equipment that our patients have access to,” Dr. Jackson said.

For example, veterans will have greater access to wheelchairs, speech devices, specialized mattresses, and home health care services that may not have been covered or were only partially covered through Medicare disability benefits, she said.

The new designation by the VA will also ease the burden on veterans who previously had to prove that their disease was connected to their military service, said Pat Wildman, director of public policy for the ALS Association. Because of the progressive nature of the disease, some veterans were dying before they had the chance to prove their service connection, he said.

At press time, the ALS Association was developing frequently asked questions and answers about the VA benefits that will be posted on the organization's Web site (www.alsa.org

It is estimated that ALS affects about 20,000–30,000 individuals in the United States. Though the number of veterans with the condition is unknown, recent studies indicate that the disease strikes military veterans at about double the rate of the general population, according to the ALS Association.

But researchers and patients may get more information about the disease prevalence thanks to the passage of the ALS Registry Act (S. 1382). The legislation passed Congress in late September and was signed into law by President Bush.

The bill will establish the first national patient registry of individuals with ALS. The registry, which will be run by the Centers for Disease Control and Prevention, could yield clues about the cause, treatment, and cure for the disease, including why vets appear to be at greater risk.

Veterans with amyotrophic lateral sclerosis can now receive services and equipment from the Department of Veterans Affairs without having to prove that their condition is connected to their military service.

The VA established a presumption of service connection for amyotrophic lateral sclerosis (ALS) for any veteran who develops the disease at any time after their separation from service. Veterans must have 90 days or more of continuous active service in the military to qualify for the benefits, according to an interim final regulation issued on Sept. 23.

Researchers have been studying the link between military service and ALS for years, and the evidence has been suggestive of an association but a definitive link has not been made. In 2001, the VA issued a policy giving “special consideration” to ALS claims made by veterans of the 1991 Gulf War, regardless of when the disease manifested itself.

VA Secretary James B. Peake said he based the decision to presumptively connect ALS to military service primarily on a November 2006 report from the Institute of Medicine that concluded that “there is limited and suggestive evidence of an association between military service and later development of ALS.” The IOM conclusion was based on a review of available evidence. The IOM committee that issued the study recommended further research to establish a definitive association, but Dr. Peake said he thought it was unlikely that further research would show the link given the rarity of the disease.

“There simply isn't time to develop the evidence needed to support compensation claims before many veterans become seriously ill,” Dr. Peake said in a statement. “My decision will make those claims much easier to process, and for them and their families to receive the compensation they have earned through their service to our nation.”

The new regulation will apply to all applications for benefits received by VA on or after Sept. 23, as well as those currently pending before the VA, the U.S. Court of Appeals for Veterans Claims, and the U.S. Court of Appeals for the Federal Circuit. VA officials are also planning to contact veterans with ALS whose claims were previously denied.

For neurologists working outside of the VA who are seeing veterans with ALS, its critical to get patients connected with a VA physician, said Dr. Carlayne E. Jackson, professor of neurology and otolaryngology at the University of Texas at San Antonio, and director of the South Texas ALS Clinic at the University Health Science Center. Once patients are connected to the VA system, a physician there will be able to help them get coverage for necessary equipment and services, she said.

“It's an opportunity to dramatically improve the services and equipment that our patients have access to,” Dr. Jackson said.

For example, veterans will have greater access to wheelchairs, speech devices, specialized mattresses, and home health care services that may not have been covered or were only partially covered through Medicare disability benefits, she said.

The new designation by the VA will also ease the burden on veterans who previously had to prove that their disease was connected to their military service, said Pat Wildman, director of public policy for the ALS Association. Because of the progressive nature of the disease, some veterans were dying before they had the chance to prove their service connection, he said.

At press time, the ALS Association was developing frequently asked questions and answers about the VA benefits that will be posted on the organization's Web site (www.alsa.org

It is estimated that ALS affects about 20,000–30,000 individuals in the United States. Though the number of veterans with the condition is unknown, recent studies indicate that the disease strikes military veterans at about double the rate of the general population, according to the ALS Association.

But researchers and patients may get more information about the disease prevalence thanks to the passage of the ALS Registry Act (S. 1382). The legislation passed Congress in late September and was signed into law by President Bush.

The bill will establish the first national patient registry of individuals with ALS. The registry, which will be run by the Centers for Disease Control and Prevention, could yield clues about the cause, treatment, and cure for the disease, including why vets appear to be at greater risk.

Veterans with amyotrophic lateral sclerosis can now receive services and equipment from the Department of Veterans Affairs without having to prove that their condition is connected to their military service.

The VA established a presumption of service connection for amyotrophic lateral sclerosis (ALS) for any veteran who develops the disease at any time after their separation from service. Veterans must have 90 days or more of continuous active service in the military to qualify for the benefits, according to an interim final regulation issued on Sept. 23.

Researchers have been studying the link between military service and ALS for years, and the evidence has been suggestive of an association but a definitive link has not been made. In 2001, the VA issued a policy giving “special consideration” to ALS claims made by veterans of the 1991 Gulf War, regardless of when the disease manifested itself.

VA Secretary James B. Peake said he based the decision to presumptively connect ALS to military service primarily on a November 2006 report from the Institute of Medicine that concluded that “there is limited and suggestive evidence of an association between military service and later development of ALS.” The IOM conclusion was based on a review of available evidence. The IOM committee that issued the study recommended further research to establish a definitive association, but Dr. Peake said he thought it was unlikely that further research would show the link given the rarity of the disease.

“There simply isn't time to develop the evidence needed to support compensation claims before many veterans become seriously ill,” Dr. Peake said in a statement. “My decision will make those claims much easier to process, and for them and their families to receive the compensation they have earned through their service to our nation.”

The new regulation will apply to all applications for benefits received by VA on or after Sept. 23, as well as those currently pending before the VA, the U.S. Court of Appeals for Veterans Claims, and the U.S. Court of Appeals for the Federal Circuit. VA officials are also planning to contact veterans with ALS whose claims were previously denied.

For neurologists working outside of the VA who are seeing veterans with ALS, its critical to get patients connected with a VA physician, said Dr. Carlayne E. Jackson, professor of neurology and otolaryngology at the University of Texas at San Antonio, and director of the South Texas ALS Clinic at the University Health Science Center. Once patients are connected to the VA system, a physician there will be able to help them get coverage for necessary equipment and services, she said.

“It's an opportunity to dramatically improve the services and equipment that our patients have access to,” Dr. Jackson said.

For example, veterans will have greater access to wheelchairs, speech devices, specialized mattresses, and home health care services that may not have been covered or were only partially covered through Medicare disability benefits, she said.

The new designation by the VA will also ease the burden on veterans who previously had to prove that their disease was connected to their military service, said Pat Wildman, director of public policy for the ALS Association. Because of the progressive nature of the disease, some veterans were dying before they had the chance to prove their service connection, he said.

At press time, the ALS Association was developing frequently asked questions and answers about the VA benefits that will be posted on the organization's Web site (www.alsa.org

It is estimated that ALS affects about 20,000–30,000 individuals in the United States. Though the number of veterans with the condition is unknown, recent studies indicate that the disease strikes military veterans at about double the rate of the general population, according to the ALS Association.

But researchers and patients may get more information about the disease prevalence thanks to the passage of the ALS Registry Act (S. 1382). The legislation passed Congress in late September and was signed into law by President Bush.

The bill will establish the first national patient registry of individuals with ALS. The registry, which will be run by the Centers for Disease Control and Prevention, could yield clues about the cause, treatment, and cure for the disease, including why vets appear to be at greater risk.

The full report on Aetna's compliance is available at http://nyrxreport.ncqa.org

Aetna Inc.'s physician-rating program recently received a passing grade from the National Committee for Quality Assurance.

The evaluation was conducted under a 2007 agreement between Aetna and New York Attorney General Andrew Cuomo, to address allegations that health plans were using physician-rating programs to steer members to less expensive providers.

To date, seven state, regional, and national insurers have signed on to the agreement and pledged not to base their physician rankings entirely on cost. The health plans have also agreed to involve physicians in measure development and to allow physicians to review their performance data and request changes.

In the most recent evaluation, NCQA reviewed the compliance efforts of Aetna Health Inc., an HMO-point of service plan, and Aetna Life Insurance Co., a preferred-provider organization, both operating in New York. The plans were found to be in full compliance with the eight requirements reviewed by NCQA.

NCQA published reviews of CIGNA Healthcare of New York, an HMO, and Connecticut General Life Insurance Company, a PPO, in July. The organization is currently reviewing United Healthcare's physician-rating program.

The full report on Aetna's compliance is available at http://nyrxreport.ncqa.org

Aetna Inc.'s physician-rating program recently received a passing grade from the National Committee for Quality Assurance.

The evaluation was conducted under a 2007 agreement between Aetna and New York Attorney General Andrew Cuomo, to address allegations that health plans were using physician-rating programs to steer members to less expensive providers.

To date, seven state, regional, and national insurers have signed on to the agreement and pledged not to base their physician rankings entirely on cost. The health plans have also agreed to involve physicians in measure development and to allow physicians to review their performance data and request changes.

In the most recent evaluation, NCQA reviewed the compliance efforts of Aetna Health Inc., an HMO-point of service plan, and Aetna Life Insurance Co., a preferred-provider organization, both operating in New York. The plans were found to be in full compliance with the eight requirements reviewed by NCQA.

NCQA published reviews of CIGNA Healthcare of New York, an HMO, and Connecticut General Life Insurance Company, a PPO, in July. The organization is currently reviewing United Healthcare's physician-rating program.

The full report on Aetna's compliance is available at http://nyrxreport.ncqa.org

Aetna Inc.'s physician-rating program recently received a passing grade from the National Committee for Quality Assurance.

The evaluation was conducted under a 2007 agreement between Aetna and New York Attorney General Andrew Cuomo, to address allegations that health plans were using physician-rating programs to steer members to less expensive providers.

To date, seven state, regional, and national insurers have signed on to the agreement and pledged not to base their physician rankings entirely on cost. The health plans have also agreed to involve physicians in measure development and to allow physicians to review their performance data and request changes.

In the most recent evaluation, NCQA reviewed the compliance efforts of Aetna Health Inc., an HMO-point of service plan, and Aetna Life Insurance Co., a preferred-provider organization, both operating in New York. The plans were found to be in full compliance with the eight requirements reviewed by NCQA.

NCQA published reviews of CIGNA Healthcare of New York, an HMO, and Connecticut General Life Insurance Company, a PPO, in July. The organization is currently reviewing United Healthcare's physician-rating program.

The study is available online at www.hschange.org/CONTENT/1015

The federal government's relaxation of self-referral and antikickback laws has had a “modest” effect in encouraging hospitals to subsidize physician purchases of electronic medical record systems, according to an analysis by the Center for Studying Health System Change.

Some hospitals are proceeding slowly, offering subsidies on electronic medical record (EMR) software to small groups of closely affiliated physicians, while other hospitals are offering only IT support services or extending their vendor discounts, according to the analysis of 24 hospitals. The analysis was funded by the Robert Wood Johnson Foundation.

In 2006, the Health and Human Services Department announced that it had created two safe harbors that would allow hospitals to subsidize up to 85% of the cost of EMR software and IT support services for physicians. For their part, physicians would be responsible for the full cost of the required hardware. The regulations are scheduled to sunset at the end of 2013.

The analysis by the Center for Studying Health System Change, which is based on in-depth interviews with executives at 24 hospitals, found that 11 of the 24 hospitals were considering offering some type of subsidy to physicians to help cover their EMR costs. The remaining 13 hospitals were not planning to provide direct subsidies to physicians, but some were considering extending their EMR vendor discounts or offering IT support services.

Hospitals that chose not to offer direct financial support to physicians had differing reasons. For example, some opposed the idea of offering EMR subsidies to physicians. Others said that granting access to vendor discounts was a sufficient incentive for physicians preparing to adopt EMRs. And other hospitals were interested in providing the financial subsidies directly to physicians but couldn't afford to do so.

For those hospital executives who were considering a direct subsidy to physicians, improving patient care and forging closer relationships with referring physicians were the top reasons cited for moving forward with EMR assistance. “Hospital executives expected physicians would be more likely to maintain, and even expand, their relationship with the hospital because of the improved efficiency from interoperability with the hospital's IT systems,” the researchers wrote.

One factor that appears not to be driving the trend toward hospital subsidies is interest on the part of physicians. The arrangement has some potential drawbacks for physicians, according to the analysis.

For example, under the safe harbors physicians are still responsible for 15% of the software costs and 100% of the hardware costs associated with setting up the EMR system. Plus, physicians using the hospital-sponsored EMR may have difficulty storing records for patients who are treated at other hospitals where the physicians provide care for patients. Also, the hospital-sponsored EMR could serve as a barrier if physicians later wanted to switch their hospital affiliations, according to the analysis.

“While hospitals have strategic incentives to provide support, particularly to tie referring physicians to their institution, the effects of the regulatory changes on physician EMR adoption will ultimately depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance,” Joy M. Grossman, Ph.D., one of the study authors, said in a statement.

The study is available online at www.hschange.org/CONTENT/1015

The federal government's relaxation of self-referral and antikickback laws has had a “modest” effect in encouraging hospitals to subsidize physician purchases of electronic medical record systems, according to an analysis by the Center for Studying Health System Change.

Some hospitals are proceeding slowly, offering subsidies on electronic medical record (EMR) software to small groups of closely affiliated physicians, while other hospitals are offering only IT support services or extending their vendor discounts, according to the analysis of 24 hospitals. The analysis was funded by the Robert Wood Johnson Foundation.

In 2006, the Health and Human Services Department announced that it had created two safe harbors that would allow hospitals to subsidize up to 85% of the cost of EMR software and IT support services for physicians. For their part, physicians would be responsible for the full cost of the required hardware. The regulations are scheduled to sunset at the end of 2013.

The analysis by the Center for Studying Health System Change, which is based on in-depth interviews with executives at 24 hospitals, found that 11 of the 24 hospitals were considering offering some type of subsidy to physicians to help cover their EMR costs. The remaining 13 hospitals were not planning to provide direct subsidies to physicians, but some were considering extending their EMR vendor discounts or offering IT support services.

Hospitals that chose not to offer direct financial support to physicians had differing reasons. For example, some opposed the idea of offering EMR subsidies to physicians. Others said that granting access to vendor discounts was a sufficient incentive for physicians preparing to adopt EMRs. And other hospitals were interested in providing the financial subsidies directly to physicians but couldn't afford to do so.

For those hospital executives who were considering a direct subsidy to physicians, improving patient care and forging closer relationships with referring physicians were the top reasons cited for moving forward with EMR assistance. “Hospital executives expected physicians would be more likely to maintain, and even expand, their relationship with the hospital because of the improved efficiency from interoperability with the hospital's IT systems,” the researchers wrote.

One factor that appears not to be driving the trend toward hospital subsidies is interest on the part of physicians. The arrangement has some potential drawbacks for physicians, according to the analysis.

For example, under the safe harbors physicians are still responsible for 15% of the software costs and 100% of the hardware costs associated with setting up the EMR system. Plus, physicians using the hospital-sponsored EMR may have difficulty storing records for patients who are treated at other hospitals where the physicians provide care for patients. Also, the hospital-sponsored EMR could serve as a barrier if physicians later wanted to switch their hospital affiliations, according to the analysis.

“While hospitals have strategic incentives to provide support, particularly to tie referring physicians to their institution, the effects of the regulatory changes on physician EMR adoption will ultimately depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance,” Joy M. Grossman, Ph.D., one of the study authors, said in a statement.

The study is available online at www.hschange.org/CONTENT/1015

The federal government's relaxation of self-referral and antikickback laws has had a “modest” effect in encouraging hospitals to subsidize physician purchases of electronic medical record systems, according to an analysis by the Center for Studying Health System Change.

Some hospitals are proceeding slowly, offering subsidies on electronic medical record (EMR) software to small groups of closely affiliated physicians, while other hospitals are offering only IT support services or extending their vendor discounts, according to the analysis of 24 hospitals. The analysis was funded by the Robert Wood Johnson Foundation.

In 2006, the Health and Human Services Department announced that it had created two safe harbors that would allow hospitals to subsidize up to 85% of the cost of EMR software and IT support services for physicians. For their part, physicians would be responsible for the full cost of the required hardware. The regulations are scheduled to sunset at the end of 2013.

The analysis by the Center for Studying Health System Change, which is based on in-depth interviews with executives at 24 hospitals, found that 11 of the 24 hospitals were considering offering some type of subsidy to physicians to help cover their EMR costs. The remaining 13 hospitals were not planning to provide direct subsidies to physicians, but some were considering extending their EMR vendor discounts or offering IT support services.

Hospitals that chose not to offer direct financial support to physicians had differing reasons. For example, some opposed the idea of offering EMR subsidies to physicians. Others said that granting access to vendor discounts was a sufficient incentive for physicians preparing to adopt EMRs. And other hospitals were interested in providing the financial subsidies directly to physicians but couldn't afford to do so.

For those hospital executives who were considering a direct subsidy to physicians, improving patient care and forging closer relationships with referring physicians were the top reasons cited for moving forward with EMR assistance. “Hospital executives expected physicians would be more likely to maintain, and even expand, their relationship with the hospital because of the improved efficiency from interoperability with the hospital's IT systems,” the researchers wrote.

One factor that appears not to be driving the trend toward hospital subsidies is interest on the part of physicians. The arrangement has some potential drawbacks for physicians, according to the analysis.

For example, under the safe harbors physicians are still responsible for 15% of the software costs and 100% of the hardware costs associated with setting up the EMR system. Plus, physicians using the hospital-sponsored EMR may have difficulty storing records for patients who are treated at other hospitals where the physicians provide care for patients. Also, the hospital-sponsored EMR could serve as a barrier if physicians later wanted to switch their hospital affiliations, according to the analysis.

“While hospitals have strategic incentives to provide support, particularly to tie referring physicians to their institution, the effects of the regulatory changes on physician EMR adoption will ultimately depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance,” Joy M. Grossman, Ph.D., one of the study authors, said in a statement.

Over the next year, officials at the American Academy of Family Physicians will weigh the best strategy for getting their voices heard when it comes to setting the values that determine Medicare payments.

Traditionally, organized medicine has come together through a body called the Relative Value Scale Update Committee (RUC) to advise officials at the Centers for Medicare and Medicaid Services on the relative values that should be assigned to CPT codes. But over the past several years, primary care physicians have grown dissatisfied with the process, which has assigned lower values to cognitive services.

Most recently, several state chapters joined to urge that the AAFP either work to gain greater representation on the RUC or leave that body and seek an alternative way to advise the CMS.

That proposal was one of two RUC-related resolutions referred by the academy's Congress of Delegates for study by the board of directors. The board plans to issue a report in 2009.

The RUC is a multispecialty expert panel sponsored by the American Medical Association that advises the CMS on the values that make up Medicare allowable charges. Specifically, the 29-member group makes recommendations on the work- and practice-expense components of the Resource-Based Relative Value Scale (RBRVS) system.

Those recommendations help determine how the multibillion dollar Medi- care physician payment budget will be distributed, said Dr. Terry L. Mills Jr., a family physician in Newton, Kan., and the AAFP's advisor to the RUC. The RUC has no formal relationship with the CMS, but CMS officials put a lot of weight on the group's recommendations and have historically accepted their advice more than 90% of the time, he said. “It's the most powerful body in medicine that no one has ever heard of,” he stated.

One of the criticisms of the RUC is that it underrepresents primary care physicians. Only 4 of the current 29 RUC members are from traditional primary care specialties. Most of the rest are from specialties dominated by procedural work.

“There's too much self-interest involved” in the RUC process, said Dr. William Gillanders, director of the family medicine residency program at Providence Milwaukie (Ore.) Hospital.

Dr. Gillanders, who is also the treasurer of the Oregon Academy of Family Physicians, said there should be greater representation of primary care physicians in making recommendations on payments issues. However, he said efforts to get the RUC to change its structure voluntarily have failed, so he wants to appeal to the CMS to mandate a change.

He supports a resolution introduced at the Congress of Delegates that would instruct the AAFP leadership to petition the CMS either to develop an independent Relative Value Scale advisory board with membership that is representative of the current physician workforce providing care to Medicare beneficiaries, or to mandate a restructuring of the RUC.

But Dr. Robert Wergin, a family physician in Milford, Neb., who was involved in advocating for changes to the RUC at the recent AAFP Congress of Delegates, favors staying involved in the RUC and trying to work within that process to gain greater representation, and ultimately greater payment, for primary care. If that approach is not viable, then AAFP will need to consider alternatives, he said. By dividing the RUC, primary care physicians would risk having less influence on the payment system, he noted.

There should also be more transparency in the RUC decision-making process, about which little is known, Dr. Wergin said.

However, Dr. Mills argued that it is premature to give up on the RUC, despite the frustration with how cognitive services are valued. “The RUC remains tremendously important,” he said.

The greater problem may not be a failing of the RUC, but of the RBRVS system as a whole, Dr. Mills said. That system works well for compensating physicians for procedures, but it fails to account for the complexity of coordinating care for chronically ill patients, he said. It would ameliorate some of the problems if AAFP and others could lobby Congress to change the reimbursement system so that complex management is recognized through a regular chronic care fee, he said.

The AAFP board of directors has already been active in examining the RUC. Earlier this year, the board approved a statement saying that the RUC has “failed” and won't be viable until it is restructured to give primary care proportional representation. AAFP has also pledged to investigate alternatives to the RUC.

Over the next year, officials at the American Academy of Family Physicians will weigh the best strategy for getting their voices heard when it comes to setting the values that determine Medicare payments.

Traditionally, organized medicine has come together through a body called the Relative Value Scale Update Committee (RUC) to advise officials at the Centers for Medicare and Medicaid Services on the relative values that should be assigned to CPT codes. But over the past several years, primary care physicians have grown dissatisfied with the process, which has assigned lower values to cognitive services.

Most recently, several state chapters joined to urge that the AAFP either work to gain greater representation on the RUC or leave that body and seek an alternative way to advise the CMS.

That proposal was one of two RUC-related resolutions referred by the academy's Congress of Delegates for study by the board of directors. The board plans to issue a report in 2009.

The RUC is a multispecialty expert panel sponsored by the American Medical Association that advises the CMS on the values that make up Medicare allowable charges. Specifically, the 29-member group makes recommendations on the work- and practice-expense components of the Resource-Based Relative Value Scale (RBRVS) system.

Those recommendations help determine how the multibillion dollar Medi- care physician payment budget will be distributed, said Dr. Terry L. Mills Jr., a family physician in Newton, Kan., and the AAFP's advisor to the RUC. The RUC has no formal relationship with the CMS, but CMS officials put a lot of weight on the group's recommendations and have historically accepted their advice more than 90% of the time, he said. “It's the most powerful body in medicine that no one has ever heard of,” he stated.

One of the criticisms of the RUC is that it underrepresents primary care physicians. Only 4 of the current 29 RUC members are from traditional primary care specialties. Most of the rest are from specialties dominated by procedural work.

“There's too much self-interest involved” in the RUC process, said Dr. William Gillanders, director of the family medicine residency program at Providence Milwaukie (Ore.) Hospital.

Dr. Gillanders, who is also the treasurer of the Oregon Academy of Family Physicians, said there should be greater representation of primary care physicians in making recommendations on payments issues. However, he said efforts to get the RUC to change its structure voluntarily have failed, so he wants to appeal to the CMS to mandate a change.

He supports a resolution introduced at the Congress of Delegates that would instruct the AAFP leadership to petition the CMS either to develop an independent Relative Value Scale advisory board with membership that is representative of the current physician workforce providing care to Medicare beneficiaries, or to mandate a restructuring of the RUC.

But Dr. Robert Wergin, a family physician in Milford, Neb., who was involved in advocating for changes to the RUC at the recent AAFP Congress of Delegates, favors staying involved in the RUC and trying to work within that process to gain greater representation, and ultimately greater payment, for primary care. If that approach is not viable, then AAFP will need to consider alternatives, he said. By dividing the RUC, primary care physicians would risk having less influence on the payment system, he noted.

There should also be more transparency in the RUC decision-making process, about which little is known, Dr. Wergin said.

However, Dr. Mills argued that it is premature to give up on the RUC, despite the frustration with how cognitive services are valued. “The RUC remains tremendously important,” he said.

The greater problem may not be a failing of the RUC, but of the RBRVS system as a whole, Dr. Mills said. That system works well for compensating physicians for procedures, but it fails to account for the complexity of coordinating care for chronically ill patients, he said. It would ameliorate some of the problems if AAFP and others could lobby Congress to change the reimbursement system so that complex management is recognized through a regular chronic care fee, he said.

The AAFP board of directors has already been active in examining the RUC. Earlier this year, the board approved a statement saying that the RUC has “failed” and won't be viable until it is restructured to give primary care proportional representation. AAFP has also pledged to investigate alternatives to the RUC.

Over the next year, officials at the American Academy of Family Physicians will weigh the best strategy for getting their voices heard when it comes to setting the values that determine Medicare payments.

Traditionally, organized medicine has come together through a body called the Relative Value Scale Update Committee (RUC) to advise officials at the Centers for Medicare and Medicaid Services on the relative values that should be assigned to CPT codes. But over the past several years, primary care physicians have grown dissatisfied with the process, which has assigned lower values to cognitive services.

Most recently, several state chapters joined to urge that the AAFP either work to gain greater representation on the RUC or leave that body and seek an alternative way to advise the CMS.

That proposal was one of two RUC-related resolutions referred by the academy's Congress of Delegates for study by the board of directors. The board plans to issue a report in 2009.

The RUC is a multispecialty expert panel sponsored by the American Medical Association that advises the CMS on the values that make up Medicare allowable charges. Specifically, the 29-member group makes recommendations on the work- and practice-expense components of the Resource-Based Relative Value Scale (RBRVS) system.

Those recommendations help determine how the multibillion dollar Medi- care physician payment budget will be distributed, said Dr. Terry L. Mills Jr., a family physician in Newton, Kan., and the AAFP's advisor to the RUC. The RUC has no formal relationship with the CMS, but CMS officials put a lot of weight on the group's recommendations and have historically accepted their advice more than 90% of the time, he said. “It's the most powerful body in medicine that no one has ever heard of,” he stated.

One of the criticisms of the RUC is that it underrepresents primary care physicians. Only 4 of the current 29 RUC members are from traditional primary care specialties. Most of the rest are from specialties dominated by procedural work.

“There's too much self-interest involved” in the RUC process, said Dr. William Gillanders, director of the family medicine residency program at Providence Milwaukie (Ore.) Hospital.

Dr. Gillanders, who is also the treasurer of the Oregon Academy of Family Physicians, said there should be greater representation of primary care physicians in making recommendations on payments issues. However, he said efforts to get the RUC to change its structure voluntarily have failed, so he wants to appeal to the CMS to mandate a change.

He supports a resolution introduced at the Congress of Delegates that would instruct the AAFP leadership to petition the CMS either to develop an independent Relative Value Scale advisory board with membership that is representative of the current physician workforce providing care to Medicare beneficiaries, or to mandate a restructuring of the RUC.

But Dr. Robert Wergin, a family physician in Milford, Neb., who was involved in advocating for changes to the RUC at the recent AAFP Congress of Delegates, favors staying involved in the RUC and trying to work within that process to gain greater representation, and ultimately greater payment, for primary care. If that approach is not viable, then AAFP will need to consider alternatives, he said. By dividing the RUC, primary care physicians would risk having less influence on the payment system, he noted.

There should also be more transparency in the RUC decision-making process, about which little is known, Dr. Wergin said.

However, Dr. Mills argued that it is premature to give up on the RUC, despite the frustration with how cognitive services are valued. “The RUC remains tremendously important,” he said.

The greater problem may not be a failing of the RUC, but of the RBRVS system as a whole, Dr. Mills said. That system works well for compensating physicians for procedures, but it fails to account for the complexity of coordinating care for chronically ill patients, he said. It would ameliorate some of the problems if AAFP and others could lobby Congress to change the reimbursement system so that complex management is recognized through a regular chronic care fee, he said.

The AAFP board of directors has already been active in examining the RUC. Earlier this year, the board approved a statement saying that the RUC has “failed” and won't be viable until it is restructured to give primary care proportional representation. AAFP has also pledged to investigate alternatives to the RUC.

The study is available online at www.hschange.org/CONTENT/1015

The federal government's relaxation of self-referral and antikickback laws has had a “modest” effect in encouraging hospitals to subsidize physician purchases of electronic medical record systems, according to an analysis by the Center for Studying Health System Change.

Some hospitals are proceeding slowly, offering subsidies on electronic medical record (EMR) software to small groups of closely affiliated physicians, while other hospitals are offering only IT support services or extending their vendor discounts, according to the analysis of 24 hospitals. The analysis was funded by the Robert Wood Johnson Foundation.

In 2006, the Health and Human Services Department announced that it had created two safe harbors that would allow hospitals to subsidize up to 85% of the cost of EMR software and IT support services for physicians. For their part, physicians would be responsible for the full cost of the required hardware. The regulations are scheduled to sunset at the end of 2013.

The analysis by the Center for Studying Health System Change, which is based on in-depth interviews with executives at 24 hospitals, found that 11 of the 24 hospitals were considering offering some type of subsidy to physicians to help cover their EMR costs. The remaining 13 hospitals were not planning to provide direct subsidies to physicians, but some were considering extending their EMR vendor discounts or offering IT support services.

Hospitals that chose not to offer direct financial support to physicians had differing reasons. For example, some opposed the idea of offering EMR subsidies to physicians. Others said that granting access to vendor discounts was a sufficient incentive for physicians preparing to adopt EMRs. And other hospitals were interested in providing the financial subsidies directly to physicians but couldn't afford to do so.

For those hospital executives who were considering a direct subsidy to physicians, improving patient care and forging closer relationships with referring physicians were the top reasons cited for moving forward with EMR assistance. “Hospital executives expected physicians would be more likely to maintain, and even expand, their relationship with the hospital because of the improved efficiency from interoperability with the hospital's IT systems,” the researchers wrote.

One factor that appears not to be driving the trend toward hospital subsidies is interest on the part of physicians. The arrangement has some potential drawbacks for physicians, according to the analysis.

For example, under the safe harbors physicians are still responsible for 15% of the software costs and 100% of the hardware costs associated with setting up the EMR system. Plus, physicians using the hospital-sponsored EMR may have difficulty storing records for patients who are treated at other hospitals where the physicians provide care for patients. Also, the hospital-sponsored EMR could serve as a barrier if physicians later wanted to switch their hospital affiliations, according to the analysis.

“While hospitals have strategic incentives to provide support, particularly to tie referring physicians to their institution, the effects of the regulatory changes on physician EMR adoption will ultimately depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance,” Joy M. Grossman, Ph.D., one of the study authors, said in a statement.

The study is available online at www.hschange.org/CONTENT/1015

The federal government's relaxation of self-referral and antikickback laws has had a “modest” effect in encouraging hospitals to subsidize physician purchases of electronic medical record systems, according to an analysis by the Center for Studying Health System Change.

Some hospitals are proceeding slowly, offering subsidies on electronic medical record (EMR) software to small groups of closely affiliated physicians, while other hospitals are offering only IT support services or extending their vendor discounts, according to the analysis of 24 hospitals. The analysis was funded by the Robert Wood Johnson Foundation.

In 2006, the Health and Human Services Department announced that it had created two safe harbors that would allow hospitals to subsidize up to 85% of the cost of EMR software and IT support services for physicians. For their part, physicians would be responsible for the full cost of the required hardware. The regulations are scheduled to sunset at the end of 2013.

The analysis by the Center for Studying Health System Change, which is based on in-depth interviews with executives at 24 hospitals, found that 11 of the 24 hospitals were considering offering some type of subsidy to physicians to help cover their EMR costs. The remaining 13 hospitals were not planning to provide direct subsidies to physicians, but some were considering extending their EMR vendor discounts or offering IT support services.

Hospitals that chose not to offer direct financial support to physicians had differing reasons. For example, some opposed the idea of offering EMR subsidies to physicians. Others said that granting access to vendor discounts was a sufficient incentive for physicians preparing to adopt EMRs. And other hospitals were interested in providing the financial subsidies directly to physicians but couldn't afford to do so.

For those hospital executives who were considering a direct subsidy to physicians, improving patient care and forging closer relationships with referring physicians were the top reasons cited for moving forward with EMR assistance. “Hospital executives expected physicians would be more likely to maintain, and even expand, their relationship with the hospital because of the improved efficiency from interoperability with the hospital's IT systems,” the researchers wrote.

One factor that appears not to be driving the trend toward hospital subsidies is interest on the part of physicians. The arrangement has some potential drawbacks for physicians, according to the analysis.

For example, under the safe harbors physicians are still responsible for 15% of the software costs and 100% of the hardware costs associated with setting up the EMR system. Plus, physicians using the hospital-sponsored EMR may have difficulty storing records for patients who are treated at other hospitals where the physicians provide care for patients. Also, the hospital-sponsored EMR could serve as a barrier if physicians later wanted to switch their hospital affiliations, according to the analysis.

“While hospitals have strategic incentives to provide support, particularly to tie referring physicians to their institution, the effects of the regulatory changes on physician EMR adoption will ultimately depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance,” Joy M. Grossman, Ph.D., one of the study authors, said in a statement.

The study is available online at www.hschange.org/CONTENT/1015

The federal government's relaxation of self-referral and antikickback laws has had a “modest” effect in encouraging hospitals to subsidize physician purchases of electronic medical record systems, according to an analysis by the Center for Studying Health System Change.

Some hospitals are proceeding slowly, offering subsidies on electronic medical record (EMR) software to small groups of closely affiliated physicians, while other hospitals are offering only IT support services or extending their vendor discounts, according to the analysis of 24 hospitals. The analysis was funded by the Robert Wood Johnson Foundation.

In 2006, the Health and Human Services Department announced that it had created two safe harbors that would allow hospitals to subsidize up to 85% of the cost of EMR software and IT support services for physicians. For their part, physicians would be responsible for the full cost of the required hardware. The regulations are scheduled to sunset at the end of 2013.

The analysis by the Center for Studying Health System Change, which is based on in-depth interviews with executives at 24 hospitals, found that 11 of the 24 hospitals were considering offering some type of subsidy to physicians to help cover their EMR costs. The remaining 13 hospitals were not planning to provide direct subsidies to physicians, but some were considering extending their EMR vendor discounts or offering IT support services.

Hospitals that chose not to offer direct financial support to physicians had differing reasons. For example, some opposed the idea of offering EMR subsidies to physicians. Others said that granting access to vendor discounts was a sufficient incentive for physicians preparing to adopt EMRs. And other hospitals were interested in providing the financial subsidies directly to physicians but couldn't afford to do so.

For those hospital executives who were considering a direct subsidy to physicians, improving patient care and forging closer relationships with referring physicians were the top reasons cited for moving forward with EMR assistance. “Hospital executives expected physicians would be more likely to maintain, and even expand, their relationship with the hospital because of the improved efficiency from interoperability with the hospital's IT systems,” the researchers wrote.

One factor that appears not to be driving the trend toward hospital subsidies is interest on the part of physicians. The arrangement has some potential drawbacks for physicians, according to the analysis.

For example, under the safe harbors physicians are still responsible for 15% of the software costs and 100% of the hardware costs associated with setting up the EMR system. Plus, physicians using the hospital-sponsored EMR may have difficulty storing records for patients who are treated at other hospitals where the physicians provide care for patients. Also, the hospital-sponsored EMR could serve as a barrier if physicians later wanted to switch their hospital affiliations, according to the analysis.

“While hospitals have strategic incentives to provide support, particularly to tie referring physicians to their institution, the effects of the regulatory changes on physician EMR adoption will ultimately depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance,” Joy M. Grossman, Ph.D., one of the study authors, said in a statement.

For more information on the CAP postponement, go to www.cms.hhs.gov/CompetitiveAcquisforBios

Medicare officials have pulled the plug at least temporarily on their Competitive Acquisition Program for Part B drugs, including infused biologics.

The program was put on hold because of “contractual issues” with the successful vendor bidders for the 2009 cycle of the program. The Competitive Acquisition Program (CAP) will remain in effect until the end of this year, but after that, physicians who had participated in the program will have to go back to purchasing drugs using the average sales price (ASP) system. CMS has not announced a time line for resuming the program.

The CAP was mandated by Congress under the 2003 Medicare Modernization Act. It was launched in July 2006 to give physicians an alternative to obtaining Part B infusion and injectable drugs through the ASP or “buy and bill” system.

The voluntary program took the purchase of these drugs out the hands of physicians. Those physicians who enrolled no longer took on the financial risk of buying drugs up front and being reimbursed by CMS later. Instead, they received drugs from an approved vendor who was selected by CMS through a competitive bidding process. Under the program, physicians were paid only for the administration of the drug.

BioScrip Inc., an Elmsford, N.Y.-based specialty pharmaceutical health care organization, has been the only approved CAP vendor throughout the history of the program. The company announced over the summer that it would not sign a new contract with CMS for CAP because the terms of the contract presented an “unacceptable short- and long-term profit risk.”

For 2008, nearly 5,000 physicians were enrolled in the CAP. The program included more than 200 drugs.

As currently designed, the CAP is “totally untenable,” said Dr. Karen Kolba, a solo rheumatologist in Santa Maria, Calif., and a member of the American College of Rheumatology's Committee on Rheumatologic Care. The delay in the program will give CMS some time to consider possible changes that could encourage more participation from rheumatologists, she said.

Dr. Kolba, who has not signed up for CAP, said the biggest problem with the program is the “all-or-nothing” requirement for ordering drugs.

Once enrolled, physicians are not allowed to choose what drugs they want to obtain through the CAP. If a drug they administer is available through the vendor, they must get it through the CAP. This is simply impractical for inexpensive, commonly used drugs such as cortisone injections, Dr. Kolba said, because CAP drugs must be ordered for specific patients and administered only to them. “It becomes something of an accounting nightmare,” she said.

But Dr. R. Mack Harrell, an endocrinologist in Fort Lauderdale, Fla., said the postponement of the CAP is likely to result in serious access problems for patients.

Many endocrinologists rely on the CAP to obtain expensive injectable drugs like thyrotropin alfa (Thyrogen), a drug that allows physicians to test for recurrence in thyroid cancer without having patients withdraw from their thyroid hormone treatments.

Without the CAP as a source of these drugs, Dr. Harrell said he fears that endocrinologists won't be able to provide these drugs in the office, forcing patients to go off their thyroid hormones for weeks at a time in order to undergo necessary testing.

Between now and the end of the year, physicians who are enrolled in the CAP must obtain drugs from BioScrip if the administration date for the drug is before Dec. 31, 2008. Any drugs that will be administered on or after Jan. 1, 2009, must be obtained through the regular ASP method.

If a physician has unused Part B drugs obtained through the CAP after Dec. 31, 2008, those drugs are considered the property of the vendor and must be purchased through the ASP system or returned to BioScrip. The drugs cannot be given away to the physician by BioScrip.

As physicians return to the ASP method of procuring drugs in 2009, they should keep in mind that they will once again be responsible for collecting deductibles and coinsurance from Medicare beneficiaries and that they should not use the CAP modifiers (J1, J2, J3, M2) when submitting claims.

CMS is also advising physicians to contact BioScrip as soon as possible to minimize the amount of unused drugs and facilitate uninterrupted access to Part B drugs.

While the program is on hold, CMS will be asking physicians to provide feedback on the program. Agency officials are looking for information on the categories of drugs provided through the program, the distribution of areas that are served by the CAP, and any procedural changes that could make the program more flexible and more attractive for vendors and physicians.

For more information on the CAP postponement, go to www.cms.hhs.gov/CompetitiveAcquisforBios

Medicare officials have pulled the plug at least temporarily on their Competitive Acquisition Program for Part B drugs, including infused biologics.

The program was put on hold because of “contractual issues” with the successful vendor bidders for the 2009 cycle of the program. The Competitive Acquisition Program (CAP) will remain in effect until the end of this year, but after that, physicians who had participated in the program will have to go back to purchasing drugs using the average sales price (ASP) system. CMS has not announced a time line for resuming the program.

The CAP was mandated by Congress under the 2003 Medicare Modernization Act. It was launched in July 2006 to give physicians an alternative to obtaining Part B infusion and injectable drugs through the ASP or “buy and bill” system.

The voluntary program took the purchase of these drugs out the hands of physicians. Those physicians who enrolled no longer took on the financial risk of buying drugs up front and being reimbursed by CMS later. Instead, they received drugs from an approved vendor who was selected by CMS through a competitive bidding process. Under the program, physicians were paid only for the administration of the drug.

BioScrip Inc., an Elmsford, N.Y.-based specialty pharmaceutical health care organization, has been the only approved CAP vendor throughout the history of the program. The company announced over the summer that it would not sign a new contract with CMS for CAP because the terms of the contract presented an “unacceptable short- and long-term profit risk.”

For 2008, nearly 5,000 physicians were enrolled in the CAP. The program included more than 200 drugs.

As currently designed, the CAP is “totally untenable,” said Dr. Karen Kolba, a solo rheumatologist in Santa Maria, Calif., and a member of the American College of Rheumatology's Committee on Rheumatologic Care. The delay in the program will give CMS some time to consider possible changes that could encourage more participation from rheumatologists, she said.

Dr. Kolba, who has not signed up for CAP, said the biggest problem with the program is the “all-or-nothing” requirement for ordering drugs.

Once enrolled, physicians are not allowed to choose what drugs they want to obtain through the CAP. If a drug they administer is available through the vendor, they must get it through the CAP. This is simply impractical for inexpensive, commonly used drugs such as cortisone injections, Dr. Kolba said, because CAP drugs must be ordered for specific patients and administered only to them. “It becomes something of an accounting nightmare,” she said.

But Dr. R. Mack Harrell, an endocrinologist in Fort Lauderdale, Fla., said the postponement of the CAP is likely to result in serious access problems for patients.

Many endocrinologists rely on the CAP to obtain expensive injectable drugs like thyrotropin alfa (Thyrogen), a drug that allows physicians to test for recurrence in thyroid cancer without having patients withdraw from their thyroid hormone treatments.

Without the CAP as a source of these drugs, Dr. Harrell said he fears that endocrinologists won't be able to provide these drugs in the office, forcing patients to go off their thyroid hormones for weeks at a time in order to undergo necessary testing.

Between now and the end of the year, physicians who are enrolled in the CAP must obtain drugs from BioScrip if the administration date for the drug is before Dec. 31, 2008. Any drugs that will be administered on or after Jan. 1, 2009, must be obtained through the regular ASP method.

If a physician has unused Part B drugs obtained through the CAP after Dec. 31, 2008, those drugs are considered the property of the vendor and must be purchased through the ASP system or returned to BioScrip. The drugs cannot be given away to the physician by BioScrip.

As physicians return to the ASP method of procuring drugs in 2009, they should keep in mind that they will once again be responsible for collecting deductibles and coinsurance from Medicare beneficiaries and that they should not use the CAP modifiers (J1, J2, J3, M2) when submitting claims.

CMS is also advising physicians to contact BioScrip as soon as possible to minimize the amount of unused drugs and facilitate uninterrupted access to Part B drugs.

While the program is on hold, CMS will be asking physicians to provide feedback on the program. Agency officials are looking for information on the categories of drugs provided through the program, the distribution of areas that are served by the CAP, and any procedural changes that could make the program more flexible and more attractive for vendors and physicians.

For more information on the CAP postponement, go to www.cms.hhs.gov/CompetitiveAcquisforBios

Medicare officials have pulled the plug at least temporarily on their Competitive Acquisition Program for Part B drugs, including infused biologics.

The program was put on hold because of “contractual issues” with the successful vendor bidders for the 2009 cycle of the program. The Competitive Acquisition Program (CAP) will remain in effect until the end of this year, but after that, physicians who had participated in the program will have to go back to purchasing drugs using the average sales price (ASP) system. CMS has not announced a time line for resuming the program.

The CAP was mandated by Congress under the 2003 Medicare Modernization Act. It was launched in July 2006 to give physicians an alternative to obtaining Part B infusion and injectable drugs through the ASP or “buy and bill” system.

The voluntary program took the purchase of these drugs out the hands of physicians. Those physicians who enrolled no longer took on the financial risk of buying drugs up front and being reimbursed by CMS later. Instead, they received drugs from an approved vendor who was selected by CMS through a competitive bidding process. Under the program, physicians were paid only for the administration of the drug.

BioScrip Inc., an Elmsford, N.Y.-based specialty pharmaceutical health care organization, has been the only approved CAP vendor throughout the history of the program. The company announced over the summer that it would not sign a new contract with CMS for CAP because the terms of the contract presented an “unacceptable short- and long-term profit risk.”

For 2008, nearly 5,000 physicians were enrolled in the CAP. The program included more than 200 drugs.

As currently designed, the CAP is “totally untenable,” said Dr. Karen Kolba, a solo rheumatologist in Santa Maria, Calif., and a member of the American College of Rheumatology's Committee on Rheumatologic Care. The delay in the program will give CMS some time to consider possible changes that could encourage more participation from rheumatologists, she said.

Dr. Kolba, who has not signed up for CAP, said the biggest problem with the program is the “all-or-nothing” requirement for ordering drugs.

Once enrolled, physicians are not allowed to choose what drugs they want to obtain through the CAP. If a drug they administer is available through the vendor, they must get it through the CAP. This is simply impractical for inexpensive, commonly used drugs such as cortisone injections, Dr. Kolba said, because CAP drugs must be ordered for specific patients and administered only to them. “It becomes something of an accounting nightmare,” she said.

But Dr. R. Mack Harrell, an endocrinologist in Fort Lauderdale, Fla., said the postponement of the CAP is likely to result in serious access problems for patients.

Many endocrinologists rely on the CAP to obtain expensive injectable drugs like thyrotropin alfa (Thyrogen), a drug that allows physicians to test for recurrence in thyroid cancer without having patients withdraw from their thyroid hormone treatments.

Without the CAP as a source of these drugs, Dr. Harrell said he fears that endocrinologists won't be able to provide these drugs in the office, forcing patients to go off their thyroid hormones for weeks at a time in order to undergo necessary testing.

Between now and the end of the year, physicians who are enrolled in the CAP must obtain drugs from BioScrip if the administration date for the drug is before Dec. 31, 2008. Any drugs that will be administered on or after Jan. 1, 2009, must be obtained through the regular ASP method.

If a physician has unused Part B drugs obtained through the CAP after Dec. 31, 2008, those drugs are considered the property of the vendor and must be purchased through the ASP system or returned to BioScrip. The drugs cannot be given away to the physician by BioScrip.

As physicians return to the ASP method of procuring drugs in 2009, they should keep in mind that they will once again be responsible for collecting deductibles and coinsurance from Medicare beneficiaries and that they should not use the CAP modifiers (J1, J2, J3, M2) when submitting claims.

CMS is also advising physicians to contact BioScrip as soon as possible to minimize the amount of unused drugs and facilitate uninterrupted access to Part B drugs.

While the program is on hold, CMS will be asking physicians to provide feedback on the program. Agency officials are looking for information on the categories of drugs provided through the program, the distribution of areas that are served by the CAP, and any procedural changes that could make the program more flexible and more attractive for vendors and physicians.