Mary Ellen Schneider

Experts are calling for an infusion of about 10,000 primary care physicians into medically underserved areas over the next several years, even as medical students' interest in primary care has waned.

The nation's community health centers, which serve rural and other medically underserved communities, are currently facing a shortage of primary care providers, according to a report from the National Association of Community Health Centers, the American Academy of Family Physicians' Robert Graham Center, and George Washington University.

To fill the current gaps and expand services to nearly 30 million people by 2015, community health centers will need at least 15,585 additional primary care providers, including nearly 10,000 physicians, as well as nurse practitioners, certified nurse midwives, and physician assistants.

The report, “Access Transformed: Building a Primary Care Workforce for the 21st Century,” focuses on expanding care through community health centers since they are already positioned to deliver services in physician shortage areas.

Policy makers will need to get more medical students interested in primary care and ensure that those newly trained physicians go to work in medically underserved areas, the report concludes.

One solution offered in the report is to expand the National Health Service Corps program, which places primary care providers in federally designated Health Professional Shortage Areas. Through this program, physicians and other providers can receive scholarships or loan repayment assistance in exchange for service in a medically underserved area.

Dr. Gary Wiltz received a National Health Service Corps scholarship more than 25 years ago and still works in the small Louisiana bayou town where he settled after training.

“It's extremely gratifying,” he said.

Dr. Wiltz, an internist and CEO of the Teche Action Clinic in Franklin, La., has experienced the shortage of primary care providers firsthand. Since he's been there, the organization has never had a full complement of providers across its four clinics. Attempts to recruit an internist and a family physician for the past 2 years have been unsuccessful.

But for physicians who practice in underserved areas, the rewards can be great. Patients hold you in high esteem and are very grateful for the care they receive, he said. “You don't just treat them,” he said. “You worship with them and shop with them.”

The National Health Service Corps is a model that works but has not received enough funding to provide scholarships to all of the qualified applicants, Dr. Wiltz said.

Retention in the program is high. In fiscal year 2006, 76% of participating clinicians stayed in their positions for at least a year after their service commitments were fulfilled. But funding for the program has declined in recent years. In FY 2004, the program's funding peaked at $169.9 million, and in FY 2008, it had fallen to $123.5 million, according to the report.

The report also calls on policy makers to find a way to “revitalize” the J-1 Visa Waiver program, which has placed fewer foreign nationals into shortage areas in recent years. Under that program, foreign nationals who have received a U.S. visa for educational purposes can opt out of going back to their home countries in exchange for practicing in a federally designated Health Professional Shortage Area.

But existing federal programs will not be enough to meet the growing demand for primary care physicians and other providers. The report also calls on Congress to revise the way graduate medical education is funded to make it financially viable for residency training programs to partner with community health centers.

Even without a formal blessing from Congress, some programs are finding ways to give residents experience in community health clinics.

For example, Riverstone Health, a community health center organization in Billings, Mont., operates the fully accredited Montana Family Medicine Residency training program. The center established the program in 1995 along with two local hospitals. The program is funded through clinic revenues, graduate medical education funds that are passed through the two hospitals, and some state assistance.

The program currently includes 18 residents and receives applications from many more students than it can accommodate, said Dr. Roxanne Fahrenwald, director. About 70% of the graduates of the program have stayed on to practice in Montana, she said.

Locating a residency program at a community health center is a natural fit, Dr. Fahrenwald said, because the traditional role of residency training programs is to care for underserved populations just like in community health centers. “I would hope a lot more people would consider it,” she said.

Physician payment is another area in need of reform, according to the report. The disparity in reimbursement between procedure-related specialties and primary care needs to be addressed to help attract more students to the field, the report said.

Dr. Gerald Fincken, D.O., a family physician in Austin, Texas, sees the impact of the payment disparities when recruiting new physicians to the large, multispecialty clinic where he works. Medical students have steep medical school loans to repay and see that not only is primary care reimbursement comparatively lower but Medicare reimbursements are declining, he said. “Medical students are becoming more savvy,” he said.

Federal policy makers will have to get more creative and figure out a way to shift dollars to increase the reimbursement for primary care; otherwise, the residency rates will continue to drop, he said.

“Income is definitely a factor that leads medical students not to choose primary care,” said Dr. James King, board chair of the American Academy of Family Physicians. Officials at the AAFP have been urging Congress to act to reexamine how they pay for primary care and to pay physicians more for providing non-visit-based services such as coordination of care through a patient-centered medical home.

Experts are calling for an infusion of about 10,000 primary care physicians into medically underserved areas over the next several years, even as medical students' interest in primary care has waned.

The nation's community health centers, which serve rural and other medically underserved communities, are currently facing a shortage of primary care providers, according to a report from the National Association of Community Health Centers, the American Academy of Family Physicians' Robert Graham Center, and George Washington University.

To fill the current gaps and expand services to nearly 30 million people by 2015, community health centers will need at least 15,585 additional primary care providers, including nearly 10,000 physicians, as well as nurse practitioners, certified nurse midwives, and physician assistants.

The report, “Access Transformed: Building a Primary Care Workforce for the 21st Century,” focuses on expanding care through community health centers since they are already positioned to deliver services in physician shortage areas.

Policy makers will need to get more medical students interested in primary care and ensure that those newly trained physicians go to work in medically underserved areas, the report concludes.

One solution offered in the report is to expand the National Health Service Corps program, which places primary care providers in federally designated Health Professional Shortage Areas. Through this program, physicians and other providers can receive scholarships or loan repayment assistance in exchange for service in a medically underserved area.

Dr. Gary Wiltz received a National Health Service Corps scholarship more than 25 years ago and still works in the small Louisiana bayou town where he settled after training.

“It's extremely gratifying,” he said.

Dr. Wiltz, an internist and CEO of the Teche Action Clinic in Franklin, La., has experienced the shortage of primary care providers firsthand. Since he's been there, the organization has never had a full complement of providers across its four clinics. Attempts to recruit an internist and a family physician for the past 2 years have been unsuccessful.

But for physicians who practice in underserved areas, the rewards can be great. Patients hold you in high esteem and are very grateful for the care they receive, he said. “You don't just treat them,” he said. “You worship with them and shop with them.”

The National Health Service Corps is a model that works but has not received enough funding to provide scholarships to all of the qualified applicants, Dr. Wiltz said.

Retention in the program is high. In fiscal year 2006, 76% of participating clinicians stayed in their positions for at least a year after their service commitments were fulfilled. But funding for the program has declined in recent years. In FY 2004, the program's funding peaked at $169.9 million, and in FY 2008, it had fallen to $123.5 million, according to the report.

The report also calls on policy makers to find a way to “revitalize” the J-1 Visa Waiver program, which has placed fewer foreign nationals into shortage areas in recent years. Under that program, foreign nationals who have received a U.S. visa for educational purposes can opt out of going back to their home countries in exchange for practicing in a federally designated Health Professional Shortage Area.

But existing federal programs will not be enough to meet the growing demand for primary care physicians and other providers. The report also calls on Congress to revise the way graduate medical education is funded to make it financially viable for residency training programs to partner with community health centers.

Even without a formal blessing from Congress, some programs are finding ways to give residents experience in community health clinics.

For example, Riverstone Health, a community health center organization in Billings, Mont., operates the fully accredited Montana Family Medicine Residency training program. The center established the program in 1995 along with two local hospitals. The program is funded through clinic revenues, graduate medical education funds that are passed through the two hospitals, and some state assistance.

The program currently includes 18 residents and receives applications from many more students than it can accommodate, said Dr. Roxanne Fahrenwald, director. About 70% of the graduates of the program have stayed on to practice in Montana, she said.

Locating a residency program at a community health center is a natural fit, Dr. Fahrenwald said, because the traditional role of residency training programs is to care for underserved populations just like in community health centers. “I would hope a lot more people would consider it,” she said.

Physician payment is another area in need of reform, according to the report. The disparity in reimbursement between procedure-related specialties and primary care needs to be addressed to help attract more students to the field, the report said.

Dr. Gerald Fincken, D.O., a family physician in Austin, Texas, sees the impact of the payment disparities when recruiting new physicians to the large, multispecialty clinic where he works. Medical students have steep medical school loans to repay and see that not only is primary care reimbursement comparatively lower but Medicare reimbursements are declining, he said. “Medical students are becoming more savvy,” he said.

Federal policy makers will have to get more creative and figure out a way to shift dollars to increase the reimbursement for primary care; otherwise, the residency rates will continue to drop, he said.

“Income is definitely a factor that leads medical students not to choose primary care,” said Dr. James King, board chair of the American Academy of Family Physicians. Officials at the AAFP have been urging Congress to act to reexamine how they pay for primary care and to pay physicians more for providing non-visit-based services such as coordination of care through a patient-centered medical home.

Experts are calling for an infusion of about 10,000 primary care physicians into medically underserved areas over the next several years, even as medical students' interest in primary care has waned.

The nation's community health centers, which serve rural and other medically underserved communities, are currently facing a shortage of primary care providers, according to a report from the National Association of Community Health Centers, the American Academy of Family Physicians' Robert Graham Center, and George Washington University.

To fill the current gaps and expand services to nearly 30 million people by 2015, community health centers will need at least 15,585 additional primary care providers, including nearly 10,000 physicians, as well as nurse practitioners, certified nurse midwives, and physician assistants.

The report, “Access Transformed: Building a Primary Care Workforce for the 21st Century,” focuses on expanding care through community health centers since they are already positioned to deliver services in physician shortage areas.

Policy makers will need to get more medical students interested in primary care and ensure that those newly trained physicians go to work in medically underserved areas, the report concludes.

One solution offered in the report is to expand the National Health Service Corps program, which places primary care providers in federally designated Health Professional Shortage Areas. Through this program, physicians and other providers can receive scholarships or loan repayment assistance in exchange for service in a medically underserved area.

Dr. Gary Wiltz received a National Health Service Corps scholarship more than 25 years ago and still works in the small Louisiana bayou town where he settled after training.

“It's extremely gratifying,” he said.

Dr. Wiltz, an internist and CEO of the Teche Action Clinic in Franklin, La., has experienced the shortage of primary care providers firsthand. Since he's been there, the organization has never had a full complement of providers across its four clinics. Attempts to recruit an internist and a family physician for the past 2 years have been unsuccessful.

But for physicians who practice in underserved areas, the rewards can be great. Patients hold you in high esteem and are very grateful for the care they receive, he said. “You don't just treat them,” he said. “You worship with them and shop with them.”

The National Health Service Corps is a model that works but has not received enough funding to provide scholarships to all of the qualified applicants, Dr. Wiltz said.

Retention in the program is high. In fiscal year 2006, 76% of participating clinicians stayed in their positions for at least a year after their service commitments were fulfilled. But funding for the program has declined in recent years. In FY 2004, the program's funding peaked at $169.9 million, and in FY 2008, it had fallen to $123.5 million, according to the report.

The report also calls on policy makers to find a way to “revitalize” the J-1 Visa Waiver program, which has placed fewer foreign nationals into shortage areas in recent years. Under that program, foreign nationals who have received a U.S. visa for educational purposes can opt out of going back to their home countries in exchange for practicing in a federally designated Health Professional Shortage Area.

But existing federal programs will not be enough to meet the growing demand for primary care physicians and other providers. The report also calls on Congress to revise the way graduate medical education is funded to make it financially viable for residency training programs to partner with community health centers.

Even without a formal blessing from Congress, some programs are finding ways to give residents experience in community health clinics.

For example, Riverstone Health, a community health center organization in Billings, Mont., operates the fully accredited Montana Family Medicine Residency training program. The center established the program in 1995 along with two local hospitals. The program is funded through clinic revenues, graduate medical education funds that are passed through the two hospitals, and some state assistance.

The program currently includes 18 residents and receives applications from many more students than it can accommodate, said Dr. Roxanne Fahrenwald, director. About 70% of the graduates of the program have stayed on to practice in Montana, she said.

Locating a residency program at a community health center is a natural fit, Dr. Fahrenwald said, because the traditional role of residency training programs is to care for underserved populations just like in community health centers. “I would hope a lot more people would consider it,” she said.

Physician payment is another area in need of reform, according to the report. The disparity in reimbursement between procedure-related specialties and primary care needs to be addressed to help attract more students to the field, the report said.

Dr. Gerald Fincken, D.O., a family physician in Austin, Texas, sees the impact of the payment disparities when recruiting new physicians to the large, multispecialty clinic where he works. Medical students have steep medical school loans to repay and see that not only is primary care reimbursement comparatively lower but Medicare reimbursements are declining, he said. “Medical students are becoming more savvy,” he said.

Federal policy makers will have to get more creative and figure out a way to shift dollars to increase the reimbursement for primary care; otherwise, the residency rates will continue to drop, he said.

“Income is definitely a factor that leads medical students not to choose primary care,” said Dr. James King, board chair of the American Academy of Family Physicians. Officials at the AAFP have been urging Congress to act to reexamine how they pay for primary care and to pay physicians more for providing non-visit-based services such as coordination of care through a patient-centered medical home.

Support for the concept of the patient-centered medical home continues to grow, with the latest nod coming from the federal Advisory Committee on Training in Primary Care Medicine and Dentistry.

The committee, which provides policy advice to Congress and the Health and Human Services secretary, is finalizing a report that recommends that policy makers invest in training physicians on how to operate within the medical home model and evaluate the health outcomes associated with this model of care.

A failure to invest in the medical home model now will impair efforts to improve quality and control costs, according to the committee.

The United States “faces a watershed moment when it can restructure health care to focus on prevention and coordinated, comprehensive care through the adoption of this promising new model of care,” the committee wrote.

The report calls for changes to Title VII, Section 747 of the Public Health Service Act. For example, the committee is recommending that the HHS secretary expand the authority of that law to include directing continuing medical education programs to train currently practicing physicians in aspects of the medical home.

The report also calls on the HHS secretary to promote dissemination of the best practices related to providing a medical home that have been identified by researchers.

Other draft recommendations from the committee include the following:

▸ Funding pilot programs that contribute to the development and evaluation of the medical home, with priority given to those programs that address the needs of underserved populations.

▸ Developing measures to evaluate the medical home in terms of accessibility and patient satisfaction, health status, quality of care, health disparities, and cost.

▸ Implementing key components of the medical home model in academic medical centers, in an effort to prepare faculty educators.

The committee's next report, which is due out in May 2009, will explore how primary care training would need to be redesigned to further the concept of the medical home.

Specifically, the report is expected to focus on the difficulties in hand-offs between pediatric specialists and adult medicine specialists when patients with chronic illnesses reach adulthood. In addition, they will consider workforce issues and medical school debt.

Support for the concept of the patient-centered medical home continues to grow, with the latest nod coming from the federal Advisory Committee on Training in Primary Care Medicine and Dentistry.

The committee, which provides policy advice to Congress and the Health and Human Services secretary, is finalizing a report that recommends that policy makers invest in training physicians on how to operate within the medical home model and evaluate the health outcomes associated with this model of care.

A failure to invest in the medical home model now will impair efforts to improve quality and control costs, according to the committee.

The United States “faces a watershed moment when it can restructure health care to focus on prevention and coordinated, comprehensive care through the adoption of this promising new model of care,” the committee wrote.

The report calls for changes to Title VII, Section 747 of the Public Health Service Act. For example, the committee is recommending that the HHS secretary expand the authority of that law to include directing continuing medical education programs to train currently practicing physicians in aspects of the medical home.

The report also calls on the HHS secretary to promote dissemination of the best practices related to providing a medical home that have been identified by researchers.

Other draft recommendations from the committee include the following:

▸ Funding pilot programs that contribute to the development and evaluation of the medical home, with priority given to those programs that address the needs of underserved populations.

▸ Developing measures to evaluate the medical home in terms of accessibility and patient satisfaction, health status, quality of care, health disparities, and cost.

▸ Implementing key components of the medical home model in academic medical centers, in an effort to prepare faculty educators.

The committee's next report, which is due out in May 2009, will explore how primary care training would need to be redesigned to further the concept of the medical home.

Specifically, the report is expected to focus on the difficulties in hand-offs between pediatric specialists and adult medicine specialists when patients with chronic illnesses reach adulthood. In addition, they will consider workforce issues and medical school debt.

Support for the concept of the patient-centered medical home continues to grow, with the latest nod coming from the federal Advisory Committee on Training in Primary Care Medicine and Dentistry.

The committee, which provides policy advice to Congress and the Health and Human Services secretary, is finalizing a report that recommends that policy makers invest in training physicians on how to operate within the medical home model and evaluate the health outcomes associated with this model of care.

A failure to invest in the medical home model now will impair efforts to improve quality and control costs, according to the committee.

The United States “faces a watershed moment when it can restructure health care to focus on prevention and coordinated, comprehensive care through the adoption of this promising new model of care,” the committee wrote.

The report calls for changes to Title VII, Section 747 of the Public Health Service Act. For example, the committee is recommending that the HHS secretary expand the authority of that law to include directing continuing medical education programs to train currently practicing physicians in aspects of the medical home.

The report also calls on the HHS secretary to promote dissemination of the best practices related to providing a medical home that have been identified by researchers.

Other draft recommendations from the committee include the following:

▸ Funding pilot programs that contribute to the development and evaluation of the medical home, with priority given to those programs that address the needs of underserved populations.

▸ Developing measures to evaluate the medical home in terms of accessibility and patient satisfaction, health status, quality of care, health disparities, and cost.

▸ Implementing key components of the medical home model in academic medical centers, in an effort to prepare faculty educators.

The committee's next report, which is due out in May 2009, will explore how primary care training would need to be redesigned to further the concept of the medical home.

Specifically, the report is expected to focus on the difficulties in hand-offs between pediatric specialists and adult medicine specialists when patients with chronic illnesses reach adulthood. In addition, they will consider workforce issues and medical school debt.

The average employer-sponsored health insurance premium rose 5% from 2007 to 2008 with average premiums for family coverage reaching $12,680, according to a report from the Kaiser Family Foundation and the Health Research and Educational Trust.

While experts said the 1-year average increase in premiums was modest, they noted that over the last 9 years the rise in premiums has outpaced growth in both wages and inflation. Since 1999, family premiums have risen from $5,791 to $12,680, while individual premiums have gone from $2,196 to $4,704, according to the report.

The findings are based on an annual survey of 2,832 randomly selected public and private companies with three or more employees. Of those companies, 1,927 responded to the full survey, while the remaining companies responded to a single question about whether they offered health coverage to their employees. The survey was conducted between January and May of this year. The full study is available online at www.kff.org

While American workers are paying more for their health insurance, they may be getting less in terms of coverage, Drew Altman, Ph.D., president and CEO of the Kaiser Family Foundation, said during a press conference to release the survey results. “We're seeing a change in this survey in the comprehensiveness of the coverage workers get, especially in small firms,” he said.

The survey showed that more workers are enrolled in plans with higher deductibles. In 2008, 18% of all covered workers had health plan deductibles of at least $1,000 for single coverage, compared with 12% in 2007 and 10% in 2006. And high deductibles were more common among employees at small companies. In 2008, 35% of workers in companies with fewer than 200 employees have deductibles of $1,000 a year for single coverage, compared with 21% last year and 16% in 2006.

American workers can expect to see more cost sharing in 2009, according to the survey results. The survey found that among employers who currently offer health benefits, 40% reported that they would be somewhat or very likely to increase the amount that employees pay for health coverage next year. Similarly, 41% reported that they would be somewhat or very likely to increase deductibles and 45% said they would be somewhat or very likely to increase office visit copayments or coinsurance amounts for employees.

The average employer-sponsored health insurance premium rose 5% from 2007 to 2008 with average premiums for family coverage reaching $12,680, according to a report from the Kaiser Family Foundation and the Health Research and Educational Trust.

While experts said the 1-year average increase in premiums was modest, they noted that over the last 9 years the rise in premiums has outpaced growth in both wages and inflation. Since 1999, family premiums have risen from $5,791 to $12,680, while individual premiums have gone from $2,196 to $4,704, according to the report.

The findings are based on an annual survey of 2,832 randomly selected public and private companies with three or more employees. Of those companies, 1,927 responded to the full survey, while the remaining companies responded to a single question about whether they offered health coverage to their employees. The survey was conducted between January and May of this year. The full study is available online at www.kff.org

While American workers are paying more for their health insurance, they may be getting less in terms of coverage, Drew Altman, Ph.D., president and CEO of the Kaiser Family Foundation, said during a press conference to release the survey results. “We're seeing a change in this survey in the comprehensiveness of the coverage workers get, especially in small firms,” he said.

The survey showed that more workers are enrolled in plans with higher deductibles. In 2008, 18% of all covered workers had health plan deductibles of at least $1,000 for single coverage, compared with 12% in 2007 and 10% in 2006. And high deductibles were more common among employees at small companies. In 2008, 35% of workers in companies with fewer than 200 employees have deductibles of $1,000 a year for single coverage, compared with 21% last year and 16% in 2006.

American workers can expect to see more cost sharing in 2009, according to the survey results. The survey found that among employers who currently offer health benefits, 40% reported that they would be somewhat or very likely to increase the amount that employees pay for health coverage next year. Similarly, 41% reported that they would be somewhat or very likely to increase deductibles and 45% said they would be somewhat or very likely to increase office visit copayments or coinsurance amounts for employees.

The average employer-sponsored health insurance premium rose 5% from 2007 to 2008 with average premiums for family coverage reaching $12,680, according to a report from the Kaiser Family Foundation and the Health Research and Educational Trust.

While experts said the 1-year average increase in premiums was modest, they noted that over the last 9 years the rise in premiums has outpaced growth in both wages and inflation. Since 1999, family premiums have risen from $5,791 to $12,680, while individual premiums have gone from $2,196 to $4,704, according to the report.

The findings are based on an annual survey of 2,832 randomly selected public and private companies with three or more employees. Of those companies, 1,927 responded to the full survey, while the remaining companies responded to a single question about whether they offered health coverage to their employees. The survey was conducted between January and May of this year. The full study is available online at www.kff.org

While American workers are paying more for their health insurance, they may be getting less in terms of coverage, Drew Altman, Ph.D., president and CEO of the Kaiser Family Foundation, said during a press conference to release the survey results. “We're seeing a change in this survey in the comprehensiveness of the coverage workers get, especially in small firms,” he said.

The survey showed that more workers are enrolled in plans with higher deductibles. In 2008, 18% of all covered workers had health plan deductibles of at least $1,000 for single coverage, compared with 12% in 2007 and 10% in 2006. And high deductibles were more common among employees at small companies. In 2008, 35% of workers in companies with fewer than 200 employees have deductibles of $1,000 a year for single coverage, compared with 21% last year and 16% in 2006.

American workers can expect to see more cost sharing in 2009, according to the survey results. The survey found that among employers who currently offer health benefits, 40% reported that they would be somewhat or very likely to increase the amount that employees pay for health coverage next year. Similarly, 41% reported that they would be somewhat or very likely to increase deductibles and 45% said they would be somewhat or very likely to increase office visit copayments or coinsurance amounts for employees.

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 spells out the consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it through the release of a Sentinel Event Alert this summer. 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 improving 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 the key is to get started now, he emphasized. “You just can't let it slide,” Dr. Nunn said.

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 spells out the consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it through the release of a Sentinel Event Alert this summer. 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 improving 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 the key is to get started now, he emphasized. “You just can't let it slide,” Dr. Nunn said.

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 spells out the consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it through the release of a Sentinel Event Alert this summer. 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 improving 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 the key is to get started now, he emphasized. “You just can't let it slide,” Dr. Nunn said.

The free pens and mugs adorned with the names of commonly prescribed drugs are soon to be a thing of the past, thanks to a new set of voluntary guidelines from the Pharmaceutical Research and Manufacturers of America.

However, the real impact of the guidelines is still up for debate.

The voluntary guidelines, which will go into effect in January, were released this summer as pressure mounted from Congress and the academic medical community for industry to rein in its marketing practices.

The new guidelines update the 2002 PhRMA Code on Interactions with Healthcare Professionals.

“Although our member companies have long been committed to responsible marketing of the life-enhancing and life-saving medicines they develop, we have heard the voices of policy-makers, health care professionals, and others telling us we can do better,” Billy Tauzin, PhRMA president and CEO, said in a statement.

Among the changes outlined in the new guidelines is a prohibition on even “modest” gifts to physicians if they lack educational value. For example, the ubiquitous pens and mugs given out by pharmaceutical representatives are no longer acceptable under PhRMA's new code of conduct. However, gifts valued at $100 or less that are used primarily for patient or health care professional education, such as an anatomical model, are still allowed on an occasional basis.

The guidelines also prohibit sales representatives and their immediate managers from taking physicians out for dinner, even if they have an educational presentation to make. However, they can still provide “modest” meals, such as pizza, in the office or at the hospital if they stay to provide their educational session there. The voluntary guidelines also prohibit companies from providing any type of entertainment or recreational items such as tickets, sports equipment, or trips, even if the item is inexpensive.

In terms of continuing medical education (CME), the guidelines call on pharmaceutical companies to separate their CME grant-making functions from their sales and marketing activities.

Subsidies to attend CME meetings should not be given directly to physicians, according to the guidelines. Instead, any funds should be given directly to the CME provider who can use the money to reduce fees for all attendees. Companies are also not allowed to provide meals directly at CME events.

The guidelines continue to allow pharmaceutical companies to provide scholarships to medical students and others in training so they can attend educational conferences, as long as the recipients are chosen by the academic or training institution.

The guidelines also call for greater transparency among physicians who work as industry consultants. Physicians who serve as company consultants or speakers and also serve on committees that set formularies or clinical practice guidelines should disclose their industry relationships, according to the PhRMA guidelines.

The changes were praised by some in the medical community as progress on the part of the pharmaceutical industry to respond to criticisms and police itself.

“It's a big step forward,” said Dr. David Korn, chief scientific officer for the Association of American Medical Colleges, which recently released its own report on industry funding of medical education.

Although the PhRMA guidelines don't go as far as some academic medical institution policies, they are significant because they appear to have the full backing of the industry, Dr. Korn said. It shows that the pharmaceutical industry has heard the concerns of the public and has deemed some interactions to be unacceptable.

“What we're talking about really is a culture change,” he concluded.

In the AAMC report, released in June, the organization calls on medical schools and teaching hospitals to prohibit the acceptance of any gifts from industry. The AAMC also instructs academic medical institutions to set up a central CME office to coordinate the distribution of industry funds, and strongly discourages participation by faculty in industry-sponsored speakers bureaus.

Time will tell whether the guidelines will result in any real changes, said Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.

Ultimately, it's up to the medical profession to make these changes, he said. Every single drug sale representative in the country would be looking for a new job if physicians refused to see them, Dr. Brody said.

All physicians should start thinking about how to get educated about new treatments without meeting with sales representatives, as well as foregoing samples and saying no to free lunches provided by pharmaceutical companies, he said.

The free pens and mugs adorned with the names of commonly prescribed drugs are soon to be a thing of the past, thanks to a new set of voluntary guidelines from the Pharmaceutical Research and Manufacturers of America.

However, the real impact of the guidelines is still up for debate.

The voluntary guidelines, which will go into effect in January, were released this summer as pressure mounted from Congress and the academic medical community for industry to rein in its marketing practices.

The new guidelines update the 2002 PhRMA Code on Interactions with Healthcare Professionals.

“Although our member companies have long been committed to responsible marketing of the life-enhancing and life-saving medicines they develop, we have heard the voices of policy-makers, health care professionals, and others telling us we can do better,” Billy Tauzin, PhRMA president and CEO, said in a statement.

Among the changes outlined in the new guidelines is a prohibition on even “modest” gifts to physicians if they lack educational value. For example, the ubiquitous pens and mugs given out by pharmaceutical representatives are no longer acceptable under PhRMA's new code of conduct. However, gifts valued at $100 or less that are used primarily for patient or health care professional education, such as an anatomical model, are still allowed on an occasional basis.

The guidelines also prohibit sales representatives and their immediate managers from taking physicians out for dinner, even if they have an educational presentation to make. However, they can still provide “modest” meals, such as pizza, in the office or at the hospital if they stay to provide their educational session there. The voluntary guidelines also prohibit companies from providing any type of entertainment or recreational items such as tickets, sports equipment, or trips, even if the item is inexpensive.

In terms of continuing medical education (CME), the guidelines call on pharmaceutical companies to separate their CME grant-making functions from their sales and marketing activities.

Subsidies to attend CME meetings should not be given directly to physicians, according to the guidelines. Instead, any funds should be given directly to the CME provider who can use the money to reduce fees for all attendees. Companies are also not allowed to provide meals directly at CME events.

The guidelines continue to allow pharmaceutical companies to provide scholarships to medical students and others in training so they can attend educational conferences, as long as the recipients are chosen by the academic or training institution.

The guidelines also call for greater transparency among physicians who work as industry consultants. Physicians who serve as company consultants or speakers and also serve on committees that set formularies or clinical practice guidelines should disclose their industry relationships, according to the PhRMA guidelines.

The changes were praised by some in the medical community as progress on the part of the pharmaceutical industry to respond to criticisms and police itself.

“It's a big step forward,” said Dr. David Korn, chief scientific officer for the Association of American Medical Colleges, which recently released its own report on industry funding of medical education.

Although the PhRMA guidelines don't go as far as some academic medical institution policies, they are significant because they appear to have the full backing of the industry, Dr. Korn said. It shows that the pharmaceutical industry has heard the concerns of the public and has deemed some interactions to be unacceptable.

“What we're talking about really is a culture change,” he concluded.

In the AAMC report, released in June, the organization calls on medical schools and teaching hospitals to prohibit the acceptance of any gifts from industry. The AAMC also instructs academic medical institutions to set up a central CME office to coordinate the distribution of industry funds, and strongly discourages participation by faculty in industry-sponsored speakers bureaus.

Time will tell whether the guidelines will result in any real changes, said Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.

Ultimately, it's up to the medical profession to make these changes, he said. Every single drug sale representative in the country would be looking for a new job if physicians refused to see them, Dr. Brody said.

All physicians should start thinking about how to get educated about new treatments without meeting with sales representatives, as well as foregoing samples and saying no to free lunches provided by pharmaceutical companies, he said.

The free pens and mugs adorned with the names of commonly prescribed drugs are soon to be a thing of the past, thanks to a new set of voluntary guidelines from the Pharmaceutical Research and Manufacturers of America.

However, the real impact of the guidelines is still up for debate.

The voluntary guidelines, which will go into effect in January, were released this summer as pressure mounted from Congress and the academic medical community for industry to rein in its marketing practices.

The new guidelines update the 2002 PhRMA Code on Interactions with Healthcare Professionals.

“Although our member companies have long been committed to responsible marketing of the life-enhancing and life-saving medicines they develop, we have heard the voices of policy-makers, health care professionals, and others telling us we can do better,” Billy Tauzin, PhRMA president and CEO, said in a statement.

Among the changes outlined in the new guidelines is a prohibition on even “modest” gifts to physicians if they lack educational value. For example, the ubiquitous pens and mugs given out by pharmaceutical representatives are no longer acceptable under PhRMA's new code of conduct. However, gifts valued at $100 or less that are used primarily for patient or health care professional education, such as an anatomical model, are still allowed on an occasional basis.

The guidelines also prohibit sales representatives and their immediate managers from taking physicians out for dinner, even if they have an educational presentation to make. However, they can still provide “modest” meals, such as pizza, in the office or at the hospital if they stay to provide their educational session there. The voluntary guidelines also prohibit companies from providing any type of entertainment or recreational items such as tickets, sports equipment, or trips, even if the item is inexpensive.

In terms of continuing medical education (CME), the guidelines call on pharmaceutical companies to separate their CME grant-making functions from their sales and marketing activities.

Subsidies to attend CME meetings should not be given directly to physicians, according to the guidelines. Instead, any funds should be given directly to the CME provider who can use the money to reduce fees for all attendees. Companies are also not allowed to provide meals directly at CME events.

The guidelines continue to allow pharmaceutical companies to provide scholarships to medical students and others in training so they can attend educational conferences, as long as the recipients are chosen by the academic or training institution.

The guidelines also call for greater transparency among physicians who work as industry consultants. Physicians who serve as company consultants or speakers and also serve on committees that set formularies or clinical practice guidelines should disclose their industry relationships, according to the PhRMA guidelines.

The changes were praised by some in the medical community as progress on the part of the pharmaceutical industry to respond to criticisms and police itself.

“It's a big step forward,” said Dr. David Korn, chief scientific officer for the Association of American Medical Colleges, which recently released its own report on industry funding of medical education.

Although the PhRMA guidelines don't go as far as some academic medical institution policies, they are significant because they appear to have the full backing of the industry, Dr. Korn said. It shows that the pharmaceutical industry has heard the concerns of the public and has deemed some interactions to be unacceptable.

“What we're talking about really is a culture change,” he concluded.

In the AAMC report, released in June, the organization calls on medical schools and teaching hospitals to prohibit the acceptance of any gifts from industry. The AAMC also instructs academic medical institutions to set up a central CME office to coordinate the distribution of industry funds, and strongly discourages participation by faculty in industry-sponsored speakers bureaus.

Time will tell whether the guidelines will result in any real changes, said Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.

Ultimately, it's up to the medical profession to make these changes, he said. Every single drug sale representative in the country would be looking for a new job if physicians refused to see them, Dr. Brody said.

All physicians should start thinking about how to get educated about new treatments without meeting with sales representatives, as well as foregoing samples and saying no to free lunches provided by pharmaceutical companies, he said.

Officials at the Centers for Medicare and Medicaid Services plan to replace the ICD-9-CM diagnosis and procedure code set with a significantly expanded set of codes—the ICD-10—by Oct. 1, 2011.

But physician groups are calling the agency's plan rushed and unworkable and want the agency to reconsider its compliance date.

In addition to the requirements for using the ICD-10 code sets, CMS also is proposing to require entities covered under HIPAA to implement updated versions of electronic transmission standards—the Accredited Standards Committee X12 Version 5010 and the National Council for Prescription Drug Programs Version D.0. Both electronic standards have a compliance date of April 1, 2010. The X12 Version 5010 must be in place before the ICD-10 codes can be used, according to CMS.

The two proposed regulations were published in the Federal Register on Aug. 22. CMS will accept comments on the proposals until Oct. 21.

The switch to ICD-10 has been under consideration by the Department of Health and Human Services since 1997. Size and specificity are two of the biggest drawbacks of the ICD-9-CM code set, according to CMS. Because many of the ICD-9-CM chapters are full, CMS has begun to assign codes to unrelated chapters, so that, for example, cardiac procedures have been put in the eye chapter.

The ICD-9-CM also fails to provide adequate clinical details, according to CMS. For example, the ICD-9-CM has a single procedure code that describes endovascular repair or occlusion of the head and neck vessels. But the code leaves out details such as a description of the artery or vein on which the repair was performed, the precise nature of the repair, or whether it was a percutaneous procedure or was transluminal with a catheter.

“Because of the new and changing medical advancements during the past 20-plus years, the functionality of the ICD-9-CM code set has been exhausted,” CMS officials wrote in the proposed regulation. “This code set is no longer able to respond to additional classification specificity, newly identified disease entities, and other advances.”

CMS also is urging a switch to the ICD-10 code sets in an effort to keep in step with other countries. As of October 2002, 99 countries had adopted ICD-10 or a clinical modification for coding and reporting morbidity data. And CMS contends that because it continues to use ICD-9-CM it has problems identifying emerging recent global health threats such as anthrax, severe acute respiratory syndrome (SARS), and monkeypox.

Under the proposal, physicians, hospitals, health plans, and other covered health care entities would be required to use the ICD-10-CM for reporting diagnoses and the ICD-10-PCS for reporting procedures. The ICD-10 code sets offer significantly more codes, about 155,000 across the two sets, compared with about 17,000 for diagnosis and procedure codes within the ICD-9-CM.

In addition to size, the ICD-10 code sets also provide greater specificity, such as being able to reflect the side of the body that is related to the diagnosis or procedure. The more detailed information available through the ICD-10 codes also will aid in the implementation of electronic health records and transmission of data for biosurveillance or pay-for-performance programs, according to CMS.

But physician groups say CMS is asking physicians and other health care providers to do too much too fast.

The American Medical Association balked at the idea of implementation of both the updated X12 Version 5010 electronic transaction standard and the ICD-10 coding system in just 3 years. The X12 Version 5010 standard should first be pilot tested before physicians and others are asked to implement it, AMA said.

“This is a massive administrative undertaking for physicians and must be implemented in a time frame that allows for physician education, software vendor updates, coder training, and testing with payers—steps that cannot be rushed and are needed for a smooth transition,” Dr. Joseph Heyman, AMA board chair, said in a statement.

The Medical Group Management Association also objected. While MGMA supports the switch to the ICD-10 code sets, they said that 3 years is not enough time for the industry to implement the new system.

Instead of a simultaneous implementation of the X12 Version 5010 standard and the ICD-10 code sets, MGMA is asking CMS to wait at least 3 years after the switch to X12 Version 5010 before implementing the ICD-10.

The switch to ICD-10 needs to be done separately because it will require significant changes from medical groups, according to MGMA. Recent MGMA research indicates that most medical practices will have to purchase software upgrades for their practice management systems or buy all new software in order to implement the transition to ICD-10.

“Moving to these new code sets has the potential to be the most complex change for the U.S. health care system in decades,” Dr. William F. Jessee, president and CEO of MGMA, said in a statement.

Officials at the Centers for Medicare and Medicaid Services plan to replace the ICD-9-CM diagnosis and procedure code set with a significantly expanded set of codes—the ICD-10—by Oct. 1, 2011.

But physician groups are calling the agency's plan rushed and unworkable and want the agency to reconsider its compliance date.

In addition to the requirements for using the ICD-10 code sets, CMS also is proposing to require entities covered under HIPAA to implement updated versions of electronic transmission standards—the Accredited Standards Committee X12 Version 5010 and the National Council for Prescription Drug Programs Version D.0. Both electronic standards have a compliance date of April 1, 2010. The X12 Version 5010 must be in place before the ICD-10 codes can be used, according to CMS.

The two proposed regulations were published in the Federal Register on Aug. 22. CMS will accept comments on the proposals until Oct. 21.

The switch to ICD-10 has been under consideration by the Department of Health and Human Services since 1997. Size and specificity are two of the biggest drawbacks of the ICD-9-CM code set, according to CMS. Because many of the ICD-9-CM chapters are full, CMS has begun to assign codes to unrelated chapters, so that, for example, cardiac procedures have been put in the eye chapter.

The ICD-9-CM also fails to provide adequate clinical details, according to CMS. For example, the ICD-9-CM has a single procedure code that describes endovascular repair or occlusion of the head and neck vessels. But the code leaves out details such as a description of the artery or vein on which the repair was performed, the precise nature of the repair, or whether it was a percutaneous procedure or was transluminal with a catheter.

“Because of the new and changing medical advancements during the past 20-plus years, the functionality of the ICD-9-CM code set has been exhausted,” CMS officials wrote in the proposed regulation. “This code set is no longer able to respond to additional classification specificity, newly identified disease entities, and other advances.”

CMS also is urging a switch to the ICD-10 code sets in an effort to keep in step with other countries. As of October 2002, 99 countries had adopted ICD-10 or a clinical modification for coding and reporting morbidity data. And CMS contends that because it continues to use ICD-9-CM it has problems identifying emerging recent global health threats such as anthrax, severe acute respiratory syndrome (SARS), and monkeypox.

Under the proposal, physicians, hospitals, health plans, and other covered health care entities would be required to use the ICD-10-CM for reporting diagnoses and the ICD-10-PCS for reporting procedures. The ICD-10 code sets offer significantly more codes, about 155,000 across the two sets, compared with about 17,000 for diagnosis and procedure codes within the ICD-9-CM.

In addition to size, the ICD-10 code sets also provide greater specificity, such as being able to reflect the side of the body that is related to the diagnosis or procedure. The more detailed information available through the ICD-10 codes also will aid in the implementation of electronic health records and transmission of data for biosurveillance or pay-for-performance programs, according to CMS.

But physician groups say CMS is asking physicians and other health care providers to do too much too fast.

The American Medical Association balked at the idea of implementation of both the updated X12 Version 5010 electronic transaction standard and the ICD-10 coding system in just 3 years. The X12 Version 5010 standard should first be pilot tested before physicians and others are asked to implement it, AMA said.

“This is a massive administrative undertaking for physicians and must be implemented in a time frame that allows for physician education, software vendor updates, coder training, and testing with payers—steps that cannot be rushed and are needed for a smooth transition,” Dr. Joseph Heyman, AMA board chair, said in a statement.

The Medical Group Management Association also objected. While MGMA supports the switch to the ICD-10 code sets, they said that 3 years is not enough time for the industry to implement the new system.

Instead of a simultaneous implementation of the X12 Version 5010 standard and the ICD-10 code sets, MGMA is asking CMS to wait at least 3 years after the switch to X12 Version 5010 before implementing the ICD-10.

The switch to ICD-10 needs to be done separately because it will require significant changes from medical groups, according to MGMA. Recent MGMA research indicates that most medical practices will have to purchase software upgrades for their practice management systems or buy all new software in order to implement the transition to ICD-10.

“Moving to these new code sets has the potential to be the most complex change for the U.S. health care system in decades,” Dr. William F. Jessee, president and CEO of MGMA, said in a statement.

Officials at the Centers for Medicare and Medicaid Services plan to replace the ICD-9-CM diagnosis and procedure code set with a significantly expanded set of codes—the ICD-10—by Oct. 1, 2011.

But physician groups are calling the agency's plan rushed and unworkable and want the agency to reconsider its compliance date.

In addition to the requirements for using the ICD-10 code sets, CMS also is proposing to require entities covered under HIPAA to implement updated versions of electronic transmission standards—the Accredited Standards Committee X12 Version 5010 and the National Council for Prescription Drug Programs Version D.0. Both electronic standards have a compliance date of April 1, 2010. The X12 Version 5010 must be in place before the ICD-10 codes can be used, according to CMS.

The two proposed regulations were published in the Federal Register on Aug. 22. CMS will accept comments on the proposals until Oct. 21.

The switch to ICD-10 has been under consideration by the Department of Health and Human Services since 1997. Size and specificity are two of the biggest drawbacks of the ICD-9-CM code set, according to CMS. Because many of the ICD-9-CM chapters are full, CMS has begun to assign codes to unrelated chapters, so that, for example, cardiac procedures have been put in the eye chapter.

The ICD-9-CM also fails to provide adequate clinical details, according to CMS. For example, the ICD-9-CM has a single procedure code that describes endovascular repair or occlusion of the head and neck vessels. But the code leaves out details such as a description of the artery or vein on which the repair was performed, the precise nature of the repair, or whether it was a percutaneous procedure or was transluminal with a catheter.

“Because of the new and changing medical advancements during the past 20-plus years, the functionality of the ICD-9-CM code set has been exhausted,” CMS officials wrote in the proposed regulation. “This code set is no longer able to respond to additional classification specificity, newly identified disease entities, and other advances.”

CMS also is urging a switch to the ICD-10 code sets in an effort to keep in step with other countries. As of October 2002, 99 countries had adopted ICD-10 or a clinical modification for coding and reporting morbidity data. And CMS contends that because it continues to use ICD-9-CM it has problems identifying emerging recent global health threats such as anthrax, severe acute respiratory syndrome (SARS), and monkeypox.

Under the proposal, physicians, hospitals, health plans, and other covered health care entities would be required to use the ICD-10-CM for reporting diagnoses and the ICD-10-PCS for reporting procedures. The ICD-10 code sets offer significantly more codes, about 155,000 across the two sets, compared with about 17,000 for diagnosis and procedure codes within the ICD-9-CM.

In addition to size, the ICD-10 code sets also provide greater specificity, such as being able to reflect the side of the body that is related to the diagnosis or procedure. The more detailed information available through the ICD-10 codes also will aid in the implementation of electronic health records and transmission of data for biosurveillance or pay-for-performance programs, according to CMS.

But physician groups say CMS is asking physicians and other health care providers to do too much too fast.

The American Medical Association balked at the idea of implementation of both the updated X12 Version 5010 electronic transaction standard and the ICD-10 coding system in just 3 years. The X12 Version 5010 standard should first be pilot tested before physicians and others are asked to implement it, AMA said.

“This is a massive administrative undertaking for physicians and must be implemented in a time frame that allows for physician education, software vendor updates, coder training, and testing with payers—steps that cannot be rushed and are needed for a smooth transition,” Dr. Joseph Heyman, AMA board chair, said in a statement.

The Medical Group Management Association also objected. While MGMA supports the switch to the ICD-10 code sets, they said that 3 years is not enough time for the industry to implement the new system.

Instead of a simultaneous implementation of the X12 Version 5010 standard and the ICD-10 code sets, MGMA is asking CMS to wait at least 3 years after the switch to X12 Version 5010 before implementing the ICD-10.

The switch to ICD-10 needs to be done separately because it will require significant changes from medical groups, according to MGMA. Recent MGMA research indicates that most medical practices will have to purchase software upgrades for their practice management systems or buy all new software in order to implement the transition to ICD-10.

“Moving to these new code sets has the potential to be the most complex change for the U.S. health care system in decades,” Dr. William F. Jessee, president and CEO of MGMA, said in a statement.

California to Vote on Parental Notice

Voters in California will once again consider whether to mandate parental notification prior to a minor's receiving an abortion. California ballots next month will include an initiative to amend the state constitution to require parental notification 48 hours in advance of minors receiving abortions. In the case of reported parental abuse, another adult family member can be notified. The minor can also seek a waiver of parental notice from a judge. The initiative, Proposition 4, includes an exemption of parental notification in the case of a medical emergency. Supporters say that parental notification would help stop sexual predators from covering up their sexual exploitation of minors through secret abortions. In contrast, opponents of the measure say that parental notification is ineffective and jeopardizes the health of young women. The initiative is being opposed by the American College of Obstetricians and Gynecologists, the California Medical Association, and the California District of the American Academy of Pediatrics. Similar ballot initiatives were defeated in California in 2005 and 2006.

Inconsistent Contraceptive Use

Some women may be using contraceptives inconsistently because they are ambivalent about getting pregnant or fantasize about the idea of a pregnancy, according to a study published in the September issue of Perspectives on Sexual and Reproductive Health. The researchers conducted in-depth interviews with 24 women and 12 men from the metropolitan Atlanta area to gauge their attitudes about unprotected sex and their experiences with unintended pregnancy. The qualitative analysis found that some individuals had greater sexual arousal at the idea of conception, others had a romantic fantasy about the idea of pregnancy, and others considered an accidental pregnancy as a way to escape a bad family situation or poverty. While the study had a small sample size, the researchers said it was useful in identifying some of the factors affecting inconsistent contraceptive use. The investigators also called on other researchers to include men in these types of studies to figure out how men's attitudes can affect the use of contraceptives.

HIV Rate Highest in Black Women

Among women, African Americans bear a heavier burden of HIV/AIDS than do other ethnic groups, according to a new analysis by researchers at the Centers for Disease Control and Prevention. The HIV incidence rate for African American women was 55.7 per 100,000 population in 2006, nearly 15 times as high as the incidence rate for white women and nearly 4 times as high as the incidence for Hispanic women. The disproportionate rates of HIV infection among African Americans in the United States could be linked to a number of factors, including poverty, stigma, limited access to health care, higher rates of other sexually transmitted diseases, and drug use, according to the CDC. The analysis was published last month in the CDC's Morbidity and Mortality Weekly Report. The results are based on extrapolations from a total of 33,802 HIV diagnoses in 2006 among individuals aged 13 years and older that were reported to the CDC from 22 states.

Stem Cell Guidelines Revised

An expert committee convened by the Institute of Medicine and the National Research Council recently revised guidelines for conducting research involving human embryonic stem cells. The guidelines, which offer national ethical standards, amend guidelines issued by the standing committee in 2005 and 2007. They were revised in part to provide guidance on the use of new human stem cells called “induced pluripotent cells.” These cells were developed recently and are derived by reprogramming nonembryonic adult cells. While these stem cells do not use embryos, many of the ethical and policy concerns are similar to those involving human embryonic stem cells, according to the Human Embryonic Stem Cell Research Advisory Committee. The revised guidelines also recommend that institutions that are conducting stem cell research notify the public about the types of research being pursued. The report was sponsored by the Ellison Medical Foundation, the Greenwall Foundation, and the Howard Hughes Medical Institute.

CMS Alters Overpayment Policy

Officials at the Centers for Medicare and Medicaid Services are changing the procedures for recovering certain overpayments made to physicians. The CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the CMS can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect on Sept. 29, will apply to all Part A and Part B claims for which a demand letter has been issued. However, a number of claims have been excluded, including Part A cost reports, Hospice Caps calculations, provider initiated adjustments, Home Health Agency Requests for Anticipated Payment, Accelerated/Advanced Payments, and certain other claims adjustments. The changes do not affect the appeal process or the normal debt collection and referral process, according to the CMS.

California to Vote on Parental Notice

Voters in California will once again consider whether to mandate parental notification prior to a minor's receiving an abortion. California ballots next month will include an initiative to amend the state constitution to require parental notification 48 hours in advance of minors receiving abortions. In the case of reported parental abuse, another adult family member can be notified. The minor can also seek a waiver of parental notice from a judge. The initiative, Proposition 4, includes an exemption of parental notification in the case of a medical emergency. Supporters say that parental notification would help stop sexual predators from covering up their sexual exploitation of minors through secret abortions. In contrast, opponents of the measure say that parental notification is ineffective and jeopardizes the health of young women. The initiative is being opposed by the American College of Obstetricians and Gynecologists, the California Medical Association, and the California District of the American Academy of Pediatrics. Similar ballot initiatives were defeated in California in 2005 and 2006.

Inconsistent Contraceptive Use

Some women may be using contraceptives inconsistently because they are ambivalent about getting pregnant or fantasize about the idea of a pregnancy, according to a study published in the September issue of Perspectives on Sexual and Reproductive Health. The researchers conducted in-depth interviews with 24 women and 12 men from the metropolitan Atlanta area to gauge their attitudes about unprotected sex and their experiences with unintended pregnancy. The qualitative analysis found that some individuals had greater sexual arousal at the idea of conception, others had a romantic fantasy about the idea of pregnancy, and others considered an accidental pregnancy as a way to escape a bad family situation or poverty. While the study had a small sample size, the researchers said it was useful in identifying some of the factors affecting inconsistent contraceptive use. The investigators also called on other researchers to include men in these types of studies to figure out how men's attitudes can affect the use of contraceptives.

HIV Rate Highest in Black Women

Among women, African Americans bear a heavier burden of HIV/AIDS than do other ethnic groups, according to a new analysis by researchers at the Centers for Disease Control and Prevention. The HIV incidence rate for African American women was 55.7 per 100,000 population in 2006, nearly 15 times as high as the incidence rate for white women and nearly 4 times as high as the incidence for Hispanic women. The disproportionate rates of HIV infection among African Americans in the United States could be linked to a number of factors, including poverty, stigma, limited access to health care, higher rates of other sexually transmitted diseases, and drug use, according to the CDC. The analysis was published last month in the CDC's Morbidity and Mortality Weekly Report. The results are based on extrapolations from a total of 33,802 HIV diagnoses in 2006 among individuals aged 13 years and older that were reported to the CDC from 22 states.

Stem Cell Guidelines Revised

An expert committee convened by the Institute of Medicine and the National Research Council recently revised guidelines for conducting research involving human embryonic stem cells. The guidelines, which offer national ethical standards, amend guidelines issued by the standing committee in 2005 and 2007. They were revised in part to provide guidance on the use of new human stem cells called “induced pluripotent cells.” These cells were developed recently and are derived by reprogramming nonembryonic adult cells. While these stem cells do not use embryos, many of the ethical and policy concerns are similar to those involving human embryonic stem cells, according to the Human Embryonic Stem Cell Research Advisory Committee. The revised guidelines also recommend that institutions that are conducting stem cell research notify the public about the types of research being pursued. The report was sponsored by the Ellison Medical Foundation, the Greenwall Foundation, and the Howard Hughes Medical Institute.

CMS Alters Overpayment Policy

Officials at the Centers for Medicare and Medicaid Services are changing the procedures for recovering certain overpayments made to physicians. The CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the CMS can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect on Sept. 29, will apply to all Part A and Part B claims for which a demand letter has been issued. However, a number of claims have been excluded, including Part A cost reports, Hospice Caps calculations, provider initiated adjustments, Home Health Agency Requests for Anticipated Payment, Accelerated/Advanced Payments, and certain other claims adjustments. The changes do not affect the appeal process or the normal debt collection and referral process, according to the CMS.

California to Vote on Parental Notice

Voters in California will once again consider whether to mandate parental notification prior to a minor's receiving an abortion. California ballots next month will include an initiative to amend the state constitution to require parental notification 48 hours in advance of minors receiving abortions. In the case of reported parental abuse, another adult family member can be notified. The minor can also seek a waiver of parental notice from a judge. The initiative, Proposition 4, includes an exemption of parental notification in the case of a medical emergency. Supporters say that parental notification would help stop sexual predators from covering up their sexual exploitation of minors through secret abortions. In contrast, opponents of the measure say that parental notification is ineffective and jeopardizes the health of young women. The initiative is being opposed by the American College of Obstetricians and Gynecologists, the California Medical Association, and the California District of the American Academy of Pediatrics. Similar ballot initiatives were defeated in California in 2005 and 2006.

Inconsistent Contraceptive Use

Some women may be using contraceptives inconsistently because they are ambivalent about getting pregnant or fantasize about the idea of a pregnancy, according to a study published in the September issue of Perspectives on Sexual and Reproductive Health. The researchers conducted in-depth interviews with 24 women and 12 men from the metropolitan Atlanta area to gauge their attitudes about unprotected sex and their experiences with unintended pregnancy. The qualitative analysis found that some individuals had greater sexual arousal at the idea of conception, others had a romantic fantasy about the idea of pregnancy, and others considered an accidental pregnancy as a way to escape a bad family situation or poverty. While the study had a small sample size, the researchers said it was useful in identifying some of the factors affecting inconsistent contraceptive use. The investigators also called on other researchers to include men in these types of studies to figure out how men's attitudes can affect the use of contraceptives.

HIV Rate Highest in Black Women

Among women, African Americans bear a heavier burden of HIV/AIDS than do other ethnic groups, according to a new analysis by researchers at the Centers for Disease Control and Prevention. The HIV incidence rate for African American women was 55.7 per 100,000 population in 2006, nearly 15 times as high as the incidence rate for white women and nearly 4 times as high as the incidence for Hispanic women. The disproportionate rates of HIV infection among African Americans in the United States could be linked to a number of factors, including poverty, stigma, limited access to health care, higher rates of other sexually transmitted diseases, and drug use, according to the CDC. The analysis was published last month in the CDC's Morbidity and Mortality Weekly Report. The results are based on extrapolations from a total of 33,802 HIV diagnoses in 2006 among individuals aged 13 years and older that were reported to the CDC from 22 states.

Stem Cell Guidelines Revised

An expert committee convened by the Institute of Medicine and the National Research Council recently revised guidelines for conducting research involving human embryonic stem cells. The guidelines, which offer national ethical standards, amend guidelines issued by the standing committee in 2005 and 2007. They were revised in part to provide guidance on the use of new human stem cells called “induced pluripotent cells.” These cells were developed recently and are derived by reprogramming nonembryonic adult cells. While these stem cells do not use embryos, many of the ethical and policy concerns are similar to those involving human embryonic stem cells, according to the Human Embryonic Stem Cell Research Advisory Committee. The revised guidelines also recommend that institutions that are conducting stem cell research notify the public about the types of research being pursued. The report was sponsored by the Ellison Medical Foundation, the Greenwall Foundation, and the Howard Hughes Medical Institute.

CMS Alters Overpayment Policy

Officials at the Centers for Medicare and Medicaid Services are changing the procedures for recovering certain overpayments made to physicians. The CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the CMS can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect on Sept. 29, will apply to all Part A and Part B claims for which a demand letter has been issued. However, a number of claims have been excluded, including Part A cost reports, Hospice Caps calculations, provider initiated adjustments, Home Health Agency Requests for Anticipated Payment, Accelerated/Advanced Payments, and certain other claims adjustments. The changes do not affect the appeal process or the normal debt collection and referral process, according to the CMS.

Policy & Practice

Neurologists Rank High in MRI Use

Most magnetic resonance imaging services paid for through Medicare Part B in 2005 were ordered by physicians in four specialties—neurology, internal medicine, orthopedic surgery, and family medicine—according to a report from the Health and Human Services Office of Inspector General. Internists topped the list by ordering 21% of the 2.6 million MRI services, followed by orthopedic surgeons (19%), and family physicians and neurologists (13% each). The “high users” of MRI, defined as those whose allowed charges put them at the 95th percentile or above for all physicians who ordered MRIs, were predominately orthopedic surgeons and neurologists. The study did not evaluate the medical appropriateness or necessity of the services ordered. The full report is available at

www.oig.hhs.gov/oei/reports/oei-01-06-00261.pdf

Imaging Cuts Reduce Costs

Medicare Part B payments for physician-performed imaging services dropped almost 13% between 2006 and 2007 due mainly to caps on physician payments called for under the Deficit Reduction Act (DRA) of 2005, according to an analysis from the Government Accountability Office (GAO). Under the DRA, Medicare fees for certain imaging services provided in the physician's office may not exceed what Medicare pays under the hospital outpatient prospective payment system. The imaging payment cap went into effect on Jan. 1, 2007. As a result, Medicare Part B per-beneficiary expenditures for imaging services fell from $419 in 2006 to $375 in 2007. Expenditures for advanced imaging services such as computer tomography and MRI fell even more. Although per-beneficiary expenditures dropped, utilization of services continued to rise, according to the GAO, which did the analysis at the request of Congress. The GAO concluded that beneficiary access at the national level was not affected by the payment cuts. However, the medical technology trade organization AdvaMed said the report indicated that the payments cuts were deeper than expected and are not in the interest of patients. Requiring accreditation of equipment and personnel in physician offices and developing appropriateness criteria would be a better approach to curb high imaging expenses, according to AdvaMed.

NIH: Environment's Role in PD?

The National Institutes of Health is awarding more than $21 million over 5 years to study how environmental factors contribute to the cause, prevention, and treatment of Parkinson's disease. The recipients of the grants, administered through the National Institute of Environmental Health Sciences (NIEHS), will attempt to develop new biomarkers in the blood that could be used to identify individuals at risk for Parkinson's disease, identify agricultural pesticides that disrupt molecular pathways, and analyze how proteins associated with Parkinson's disease are modified by environmental toxins, Cindy Lawler, Ph.D., NIEHS program administrator, said in a statement.

Cephalon Pays $425 Million

Cephalon Inc. has agreed to pay more than $425 million to settle claims that it inappropriately marketed three drugs for off-label uses, according to the U.S. Justice Department. The settlement will resolve civil and criminal complaints alleging that the company marketed Gabitril (tiagabine), Actiq (oral transmucosal fentanyl), and Provigil (modafinil) for off-label uses. Between 2001 and 2006, Cephalon allegedly promoted Actiq, which is an approved pain treatment in opioid-tolerant cancer patients, as a treatment for migraine, sickle-cell pain, and injuries. The epilepsy treatment Gabitril was allegedly promoted for treatment of anxiety, insomnia, and pain. Provigil, which was originally approved to treat excessive daytime sleepiness associated with narcolepsy, was allegedly promoted off label as a nonstimulant drug for sleepiness, tiredness, decreased activity, and fatigue. Under the settlement, Cephalon has entered into a 5-year Corporate Integrity Agreement with the Heath and Human Services Office of Inspector General. The agreement requires the company to notify physicians of the terms of the settlement and to begin disclosing any payments made to physicians on its Web site by Jan. 31, 2010.

Few Nabbed for Pain Prescribing

Few physicians have been charged or sanctioned for prescribing pain medications improperly, according to a study. From 1998 to 2006, only 725 individual physicians, or about 0.1% of practicing physicians in the United States, had been criminally charged or administratively reviewed for offenses involving the prescribing of opioid analgesics. Nearly 40% of the cases involved family medicine or general practice physicians, and 23.7% involved internists. In contrast, only 3.5% of cases involved pain medicine specialists. The high number of investigations of primary care physicians is not surprising given the shortage of pain specialists, the researchers wrote. “Practicing physicians, including pain medicine specialists, have little objective cause for concern about being prosecuted by law enforcement or disciplined by state medical boards in connection with the prescribing of [controlled substance] pain medications,” the researchers wrote (Pain Med. 2008;9:737-47 [Epub doi:10.1111/ j.1526-4637.2008.00482.x]). The study was conducted by researchers from the National Association of Attorneys General, the Federation of State Medical Boards, and the Center for Practical Bioethics.

Policy & Practice

Neurologists Rank High in MRI Use

Most magnetic resonance imaging services paid for through Medicare Part B in 2005 were ordered by physicians in four specialties—neurology, internal medicine, orthopedic surgery, and family medicine—according to a report from the Health and Human Services Office of Inspector General. Internists topped the list by ordering 21% of the 2.6 million MRI services, followed by orthopedic surgeons (19%), and family physicians and neurologists (13% each). The “high users” of MRI, defined as those whose allowed charges put them at the 95th percentile or above for all physicians who ordered MRIs, were predominately orthopedic surgeons and neurologists. The study did not evaluate the medical appropriateness or necessity of the services ordered. The full report is available at

www.oig.hhs.gov/oei/reports/oei-01-06-00261.pdf

Imaging Cuts Reduce Costs

Medicare Part B payments for physician-performed imaging services dropped almost 13% between 2006 and 2007 due mainly to caps on physician payments called for under the Deficit Reduction Act (DRA) of 2005, according to an analysis from the Government Accountability Office (GAO). Under the DRA, Medicare fees for certain imaging services provided in the physician's office may not exceed what Medicare pays under the hospital outpatient prospective payment system. The imaging payment cap went into effect on Jan. 1, 2007. As a result, Medicare Part B per-beneficiary expenditures for imaging services fell from $419 in 2006 to $375 in 2007. Expenditures for advanced imaging services such as computer tomography and MRI fell even more. Although per-beneficiary expenditures dropped, utilization of services continued to rise, according to the GAO, which did the analysis at the request of Congress. The GAO concluded that beneficiary access at the national level was not affected by the payment cuts. However, the medical technology trade organization AdvaMed said the report indicated that the payments cuts were deeper than expected and are not in the interest of patients. Requiring accreditation of equipment and personnel in physician offices and developing appropriateness criteria would be a better approach to curb high imaging expenses, according to AdvaMed.

NIH: Environment's Role in PD?

The National Institutes of Health is awarding more than $21 million over 5 years to study how environmental factors contribute to the cause, prevention, and treatment of Parkinson's disease. The recipients of the grants, administered through the National Institute of Environmental Health Sciences (NIEHS), will attempt to develop new biomarkers in the blood that could be used to identify individuals at risk for Parkinson's disease, identify agricultural pesticides that disrupt molecular pathways, and analyze how proteins associated with Parkinson's disease are modified by environmental toxins, Cindy Lawler, Ph.D., NIEHS program administrator, said in a statement.

Cephalon Pays $425 Million

Cephalon Inc. has agreed to pay more than $425 million to settle claims that it inappropriately marketed three drugs for off-label uses, according to the U.S. Justice Department. The settlement will resolve civil and criminal complaints alleging that the company marketed Gabitril (tiagabine), Actiq (oral transmucosal fentanyl), and Provigil (modafinil) for off-label uses. Between 2001 and 2006, Cephalon allegedly promoted Actiq, which is an approved pain treatment in opioid-tolerant cancer patients, as a treatment for migraine, sickle-cell pain, and injuries. The epilepsy treatment Gabitril was allegedly promoted for treatment of anxiety, insomnia, and pain. Provigil, which was originally approved to treat excessive daytime sleepiness associated with narcolepsy, was allegedly promoted off label as a nonstimulant drug for sleepiness, tiredness, decreased activity, and fatigue. Under the settlement, Cephalon has entered into a 5-year Corporate Integrity Agreement with the Heath and Human Services Office of Inspector General. The agreement requires the company to notify physicians of the terms of the settlement and to begin disclosing any payments made to physicians on its Web site by Jan. 31, 2010.

Few Nabbed for Pain Prescribing

Few physicians have been charged or sanctioned for prescribing pain medications improperly, according to a study. From 1998 to 2006, only 725 individual physicians, or about 0.1% of practicing physicians in the United States, had been criminally charged or administratively reviewed for offenses involving the prescribing of opioid analgesics. Nearly 40% of the cases involved family medicine or general practice physicians, and 23.7% involved internists. In contrast, only 3.5% of cases involved pain medicine specialists. The high number of investigations of primary care physicians is not surprising given the shortage of pain specialists, the researchers wrote. “Practicing physicians, including pain medicine specialists, have little objective cause for concern about being prosecuted by law enforcement or disciplined by state medical boards in connection with the prescribing of [controlled substance] pain medications,” the researchers wrote (Pain Med. 2008;9:737-47 [Epub doi:10.1111/ j.1526-4637.2008.00482.x]). The study was conducted by researchers from the National Association of Attorneys General, the Federation of State Medical Boards, and the Center for Practical Bioethics.

Policy & Practice

Neurologists Rank High in MRI Use

Most magnetic resonance imaging services paid for through Medicare Part B in 2005 were ordered by physicians in four specialties—neurology, internal medicine, orthopedic surgery, and family medicine—according to a report from the Health and Human Services Office of Inspector General. Internists topped the list by ordering 21% of the 2.6 million MRI services, followed by orthopedic surgeons (19%), and family physicians and neurologists (13% each). The “high users” of MRI, defined as those whose allowed charges put them at the 95th percentile or above for all physicians who ordered MRIs, were predominately orthopedic surgeons and neurologists. The study did not evaluate the medical appropriateness or necessity of the services ordered. The full report is available at

www.oig.hhs.gov/oei/reports/oei-01-06-00261.pdf

Imaging Cuts Reduce Costs

Medicare Part B payments for physician-performed imaging services dropped almost 13% between 2006 and 2007 due mainly to caps on physician payments called for under the Deficit Reduction Act (DRA) of 2005, according to an analysis from the Government Accountability Office (GAO). Under the DRA, Medicare fees for certain imaging services provided in the physician's office may not exceed what Medicare pays under the hospital outpatient prospective payment system. The imaging payment cap went into effect on Jan. 1, 2007. As a result, Medicare Part B per-beneficiary expenditures for imaging services fell from $419 in 2006 to $375 in 2007. Expenditures for advanced imaging services such as computer tomography and MRI fell even more. Although per-beneficiary expenditures dropped, utilization of services continued to rise, according to the GAO, which did the analysis at the request of Congress. The GAO concluded that beneficiary access at the national level was not affected by the payment cuts. However, the medical technology trade organization AdvaMed said the report indicated that the payments cuts were deeper than expected and are not in the interest of patients. Requiring accreditation of equipment and personnel in physician offices and developing appropriateness criteria would be a better approach to curb high imaging expenses, according to AdvaMed.

NIH: Environment's Role in PD?

The National Institutes of Health is awarding more than $21 million over 5 years to study how environmental factors contribute to the cause, prevention, and treatment of Parkinson's disease. The recipients of the grants, administered through the National Institute of Environmental Health Sciences (NIEHS), will attempt to develop new biomarkers in the blood that could be used to identify individuals at risk for Parkinson's disease, identify agricultural pesticides that disrupt molecular pathways, and analyze how proteins associated with Parkinson's disease are modified by environmental toxins, Cindy Lawler, Ph.D., NIEHS program administrator, said in a statement.

Cephalon Pays $425 Million

Cephalon Inc. has agreed to pay more than $425 million to settle claims that it inappropriately marketed three drugs for off-label uses, according to the U.S. Justice Department. The settlement will resolve civil and criminal complaints alleging that the company marketed Gabitril (tiagabine), Actiq (oral transmucosal fentanyl), and Provigil (modafinil) for off-label uses. Between 2001 and 2006, Cephalon allegedly promoted Actiq, which is an approved pain treatment in opioid-tolerant cancer patients, as a treatment for migraine, sickle-cell pain, and injuries. The epilepsy treatment Gabitril was allegedly promoted for treatment of anxiety, insomnia, and pain. Provigil, which was originally approved to treat excessive daytime sleepiness associated with narcolepsy, was allegedly promoted off label as a nonstimulant drug for sleepiness, tiredness, decreased activity, and fatigue. Under the settlement, Cephalon has entered into a 5-year Corporate Integrity Agreement with the Heath and Human Services Office of Inspector General. The agreement requires the company to notify physicians of the terms of the settlement and to begin disclosing any payments made to physicians on its Web site by Jan. 31, 2010.

Few Nabbed for Pain Prescribing

Few physicians have been charged or sanctioned for prescribing pain medications improperly, according to a study. From 1998 to 2006, only 725 individual physicians, or about 0.1% of practicing physicians in the United States, had been criminally charged or administratively reviewed for offenses involving the prescribing of opioid analgesics. Nearly 40% of the cases involved family medicine or general practice physicians, and 23.7% involved internists. In contrast, only 3.5% of cases involved pain medicine specialists. The high number of investigations of primary care physicians is not surprising given the shortage of pain specialists, the researchers wrote. “Practicing physicians, including pain medicine specialists, have little objective cause for concern about being prosecuted by law enforcement or disciplined by state medical boards in connection with the prescribing of [controlled substance] pain medications,” the researchers wrote (Pain Med. 2008;9:737-47 [Epub doi:10.1111/ j.1526-4637.2008.00482.x]). The study was conducted by researchers from the National Association of Attorneys General, the Federation of State Medical Boards, and the Center for Practical Bioethics.

OA Hospitalizations Skyrocket

Hospitalizations for osteoarthritis more than doubled between 1993 and 2006, according to data from the Agency for Healthcare Research and Quality. In 2006, there were about 735,000 hospitalizations for osteoarthritis in the United States, up from about 322,000 in 1993. But most of the increase occurred between 2000 and 2006, when hospitalizations for the condition rose from about 443,000 to 735,000. AHRQ officials attribute most of the increase in osteoarthritis hospitalizations to the rising number of knee replacement surgeries. In 2006, osteoarthritis was the principal diagnosis in about 90% of knee surgery hospitalizations and 50% of hip replacement hospitalizations, according to the agency. While osteoarthritis hospitalizations were on the rise, hospital stays for rheumatoid arthritis were actually on the decline. Rheumatoid arthritis stays dropped from about 30,400 in 1993 to about 18,900 in 2006. The AHRQ data are based on the 2006 Nationwide Inpatient Sample, which includes all-payer discharge data from 1,045 hospitals located in 38 states.

Osteoporosis: Women's Disease?

Women aged 30 years and older are more likely to report being at risk for osteoporosis than are men and young adults, according to a study published in the October issue of Health Education & Behavior. In a study of 300 men and women across a range of age groups (18–25, 30–50, and 50-plus), the researchers used the Osteoporosis Health Belief Scale to gauge participants' perceptions about their susceptibility to osteoporosis, the seriousness of the condition, and their motivation to make changes to their health behaviors. The 35-item, self-report questionnaire grades responses on a 5-point scale. The responses revealed that women aged 30–50 years and women aged 50 and older had the highest susceptibility scores. Men aged 18–25 years had the lowest susceptibility scores, according to the study. However, the scores related to the seriousness of the condition and the motivation to change health behaviors were not significantly different among the various groups. The finding suggests that men and women of all ages may be unaware of the serious consequences of osteoporosis, the researchers wrote.

Few MDs Targeted for Pain Med Misuse

Few physicians have been charged or sanctioned for prescribing pain medications improperly, according to a study. From 1998 to 2006, only 725 individual physicians, or about 0.1% of practicing physicians, in the United States had been criminally charged or administratively reviewed for offenses involving the prescribing of opioid analgesics. Nearly 40% of the cases involved family medicine or general practice physicians and 23.7% involved internists. In contrast, only 3.5% of cases involved pain medicine specialists. The high number of investigations of primary care physicians is not surprising given that shortage of pain specialists, the researchers wrote. “Practicing physicians, including pain medicine specialists, have little objective cause for concern about being prosecuted by law enforcement or disciplined by state medical boards in connection with the prescribing of [controlled substance] pain medications,” the researchers wrote (Pain Med. 2008;9:737–47 [Epub

doi:10.1111/j.1526-4637.2008.00482.x

Grants to Doctors in Hurricanes

The AMA Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricane Gustav, which affected Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore their damaged medical practices in those locations, said the AMA. Donations may be at

www.ama-assn.org/ama/pub/category/7611.html

CMS Alters Overpayment Policy

Centers for Medicare and Medicaid Services officials are changing the procedures for recovering certain overpayments made to physicians. The CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the CMS can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect Sept. 29, will apply to all Part A and Part B claims for which a demand letter has been issued.

OA Hospitalizations Skyrocket

Hospitalizations for osteoarthritis more than doubled between 1993 and 2006, according to data from the Agency for Healthcare Research and Quality. In 2006, there were about 735,000 hospitalizations for osteoarthritis in the United States, up from about 322,000 in 1993. But most of the increase occurred between 2000 and 2006, when hospitalizations for the condition rose from about 443,000 to 735,000. AHRQ officials attribute most of the increase in osteoarthritis hospitalizations to the rising number of knee replacement surgeries. In 2006, osteoarthritis was the principal diagnosis in about 90% of knee surgery hospitalizations and 50% of hip replacement hospitalizations, according to the agency. While osteoarthritis hospitalizations were on the rise, hospital stays for rheumatoid arthritis were actually on the decline. Rheumatoid arthritis stays dropped from about 30,400 in 1993 to about 18,900 in 2006. The AHRQ data are based on the 2006 Nationwide Inpatient Sample, which includes all-payer discharge data from 1,045 hospitals located in 38 states.

Osteoporosis: Women's Disease?

Women aged 30 years and older are more likely to report being at risk for osteoporosis than are men and young adults, according to a study published in the October issue of Health Education & Behavior. In a study of 300 men and women across a range of age groups (18–25, 30–50, and 50-plus), the researchers used the Osteoporosis Health Belief Scale to gauge participants' perceptions about their susceptibility to osteoporosis, the seriousness of the condition, and their motivation to make changes to their health behaviors. The 35-item, self-report questionnaire grades responses on a 5-point scale. The responses revealed that women aged 30–50 years and women aged 50 and older had the highest susceptibility scores. Men aged 18–25 years had the lowest susceptibility scores, according to the study. However, the scores related to the seriousness of the condition and the motivation to change health behaviors were not significantly different among the various groups. The finding suggests that men and women of all ages may be unaware of the serious consequences of osteoporosis, the researchers wrote.

Few MDs Targeted for Pain Med Misuse

Few physicians have been charged or sanctioned for prescribing pain medications improperly, according to a study. From 1998 to 2006, only 725 individual physicians, or about 0.1% of practicing physicians, in the United States had been criminally charged or administratively reviewed for offenses involving the prescribing of opioid analgesics. Nearly 40% of the cases involved family medicine or general practice physicians and 23.7% involved internists. In contrast, only 3.5% of cases involved pain medicine specialists. The high number of investigations of primary care physicians is not surprising given that shortage of pain specialists, the researchers wrote. “Practicing physicians, including pain medicine specialists, have little objective cause for concern about being prosecuted by law enforcement or disciplined by state medical boards in connection with the prescribing of [controlled substance] pain medications,” the researchers wrote (Pain Med. 2008;9:737–47 [Epub

doi:10.1111/j.1526-4637.2008.00482.x

Grants to Doctors in Hurricanes

The AMA Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricane Gustav, which affected Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore their damaged medical practices in those locations, said the AMA. Donations may be at

www.ama-assn.org/ama/pub/category/7611.html

CMS Alters Overpayment Policy

Centers for Medicare and Medicaid Services officials are changing the procedures for recovering certain overpayments made to physicians. The CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the CMS can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect Sept. 29, will apply to all Part A and Part B claims for which a demand letter has been issued.

OA Hospitalizations Skyrocket

Hospitalizations for osteoarthritis more than doubled between 1993 and 2006, according to data from the Agency for Healthcare Research and Quality. In 2006, there were about 735,000 hospitalizations for osteoarthritis in the United States, up from about 322,000 in 1993. But most of the increase occurred between 2000 and 2006, when hospitalizations for the condition rose from about 443,000 to 735,000. AHRQ officials attribute most of the increase in osteoarthritis hospitalizations to the rising number of knee replacement surgeries. In 2006, osteoarthritis was the principal diagnosis in about 90% of knee surgery hospitalizations and 50% of hip replacement hospitalizations, according to the agency. While osteoarthritis hospitalizations were on the rise, hospital stays for rheumatoid arthritis were actually on the decline. Rheumatoid arthritis stays dropped from about 30,400 in 1993 to about 18,900 in 2006. The AHRQ data are based on the 2006 Nationwide Inpatient Sample, which includes all-payer discharge data from 1,045 hospitals located in 38 states.

Osteoporosis: Women's Disease?

Women aged 30 years and older are more likely to report being at risk for osteoporosis than are men and young adults, according to a study published in the October issue of Health Education & Behavior. In a study of 300 men and women across a range of age groups (18–25, 30–50, and 50-plus), the researchers used the Osteoporosis Health Belief Scale to gauge participants' perceptions about their susceptibility to osteoporosis, the seriousness of the condition, and their motivation to make changes to their health behaviors. The 35-item, self-report questionnaire grades responses on a 5-point scale. The responses revealed that women aged 30–50 years and women aged 50 and older had the highest susceptibility scores. Men aged 18–25 years had the lowest susceptibility scores, according to the study. However, the scores related to the seriousness of the condition and the motivation to change health behaviors were not significantly different among the various groups. The finding suggests that men and women of all ages may be unaware of the serious consequences of osteoporosis, the researchers wrote.

Few MDs Targeted for Pain Med Misuse

Few physicians have been charged or sanctioned for prescribing pain medications improperly, according to a study. From 1998 to 2006, only 725 individual physicians, or about 0.1% of practicing physicians, in the United States had been criminally charged or administratively reviewed for offenses involving the prescribing of opioid analgesics. Nearly 40% of the cases involved family medicine or general practice physicians and 23.7% involved internists. In contrast, only 3.5% of cases involved pain medicine specialists. The high number of investigations of primary care physicians is not surprising given that shortage of pain specialists, the researchers wrote. “Practicing physicians, including pain medicine specialists, have little objective cause for concern about being prosecuted by law enforcement or disciplined by state medical boards in connection with the prescribing of [controlled substance] pain medications,” the researchers wrote (Pain Med. 2008;9:737–47 [Epub

doi:10.1111/j.1526-4637.2008.00482.x

Grants to Doctors in Hurricanes

The AMA Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricane Gustav, which affected Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore their damaged medical practices in those locations, said the AMA. Donations may be at

www.ama-assn.org/ama/pub/category/7611.html

CMS Alters Overpayment Policy

Centers for Medicare and Medicaid Services officials are changing the procedures for recovering certain overpayments made to physicians. The CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the CMS can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect Sept. 29, will apply to all Part A and Part B claims for which a demand letter has been issued.

A growing number of working-age Americans are struggling to pay their medical bills or have gone into debt because of high medical expenses, according to a new report from the Commonwealth Fund.

In 2007, 41% of U.S. adults aged younger than 65 reported having medical bill problems or medical debt, versus 34% in 2005. The problem is growing across all income groups but is most common among low- and moderate-income individuals, where more than half reported being unable to pay their medical bills, being contacted by a collection agency about an unpaid medical bill, significantly changing their way of life to pay a medical bill, or paying off medical debt over time.

As health care costs have risen, employers have struggled to provide employee health insurance, leading some to drop coverage or increase employee cost sharing, said Sara R. Collins, Ph.D., lead author of the report and assistant vice president at the Commonwealth Fund.

At the same time, most Americans are facing relatively stagnant wages and rising prices for food and gas, Dr. Collins said during a press briefing.

The findings are based on the Commonwealth Fund Biennial Health Insurance Survey, a nationally representative telephone survey conducted in 2001, 2003, 2005, and 2007. The 2007 data come from an analysis of survey responses from 2,616 adults aged under 65 obtained between June and October 2007.

About 34% of adults who were uninsured at the time of the survey reported owing $4,000 or more in medical bills, compared with 20% of those who were insured.

Both insured and uninsured Americans are spending more out of pocket for their care. In 2007, 48% of Americans aged 19–64 years spent 5% or more of their income annually on out-of-pocket costs and premiums, up from 41% in 2001.

And 33% of working-age Americans spent 10% or more annually on these out-of-pocket medical expenses, compared with 21% in 2001.

A growing number of working-age Americans are struggling to pay their medical bills or have gone into debt because of high medical expenses, according to a new report from the Commonwealth Fund.

In 2007, 41% of U.S. adults aged younger than 65 reported having medical bill problems or medical debt, versus 34% in 2005. The problem is growing across all income groups but is most common among low- and moderate-income individuals, where more than half reported being unable to pay their medical bills, being contacted by a collection agency about an unpaid medical bill, significantly changing their way of life to pay a medical bill, or paying off medical debt over time.

As health care costs have risen, employers have struggled to provide employee health insurance, leading some to drop coverage or increase employee cost sharing, said Sara R. Collins, Ph.D., lead author of the report and assistant vice president at the Commonwealth Fund.

At the same time, most Americans are facing relatively stagnant wages and rising prices for food and gas, Dr. Collins said during a press briefing.

The findings are based on the Commonwealth Fund Biennial Health Insurance Survey, a nationally representative telephone survey conducted in 2001, 2003, 2005, and 2007. The 2007 data come from an analysis of survey responses from 2,616 adults aged under 65 obtained between June and October 2007.

About 34% of adults who were uninsured at the time of the survey reported owing $4,000 or more in medical bills, compared with 20% of those who were insured.

Both insured and uninsured Americans are spending more out of pocket for their care. In 2007, 48% of Americans aged 19–64 years spent 5% or more of their income annually on out-of-pocket costs and premiums, up from 41% in 2001.

And 33% of working-age Americans spent 10% or more annually on these out-of-pocket medical expenses, compared with 21% in 2001.

A growing number of working-age Americans are struggling to pay their medical bills or have gone into debt because of high medical expenses, according to a new report from the Commonwealth Fund.

In 2007, 41% of U.S. adults aged younger than 65 reported having medical bill problems or medical debt, versus 34% in 2005. The problem is growing across all income groups but is most common among low- and moderate-income individuals, where more than half reported being unable to pay their medical bills, being contacted by a collection agency about an unpaid medical bill, significantly changing their way of life to pay a medical bill, or paying off medical debt over time.

As health care costs have risen, employers have struggled to provide employee health insurance, leading some to drop coverage or increase employee cost sharing, said Sara R. Collins, Ph.D., lead author of the report and assistant vice president at the Commonwealth Fund.

At the same time, most Americans are facing relatively stagnant wages and rising prices for food and gas, Dr. Collins said during a press briefing.

The findings are based on the Commonwealth Fund Biennial Health Insurance Survey, a nationally representative telephone survey conducted in 2001, 2003, 2005, and 2007. The 2007 data come from an analysis of survey responses from 2,616 adults aged under 65 obtained between June and October 2007.

About 34% of adults who were uninsured at the time of the survey reported owing $4,000 or more in medical bills, compared with 20% of those who were insured.

Both insured and uninsured Americans are spending more out of pocket for their care. In 2007, 48% of Americans aged 19–64 years spent 5% or more of their income annually on out-of-pocket costs and premiums, up from 41% in 2001.

And 33% of working-age Americans spent 10% or more annually on these out-of-pocket medical expenses, compared with 21% in 2001.