Mary Ellen Schneider

TNF-α Inhibitors Are Top Choice

Tumor necrosis factor-α inhibitors are likely to continue to dominate the rheumatoid arthritis marketplace, according to the results of a survey of 102 rheumatologists conducted by Decision Resources. Almost all reported prescribing TNF-α inhibitors as a first-line biologic therapy. Most reported trying two or more TNF-α inhibitors before trying a treatment with a different mechanism of action. Physicians said they preferred TNF-α inhibitors because they were familiar with the drugs and these drugs were effective in treating RA. The class of drugs is expected to get a boost with the upcoming launch of two new drugs—certolizumab pegol (Cimzia) and golimumab, according to Decision Resources. “Most rheumatologists expect the dominance of TNF-α inhibitors to continue, and possibly expand, over the next 2 years,” Decision Resources director Cindy Mundy, Ph.D., said in a statement. “Following the launches of Cimzia and golimumab, nearly half of surveyed rheumatologists expect to prescribe three or more TNF-α inhibitors before moving to a different class of agents.”

New Leadership at NIAMS

Dr. Robert H. Carter, a leading researcher and rheumatologist, will become the new deputy director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), part of the National Institutes of Health, this fall. Dr. Carter is a former director of the division of clinical immunology and rheumatology at the University of Alabama at Birmingham and is the principal investigator of the university's NIAMS-supported Rheumatic Disease Core Center. In his new role, Dr. Carter will assist in developing the NIAMS portfolio of research from basic science to translational research. “His stellar credentials as a scientist and his broad experience in NIH extramural activities will contribute to NIAMS' long history of excellence in biomedical research,” Dr. Stephen Katz, NIAMS director, said in a statement.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people—66% of all adults and 81% of those who have online access—said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers who conducted the poll noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, in contrast to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the poll calls “cybercondriacs”—indicating that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

Home Drug Errors Rise

A shift in the number of medications being taken outside of the hospital has correlated with a sharp increase in the number of fatal medication errors in the home, researchers reported in the Archives of Internal Medicine. In the study, sociologists at the University of California, San Diego, found a 3,196% increase in fatal domestic medication errors involving alcohol and/or street drugs, and a 564% increase in domestic medication fatalities not involving alcohol and/or street drugs. The study examined nearly 50 million U.S. death certificates from 1983 to 2004, and focused on the 200,000 deaths involving medication errors. The authors said they noted that it may be possible to reduce fatal medication errors by focusing education efforts on domestic settings in addition to clinical settings.

GAO: Part D Problems Continue

Almost 3 years after the Medicare Part D drug program went into effect, the Centers for Medicare and Medicaid Services still faces significant and continuing problems resolving beneficiaries' complaints and grievances, a Government Accountability Office report found. GAO said that there have been 630,000 complaints filed with the CMS against drug plans since Part D went into effect, most involving problems of enrollment and disenrollment. Although GAO found that the number of complaints, and the time to resolve them, had declined in the first 2 years of the program, it also found that “a substantial proportion of the most critical complaints—those filed when beneficiaries were at risk of exhausting their medications—were not resolved within CMS's applicable time frames.”

TNF-α Inhibitors Are Top Choice

Tumor necrosis factor-α inhibitors are likely to continue to dominate the rheumatoid arthritis marketplace, according to the results of a survey of 102 rheumatologists conducted by Decision Resources. Almost all reported prescribing TNF-α inhibitors as a first-line biologic therapy. Most reported trying two or more TNF-α inhibitors before trying a treatment with a different mechanism of action. Physicians said they preferred TNF-α inhibitors because they were familiar with the drugs and these drugs were effective in treating RA. The class of drugs is expected to get a boost with the upcoming launch of two new drugs—certolizumab pegol (Cimzia) and golimumab, according to Decision Resources. “Most rheumatologists expect the dominance of TNF-α inhibitors to continue, and possibly expand, over the next 2 years,” Decision Resources director Cindy Mundy, Ph.D., said in a statement. “Following the launches of Cimzia and golimumab, nearly half of surveyed rheumatologists expect to prescribe three or more TNF-α inhibitors before moving to a different class of agents.”

New Leadership at NIAMS

Dr. Robert H. Carter, a leading researcher and rheumatologist, will become the new deputy director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), part of the National Institutes of Health, this fall. Dr. Carter is a former director of the division of clinical immunology and rheumatology at the University of Alabama at Birmingham and is the principal investigator of the university's NIAMS-supported Rheumatic Disease Core Center. In his new role, Dr. Carter will assist in developing the NIAMS portfolio of research from basic science to translational research. “His stellar credentials as a scientist and his broad experience in NIH extramural activities will contribute to NIAMS' long history of excellence in biomedical research,” Dr. Stephen Katz, NIAMS director, said in a statement.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people—66% of all adults and 81% of those who have online access—said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers who conducted the poll noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, in contrast to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the poll calls “cybercondriacs”—indicating that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

Home Drug Errors Rise

A shift in the number of medications being taken outside of the hospital has correlated with a sharp increase in the number of fatal medication errors in the home, researchers reported in the Archives of Internal Medicine. In the study, sociologists at the University of California, San Diego, found a 3,196% increase in fatal domestic medication errors involving alcohol and/or street drugs, and a 564% increase in domestic medication fatalities not involving alcohol and/or street drugs. The study examined nearly 50 million U.S. death certificates from 1983 to 2004, and focused on the 200,000 deaths involving medication errors. The authors said they noted that it may be possible to reduce fatal medication errors by focusing education efforts on domestic settings in addition to clinical settings.

GAO: Part D Problems Continue

Almost 3 years after the Medicare Part D drug program went into effect, the Centers for Medicare and Medicaid Services still faces significant and continuing problems resolving beneficiaries' complaints and grievances, a Government Accountability Office report found. GAO said that there have been 630,000 complaints filed with the CMS against drug plans since Part D went into effect, most involving problems of enrollment and disenrollment. Although GAO found that the number of complaints, and the time to resolve them, had declined in the first 2 years of the program, it also found that “a substantial proportion of the most critical complaints—those filed when beneficiaries were at risk of exhausting their medications—were not resolved within CMS's applicable time frames.”

TNF-α Inhibitors Are Top Choice

Tumor necrosis factor-α inhibitors are likely to continue to dominate the rheumatoid arthritis marketplace, according to the results of a survey of 102 rheumatologists conducted by Decision Resources. Almost all reported prescribing TNF-α inhibitors as a first-line biologic therapy. Most reported trying two or more TNF-α inhibitors before trying a treatment with a different mechanism of action. Physicians said they preferred TNF-α inhibitors because they were familiar with the drugs and these drugs were effective in treating RA. The class of drugs is expected to get a boost with the upcoming launch of two new drugs—certolizumab pegol (Cimzia) and golimumab, according to Decision Resources. “Most rheumatologists expect the dominance of TNF-α inhibitors to continue, and possibly expand, over the next 2 years,” Decision Resources director Cindy Mundy, Ph.D., said in a statement. “Following the launches of Cimzia and golimumab, nearly half of surveyed rheumatologists expect to prescribe three or more TNF-α inhibitors before moving to a different class of agents.”

New Leadership at NIAMS

Dr. Robert H. Carter, a leading researcher and rheumatologist, will become the new deputy director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), part of the National Institutes of Health, this fall. Dr. Carter is a former director of the division of clinical immunology and rheumatology at the University of Alabama at Birmingham and is the principal investigator of the university's NIAMS-supported Rheumatic Disease Core Center. In his new role, Dr. Carter will assist in developing the NIAMS portfolio of research from basic science to translational research. “His stellar credentials as a scientist and his broad experience in NIH extramural activities will contribute to NIAMS' long history of excellence in biomedical research,” Dr. Stephen Katz, NIAMS director, said in a statement.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people—66% of all adults and 81% of those who have online access—said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers who conducted the poll noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, in contrast to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the poll calls “cybercondriacs”—indicating that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

Home Drug Errors Rise

A shift in the number of medications being taken outside of the hospital has correlated with a sharp increase in the number of fatal medication errors in the home, researchers reported in the Archives of Internal Medicine. In the study, sociologists at the University of California, San Diego, found a 3,196% increase in fatal domestic medication errors involving alcohol and/or street drugs, and a 564% increase in domestic medication fatalities not involving alcohol and/or street drugs. The study examined nearly 50 million U.S. death certificates from 1983 to 2004, and focused on the 200,000 deaths involving medication errors. The authors said they noted that it may be possible to reduce fatal medication errors by focusing education efforts on domestic settings in addition to clinical settings.

GAO: Part D Problems Continue

Almost 3 years after the Medicare Part D drug program went into effect, the Centers for Medicare and Medicaid Services still faces significant and continuing problems resolving beneficiaries' complaints and grievances, a Government Accountability Office report found. GAO said that there have been 630,000 complaints filed with the CMS against drug plans since Part D went into effect, most involving problems of enrollment and disenrollment. Although GAO found that the number of complaints, and the time to resolve them, had declined in the first 2 years of the program, it also found that “a substantial proportion of the most critical complaints—those filed when beneficiaries were at risk of exhausting their medications—were not resolved within CMS's applicable time frames.”

The presidential candidates aren't the only ones with proposals to reform the American health care system.

While the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan to cover all adults and children below 150% of the federal poverty level. And the plan would include individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians and investing in better health information technology, according to the Commonwealth Fund.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans. Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as would apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance. The plan also calls for moving toward a system that rewards evidence-based care and prevention.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

While the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan to cover all adults and children below 150% of the federal poverty level. And the plan would include individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians and investing in better health information technology, according to the Commonwealth Fund.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans. Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as would apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance. The plan also calls for moving toward a system that rewards evidence-based care and prevention.

The presidential candidates aren't the only ones with proposals to reform the American health care system.

While the designs are different, more and more players in the health care arena are unveiling their own detailed plans to provide health care coverage for all or most Americans.

For instance, the Commonwealth Fund recently outlined a proposal called “Building Blocks” that seeks to cover 44 million of the 48 million Americans estimated to be uninsured in 2008. At the center of the proposal is a national health insurance connector that would allow small businesses and individuals without large employer insurance to shop for a health plan.

The connector would feature both private plans and a “Medicare Extra” option. The Medicare Extra plan would offer premiums of $259 a month for individuals and $702 a month for families, 30% lower than the average premium charged to employers today, according to the Commonwealth Fund, a private foundation that supports research on health policy reform.

The plan also calls for expanding Medicaid and the State Children's Health Insurance Plan to cover all adults and children below 150% of the federal poverty level. And the plan would include individual and employer mandates for health coverage.

Using modeling from the Lewin Group, officials at the Commonwealth Fund estimate that the proposal would add $15 billion to current total health spending in the United States during the first year and about $218 billion over 10 years. But the plan could actually save $1.6 trillion over 10 years if it is combined with other reforms such as changing Medicare payments to hospitals and physicians and investing in better health information technology, according to the Commonwealth Fund.

In the meantime, the Healthcare Leadership Council, a coalition of hospitals, health plans, and pharmaceutical and device manufacturers that aims to improve the quality and affordability of health care, has brought forward its own market-based proposal aimed at covering all Americans. Called “Closing the Gap,” the proposal calls for subsidies and tax breaks to help individuals afford coverage, improving health care quality through health information technology and care coordination, and realigning the financial incentives in the health care system to pay for value.

For example, the plan calls on the government to provide premium subsidies to help employees afford their employer-sponsored insurance premiums. The plan also calls for applying the same tax breaks to individually purchased health insurance as would apply to employer-sponsored coverage. However, the group did not endorse the idea of individual mandates for health insurance. The plan also calls for moving toward a system that rewards evidence-based care and prevention.

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 American College of Physicians were still analyzing the CMS proposal at press time, but said they continue to have concerns about the switch to ICD-10. In a letter to CMS in January 2007, ACP said it opposes the change to ICD-10 for outpatient diagnosis coding and that such a switch would be expensive and time consuming for physicians, especially those in small practices. For some practices, the adoption of ICD-10 would require purchasing a completely new practice management system, which could cost anywhere from $5,000 to $30,000.

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 American College of Physicians were still analyzing the CMS proposal at press time, but said they continue to have concerns about the switch to ICD-10. In a letter to CMS in January 2007, ACP said it opposes the change to ICD-10 for outpatient diagnosis coding and that such a switch would be expensive and time consuming for physicians, especially those in small practices. For some practices, the adoption of ICD-10 would require purchasing a completely new practice management system, which could cost anywhere from $5,000 to $30,000.

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 American College of Physicians were still analyzing the CMS proposal at press time, but said they continue to have concerns about the switch to ICD-10. In a letter to CMS in January 2007, ACP said it opposes the change to ICD-10 for outpatient diagnosis coding and that such a switch would be expensive and time consuming for physicians, especially those in small practices. For some practices, the adoption of ICD-10 would require purchasing a completely new practice management system, which could cost anywhere from $5,000 to $30,000.

Privacy should be the top priority when developing certification criteria for personal health records, a task force created by the Certification Commission for Healthcare Information Technology has recommended.

Adequate security and interoperability also must be included in certification efforts, according to the task force.

The Certification Commission for Healthcare Information Technology (CCHIT) will use these recommendations as it prepares to begin certifying personal health records (PHRs) next summer.

Since the PHR field is still “rapidly evolving,” the task force said that certification requirements should not be so prescriptive that they interfere with the progress of the technology.

The task force recommended that the voluntary certification process should apply to any products or services that collect, receive, store, or use health information provided by consumers. Certification should also apply to products or services that transmit or disclose to a third party any personal health information.

This would allow the CCHIT to offer certification to a range of products and applications, from those that offer a PHR application and connectivity as an accessory to an HER, to stand-alone PHRs.

CCHIT hopes that, just as it did in the EHR field, certification will create a floor of functionality, security, and interoperability, said Dr. Paul Tang, cochair of the PHR Advisory Task Force and vice president and chief medical information officer for the Palo Alto (Calif.) Medical Foundation.

The task force called for requirements to maintain privacy in monitoring and enforcement, and for consumer protection that would allow patients to remove their data if certification is revoked. The group also recommended that standards-based criteria be developed that would require PHRs to send and receive data from as many potential data sources as possible, including ambulatory EHRs, hospital EHRs, labs, and networks.

If done right, certification would have significant benefits for both physicians and patients, Dr. Tang said. A PHR could provide physicians with better access to secure, authenticated data that could help them make decisions, while patients would have more control over their own care, he said.

“The physician benefits by what benefits the patient,” Dr. Tang said.

In July, the task force made its recommendations and handed over responsibility for PHR certification to a CCHIT work group. That work group will develop the actual certification criteria that will be used to test PHR products starting next July, according to Dr. Jody Pettit, strategic leader for CCHIT's PHR work group.

Offering certification for PHR platforms and applications could help spur consumer acceptance of PHRs, Dr. Pettit said. “The consumer wouldn't feel so far out on a limb in terms of putting in their data,” she said.

Privacy should be the top priority when developing certification criteria for personal health records, a task force created by the Certification Commission for Healthcare Information Technology has recommended.

Adequate security and interoperability also must be included in certification efforts, according to the task force.

The Certification Commission for Healthcare Information Technology (CCHIT) will use these recommendations as it prepares to begin certifying personal health records (PHRs) next summer.

Since the PHR field is still “rapidly evolving,” the task force said that certification requirements should not be so prescriptive that they interfere with the progress of the technology.

The task force recommended that the voluntary certification process should apply to any products or services that collect, receive, store, or use health information provided by consumers. Certification should also apply to products or services that transmit or disclose to a third party any personal health information.

This would allow the CCHIT to offer certification to a range of products and applications, from those that offer a PHR application and connectivity as an accessory to an HER, to stand-alone PHRs.

CCHIT hopes that, just as it did in the EHR field, certification will create a floor of functionality, security, and interoperability, said Dr. Paul Tang, cochair of the PHR Advisory Task Force and vice president and chief medical information officer for the Palo Alto (Calif.) Medical Foundation.

The task force called for requirements to maintain privacy in monitoring and enforcement, and for consumer protection that would allow patients to remove their data if certification is revoked. The group also recommended that standards-based criteria be developed that would require PHRs to send and receive data from as many potential data sources as possible, including ambulatory EHRs, hospital EHRs, labs, and networks.

If done right, certification would have significant benefits for both physicians and patients, Dr. Tang said. A PHR could provide physicians with better access to secure, authenticated data that could help them make decisions, while patients would have more control over their own care, he said.

“The physician benefits by what benefits the patient,” Dr. Tang said.

In July, the task force made its recommendations and handed over responsibility for PHR certification to a CCHIT work group. That work group will develop the actual certification criteria that will be used to test PHR products starting next July, according to Dr. Jody Pettit, strategic leader for CCHIT's PHR work group.

Offering certification for PHR platforms and applications could help spur consumer acceptance of PHRs, Dr. Pettit said. “The consumer wouldn't feel so far out on a limb in terms of putting in their data,” she said.

Privacy should be the top priority when developing certification criteria for personal health records, a task force created by the Certification Commission for Healthcare Information Technology has recommended.

Adequate security and interoperability also must be included in certification efforts, according to the task force.

The Certification Commission for Healthcare Information Technology (CCHIT) will use these recommendations as it prepares to begin certifying personal health records (PHRs) next summer.

Since the PHR field is still “rapidly evolving,” the task force said that certification requirements should not be so prescriptive that they interfere with the progress of the technology.

The task force recommended that the voluntary certification process should apply to any products or services that collect, receive, store, or use health information provided by consumers. Certification should also apply to products or services that transmit or disclose to a third party any personal health information.

This would allow the CCHIT to offer certification to a range of products and applications, from those that offer a PHR application and connectivity as an accessory to an HER, to stand-alone PHRs.

CCHIT hopes that, just as it did in the EHR field, certification will create a floor of functionality, security, and interoperability, said Dr. Paul Tang, cochair of the PHR Advisory Task Force and vice president and chief medical information officer for the Palo Alto (Calif.) Medical Foundation.

The task force called for requirements to maintain privacy in monitoring and enforcement, and for consumer protection that would allow patients to remove their data if certification is revoked. The group also recommended that standards-based criteria be developed that would require PHRs to send and receive data from as many potential data sources as possible, including ambulatory EHRs, hospital EHRs, labs, and networks.

If done right, certification would have significant benefits for both physicians and patients, Dr. Tang said. A PHR could provide physicians with better access to secure, authenticated data that could help them make decisions, while patients would have more control over their own care, he said.

“The physician benefits by what benefits the patient,” Dr. Tang said.

In July, the task force made its recommendations and handed over responsibility for PHR certification to a CCHIT work group. That work group will develop the actual certification criteria that will be used to test PHR products starting next July, according to Dr. Jody Pettit, strategic leader for CCHIT's PHR work group.

Offering certification for PHR platforms and applications could help spur consumer acceptance of PHRs, Dr. Pettit said. “The consumer wouldn't feel so far out on a limb in terms of putting in their data,” she said.

Privacy should be the top priority when developing certification criteria for personal health records, a task force created by the Certification Commission for Healthcare Information Technology has recommended.

Adequate security and interoperability also must be included in certification efforts, according to the task force.

The Certification Commission for Healthcare Information Technology (CCHIT) will use these recommendations as it prepares to begin certifying personal health records (PHRs) next summer.

Since the PHR field is still “rapidly evolving,” the task force said that certification requirements should not be so prescriptive that they interfere with the progress of the technology.

The task force recommended that the voluntary certification process should apply to any products or services that collect, receive, store, or use health information provided by consumers. Certification should also apply to products or services that transmit or disclose to a third party any personal health information.

This would allow the CCHIT to offer certification to a range of products and applications, from those that offer a PHR application and connectivity as an accessory to an HER, to stand-alone PHRs.

CCHIT hopes that, just as it did in the EHR field, certification will create a floor of functionality, security, and interoperability, said Dr. Paul Tang, cochair of the PHR Advisory Task Force and vice president and chief medical information officer for the Palo Alto (Calif.) Medical Foundation.

The task force called for requirements to maintain privacy in monitoring and enforcement, and for consumer protection that would allow patients to remove their data if certification is revoked. The group also recommended that standards-based criteria be developed that would require PHRs to send and receive data from as many potential data sources as possible, including ambulatory EHRs, hospital EHRs, and labs.

In July, the task force made its recommendations and handed over responsibility for PHR certification to a CCHIT work group. That work group will develop the actual certification criteria that will be used to test PHR products starting next July, according to Dr. Jody Pettit, strategic leader for CCHIT's PHR work group.

Privacy should be the top priority when developing certification criteria for personal health records, a task force created by the Certification Commission for Healthcare Information Technology has recommended.

Adequate security and interoperability also must be included in certification efforts, according to the task force.

The Certification Commission for Healthcare Information Technology (CCHIT) will use these recommendations as it prepares to begin certifying personal health records (PHRs) next summer.

Since the PHR field is still “rapidly evolving,” the task force said that certification requirements should not be so prescriptive that they interfere with the progress of the technology.

The task force recommended that the voluntary certification process should apply to any products or services that collect, receive, store, or use health information provided by consumers. Certification should also apply to products or services that transmit or disclose to a third party any personal health information.

This would allow the CCHIT to offer certification to a range of products and applications, from those that offer a PHR application and connectivity as an accessory to an HER, to stand-alone PHRs.

CCHIT hopes that, just as it did in the EHR field, certification will create a floor of functionality, security, and interoperability, said Dr. Paul Tang, cochair of the PHR Advisory Task Force and vice president and chief medical information officer for the Palo Alto (Calif.) Medical Foundation.

The task force called for requirements to maintain privacy in monitoring and enforcement, and for consumer protection that would allow patients to remove their data if certification is revoked. The group also recommended that standards-based criteria be developed that would require PHRs to send and receive data from as many potential data sources as possible, including ambulatory EHRs, hospital EHRs, and labs.

In July, the task force made its recommendations and handed over responsibility for PHR certification to a CCHIT work group. That work group will develop the actual certification criteria that will be used to test PHR products starting next July, according to Dr. Jody Pettit, strategic leader for CCHIT's PHR work group.

Privacy should be the top priority when developing certification criteria for personal health records, a task force created by the Certification Commission for Healthcare Information Technology has recommended.

Adequate security and interoperability also must be included in certification efforts, according to the task force.

The Certification Commission for Healthcare Information Technology (CCHIT) will use these recommendations as it prepares to begin certifying personal health records (PHRs) next summer.

Since the PHR field is still “rapidly evolving,” the task force said that certification requirements should not be so prescriptive that they interfere with the progress of the technology.

The task force recommended that the voluntary certification process should apply to any products or services that collect, receive, store, or use health information provided by consumers. Certification should also apply to products or services that transmit or disclose to a third party any personal health information.

This would allow the CCHIT to offer certification to a range of products and applications, from those that offer a PHR application and connectivity as an accessory to an HER, to stand-alone PHRs.

CCHIT hopes that, just as it did in the EHR field, certification will create a floor of functionality, security, and interoperability, said Dr. Paul Tang, cochair of the PHR Advisory Task Force and vice president and chief medical information officer for the Palo Alto (Calif.) Medical Foundation.

The task force called for requirements to maintain privacy in monitoring and enforcement, and for consumer protection that would allow patients to remove their data if certification is revoked. The group also recommended that standards-based criteria be developed that would require PHRs to send and receive data from as many potential data sources as possible, including ambulatory EHRs, hospital EHRs, and labs.

In July, the task force made its recommendations and handed over responsibility for PHR certification to a CCHIT work group. That work group will develop the actual certification criteria that will be used to test PHR products starting next July, according to Dr. Jody Pettit, strategic leader for CCHIT's PHR work group.

On average, Medicare beneficiaries can expect to pay about $28 per month for standard Part D prescription drug coverage next year. The estimates from the Centers for Medicare and Medicaid Services are based on bids submitted for both prescription drug plans and Medicare Advantage drug plans. The estimated monthly premiums are about $3 higher than the average monthly premium costs this year, but 37% lower than projections made when the Medicare prescription drug benefit was created in 2003. The $3 increase is based in part on rising drug costs in general and higher costs for catastrophic drug coverage. In some cases, price increases could be significant, Kerry Weems, CMS acting administrator, said during a teleconference to announce the premium estimates. However, he noted that most beneficiaries will have the option to switch to a prescription drug plan with the same or lower premiums as they paid this year. Open enrollment for the fourth year of the Medicare Part D program is set to begin in November.

On average, Medicare beneficiaries can expect to pay about $28 per month for standard Part D prescription drug coverage next year. The estimates from the Centers for Medicare and Medicaid Services are based on bids submitted for both prescription drug plans and Medicare Advantage drug plans. The estimated monthly premiums are about $3 higher than the average monthly premium costs this year, but 37% lower than projections made when the Medicare prescription drug benefit was created in 2003. The $3 increase is based in part on rising drug costs in general and higher costs for catastrophic drug coverage. In some cases, price increases could be significant, Kerry Weems, CMS acting administrator, said during a teleconference to announce the premium estimates. However, he noted that most beneficiaries will have the option to switch to a prescription drug plan with the same or lower premiums as they paid this year. Open enrollment for the fourth year of the Medicare Part D program is set to begin in November.

On average, Medicare beneficiaries can expect to pay about $28 per month for standard Part D prescription drug coverage next year. The estimates from the Centers for Medicare and Medicaid Services are based on bids submitted for both prescription drug plans and Medicare Advantage drug plans. The estimated monthly premiums are about $3 higher than the average monthly premium costs this year, but 37% lower than projections made when the Medicare prescription drug benefit was created in 2003. The $3 increase is based in part on rising drug costs in general and higher costs for catastrophic drug coverage. In some cases, price increases could be significant, Kerry Weems, CMS acting administrator, said during a teleconference to announce the premium estimates. However, he noted that most beneficiaries will have the option to switch to a prescription drug plan with the same or lower premiums as they paid this year. Open enrollment for the fourth year of the Medicare Part D program is set to begin in November.

The federal government will soon be rating the nation's nursing homes on a five-star quality scale.

Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, announced the plan during a teleconference. The new, simple rating system will give patients and their families an easy way to evaluate quality at the nation's nursing homes, said Mr. Weems.

Officials will spend the next few months figuring out how to determine the number of stars a facility deserves. Mr. Weems said the agency will base the system on existing data sources including annual inspections of the facility, information on 19 quality measures, and staffing data. But he added that he's open to incorporating other consistent, accurate, and reliable data sources.

The task between now and December of this year, when the CMS plans to have the rating system up and running on its Nursing Home Compare Web site, is to determine how to weight data to distinguish high- and low-performing facilities, Mr. Weems said. The CMS is seeking comments on how to make the system informative and user friendly.

Last year, the CMS instituted a star rating system for Medicare Advantage plans. However, this will be the first star system introduced to the Medicare fee-for-service program, according to the CMS.

“Transparent information is an effective incentive for quality,” Mr. Weems said.

The American Health Care Association, a federation of state health organizations representing long-term care providers, welcomed the new system. However, the group cautioned that relying heavily on survey data is not the best way to assess quality. CMS officials should also consider incorporating metrics such as consumer and staff satisfaction, the organization said in a statement.

Sen. Herb Kohl (D-Wis.), who as chairman of the Senate Special Committee on Aging has been pushing the CMS to increase nursing home-quality information on the Web site, commended Mr. Weems for the new plan.

In a prepared statement, however, Sen. Kohl raised the issue that some of the data that will go into the star ratings are not objective measures. “Some of this information is self-reported [by nursing homes], and could be made more reliable, but we are moving in the right direction,” he said.

Comments on the system can be sent to bettercare@cms.hhs.gov

The federal government will soon be rating the nation's nursing homes on a five-star quality scale.

Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, announced the plan during a teleconference. The new, simple rating system will give patients and their families an easy way to evaluate quality at the nation's nursing homes, said Mr. Weems.

Officials will spend the next few months figuring out how to determine the number of stars a facility deserves. Mr. Weems said the agency will base the system on existing data sources including annual inspections of the facility, information on 19 quality measures, and staffing data. But he added that he's open to incorporating other consistent, accurate, and reliable data sources.

The task between now and December of this year, when the CMS plans to have the rating system up and running on its Nursing Home Compare Web site, is to determine how to weight data to distinguish high- and low-performing facilities, Mr. Weems said. The CMS is seeking comments on how to make the system informative and user friendly.

Last year, the CMS instituted a star rating system for Medicare Advantage plans. However, this will be the first star system introduced to the Medicare fee-for-service program, according to the CMS.

“Transparent information is an effective incentive for quality,” Mr. Weems said.

The American Health Care Association, a federation of state health organizations representing long-term care providers, welcomed the new system. However, the group cautioned that relying heavily on survey data is not the best way to assess quality. CMS officials should also consider incorporating metrics such as consumer and staff satisfaction, the organization said in a statement.

Sen. Herb Kohl (D-Wis.), who as chairman of the Senate Special Committee on Aging has been pushing the CMS to increase nursing home-quality information on the Web site, commended Mr. Weems for the new plan.

In a prepared statement, however, Sen. Kohl raised the issue that some of the data that will go into the star ratings are not objective measures. “Some of this information is self-reported [by nursing homes], and could be made more reliable, but we are moving in the right direction,” he said.

Comments on the system can be sent to bettercare@cms.hhs.gov

The federal government will soon be rating the nation's nursing homes on a five-star quality scale.

Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, announced the plan during a teleconference. The new, simple rating system will give patients and their families an easy way to evaluate quality at the nation's nursing homes, said Mr. Weems.

Officials will spend the next few months figuring out how to determine the number of stars a facility deserves. Mr. Weems said the agency will base the system on existing data sources including annual inspections of the facility, information on 19 quality measures, and staffing data. But he added that he's open to incorporating other consistent, accurate, and reliable data sources.

The task between now and December of this year, when the CMS plans to have the rating system up and running on its Nursing Home Compare Web site, is to determine how to weight data to distinguish high- and low-performing facilities, Mr. Weems said. The CMS is seeking comments on how to make the system informative and user friendly.

Last year, the CMS instituted a star rating system for Medicare Advantage plans. However, this will be the first star system introduced to the Medicare fee-for-service program, according to the CMS.

“Transparent information is an effective incentive for quality,” Mr. Weems said.

The American Health Care Association, a federation of state health organizations representing long-term care providers, welcomed the new system. However, the group cautioned that relying heavily on survey data is not the best way to assess quality. CMS officials should also consider incorporating metrics such as consumer and staff satisfaction, the organization said in a statement.

Sen. Herb Kohl (D-Wis.), who as chairman of the Senate Special Committee on Aging has been pushing the CMS to increase nursing home-quality information on the Web site, commended Mr. Weems for the new plan.

In a prepared statement, however, Sen. Kohl raised the issue that some of the data that will go into the star ratings are not objective measures. “Some of this information is self-reported [by nursing homes], and could be made more reliable, but we are moving in the right direction,” he said.

Comments on the system can be sent to bettercare@cms.hhs.gov

Providing financial incentives to hospitals has resulted in significant gains in quality of care for patients with acute myocardial infarction, heart failure, and pneumonia, and for those undergoing coronary artery bypass graft and hip and knee replacement, according to the third-year results from a Medicare demonstration project.

For example, from 2003 to 2006, hospitals who participated in the demonstration project improved their composite quality scores by 15.8% on average for the five clinical areas measured. The third-year results of the demonstration were released in June.

The Hospital Quality Incentive Demonstration was launched in October 2003 by officials at the Centers for Medicare and Medicaid Services and Premier Inc., an alliance of not-for-profit hospitals and health care systems. The demonstration, which involves more than 250 hospitals in 36 states, was designed to test whether offering bonuses to top-performing hospitals would improve safety, quality, and efficiency of care.

“These Premier results show that value-based purchasing can achieve excellent results in Medicare,” Kerry Weems, acting CMS administrator, said in a statement. “Given these results, it is time to take the next step and implement hospital value-based purchasing for the Medicare program so that citizens across the nation can benefit from improved safety and quality.”

CMS officials submitted a proposal to Congress last year that calls for the implementation of value-based purchasing for hospitals within Medicare. Under the plan, a percentage of each hospital's payment per discharge would be tied to the hospital's performance on a set of clinical measures. New legislation would be required to implement these changes, according to the agency.

In the meantime, CMS has extended the hospital demonstration project for another 3 years.

During the first 3 years, hospitals in the top 20% in each of the five clinical areas received bonuses. The top 10% of hospitals received a 2% incentive payment; those in the second decile received a 1% payment. And all hospitals that performed in the top 50% in each clinical area received public recognition on the CMS Web site. Beginning with the fourth-year results, hospitals also will be rewarded for meeting a certain quality threshold.

From October 2003 to the end of 2006, hospitals on average showed improvements for all five high-volume inpatient conditions, based on an aggregate of all quality measures in each clinical area.

For example, the average composite quality score rose from 87% to 96% for patients with acute myocardial infarction, from 85% to 97% for patients undergoing coronary artery bypass graft, and from 64% to 89% for patients with heart failure. For patients with pneumonia, the composite quality score rose from 69% to 90% for hospitals in the demonstration project. In addition, the composite quality score rose from 85% to 97% for patients who underwent hip and knee replacement.

In the third year of the demonstration project, which ended in 2006, CMS awarded a total of $7 million in incentive payments to 112 top-performing hospitals. Over the course of the first 3 years of the project, CMS has paid out more than $24.5 million in incentives.

Providing financial incentives to hospitals has resulted in significant gains in quality of care for patients with acute myocardial infarction, heart failure, and pneumonia, and for those undergoing coronary artery bypass graft and hip and knee replacement, according to the third-year results from a Medicare demonstration project.

For example, from 2003 to 2006, hospitals who participated in the demonstration project improved their composite quality scores by 15.8% on average for the five clinical areas measured. The third-year results of the demonstration were released in June.

The Hospital Quality Incentive Demonstration was launched in October 2003 by officials at the Centers for Medicare and Medicaid Services and Premier Inc., an alliance of not-for-profit hospitals and health care systems. The demonstration, which involves more than 250 hospitals in 36 states, was designed to test whether offering bonuses to top-performing hospitals would improve safety, quality, and efficiency of care.

“These Premier results show that value-based purchasing can achieve excellent results in Medicare,” Kerry Weems, acting CMS administrator, said in a statement. “Given these results, it is time to take the next step and implement hospital value-based purchasing for the Medicare program so that citizens across the nation can benefit from improved safety and quality.”

CMS officials submitted a proposal to Congress last year that calls for the implementation of value-based purchasing for hospitals within Medicare. Under the plan, a percentage of each hospital's payment per discharge would be tied to the hospital's performance on a set of clinical measures. New legislation would be required to implement these changes, according to the agency.

In the meantime, CMS has extended the hospital demonstration project for another 3 years.

During the first 3 years, hospitals in the top 20% in each of the five clinical areas received bonuses. The top 10% of hospitals received a 2% incentive payment; those in the second decile received a 1% payment. And all hospitals that performed in the top 50% in each clinical area received public recognition on the CMS Web site. Beginning with the fourth-year results, hospitals also will be rewarded for meeting a certain quality threshold.

From October 2003 to the end of 2006, hospitals on average showed improvements for all five high-volume inpatient conditions, based on an aggregate of all quality measures in each clinical area.

For example, the average composite quality score rose from 87% to 96% for patients with acute myocardial infarction, from 85% to 97% for patients undergoing coronary artery bypass graft, and from 64% to 89% for patients with heart failure. For patients with pneumonia, the composite quality score rose from 69% to 90% for hospitals in the demonstration project. In addition, the composite quality score rose from 85% to 97% for patients who underwent hip and knee replacement.

In the third year of the demonstration project, which ended in 2006, CMS awarded a total of $7 million in incentive payments to 112 top-performing hospitals. Over the course of the first 3 years of the project, CMS has paid out more than $24.5 million in incentives.

Providing financial incentives to hospitals has resulted in significant gains in quality of care for patients with acute myocardial infarction, heart failure, and pneumonia, and for those undergoing coronary artery bypass graft and hip and knee replacement, according to the third-year results from a Medicare demonstration project.

For example, from 2003 to 2006, hospitals who participated in the demonstration project improved their composite quality scores by 15.8% on average for the five clinical areas measured. The third-year results of the demonstration were released in June.

The Hospital Quality Incentive Demonstration was launched in October 2003 by officials at the Centers for Medicare and Medicaid Services and Premier Inc., an alliance of not-for-profit hospitals and health care systems. The demonstration, which involves more than 250 hospitals in 36 states, was designed to test whether offering bonuses to top-performing hospitals would improve safety, quality, and efficiency of care.

“These Premier results show that value-based purchasing can achieve excellent results in Medicare,” Kerry Weems, acting CMS administrator, said in a statement. “Given these results, it is time to take the next step and implement hospital value-based purchasing for the Medicare program so that citizens across the nation can benefit from improved safety and quality.”

CMS officials submitted a proposal to Congress last year that calls for the implementation of value-based purchasing for hospitals within Medicare. Under the plan, a percentage of each hospital's payment per discharge would be tied to the hospital's performance on a set of clinical measures. New legislation would be required to implement these changes, according to the agency.

In the meantime, CMS has extended the hospital demonstration project for another 3 years.

During the first 3 years, hospitals in the top 20% in each of the five clinical areas received bonuses. The top 10% of hospitals received a 2% incentive payment; those in the second decile received a 1% payment. And all hospitals that performed in the top 50% in each clinical area received public recognition on the CMS Web site. Beginning with the fourth-year results, hospitals also will be rewarded for meeting a certain quality threshold.

From October 2003 to the end of 2006, hospitals on average showed improvements for all five high-volume inpatient conditions, based on an aggregate of all quality measures in each clinical area.

For example, the average composite quality score rose from 87% to 96% for patients with acute myocardial infarction, from 85% to 97% for patients undergoing coronary artery bypass graft, and from 64% to 89% for patients with heart failure. For patients with pneumonia, the composite quality score rose from 69% to 90% for hospitals in the demonstration project. In addition, the composite quality score rose from 85% to 97% for patients who underwent hip and knee replacement.

In the third year of the demonstration project, which ended in 2006, CMS awarded a total of $7 million in incentive payments to 112 top-performing hospitals. Over the course of the first 3 years of the project, CMS has paid out more than $24.5 million in incentives.

A welcoming environment for gay and lesbian residents is a part of the culture at Village Nursing Home in New York City.

Staff of the facility's parent, Village Care of New York Inc., screen prospective workers to ensure that they can care for lesbian, gay, bisexual, or transgender (LGBT) residents without bias. Staff at all of Village Care's services are instructed to ask elderly people about their significant others, to include partners in treatment discussions, and to offer gay-focused social events. It's more than just good care, said Arthur Y. Webb, president and CEO of Village Care. It's good business. The company's nursing homes and community programs for elders are able to attract a key demographic that keeps the nursing home and other programs thriving, said Webb.

While many long-term care facilities hardly acknowledge the existence of LGBT seniors, several facilities and programs around the country are embracing them. The people who run those programs and have become experts in LGBT issues caution others that the clock is ticking to when the unique social and medical issues faced by this community will be common in many long-term care facilities.

If those issues are not addressed, a growing population of vulnerable seniors will suffer in unfriendly situations, said Lisa Krinsky, director of the LGBT Aging Project in Boston. “There's tremendous concern and fear about having to be closeted,” said Krinsky.

The LGBT Aging Project contracts with nursing homes to train staff members about LGBT aging issues and conducts programs designed to integrate awareness of those issues into facilities' cultures through its Open Door Task Force. “The intent is to go beyond a one-time only training session,” said Krinsky.

LGBT training begins with Krinsky's faculty examining the messages and policies coming from a facility's leadership. Next, the faculty examines how the staff actually puts these policies into practice. Finally, the trainers and trainees work on communicating to the gay community and local health care providers that the facility welcomes LGBT seniors.

A frequent question is whether making a facility more openly accepting of LGBT resident will mean it will be known as a “gay” place, said Krinsky. She advises staff and leadership to make changes in the larger context of enhancing acceptance of all types of residents.

“It's a very new field,” said Karen Taylor, director of advocacy and training at the New York-based Services and Advocacy for GLBT Elders (SAGE), which has developed its own curriculum specific to LGBT aging issues in long-term care facilities.

SAGE training deals with nursing home staffs' frequent discomfort in dealing not only with homosexuality but also with heterosexuality in nursing home residents, said Ms. Taylor. The idea of intimacy between residents can be uncomfortable for staff, but it should be addressed as part of providing quality health care, she said.

One thing to keep in mind is that sexual identity and gender identity is about more than just sexual practices, Taylor said. It's about culture, friendship circles, and life experiences.

SAGE teaches ways to make residents feel that their culture is respected. Nursing homes tend not to use neutral language around sexual identity and orientation, she said. Just changing the words used on intake forms is important. These, for example, typically give residents only standard choices for designating their relationship status: married, single, divorced, and widowed.

Facilities can become more inclusive by allowing residents to indicate that they have partners or significant others. The answer can in turn open up the possibility of residents saying who is important in their lives, and staff's acknowledgment of those relationships can ease a new resident's sense of isolation.

Staff should follow up on other information given by residents, said Ms. Taylor. For example, if someone mentions that he or she has had a roommate for many years, the aide taking that information should acknowledge that this person must have been significant in the resident's life.

That doesn't mean the staff should be asking residents whether they're gay or trying to force anyone to live “out” in the facility. The older LGBT generation may not be comfortable with peers knowing their sexuality or gender identity, Ms. Taylor said. Residents should be allowed to be as out as they feel safe to be, she said.

On the other hand, some LGBT seniors have been open about their sexuality for most or all of their adult lives, and they are looking for long-term care facilities that not only accommodate their needs, but also seek out other residents like them.

At the RainbowVision Properties assisted living community in Santa Fe, N.M., LGBT seniors can live in the majority, said Joy Silver, president and CEO of the organization. RainbowVision offers housing for the “second 50 years,” including community assistance in several cities and new assisted living locations to come in Palm Springs, Calif., and the San Francisco area.

At RainbowVision properties, sexual orientation is understood without having to be explained, said Silver.

The facility is not exclusively LGBT—about a quarter of the population at RainbowVision in Santa Fe is heterosexual, Silver said. Individuals, gay and straight alike, come to the community for the social programs, entertainment, creative environment, and amenities.

For LGBT residents, the attraction is often the chance to share their history, said Silver. In some cases, residents came from communities that were “gay friendly” and would feel uncomfortable living their later years even in a facility open to LGBT residents—but without many. “It's more than simply diversity training,” Ms. Silver said.

A welcoming environment for gay and lesbian residents is a part of the culture at Village Nursing Home in New York City.

Staff of the facility's parent, Village Care of New York Inc., screen prospective workers to ensure that they can care for lesbian, gay, bisexual, or transgender (LGBT) residents without bias. Staff at all of Village Care's services are instructed to ask elderly people about their significant others, to include partners in treatment discussions, and to offer gay-focused social events. It's more than just good care, said Arthur Y. Webb, president and CEO of Village Care. It's good business. The company's nursing homes and community programs for elders are able to attract a key demographic that keeps the nursing home and other programs thriving, said Webb.

While many long-term care facilities hardly acknowledge the existence of LGBT seniors, several facilities and programs around the country are embracing them. The people who run those programs and have become experts in LGBT issues caution others that the clock is ticking to when the unique social and medical issues faced by this community will be common in many long-term care facilities.

If those issues are not addressed, a growing population of vulnerable seniors will suffer in unfriendly situations, said Lisa Krinsky, director of the LGBT Aging Project in Boston. “There's tremendous concern and fear about having to be closeted,” said Krinsky.

The LGBT Aging Project contracts with nursing homes to train staff members about LGBT aging issues and conducts programs designed to integrate awareness of those issues into facilities' cultures through its Open Door Task Force. “The intent is to go beyond a one-time only training session,” said Krinsky.

LGBT training begins with Krinsky's faculty examining the messages and policies coming from a facility's leadership. Next, the faculty examines how the staff actually puts these policies into practice. Finally, the trainers and trainees work on communicating to the gay community and local health care providers that the facility welcomes LGBT seniors.

A frequent question is whether making a facility more openly accepting of LGBT resident will mean it will be known as a “gay” place, said Krinsky. She advises staff and leadership to make changes in the larger context of enhancing acceptance of all types of residents.

“It's a very new field,” said Karen Taylor, director of advocacy and training at the New York-based Services and Advocacy for GLBT Elders (SAGE), which has developed its own curriculum specific to LGBT aging issues in long-term care facilities.

SAGE training deals with nursing home staffs' frequent discomfort in dealing not only with homosexuality but also with heterosexuality in nursing home residents, said Ms. Taylor. The idea of intimacy between residents can be uncomfortable for staff, but it should be addressed as part of providing quality health care, she said.

One thing to keep in mind is that sexual identity and gender identity is about more than just sexual practices, Taylor said. It's about culture, friendship circles, and life experiences.

SAGE teaches ways to make residents feel that their culture is respected. Nursing homes tend not to use neutral language around sexual identity and orientation, she said. Just changing the words used on intake forms is important. These, for example, typically give residents only standard choices for designating their relationship status: married, single, divorced, and widowed.

Facilities can become more inclusive by allowing residents to indicate that they have partners or significant others. The answer can in turn open up the possibility of residents saying who is important in their lives, and staff's acknowledgment of those relationships can ease a new resident's sense of isolation.

Staff should follow up on other information given by residents, said Ms. Taylor. For example, if someone mentions that he or she has had a roommate for many years, the aide taking that information should acknowledge that this person must have been significant in the resident's life.

That doesn't mean the staff should be asking residents whether they're gay or trying to force anyone to live “out” in the facility. The older LGBT generation may not be comfortable with peers knowing their sexuality or gender identity, Ms. Taylor said. Residents should be allowed to be as out as they feel safe to be, she said.

On the other hand, some LGBT seniors have been open about their sexuality for most or all of their adult lives, and they are looking for long-term care facilities that not only accommodate their needs, but also seek out other residents like them.

At the RainbowVision Properties assisted living community in Santa Fe, N.M., LGBT seniors can live in the majority, said Joy Silver, president and CEO of the organization. RainbowVision offers housing for the “second 50 years,” including community assistance in several cities and new assisted living locations to come in Palm Springs, Calif., and the San Francisco area.

At RainbowVision properties, sexual orientation is understood without having to be explained, said Silver.

The facility is not exclusively LGBT—about a quarter of the population at RainbowVision in Santa Fe is heterosexual, Silver said. Individuals, gay and straight alike, come to the community for the social programs, entertainment, creative environment, and amenities.

For LGBT residents, the attraction is often the chance to share their history, said Silver. In some cases, residents came from communities that were “gay friendly” and would feel uncomfortable living their later years even in a facility open to LGBT residents—but without many. “It's more than simply diversity training,” Ms. Silver said.

A welcoming environment for gay and lesbian residents is a part of the culture at Village Nursing Home in New York City.

Staff of the facility's parent, Village Care of New York Inc., screen prospective workers to ensure that they can care for lesbian, gay, bisexual, or transgender (LGBT) residents without bias. Staff at all of Village Care's services are instructed to ask elderly people about their significant others, to include partners in treatment discussions, and to offer gay-focused social events. It's more than just good care, said Arthur Y. Webb, president and CEO of Village Care. It's good business. The company's nursing homes and community programs for elders are able to attract a key demographic that keeps the nursing home and other programs thriving, said Webb.

While many long-term care facilities hardly acknowledge the existence of LGBT seniors, several facilities and programs around the country are embracing them. The people who run those programs and have become experts in LGBT issues caution others that the clock is ticking to when the unique social and medical issues faced by this community will be common in many long-term care facilities.

If those issues are not addressed, a growing population of vulnerable seniors will suffer in unfriendly situations, said Lisa Krinsky, director of the LGBT Aging Project in Boston. “There's tremendous concern and fear about having to be closeted,” said Krinsky.

The LGBT Aging Project contracts with nursing homes to train staff members about LGBT aging issues and conducts programs designed to integrate awareness of those issues into facilities' cultures through its Open Door Task Force. “The intent is to go beyond a one-time only training session,” said Krinsky.

LGBT training begins with Krinsky's faculty examining the messages and policies coming from a facility's leadership. Next, the faculty examines how the staff actually puts these policies into practice. Finally, the trainers and trainees work on communicating to the gay community and local health care providers that the facility welcomes LGBT seniors.

A frequent question is whether making a facility more openly accepting of LGBT resident will mean it will be known as a “gay” place, said Krinsky. She advises staff and leadership to make changes in the larger context of enhancing acceptance of all types of residents.

“It's a very new field,” said Karen Taylor, director of advocacy and training at the New York-based Services and Advocacy for GLBT Elders (SAGE), which has developed its own curriculum specific to LGBT aging issues in long-term care facilities.

SAGE training deals with nursing home staffs' frequent discomfort in dealing not only with homosexuality but also with heterosexuality in nursing home residents, said Ms. Taylor. The idea of intimacy between residents can be uncomfortable for staff, but it should be addressed as part of providing quality health care, she said.

One thing to keep in mind is that sexual identity and gender identity is about more than just sexual practices, Taylor said. It's about culture, friendship circles, and life experiences.

SAGE teaches ways to make residents feel that their culture is respected. Nursing homes tend not to use neutral language around sexual identity and orientation, she said. Just changing the words used on intake forms is important. These, for example, typically give residents only standard choices for designating their relationship status: married, single, divorced, and widowed.

Facilities can become more inclusive by allowing residents to indicate that they have partners or significant others. The answer can in turn open up the possibility of residents saying who is important in their lives, and staff's acknowledgment of those relationships can ease a new resident's sense of isolation.

Staff should follow up on other information given by residents, said Ms. Taylor. For example, if someone mentions that he or she has had a roommate for many years, the aide taking that information should acknowledge that this person must have been significant in the resident's life.

That doesn't mean the staff should be asking residents whether they're gay or trying to force anyone to live “out” in the facility. The older LGBT generation may not be comfortable with peers knowing their sexuality or gender identity, Ms. Taylor said. Residents should be allowed to be as out as they feel safe to be, she said.

On the other hand, some LGBT seniors have been open about their sexuality for most or all of their adult lives, and they are looking for long-term care facilities that not only accommodate their needs, but also seek out other residents like them.

At the RainbowVision Properties assisted living community in Santa Fe, N.M., LGBT seniors can live in the majority, said Joy Silver, president and CEO of the organization. RainbowVision offers housing for the “second 50 years,” including community assistance in several cities and new assisted living locations to come in Palm Springs, Calif., and the San Francisco area.

At RainbowVision properties, sexual orientation is understood without having to be explained, said Silver.

The facility is not exclusively LGBT—about a quarter of the population at RainbowVision in Santa Fe is heterosexual, Silver said. Individuals, gay and straight alike, come to the community for the social programs, entertainment, creative environment, and amenities.

For LGBT residents, the attraction is often the chance to share their history, said Silver. In some cases, residents came from communities that were “gay friendly” and would feel uncomfortable living their later years even in a facility open to LGBT residents—but without many. “It's more than simply diversity training,” Ms. Silver said.

NEW YORK — Busy STD clinics may be able to offer “express visits” that provide disease screening only for asymptomatic patients without missing infected individuals.

Researchers with the New York City Department of Mental Health and Hygiene and the Centers for Disease Control and Prevention evaluated the impact of instituting routine express visits in nine of the city's free walk-in clinics. During an express visit, asymptomatic patients with no known contact with an STD case were given the option of skipping the physician visit and being screened for gonorrhea, chlamydia, syphilis, and HIV.

The use of express visits allowed the clinic staff to screen a large number of asymptomatic patients, resulted in better use of physician resources, allowed for the treatment of more patients who were positive for gonorrhea or chlamydia infections, and improved the time to treatment, according to the results of the study.

In 2006, the nine clinics conducted 18,421 physician visits and 6,064 express visits. The proportion of patients who presented with symptoms during the physician visit increased from 74% in 2005 to 86% in 2006. There also was a decrease in the time to treatment for those seen during a physician visit. The median time to treatment dropped from 14 days in 2005 to 10 days in 2006. The median time to treatment for those who underwent express visits in 2006 was 9 days.

The number of gonorrhea or chlamydia infections that were diagnosed during a physician visit increased following the establishment of express visits in 2006. The number of gonorrhea or chlamydia infections detected during physician visits rose from 2,043 in 2005 to 2,081 in 2006. There were also 536 cases diagnosed during express visits.

Express visits appear to work well for the “worried well” population, Jessica M. Borrelli, a research scientist in the bureau of STD control of the New York City Department of Mental Health and Hygiene, said in an interview. For example, individuals who come in because they have a new sexual partner can be screened for STDs without tying up physician time, she said. Ms. Borrelli presented the poster at a joint conference of the American Sexually Transmitted Diseases Association and the British Association for Sexual Health and HIV.

In 2005, the express visit option was conceived in an effort to deal with the increasing patient volume at New York City STD clinics. The following year, the express visit was introduced as a routine option. The researchers used clinic electronic medical records to compare patient data from September-December 2005—before express visits became routine—with patient data from September to December 2006—after the express visits were established.

NEW YORK — Busy STD clinics may be able to offer “express visits” that provide disease screening only for asymptomatic patients without missing infected individuals.

Researchers with the New York City Department of Mental Health and Hygiene and the Centers for Disease Control and Prevention evaluated the impact of instituting routine express visits in nine of the city's free walk-in clinics. During an express visit, asymptomatic patients with no known contact with an STD case were given the option of skipping the physician visit and being screened for gonorrhea, chlamydia, syphilis, and HIV.

The use of express visits allowed the clinic staff to screen a large number of asymptomatic patients, resulted in better use of physician resources, allowed for the treatment of more patients who were positive for gonorrhea or chlamydia infections, and improved the time to treatment, according to the results of the study.

In 2006, the nine clinics conducted 18,421 physician visits and 6,064 express visits. The proportion of patients who presented with symptoms during the physician visit increased from 74% in 2005 to 86% in 2006. There also was a decrease in the time to treatment for those seen during a physician visit. The median time to treatment dropped from 14 days in 2005 to 10 days in 2006. The median time to treatment for those who underwent express visits in 2006 was 9 days.

The number of gonorrhea or chlamydia infections that were diagnosed during a physician visit increased following the establishment of express visits in 2006. The number of gonorrhea or chlamydia infections detected during physician visits rose from 2,043 in 2005 to 2,081 in 2006. There were also 536 cases diagnosed during express visits.

Express visits appear to work well for the “worried well” population, Jessica M. Borrelli, a research scientist in the bureau of STD control of the New York City Department of Mental Health and Hygiene, said in an interview. For example, individuals who come in because they have a new sexual partner can be screened for STDs without tying up physician time, she said. Ms. Borrelli presented the poster at a joint conference of the American Sexually Transmitted Diseases Association and the British Association for Sexual Health and HIV.

In 2005, the express visit option was conceived in an effort to deal with the increasing patient volume at New York City STD clinics. The following year, the express visit was introduced as a routine option. The researchers used clinic electronic medical records to compare patient data from September-December 2005—before express visits became routine—with patient data from September to December 2006—after the express visits were established.

NEW YORK — Busy STD clinics may be able to offer “express visits” that provide disease screening only for asymptomatic patients without missing infected individuals.

Researchers with the New York City Department of Mental Health and Hygiene and the Centers for Disease Control and Prevention evaluated the impact of instituting routine express visits in nine of the city's free walk-in clinics. During an express visit, asymptomatic patients with no known contact with an STD case were given the option of skipping the physician visit and being screened for gonorrhea, chlamydia, syphilis, and HIV.

The use of express visits allowed the clinic staff to screen a large number of asymptomatic patients, resulted in better use of physician resources, allowed for the treatment of more patients who were positive for gonorrhea or chlamydia infections, and improved the time to treatment, according to the results of the study.

In 2006, the nine clinics conducted 18,421 physician visits and 6,064 express visits. The proportion of patients who presented with symptoms during the physician visit increased from 74% in 2005 to 86% in 2006. There also was a decrease in the time to treatment for those seen during a physician visit. The median time to treatment dropped from 14 days in 2005 to 10 days in 2006. The median time to treatment for those who underwent express visits in 2006 was 9 days.

The number of gonorrhea or chlamydia infections that were diagnosed during a physician visit increased following the establishment of express visits in 2006. The number of gonorrhea or chlamydia infections detected during physician visits rose from 2,043 in 2005 to 2,081 in 2006. There were also 536 cases diagnosed during express visits.

Express visits appear to work well for the “worried well” population, Jessica M. Borrelli, a research scientist in the bureau of STD control of the New York City Department of Mental Health and Hygiene, said in an interview. For example, individuals who come in because they have a new sexual partner can be screened for STDs without tying up physician time, she said. Ms. Borrelli presented the poster at a joint conference of the American Sexually Transmitted Diseases Association and the British Association for Sexual Health and HIV.

In 2005, the express visit option was conceived in an effort to deal with the increasing patient volume at New York City STD clinics. The following year, the express visit was introduced as a routine option. The researchers used clinic electronic medical records to compare patient data from September-December 2005—before express visits became routine—with patient data from September to December 2006—after the express visits were established.