Mary Ellen Schneider

About 17% of U.S. physicians have electronic health records in their offices, but only 4% of those doctors have comprehensive systems, according to a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% reported that their practice had purchased a system that had yet to be implemented. And 26% said that their practice was planning to purchase an EHR system in the next 2 years, according to a survey (N. Engl. J. Med. 2008;359:50–60).

"If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3–5 years," Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing to release the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of which 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. "We're not surprised by that, given their worries about the cost of the system," said Dr. DesRoches.

Physicians are also seeking legal protection from personal liability if the electronic record is tampered with by an outside party, she said.

About 17% of U.S. physicians have electronic health records in their offices, but only 4% of those doctors have comprehensive systems, according to a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% reported that their practice had purchased a system that had yet to be implemented. And 26% said that their practice was planning to purchase an EHR system in the next 2 years, according to a survey (N. Engl. J. Med. 2008;359:50–60).

"If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3–5 years," Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing to release the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of which 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. "We're not surprised by that, given their worries about the cost of the system," said Dr. DesRoches.

Physicians are also seeking legal protection from personal liability if the electronic record is tampered with by an outside party, she said.

About 17% of U.S. physicians have electronic health records in their offices, but only 4% of those doctors have comprehensive systems, according to a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% reported that their practice had purchased a system that had yet to be implemented. And 26% said that their practice was planning to purchase an EHR system in the next 2 years, according to a survey (N. Engl. J. Med. 2008;359:50–60).

"If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3–5 years," Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing to release the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of which 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. "We're not surprised by that, given their worries about the cost of the system," said Dr. DesRoches.

Physicians are also seeking legal protection from personal liability if the electronic record is tampered with by an outside party, she said.

Reducing Unintended Pregnancies

In the absence of publicly funded family planning services, the number of abortions and unplanned pregnancies in the United States would have been nearly 50% higher in 2004, according to an analysis from the Guttmacher Institute, which conducts research on reproductive health issues. The researchers estimated that in 2004, women who received care at publicly funded family planning clinics avoided more than 1.4 million unintended pregnancies. The researchers also calculated that the government saved about $4 for every $1 spent on family planning services. “These new data add to the growing body of evidence that investing in publicly funded contraceptive services can make an enormous impact on helping women reduce unintended pregnancies, abortions, and unplanned births, all while saving money,” Lawrence Finer, Ph.D., one of the study authors, said in a statement. The findings are based on a variety of data sources including results from the National Survey of Family Growth, Title X data on clients and revenues, data on Medicaid expenditures, and previously published estimates of unintended pregnancies. The study, which was funded by a grant from the Department of Health and Human Services, appears in the August issue of the Journal of Health Care for the Poor and Underserved and is available online at

www.guttmacher.org

ACOG Highlights HIV/AIDS

The American College of Obstetricians and Gynecologists is urging ob.gyns. to pay special attention to African American and Hispanic women who may be at risk for HIV/AIDS infection. In a committee opinion issued this month, ACOG noted that African American and Hispanic women account for more than 80% of new diagnoses of HIV/AIDS in women the United States. These women are at an increased risk for HIV infection for several reasons but often they acquire the disease through heterosexual contact with a partner who did not disclose their risk factors for the disease. ACOG recommends routine screening for all women aged 19-64 years and targeted screening for women outside of that age range who are at risk. All women, particularly minority women, should receive counseling on safe sex practices and consistent condom use, ACOG recommended. And physicians need to train their staff on risk reduction interventions aimed at minority women. The committee opinion is published in the August issue of Obstetrics and Gynecology.

Court to Review Va. Abortion Ban

This fall a federal appeals court will reconsider its decision to strike down Virginia's ban on so-called partial birth abortion. The 4th U.S. Circuit Court of Appeals recently granted a petition filed by the state to rehear the case of Richmond Medical Center v. Herring with a full panel of judges. In May, a three-judge panel of the appeals court struck down the abortion ban, saying that it imposed an “undue burden on a woman's right to choose an abortion.” Critics first challenged the law in 2003 saying that it was so broad it would essentially outlaw all common abortion methods starting in the early second trimester. Oral arguments in the case are schedule for late October.

New Leadership in Women's Health

Dr. Janine Austin Clayton, an ophthalmologist and researcher, has been appointed as the new deputy director of the Office of Research on Women's Health at the National Institutes of Health. Most recently, Dr. Clayton was the deputy clinical director at the National Eye Institute, also part of the NIH. In her new post, Dr. Clayton will work on the administration of research programs, policies on inclusion of women and minorities in clinical research, and coordination of activities across NIH. The research office aims to ensure that women are adequately represented on research studies supported by NIH and to help women advance in careers in the biomedical sector.

Feds Scrutinize Generic Maker

India's Ranbaxy Inc., one of the top 10 generic drug makers in the world, is being investigated by various arms of the federal government for allegedly introducing “adulterated or misbranded products” into the U.S. market. The company's auditor, Parexel Consulting, is also under scrutiny. According to a subpoena for documents filed in the U.S. District Court for the District of Maryland by the Department of Justice and the U.S. Attorney's Office in Maryland, Ranbaxy submitted false information to the Food and Drug Administration on sterility and bioequivalence, covered up good manufacturing practice violations, and defrauded Medicare. Rep. John Dingell (D-Mich.) and Rep. Bart Stupak (D-Mich.) said that they will formally investigate the Ranbaxy situation. “If these allegations are true, Ranbaxy has imperiled the safety of Americans in a manner similar to the generic drug scandal we uncovered 20 years ago,” said Rep. Dingell.

Reducing Unintended Pregnancies

In the absence of publicly funded family planning services, the number of abortions and unplanned pregnancies in the United States would have been nearly 50% higher in 2004, according to an analysis from the Guttmacher Institute, which conducts research on reproductive health issues. The researchers estimated that in 2004, women who received care at publicly funded family planning clinics avoided more than 1.4 million unintended pregnancies. The researchers also calculated that the government saved about $4 for every $1 spent on family planning services. “These new data add to the growing body of evidence that investing in publicly funded contraceptive services can make an enormous impact on helping women reduce unintended pregnancies, abortions, and unplanned births, all while saving money,” Lawrence Finer, Ph.D., one of the study authors, said in a statement. The findings are based on a variety of data sources including results from the National Survey of Family Growth, Title X data on clients and revenues, data on Medicaid expenditures, and previously published estimates of unintended pregnancies. The study, which was funded by a grant from the Department of Health and Human Services, appears in the August issue of the Journal of Health Care for the Poor and Underserved and is available online at

www.guttmacher.org

ACOG Highlights HIV/AIDS

The American College of Obstetricians and Gynecologists is urging ob.gyns. to pay special attention to African American and Hispanic women who may be at risk for HIV/AIDS infection. In a committee opinion issued this month, ACOG noted that African American and Hispanic women account for more than 80% of new diagnoses of HIV/AIDS in women the United States. These women are at an increased risk for HIV infection for several reasons but often they acquire the disease through heterosexual contact with a partner who did not disclose their risk factors for the disease. ACOG recommends routine screening for all women aged 19-64 years and targeted screening for women outside of that age range who are at risk. All women, particularly minority women, should receive counseling on safe sex practices and consistent condom use, ACOG recommended. And physicians need to train their staff on risk reduction interventions aimed at minority women. The committee opinion is published in the August issue of Obstetrics and Gynecology.

Court to Review Va. Abortion Ban

This fall a federal appeals court will reconsider its decision to strike down Virginia's ban on so-called partial birth abortion. The 4th U.S. Circuit Court of Appeals recently granted a petition filed by the state to rehear the case of Richmond Medical Center v. Herring with a full panel of judges. In May, a three-judge panel of the appeals court struck down the abortion ban, saying that it imposed an “undue burden on a woman's right to choose an abortion.” Critics first challenged the law in 2003 saying that it was so broad it would essentially outlaw all common abortion methods starting in the early second trimester. Oral arguments in the case are schedule for late October.

New Leadership in Women's Health

Dr. Janine Austin Clayton, an ophthalmologist and researcher, has been appointed as the new deputy director of the Office of Research on Women's Health at the National Institutes of Health. Most recently, Dr. Clayton was the deputy clinical director at the National Eye Institute, also part of the NIH. In her new post, Dr. Clayton will work on the administration of research programs, policies on inclusion of women and minorities in clinical research, and coordination of activities across NIH. The research office aims to ensure that women are adequately represented on research studies supported by NIH and to help women advance in careers in the biomedical sector.

Feds Scrutinize Generic Maker

India's Ranbaxy Inc., one of the top 10 generic drug makers in the world, is being investigated by various arms of the federal government for allegedly introducing “adulterated or misbranded products” into the U.S. market. The company's auditor, Parexel Consulting, is also under scrutiny. According to a subpoena for documents filed in the U.S. District Court for the District of Maryland by the Department of Justice and the U.S. Attorney's Office in Maryland, Ranbaxy submitted false information to the Food and Drug Administration on sterility and bioequivalence, covered up good manufacturing practice violations, and defrauded Medicare. Rep. John Dingell (D-Mich.) and Rep. Bart Stupak (D-Mich.) said that they will formally investigate the Ranbaxy situation. “If these allegations are true, Ranbaxy has imperiled the safety of Americans in a manner similar to the generic drug scandal we uncovered 20 years ago,” said Rep. Dingell.

Reducing Unintended Pregnancies

In the absence of publicly funded family planning services, the number of abortions and unplanned pregnancies in the United States would have been nearly 50% higher in 2004, according to an analysis from the Guttmacher Institute, which conducts research on reproductive health issues. The researchers estimated that in 2004, women who received care at publicly funded family planning clinics avoided more than 1.4 million unintended pregnancies. The researchers also calculated that the government saved about $4 for every $1 spent on family planning services. “These new data add to the growing body of evidence that investing in publicly funded contraceptive services can make an enormous impact on helping women reduce unintended pregnancies, abortions, and unplanned births, all while saving money,” Lawrence Finer, Ph.D., one of the study authors, said in a statement. The findings are based on a variety of data sources including results from the National Survey of Family Growth, Title X data on clients and revenues, data on Medicaid expenditures, and previously published estimates of unintended pregnancies. The study, which was funded by a grant from the Department of Health and Human Services, appears in the August issue of the Journal of Health Care for the Poor and Underserved and is available online at

www.guttmacher.org

ACOG Highlights HIV/AIDS

The American College of Obstetricians and Gynecologists is urging ob.gyns. to pay special attention to African American and Hispanic women who may be at risk for HIV/AIDS infection. In a committee opinion issued this month, ACOG noted that African American and Hispanic women account for more than 80% of new diagnoses of HIV/AIDS in women the United States. These women are at an increased risk for HIV infection for several reasons but often they acquire the disease through heterosexual contact with a partner who did not disclose their risk factors for the disease. ACOG recommends routine screening for all women aged 19-64 years and targeted screening for women outside of that age range who are at risk. All women, particularly minority women, should receive counseling on safe sex practices and consistent condom use, ACOG recommended. And physicians need to train their staff on risk reduction interventions aimed at minority women. The committee opinion is published in the August issue of Obstetrics and Gynecology.

Court to Review Va. Abortion Ban

This fall a federal appeals court will reconsider its decision to strike down Virginia's ban on so-called partial birth abortion. The 4th U.S. Circuit Court of Appeals recently granted a petition filed by the state to rehear the case of Richmond Medical Center v. Herring with a full panel of judges. In May, a three-judge panel of the appeals court struck down the abortion ban, saying that it imposed an “undue burden on a woman's right to choose an abortion.” Critics first challenged the law in 2003 saying that it was so broad it would essentially outlaw all common abortion methods starting in the early second trimester. Oral arguments in the case are schedule for late October.

New Leadership in Women's Health

Dr. Janine Austin Clayton, an ophthalmologist and researcher, has been appointed as the new deputy director of the Office of Research on Women's Health at the National Institutes of Health. Most recently, Dr. Clayton was the deputy clinical director at the National Eye Institute, also part of the NIH. In her new post, Dr. Clayton will work on the administration of research programs, policies on inclusion of women and minorities in clinical research, and coordination of activities across NIH. The research office aims to ensure that women are adequately represented on research studies supported by NIH and to help women advance in careers in the biomedical sector.

Feds Scrutinize Generic Maker

India's Ranbaxy Inc., one of the top 10 generic drug makers in the world, is being investigated by various arms of the federal government for allegedly introducing “adulterated or misbranded products” into the U.S. market. The company's auditor, Parexel Consulting, is also under scrutiny. According to a subpoena for documents filed in the U.S. District Court for the District of Maryland by the Department of Justice and the U.S. Attorney's Office in Maryland, Ranbaxy submitted false information to the Food and Drug Administration on sterility and bioequivalence, covered up good manufacturing practice violations, and defrauded Medicare. Rep. John Dingell (D-Mich.) and Rep. Bart Stupak (D-Mich.) said that they will formally investigate the Ranbaxy situation. “If these allegations are true, Ranbaxy has imperiled the safety of Americans in a manner similar to the generic drug scandal we uncovered 20 years ago,” said Rep. Dingell.

With only a few months left before election day, Sen. John McCain (R-Ariz.) has been crisscrossing the country touting his plan to make health insurance affordable and portable.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The proposed tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach would include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase of coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” Mr. Hickey said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund.

The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs.

The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by his Democratic opponent, Sen. Barack Obama (Ill.), said Naoma Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and to put a greater emphasis on chronic disease care and management.

Sen. McCain proposes to provide a tax credit while eliminating the tax exclusion for health benefits. John McCain 2008/

With only a few months left before election day, Sen. John McCain (R-Ariz.) has been crisscrossing the country touting his plan to make health insurance affordable and portable.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The proposed tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach would include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase of coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” Mr. Hickey said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund.

The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs.

The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by his Democratic opponent, Sen. Barack Obama (Ill.), said Naoma Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and to put a greater emphasis on chronic disease care and management.

Sen. McCain proposes to provide a tax credit while eliminating the tax exclusion for health benefits. John McCain 2008/

With only a few months left before election day, Sen. John McCain (R-Ariz.) has been crisscrossing the country touting his plan to make health insurance affordable and portable.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The proposed tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach would include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States.

“We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to the purchase of coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” Mr. Hickey said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund.

The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

The proposal is raising some concerns among physicians. Dr. Jack Lewin, chief executive officer of the American College of Cardiology, called on Sen. McCain to rethink his tax proposal, saying that taking away the employee tax exclusion would “undoubtedly” cause a shift to individual coverage and force many people into government health care programs.

The focus should be on expanding coverage to the uninsured, not destabilizing the current system of coverage, he said.

But Dr. Lewin praised the direction of Sen. McCain's quality of care proposals, which include plans aimed at increasing the adoption of health information technology and paying physicians for prevention and chronic disease management.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by his Democratic opponent, Sen. Barack Obama (Ill.), said Naoma Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of “sound science” and to put a greater emphasis on chronic disease care and management.

Sen. McCain proposes to provide a tax credit while eliminating the tax exclusion for health benefits. John McCain 2008/

About 17% of U.S. physicians have electronic health records in their offices, although only 4% of all doctors have comprehensive systems, according to results from a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% told the survey that their practice had purchased a system that had yet to be implemented and 26% said that their practice was planning to purchase an EHR system in the next 2 years (N. Engl. J. Med. 2008;359:50-60).

“If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3 to 5 years,” Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing on the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at the Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of which 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. “We're not surprised by that, given their worries about the cost of the system,” Dr. DesRoches said. Physicians are also seeking legal protection from personal liability if the record is tampered with by an outside party.

“This suggests that we might be able to significantly increase the rate of adoption by easing the financial burden on office-based providers. I think this is particularly true for providers in smaller one- and two-physician practices,” she said.

These types of incentives will be critical to increasing adoption, said Dr. Richard J. Baron, an internist in a five-physician community-based practice in Philadelphia that implemented an EHR in July 2004. While the use of the EHR has changed his practice for the better, Dr. Baron said the process of implementing the system was both disruptive and costly.

Not only did the practice spend more than $40,000 per physician to purchase their EHR system but they are also spending $60,000 annually for technical support. In the current reimbursement system, a primary care physician is much more likely to get a return on investment with the purchase of a new scanner than for adopting an EHR, he said.

It would be helpful to find a mechanism to aggregate funding from the stakeholders who benefit financially when physicians adopt EHRs, Dr. Baron said.

“I really think new financing strategies are desperately needed,” he commented.

About 17% of U.S. physicians have electronic health records in their offices, although only 4% of all doctors have comprehensive systems, according to results from a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% told the survey that their practice had purchased a system that had yet to be implemented and 26% said that their practice was planning to purchase an EHR system in the next 2 years (N. Engl. J. Med. 2008;359:50-60).

“If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3 to 5 years,” Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing on the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at the Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of which 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. “We're not surprised by that, given their worries about the cost of the system,” Dr. DesRoches said. Physicians are also seeking legal protection from personal liability if the record is tampered with by an outside party.

“This suggests that we might be able to significantly increase the rate of adoption by easing the financial burden on office-based providers. I think this is particularly true for providers in smaller one- and two-physician practices,” she said.

These types of incentives will be critical to increasing adoption, said Dr. Richard J. Baron, an internist in a five-physician community-based practice in Philadelphia that implemented an EHR in July 2004. While the use of the EHR has changed his practice for the better, Dr. Baron said the process of implementing the system was both disruptive and costly.

Not only did the practice spend more than $40,000 per physician to purchase their EHR system but they are also spending $60,000 annually for technical support. In the current reimbursement system, a primary care physician is much more likely to get a return on investment with the purchase of a new scanner than for adopting an EHR, he said.

It would be helpful to find a mechanism to aggregate funding from the stakeholders who benefit financially when physicians adopt EHRs, Dr. Baron said.

“I really think new financing strategies are desperately needed,” he commented.

About 17% of U.S. physicians have electronic health records in their offices, although only 4% of all doctors have comprehensive systems, according to results from a survey of more than 2,700 physicians nationwide.

However, more physicians are planning to purchase or implement the technology soon. For example, of the 83% of physicians without an EHR, 16% told the survey that their practice had purchased a system that had yet to be implemented and 26% said that their practice was planning to purchase an EHR system in the next 2 years (N. Engl. J. Med. 2008;359:50-60).

“If these intentions are realized, we could see a good-sized increase in the number of physicians with an EHR over the next 3 to 5 years,” Catherine DesRoches, Ph.D., the lead author of the study, said during a press briefing on the survey results. Dr. DesRoches is an assistant in health policy at the Institute for Health Policy at Massachusetts General Hospital in Boston.

The nationally representative survey was conducted between September 2007 and March 2008 by researchers at the Massachusetts General Hospital, Cornell University, and George Washington University. The study was funded by the Office of the National Coordinator for Health Information Technology, part of the Health and Human Services department, and the Robert Wood Johnson Foundation. Some of the researchers reported receiving grant support from GE Healthcare, which markets EHRs.

The Office of the National Coordinator for Health Information Technology commissioned the survey to provide a definitive national estimate of EHR adoption by physicians in the United States. Previous estimates of adoption range from 9% to 29%, but most of the estimates are based on small sample sizes or incomplete definitions of an EHR, according to the researchers.

The researchers randomly selected 4,484 eligible physicians from the American Medical Association's 2007 Physician Masterfile, of which 2,758 completed the survey. The survey found that 4% of physicians have a fully functional EHR. The researchers defined a fully functional EHR as one that includes the ability to write and send orders electronically, the ability to view lab results and images, and the ability to provide clinical decision support and reminders. In addition, about 13% of physicians reported having a basic EHR, which has electronic prescribing but lacks clinical decision support and certain order entry capabilities.

Physicians were more likely to report having a fully functional system if it was integrated with their hospital system, the survey found. For example, 71% of physicians who reported a fully functional EHR said that their system was integrated with their affiliated hospital system, compared with 56% among those physicians with a basic EHR system.

Adoption continues to be influenced by the size and setting of a practice. For example, the survey showed that adoption was more likely among physicians who practiced in large groups (at least 50 physicians) than among those who practiced in groups of 3 physicians or fewer.

Most physicians who have adopted EHRs reported satisfaction with the system and positive effects on quality of care and communication. About 93% of physicians who have implemented fully functional EHRs reported being satisfied with their systems, along with 88% of physicians with basic systems.

Cost continues to slow adoption, the researchers found. Capital costs were cited as barriers by 66% of physicians without an EHR. Other barriers noted by physicians without an EHR include finding a system that meets their needs (54%), concerns about the return on investment (50%), and worries that the system will become obsolete (44%).

But adoption could be improved by helping physicians to purchase EHRs through loans or direct payments, and by offering additional payment for the use of a system, according to the survey. “We're not surprised by that, given their worries about the cost of the system,” Dr. DesRoches said. Physicians are also seeking legal protection from personal liability if the record is tampered with by an outside party.

“This suggests that we might be able to significantly increase the rate of adoption by easing the financial burden on office-based providers. I think this is particularly true for providers in smaller one- and two-physician practices,” she said.

These types of incentives will be critical to increasing adoption, said Dr. Richard J. Baron, an internist in a five-physician community-based practice in Philadelphia that implemented an EHR in July 2004. While the use of the EHR has changed his practice for the better, Dr. Baron said the process of implementing the system was both disruptive and costly.

Not only did the practice spend more than $40,000 per physician to purchase their EHR system but they are also spending $60,000 annually for technical support. In the current reimbursement system, a primary care physician is much more likely to get a return on investment with the purchase of a new scanner than for adopting an EHR, he said.

It would be helpful to find a mechanism to aggregate funding from the stakeholders who benefit financially when physicians adopt EHRs, Dr. Baron said.

“I really think new financing strategies are desperately needed,” he commented.

One in five Americans postponed or skipped needed medical care last year because of cost, insurance problems, or difficulty getting an appointment, according to a report from the Center for Studying Health System Change.

Researchers, who compared nationwide survey data from the years 2003 and 2007, found that the number of Americans who reported problems with access to health care increased dramatically during the intervening period. In 2007, more than 23 million individuals (8%) said that they went without needed medical care, compared with 13.5 million (5.2%) in 2003.

There were even more problems with delaying care. In 2007, 36 million (12.3%) reported that they delayed seeking care, compared with 23.5 million (8.4%) in 2003.

The most recent figures come from the 2007 Health Tracking Household Survey, a nationally representative sample of about 18,000 individuals. The earlier data are drawn from a similar survey with a sample size of about 47,000 individuals.

“The change is not only large, but it is widespread,” Peter J. Cunningham, Ph.D., the lead author of the study and a senior fellow at the Center for Studying Health System Change, said during a press conference. “It's changing for a lot of people.”

Specifically, the researchers found that access problems were increasingly affecting people with and without insurance. In 2007, about 20% of uninsured people and 11% of insured people reported delaying care. In addition, 17.5% of uninsured people and 6.3% of insured people reported unmet medical needs.

But while more uninsured people reported access problems, the rate of increase for unmet medical needs between 2003 and 2007 was higher among people who had insurance. Of the additional 9.5 million people who reported unmet needs between 2003 and 2007, 6.7 million had health insurance, Mr. Cunningham said.

The researchers also found greater unmet medical needs among individuals with fair or poor health and among children from families with lower incomes. For example, unmet medical needs increased from 11.9% in 2003 to 17% in 2007 for people who were in fair or poor health.

And researchers saw the gap in access to care between low- and higher-income children widen in 2007 after having been virtually eliminated in 2003 following expansions of the Medicaid and State Children's Health Insurance Programs. In 2003, 2.2% of children below 200% of poverty experienced unmet medical needs, the same percentage as those children whose family incomes were at 200% of poverty or higher. However, in 2007, 5.4% of children below 200% of poverty had unmet medical needs, compared with 2.9% of children at 200% of poverty or higher.

The most commonly cited reason for access problems continues to be cost. In 2007, 69% of people who decided to delay or forgo needed medical care said worries about cost were the reason, which was up from 65.2% in 2003. Among insured people, cost worries were cited by 60.8% of people in 2007, compared with 53.7% in 2003.

“Insured people are facing growing cost pressures,” Mr. Cunningham said. “Financial barriers to care are no longer just a concern for the uninsured.”

One in five Americans postponed or skipped needed medical care last year because of cost, insurance problems, or difficulty getting an appointment, according to a report from the Center for Studying Health System Change.

Researchers, who compared nationwide survey data from the years 2003 and 2007, found that the number of Americans who reported problems with access to health care increased dramatically during the intervening period. In 2007, more than 23 million individuals (8%) said that they went without needed medical care, compared with 13.5 million (5.2%) in 2003.

There were even more problems with delaying care. In 2007, 36 million (12.3%) reported that they delayed seeking care, compared with 23.5 million (8.4%) in 2003.

The most recent figures come from the 2007 Health Tracking Household Survey, a nationally representative sample of about 18,000 individuals. The earlier data are drawn from a similar survey with a sample size of about 47,000 individuals.

“The change is not only large, but it is widespread,” Peter J. Cunningham, Ph.D., the lead author of the study and a senior fellow at the Center for Studying Health System Change, said during a press conference. “It's changing for a lot of people.”

Specifically, the researchers found that access problems were increasingly affecting people with and without insurance. In 2007, about 20% of uninsured people and 11% of insured people reported delaying care. In addition, 17.5% of uninsured people and 6.3% of insured people reported unmet medical needs.

But while more uninsured people reported access problems, the rate of increase for unmet medical needs between 2003 and 2007 was higher among people who had insurance. Of the additional 9.5 million people who reported unmet needs between 2003 and 2007, 6.7 million had health insurance, Mr. Cunningham said.

The researchers also found greater unmet medical needs among individuals with fair or poor health and among children from families with lower incomes. For example, unmet medical needs increased from 11.9% in 2003 to 17% in 2007 for people who were in fair or poor health.

And researchers saw the gap in access to care between low- and higher-income children widen in 2007 after having been virtually eliminated in 2003 following expansions of the Medicaid and State Children's Health Insurance Programs. In 2003, 2.2% of children below 200% of poverty experienced unmet medical needs, the same percentage as those children whose family incomes were at 200% of poverty or higher. However, in 2007, 5.4% of children below 200% of poverty had unmet medical needs, compared with 2.9% of children at 200% of poverty or higher.

The most commonly cited reason for access problems continues to be cost. In 2007, 69% of people who decided to delay or forgo needed medical care said worries about cost were the reason, which was up from 65.2% in 2003. Among insured people, cost worries were cited by 60.8% of people in 2007, compared with 53.7% in 2003.

“Insured people are facing growing cost pressures,” Mr. Cunningham said. “Financial barriers to care are no longer just a concern for the uninsured.”

One in five Americans postponed or skipped needed medical care last year because of cost, insurance problems, or difficulty getting an appointment, according to a report from the Center for Studying Health System Change.

Researchers, who compared nationwide survey data from the years 2003 and 2007, found that the number of Americans who reported problems with access to health care increased dramatically during the intervening period. In 2007, more than 23 million individuals (8%) said that they went without needed medical care, compared with 13.5 million (5.2%) in 2003.

There were even more problems with delaying care. In 2007, 36 million (12.3%) reported that they delayed seeking care, compared with 23.5 million (8.4%) in 2003.

The most recent figures come from the 2007 Health Tracking Household Survey, a nationally representative sample of about 18,000 individuals. The earlier data are drawn from a similar survey with a sample size of about 47,000 individuals.

“The change is not only large, but it is widespread,” Peter J. Cunningham, Ph.D., the lead author of the study and a senior fellow at the Center for Studying Health System Change, said during a press conference. “It's changing for a lot of people.”

Specifically, the researchers found that access problems were increasingly affecting people with and without insurance. In 2007, about 20% of uninsured people and 11% of insured people reported delaying care. In addition, 17.5% of uninsured people and 6.3% of insured people reported unmet medical needs.

But while more uninsured people reported access problems, the rate of increase for unmet medical needs between 2003 and 2007 was higher among people who had insurance. Of the additional 9.5 million people who reported unmet needs between 2003 and 2007, 6.7 million had health insurance, Mr. Cunningham said.

The researchers also found greater unmet medical needs among individuals with fair or poor health and among children from families with lower incomes. For example, unmet medical needs increased from 11.9% in 2003 to 17% in 2007 for people who were in fair or poor health.

And researchers saw the gap in access to care between low- and higher-income children widen in 2007 after having been virtually eliminated in 2003 following expansions of the Medicaid and State Children's Health Insurance Programs. In 2003, 2.2% of children below 200% of poverty experienced unmet medical needs, the same percentage as those children whose family incomes were at 200% of poverty or higher. However, in 2007, 5.4% of children below 200% of poverty had unmet medical needs, compared with 2.9% of children at 200% of poverty or higher.

The most commonly cited reason for access problems continues to be cost. In 2007, 69% of people who decided to delay or forgo needed medical care said worries about cost were the reason, which was up from 65.2% in 2003. Among insured people, cost worries were cited by 60.8% of people in 2007, compared with 53.7% in 2003.

“Insured people are facing growing cost pressures,” Mr. Cunningham said. “Financial barriers to care are no longer just a concern for the uninsured.”

Federal officials are urging physicians to begin electronic prescribing as soon as possible now that Congress has authorized bonus payments for the successful use of the technology.

Under the recently enacted Medicare Improvements for Patients and Providers Act (H.R. 6331)—the same law that eliminated the 10.6% Medicare physician pay cut—Congress also outlined plans to ramp up e-prescribing beginning next year. Under the law, bonus payments will gradually decrease and eventually physicians will be penalized if they don't transmit prescriptions electronically.

“We expect this will have a profound effect on the adoption and use of e-prescribing,” Health and Human Services Secretary Mike Leavitt said during a press conference to explain the details of the new initiative.

The widespread use of e-prescribing will create benefits for patients and the health system as a whole by allowing for real-time cross-checking for drug-drug interactions and providing automatic error screening of prescriptions, Mr. Leavitt said.

It also is expected to save money. Medicare could save up to $156 million over a 5-year period by avoiding adverse drug events, according to the Centers for Medicare and Medicaid Services.

The incentive payments will be awarded through the Physician Quality Reporting Initiative, Medicare's voluntary program that provides incentives to physicians who successfully report on certain quality measures. CMS officials have developed measures specific to e-prescribing and will be releasing guidance on how they define the routine use of e-prescribing. They also plan to host a conference on the technical details of the plan this fall.

The e-prescribing bonuses will be in addition to the current bonuses.

During 2009 and 2010, physicians who successfully report on e-prescribing measures will be eligible to earn 2% of total allowed Medicare charges. In 2011 and 2012, the incentive payment will drop to 1% and then to 0.5% in 2013.

Beginning in 2012, eligible physicians who do not e-prescribe will see their total allowed Medicare charges cut by 1% with that amount increasing to 2% by 2014, according to the provisions of H.R. 6331.

The law grants an exemption for those providers for whom the requirement would be a “significant hardship,” such as a physician practicing in a rural area without sufficient Internet access.

CMS officials already have laid the groundwork for the increased use of e-prescribing by issuing standards around the transmission of electronic prescriptions, Mr. Leavitt said. With the authorization of bonus payments, the government will be able ease some of the costs of adopting e-prescribing technology.

According to CMS estimates, the average the cost of acquiring and setting up an e-prescribing system is about $3,000 per prescriber, with ongoing maintenance costs of $80-$400 per month.

Dr. James King, a family physician in Selmer, Tenn., and president of the American Academy of Family Physicians, estimated that he spent about $10,000 to implement an e-prescribing system in his practice. But, even with the technology in place, he is able to e-prescribe only some of the time. For example, not all pharmacies in his area are able to receive electronic prescriptions, he can't prescribe some narcotic drugs electronically, and he cannot prescribe medications electronically across state lines for his patients who live in Mississippi.

That's why Dr. King said he is pleased that Congress chose to proceed first with payment incentives, so that policy makers have time to remove some of these barriers.

He urged physicians to adopt the technology. In addition to improving quality and safety for patients, it allows the physicians to engage in more “two-way communication,” he said. For example, e-prescriptions generally allow physicians access to information about whether the patient has filled the prescription. And e-prescribing should improve efficiency, allowing physicians to devote more time to patient care, he said.

A significant number of family physicians are likely to be ready to begin e-prescribing in January, Dr. King said. The AAFP estimates that about half of their members either have electronic health records (EHRs) with e-prescribing capabilities or plan to implement them by the end of the year.

Federal officials are urging physicians to begin electronic prescribing as soon as possible now that Congress has authorized bonus payments for the successful use of the technology.

Under the recently enacted Medicare Improvements for Patients and Providers Act (H.R. 6331)—the same law that eliminated the 10.6% Medicare physician pay cut—Congress also outlined plans to ramp up e-prescribing beginning next year. Under the law, bonus payments will gradually decrease and eventually physicians will be penalized if they don't transmit prescriptions electronically.

“We expect this will have a profound effect on the adoption and use of e-prescribing,” Health and Human Services Secretary Mike Leavitt said during a press conference to explain the details of the new initiative.

The widespread use of e-prescribing will create benefits for patients and the health system as a whole by allowing for real-time cross-checking for drug-drug interactions and providing automatic error screening of prescriptions, Mr. Leavitt said.

It also is expected to save money. Medicare could save up to $156 million over a 5-year period by avoiding adverse drug events, according to the Centers for Medicare and Medicaid Services.

The incentive payments will be awarded through the Physician Quality Reporting Initiative, Medicare's voluntary program that provides incentives to physicians who successfully report on certain quality measures. CMS officials have developed measures specific to e-prescribing and will be releasing guidance on how they define the routine use of e-prescribing. They also plan to host a conference on the technical details of the plan this fall.

The e-prescribing bonuses will be in addition to the current bonuses.

During 2009 and 2010, physicians who successfully report on e-prescribing measures will be eligible to earn 2% of total allowed Medicare charges. In 2011 and 2012, the incentive payment will drop to 1% and then to 0.5% in 2013.

Beginning in 2012, eligible physicians who do not e-prescribe will see their total allowed Medicare charges cut by 1% with that amount increasing to 2% by 2014, according to the provisions of H.R. 6331.

The law grants an exemption for those providers for whom the requirement would be a “significant hardship,” such as a physician practicing in a rural area without sufficient Internet access.

CMS officials already have laid the groundwork for the increased use of e-prescribing by issuing standards around the transmission of electronic prescriptions, Mr. Leavitt said. With the authorization of bonus payments, the government will be able ease some of the costs of adopting e-prescribing technology.

According to CMS estimates, the average the cost of acquiring and setting up an e-prescribing system is about $3,000 per prescriber, with ongoing maintenance costs of $80-$400 per month.

Dr. James King, a family physician in Selmer, Tenn., and president of the American Academy of Family Physicians, estimated that he spent about $10,000 to implement an e-prescribing system in his practice. But, even with the technology in place, he is able to e-prescribe only some of the time. For example, not all pharmacies in his area are able to receive electronic prescriptions, he can't prescribe some narcotic drugs electronically, and he cannot prescribe medications electronically across state lines for his patients who live in Mississippi.

That's why Dr. King said he is pleased that Congress chose to proceed first with payment incentives, so that policy makers have time to remove some of these barriers.

He urged physicians to adopt the technology. In addition to improving quality and safety for patients, it allows the physicians to engage in more “two-way communication,” he said. For example, e-prescriptions generally allow physicians access to information about whether the patient has filled the prescription. And e-prescribing should improve efficiency, allowing physicians to devote more time to patient care, he said.

A significant number of family physicians are likely to be ready to begin e-prescribing in January, Dr. King said. The AAFP estimates that about half of their members either have electronic health records (EHRs) with e-prescribing capabilities or plan to implement them by the end of the year.

Federal officials are urging physicians to begin electronic prescribing as soon as possible now that Congress has authorized bonus payments for the successful use of the technology.

Under the recently enacted Medicare Improvements for Patients and Providers Act (H.R. 6331)—the same law that eliminated the 10.6% Medicare physician pay cut—Congress also outlined plans to ramp up e-prescribing beginning next year. Under the law, bonus payments will gradually decrease and eventually physicians will be penalized if they don't transmit prescriptions electronically.

“We expect this will have a profound effect on the adoption and use of e-prescribing,” Health and Human Services Secretary Mike Leavitt said during a press conference to explain the details of the new initiative.

The widespread use of e-prescribing will create benefits for patients and the health system as a whole by allowing for real-time cross-checking for drug-drug interactions and providing automatic error screening of prescriptions, Mr. Leavitt said.

It also is expected to save money. Medicare could save up to $156 million over a 5-year period by avoiding adverse drug events, according to the Centers for Medicare and Medicaid Services.

The incentive payments will be awarded through the Physician Quality Reporting Initiative, Medicare's voluntary program that provides incentives to physicians who successfully report on certain quality measures. CMS officials have developed measures specific to e-prescribing and will be releasing guidance on how they define the routine use of e-prescribing. They also plan to host a conference on the technical details of the plan this fall.

The e-prescribing bonuses will be in addition to the current bonuses.

During 2009 and 2010, physicians who successfully report on e-prescribing measures will be eligible to earn 2% of total allowed Medicare charges. In 2011 and 2012, the incentive payment will drop to 1% and then to 0.5% in 2013.

Beginning in 2012, eligible physicians who do not e-prescribe will see their total allowed Medicare charges cut by 1% with that amount increasing to 2% by 2014, according to the provisions of H.R. 6331.

The law grants an exemption for those providers for whom the requirement would be a “significant hardship,” such as a physician practicing in a rural area without sufficient Internet access.

CMS officials already have laid the groundwork for the increased use of e-prescribing by issuing standards around the transmission of electronic prescriptions, Mr. Leavitt said. With the authorization of bonus payments, the government will be able ease some of the costs of adopting e-prescribing technology.

According to CMS estimates, the average the cost of acquiring and setting up an e-prescribing system is about $3,000 per prescriber, with ongoing maintenance costs of $80-$400 per month.

Dr. James King, a family physician in Selmer, Tenn., and president of the American Academy of Family Physicians, estimated that he spent about $10,000 to implement an e-prescribing system in his practice. But, even with the technology in place, he is able to e-prescribe only some of the time. For example, not all pharmacies in his area are able to receive electronic prescriptions, he can't prescribe some narcotic drugs electronically, and he cannot prescribe medications electronically across state lines for his patients who live in Mississippi.

That's why Dr. King said he is pleased that Congress chose to proceed first with payment incentives, so that policy makers have time to remove some of these barriers.

He urged physicians to adopt the technology. In addition to improving quality and safety for patients, it allows the physicians to engage in more “two-way communication,” he said. For example, e-prescriptions generally allow physicians access to information about whether the patient has filled the prescription. And e-prescribing should improve efficiency, allowing physicians to devote more time to patient care, he said.

A significant number of family physicians are likely to be ready to begin e-prescribing in January, Dr. King said. The AAFP estimates that about half of their members either have electronic health records (EHRs) with e-prescribing capabilities or plan to implement them by the end of the year.

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago.

These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States.

For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health as well as mental health issues.

Dr. Warren A. Jones, who was the first African American president of the American Academy of Family Physicians, agreed that further action will be needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change in the mind-set of the AMA leadership.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313).

The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-5).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, the AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. The commission has been working to expand the reach of the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal of these efforts is to have as much diversity among physicians as there is in the general population; African Americans make up about 12% of the inhabitants of the United States, Dr. Davis said. “Obviously, we have a long way to go,” he said.

'Talk is cheap,' and the AMA should back it up by supporting research into minority health issues. Dr. Bell

The AMA's apology is a signal of change in the mind-set of the organization's leadership. DR. JONES

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago.

These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States.

For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health as well as mental health issues.

Dr. Warren A. Jones, who was the first African American president of the American Academy of Family Physicians, agreed that further action will be needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change in the mind-set of the AMA leadership.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313).

The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-5).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, the AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. The commission has been working to expand the reach of the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal of these efforts is to have as much diversity among physicians as there is in the general population; African Americans make up about 12% of the inhabitants of the United States, Dr. Davis said. “Obviously, we have a long way to go,” he said.

'Talk is cheap,' and the AMA should back it up by supporting research into minority health issues. Dr. Bell

The AMA's apology is a signal of change in the mind-set of the organization's leadership. DR. JONES

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago.

These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States.

For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health as well as mental health issues.

Dr. Warren A. Jones, who was the first African American president of the American Academy of Family Physicians, agreed that further action will be needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change in the mind-set of the AMA leadership.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313).

The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-5).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, the AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. The commission has been working to expand the reach of the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal of these efforts is to have as much diversity among physicians as there is in the general population; African Americans make up about 12% of the inhabitants of the United States, Dr. Davis said. “Obviously, we have a long way to go,” he said.

'Talk is cheap,' and the AMA should back it up by supporting research into minority health issues. Dr. Bell

The AMA's apology is a signal of change in the mind-set of the organization's leadership. DR. JONES

With Sen. Barack Obama (D-Ill.) set to become the Democratic Party's presidential nominee this month, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program.

Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but who still needed financial assistance to purchase their health insurance.

Sen. Obama also would guarantee that no American could be turned down for health insurance because of illness or a preexisting condition. However, his proposal stops short of requiring all Americans to purchase coverage. Instead, the plan mandates coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. For example, he would target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers. Under his plan, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage widespread adoption of EHRs. The idea is that the investment would reap savings through increased efficiencies since paper records are more costly to store and process than are electronic ones, according to the Obama campaign. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

“I want to wake up and know that every single American has health care when they need it, that every senior has prescription drugs they can afford, and that no parents are going to bed at night worrying about how they'll afford medicine for a sick child,” Sen. Obama said in June during a health care town hall meeting in Bristol, Va.

If elected, Sen. Obama has pledged to implement his health care proposal by the end of his first term as president.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market.

“That is not a level playing field,” said Ms. Turner, who also is an adviser to the presidential campaign of Sen. John McCain (R-Ariz.).

Sen. Obama's approach is really a “backdoor” to getting everyone on a government-funded health plan, she said.

Ms. Turner also criticized Sen. Obama's plan to have the federal government take on a portion of the costs of catastrophic health costs in employer-sponsored health plans. This type of approach would require the government to be heavily involved in auditing health care expenditures, she said.

Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Keys on Tax Changes, Cost Control,” June 2008, p. 34, for more details on Sen. McCain's plan.) While in the long-term it might be a good idea to move away from that system, that should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are somewhat murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute. However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. Unlike in 1992, there has been far more “plowing of the ground,” he said. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Naomi P. Senkeeto, a health policy analyst at the American College of Physicians, agreed that there are reasons to be optimistic about health reform passage this time around. This year, both candidates have recognized the need for health care reform and all of the stakeholders are at the table, she said.

While much depends on the new president and the makeup of Congress, it is increasingly clear that how the reform will look will also depend on how quickly the issues are taken up following the inauguration. There is a growing sense that given all the competing priorities, if health care is not addressed in the first 100 days it will be increasingly difficult to pass. “It's really important to hit the ground running,” Ms. Senkeeto said.

Sen. Barack Obama's plan also includes a universal coverage mandate for children.

With Sen. Barack Obama (D-Ill.) set to become the Democratic Party's presidential nominee this month, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program.

Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but who still needed financial assistance to purchase their health insurance.

Sen. Obama also would guarantee that no American could be turned down for health insurance because of illness or a preexisting condition. However, his proposal stops short of requiring all Americans to purchase coverage. Instead, the plan mandates coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. For example, he would target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers. Under his plan, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage widespread adoption of EHRs. The idea is that the investment would reap savings through increased efficiencies since paper records are more costly to store and process than are electronic ones, according to the Obama campaign. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

“I want to wake up and know that every single American has health care when they need it, that every senior has prescription drugs they can afford, and that no parents are going to bed at night worrying about how they'll afford medicine for a sick child,” Sen. Obama said in June during a health care town hall meeting in Bristol, Va.

If elected, Sen. Obama has pledged to implement his health care proposal by the end of his first term as president.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market.

“That is not a level playing field,” said Ms. Turner, who also is an adviser to the presidential campaign of Sen. John McCain (R-Ariz.).

Sen. Obama's approach is really a “backdoor” to getting everyone on a government-funded health plan, she said.

Ms. Turner also criticized Sen. Obama's plan to have the federal government take on a portion of the costs of catastrophic health costs in employer-sponsored health plans. This type of approach would require the government to be heavily involved in auditing health care expenditures, she said.

Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Keys on Tax Changes, Cost Control,” June 2008, p. 34, for more details on Sen. McCain's plan.) While in the long-term it might be a good idea to move away from that system, that should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are somewhat murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute. However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. Unlike in 1992, there has been far more “plowing of the ground,” he said. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Naomi P. Senkeeto, a health policy analyst at the American College of Physicians, agreed that there are reasons to be optimistic about health reform passage this time around. This year, both candidates have recognized the need for health care reform and all of the stakeholders are at the table, she said.

While much depends on the new president and the makeup of Congress, it is increasingly clear that how the reform will look will also depend on how quickly the issues are taken up following the inauguration. There is a growing sense that given all the competing priorities, if health care is not addressed in the first 100 days it will be increasingly difficult to pass. “It's really important to hit the ground running,” Ms. Senkeeto said.

Sen. Barack Obama's plan also includes a universal coverage mandate for children.

With Sen. Barack Obama (D-Ill.) set to become the Democratic Party's presidential nominee this month, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program.

Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but who still needed financial assistance to purchase their health insurance.

Sen. Obama also would guarantee that no American could be turned down for health insurance because of illness or a preexisting condition. However, his proposal stops short of requiring all Americans to purchase coverage. Instead, the plan mandates coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. For example, he would target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers. Under his plan, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage widespread adoption of EHRs. The idea is that the investment would reap savings through increased efficiencies since paper records are more costly to store and process than are electronic ones, according to the Obama campaign. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

“I want to wake up and know that every single American has health care when they need it, that every senior has prescription drugs they can afford, and that no parents are going to bed at night worrying about how they'll afford medicine for a sick child,” Sen. Obama said in June during a health care town hall meeting in Bristol, Va.

If elected, Sen. Obama has pledged to implement his health care proposal by the end of his first term as president.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market.

“That is not a level playing field,” said Ms. Turner, who also is an adviser to the presidential campaign of Sen. John McCain (R-Ariz.).

Sen. Obama's approach is really a “backdoor” to getting everyone on a government-funded health plan, she said.

Ms. Turner also criticized Sen. Obama's plan to have the federal government take on a portion of the costs of catastrophic health costs in employer-sponsored health plans. This type of approach would require the government to be heavily involved in auditing health care expenditures, she said.

Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Keys on Tax Changes, Cost Control,” June 2008, p. 34, for more details on Sen. McCain's plan.) While in the long-term it might be a good idea to move away from that system, that should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are somewhat murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute. However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. Unlike in 1992, there has been far more “plowing of the ground,” he said. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Naomi P. Senkeeto, a health policy analyst at the American College of Physicians, agreed that there are reasons to be optimistic about health reform passage this time around. This year, both candidates have recognized the need for health care reform and all of the stakeholders are at the table, she said.

While much depends on the new president and the makeup of Congress, it is increasingly clear that how the reform will look will also depend on how quickly the issues are taken up following the inauguration. There is a growing sense that given all the competing priorities, if health care is not addressed in the first 100 days it will be increasingly difficult to pass. “It's really important to hit the ground running,” Ms. Senkeeto said.

Sen. Barack Obama's plan also includes a universal coverage mandate for children.

Citing new information on obesity, poor diet, and lack of exercise, the American Academy of Pediatrics has called on its members to become more aggressive in screening children for dyslipidemia.

AAP now recommends that children aged 2-10 years should be screened if they have a family history of dyslipidemia or premature cardiovascular disease.

Screening is also advised in children with an unknown family history or who have other risk factors for cardiovascular disease within their families such as overweight/obesity, hypertension, smoking, or diabetes mellitus.

Children whose results are within the normal reference range should be retested in 3-5 years, according to AAP's Committee on Nutrition, which developed the new recommendations.

The statement replaces the organization's 1998 guidelines on managing cholesterol in childhood, which have become “outdated” in light of new research, according to AAP.

The organization also issued targeted treatment recommendations in its new statement, which were published in the journal Pediatrics (2008;122:198-208).

The organization advised that weight management, including nutritional counseling and increased physical activity, should be the “primary treatment” approach for children and adolescents who are overweight or obese and have either a high triglyceride concentration or a low HDL cholesterol concentration, the policy statement said.

However, drug therapy should be considered for children aged 8 years and older with an LDL cholesterol concentration of 190 mg/dL or greater. Pharmacological treatment should also be explored for children with an LDL cholesterol concentration of 160 mg/dL or greater with a family history of early heart disease, or two or more additional risk factors for cardiovascular disease, or an LDL cholesterol concentration of 130 mg/dL or greater plus diabetes mellitus.

Given autopsy studies demonstrating that the atherosclerotic process begins in childhood and more data showing the safety and effectiveness of drug therapies, members of AAP's Committee on Nutrition wanted to offer physicians more options for treating children with high LDL cholesterol concentrations, said Dr. Marcie Beth Schneider, a member of the Committee on Nutrition and an adolescent medicine specialist in Greenwich, Conn.

No one wants to short-circuit the use of diet and exercise interventions, she said, but drugs might be an appropriate addition for some patients when lifestyle changes do not yield results over time. “This is an adjunctive therapy,” she said.

The new AAP statement provides a review of the available pharmacologic treatments including bile acid-binding resins, niacin, statins, cholesterol-absorption inhibitors, and fibrates. The AAP statement notes that niacin should not be used routinely in the treatment of pediatric dyslipidemia because of adverse effects such as flushing, hepatic failure, myopathy, glucose intolerance, and hyperuricemia.

The new recommendations from AAP are “moderate and balanced,” said Dr. Roberta Williams, chair of the department of pediatrics at the University of Southern California, Los Angeles. “It is important to stress that any pharmacologic intervention be preceded by vigorous nonpharmacologic strategies,” she said. “It is unlikely that lowering LDL and triglycerides to mildly elevated levels will produce negative consequences, but it will be critical to monitor patients as directed in the guidelines and not try to lower levels more than recommended because of potential consequences for growth and development.”

Dr. Antonio Gotto, a lipid expert and dean of the Weill Cornell Medical College, New York, agreed that the AAP recommendations are a reasonable approach to the management of dyslipidemia in children.

For those children and adolescents who require treatment, pediatricians have good options in either the statins or the cholesterol absorption inhibitor ezetimibe, he said. While there are not long-term data on statin use in children, such use has been shown to be both safe and effective. But ezetimibe offers a safe alternative without the systemic effects of statins, said Dr. Gotto, who consults for Merck & Co., which markets simvastatin (Zocor) and ezetimibe (Zetia).

If followed, Dr. Gotto said the AAP recommendations could make a real difference in preventing dyslipidemia and cardiovascular disease. “The evidence we have is that starting earlier makes a big difference,” he said.

Dr. Sarah Clauss said that, while appropriate medical practice, the guidelines aren't a major departure from previous statements from the AAP and other organizations. The recommendations underscore the need to recognize risk factors other than inherited cholesterol such as overweight, obesity, and diabetes. They also highlight the need not to wait to screen children for dyslipidemia. Waiting until after age 10 to screen can produce inaccurate results since most adolescents experience a natural decrease in LDL concentrations during puberty, said Dr. Clauss, a pediatric cardiologist at Children's National Medical Center in Washington.

Dr. Clauss also supported AAP's advice on targeting medication treatment to children with elevated LDL cholesterol concentrations after diet and lifestyle modifications were attempted. “I hope people aren't getting the message that we'll be starting more and more children on medications,” she said.

But Dr. Lawrence D. Rosen, a pediatrician in Oradell, N.J., and vice chair of AAP's section on complementary and integrative medicine, objected to the focus on medication in the new recommendations.

While there is a lot of good information in the paper, he said, he is concerned that there is not enough research to warrant publicly advocating for the use of pharmacological therapy in children. The better approach would have been a strong message about the problem of obesity and metabolic syndrome and a call for greater research into preventive approaches, Dr. Rosen said.

The AAP statement also outlines an updated population approach to preventing cardiovascular disease. For example, the organization recommends following the government-issued Dietary Guidelines for Americans, including using low-fat dairy products, in children as young as 2 years. Reduced-fat milk can also be used in children between 1 and 2 years of age if they have a family history of obesity, dyslipidemia, or cardiovascular disease, or overweight/obesity is a concern.

In an effort to address concerns about conflicts of interest, AAP policy requires that all of its committee members sign conflict of interest disclosure forms and declare any potential conflicts related to the committee's charge at each meeting. Members are asked to voluntarily recuse themselves if a potential conflict exists. The process is supervised by committee oversight bodies, according to AAP.

Citing new information on obesity, poor diet, and lack of exercise, the American Academy of Pediatrics has called on its members to become more aggressive in screening children for dyslipidemia.

AAP now recommends that children aged 2-10 years should be screened if they have a family history of dyslipidemia or premature cardiovascular disease.

Screening is also advised in children with an unknown family history or who have other risk factors for cardiovascular disease within their families such as overweight/obesity, hypertension, smoking, or diabetes mellitus.

Children whose results are within the normal reference range should be retested in 3-5 years, according to AAP's Committee on Nutrition, which developed the new recommendations.

The statement replaces the organization's 1998 guidelines on managing cholesterol in childhood, which have become “outdated” in light of new research, according to AAP.

The organization also issued targeted treatment recommendations in its new statement, which were published in the journal Pediatrics (2008;122:198-208).

The organization advised that weight management, including nutritional counseling and increased physical activity, should be the “primary treatment” approach for children and adolescents who are overweight or obese and have either a high triglyceride concentration or a low HDL cholesterol concentration, the policy statement said.

However, drug therapy should be considered for children aged 8 years and older with an LDL cholesterol concentration of 190 mg/dL or greater. Pharmacological treatment should also be explored for children with an LDL cholesterol concentration of 160 mg/dL or greater with a family history of early heart disease, or two or more additional risk factors for cardiovascular disease, or an LDL cholesterol concentration of 130 mg/dL or greater plus diabetes mellitus.

Given autopsy studies demonstrating that the atherosclerotic process begins in childhood and more data showing the safety and effectiveness of drug therapies, members of AAP's Committee on Nutrition wanted to offer physicians more options for treating children with high LDL cholesterol concentrations, said Dr. Marcie Beth Schneider, a member of the Committee on Nutrition and an adolescent medicine specialist in Greenwich, Conn.

No one wants to short-circuit the use of diet and exercise interventions, she said, but drugs might be an appropriate addition for some patients when lifestyle changes do not yield results over time. “This is an adjunctive therapy,” she said.

The new AAP statement provides a review of the available pharmacologic treatments including bile acid-binding resins, niacin, statins, cholesterol-absorption inhibitors, and fibrates. The AAP statement notes that niacin should not be used routinely in the treatment of pediatric dyslipidemia because of adverse effects such as flushing, hepatic failure, myopathy, glucose intolerance, and hyperuricemia.

The new recommendations from AAP are “moderate and balanced,” said Dr. Roberta Williams, chair of the department of pediatrics at the University of Southern California, Los Angeles. “It is important to stress that any pharmacologic intervention be preceded by vigorous nonpharmacologic strategies,” she said. “It is unlikely that lowering LDL and triglycerides to mildly elevated levels will produce negative consequences, but it will be critical to monitor patients as directed in the guidelines and not try to lower levels more than recommended because of potential consequences for growth and development.”

Dr. Antonio Gotto, a lipid expert and dean of the Weill Cornell Medical College, New York, agreed that the AAP recommendations are a reasonable approach to the management of dyslipidemia in children.

For those children and adolescents who require treatment, pediatricians have good options in either the statins or the cholesterol absorption inhibitor ezetimibe, he said. While there are not long-term data on statin use in children, such use has been shown to be both safe and effective. But ezetimibe offers a safe alternative without the systemic effects of statins, said Dr. Gotto, who consults for Merck & Co., which markets simvastatin (Zocor) and ezetimibe (Zetia).

If followed, Dr. Gotto said the AAP recommendations could make a real difference in preventing dyslipidemia and cardiovascular disease. “The evidence we have is that starting earlier makes a big difference,” he said.

Dr. Sarah Clauss said that, while appropriate medical practice, the guidelines aren't a major departure from previous statements from the AAP and other organizations. The recommendations underscore the need to recognize risk factors other than inherited cholesterol such as overweight, obesity, and diabetes. They also highlight the need not to wait to screen children for dyslipidemia. Waiting until after age 10 to screen can produce inaccurate results since most adolescents experience a natural decrease in LDL concentrations during puberty, said Dr. Clauss, a pediatric cardiologist at Children's National Medical Center in Washington.

Dr. Clauss also supported AAP's advice on targeting medication treatment to children with elevated LDL cholesterol concentrations after diet and lifestyle modifications were attempted. “I hope people aren't getting the message that we'll be starting more and more children on medications,” she said.

But Dr. Lawrence D. Rosen, a pediatrician in Oradell, N.J., and vice chair of AAP's section on complementary and integrative medicine, objected to the focus on medication in the new recommendations.

While there is a lot of good information in the paper, he said, he is concerned that there is not enough research to warrant publicly advocating for the use of pharmacological therapy in children. The better approach would have been a strong message about the problem of obesity and metabolic syndrome and a call for greater research into preventive approaches, Dr. Rosen said.

The AAP statement also outlines an updated population approach to preventing cardiovascular disease. For example, the organization recommends following the government-issued Dietary Guidelines for Americans, including using low-fat dairy products, in children as young as 2 years. Reduced-fat milk can also be used in children between 1 and 2 years of age if they have a family history of obesity, dyslipidemia, or cardiovascular disease, or overweight/obesity is a concern.

In an effort to address concerns about conflicts of interest, AAP policy requires that all of its committee members sign conflict of interest disclosure forms and declare any potential conflicts related to the committee's charge at each meeting. Members are asked to voluntarily recuse themselves if a potential conflict exists. The process is supervised by committee oversight bodies, according to AAP.

Citing new information on obesity, poor diet, and lack of exercise, the American Academy of Pediatrics has called on its members to become more aggressive in screening children for dyslipidemia.

AAP now recommends that children aged 2-10 years should be screened if they have a family history of dyslipidemia or premature cardiovascular disease.

Screening is also advised in children with an unknown family history or who have other risk factors for cardiovascular disease within their families such as overweight/obesity, hypertension, smoking, or diabetes mellitus.

Children whose results are within the normal reference range should be retested in 3-5 years, according to AAP's Committee on Nutrition, which developed the new recommendations.

The statement replaces the organization's 1998 guidelines on managing cholesterol in childhood, which have become “outdated” in light of new research, according to AAP.

The organization also issued targeted treatment recommendations in its new statement, which were published in the journal Pediatrics (2008;122:198-208).

The organization advised that weight management, including nutritional counseling and increased physical activity, should be the “primary treatment” approach for children and adolescents who are overweight or obese and have either a high triglyceride concentration or a low HDL cholesterol concentration, the policy statement said.

However, drug therapy should be considered for children aged 8 years and older with an LDL cholesterol concentration of 190 mg/dL or greater. Pharmacological treatment should also be explored for children with an LDL cholesterol concentration of 160 mg/dL or greater with a family history of early heart disease, or two or more additional risk factors for cardiovascular disease, or an LDL cholesterol concentration of 130 mg/dL or greater plus diabetes mellitus.

Given autopsy studies demonstrating that the atherosclerotic process begins in childhood and more data showing the safety and effectiveness of drug therapies, members of AAP's Committee on Nutrition wanted to offer physicians more options for treating children with high LDL cholesterol concentrations, said Dr. Marcie Beth Schneider, a member of the Committee on Nutrition and an adolescent medicine specialist in Greenwich, Conn.

No one wants to short-circuit the use of diet and exercise interventions, she said, but drugs might be an appropriate addition for some patients when lifestyle changes do not yield results over time. “This is an adjunctive therapy,” she said.

The new AAP statement provides a review of the available pharmacologic treatments including bile acid-binding resins, niacin, statins, cholesterol-absorption inhibitors, and fibrates. The AAP statement notes that niacin should not be used routinely in the treatment of pediatric dyslipidemia because of adverse effects such as flushing, hepatic failure, myopathy, glucose intolerance, and hyperuricemia.

The new recommendations from AAP are “moderate and balanced,” said Dr. Roberta Williams, chair of the department of pediatrics at the University of Southern California, Los Angeles. “It is important to stress that any pharmacologic intervention be preceded by vigorous nonpharmacologic strategies,” she said. “It is unlikely that lowering LDL and triglycerides to mildly elevated levels will produce negative consequences, but it will be critical to monitor patients as directed in the guidelines and not try to lower levels more than recommended because of potential consequences for growth and development.”

Dr. Antonio Gotto, a lipid expert and dean of the Weill Cornell Medical College, New York, agreed that the AAP recommendations are a reasonable approach to the management of dyslipidemia in children.

For those children and adolescents who require treatment, pediatricians have good options in either the statins or the cholesterol absorption inhibitor ezetimibe, he said. While there are not long-term data on statin use in children, such use has been shown to be both safe and effective. But ezetimibe offers a safe alternative without the systemic effects of statins, said Dr. Gotto, who consults for Merck & Co., which markets simvastatin (Zocor) and ezetimibe (Zetia).

If followed, Dr. Gotto said the AAP recommendations could make a real difference in preventing dyslipidemia and cardiovascular disease. “The evidence we have is that starting earlier makes a big difference,” he said.

Dr. Sarah Clauss said that, while appropriate medical practice, the guidelines aren't a major departure from previous statements from the AAP and other organizations. The recommendations underscore the need to recognize risk factors other than inherited cholesterol such as overweight, obesity, and diabetes. They also highlight the need not to wait to screen children for dyslipidemia. Waiting until after age 10 to screen can produce inaccurate results since most adolescents experience a natural decrease in LDL concentrations during puberty, said Dr. Clauss, a pediatric cardiologist at Children's National Medical Center in Washington.

Dr. Clauss also supported AAP's advice on targeting medication treatment to children with elevated LDL cholesterol concentrations after diet and lifestyle modifications were attempted. “I hope people aren't getting the message that we'll be starting more and more children on medications,” she said.

But Dr. Lawrence D. Rosen, a pediatrician in Oradell, N.J., and vice chair of AAP's section on complementary and integrative medicine, objected to the focus on medication in the new recommendations.

While there is a lot of good information in the paper, he said, he is concerned that there is not enough research to warrant publicly advocating for the use of pharmacological therapy in children. The better approach would have been a strong message about the problem of obesity and metabolic syndrome and a call for greater research into preventive approaches, Dr. Rosen said.

The AAP statement also outlines an updated population approach to preventing cardiovascular disease. For example, the organization recommends following the government-issued Dietary Guidelines for Americans, including using low-fat dairy products, in children as young as 2 years. Reduced-fat milk can also be used in children between 1 and 2 years of age if they have a family history of obesity, dyslipidemia, or cardiovascular disease, or overweight/obesity is a concern.

In an effort to address concerns about conflicts of interest, AAP policy requires that all of its committee members sign conflict of interest disclosure forms and declare any potential conflicts related to the committee's charge at each meeting. Members are asked to voluntarily recuse themselves if a potential conflict exists. The process is supervised by committee oversight bodies, according to AAP.

More than 80% of men with erectile dysfunction know that the condition can be an indicator of other serious diseases, but 38% of men with the condition still haven't spoken to their physician about it, according to a survey sponsored by Eli Lilly & Co.

Many men cited their own discomfort as the main barrier to discussing their sexual health, but they also said that they didn't know what to ask, or thought that other health topics were more important to discuss during the visit.

The online survey of 300 men aged 45 and older who reported experiencing erectile dysfunction at least occasionally was presented during a Webcast sponsored by the Men's Health Network and Eli Lilly, which markets tadalafil (Cialis) for the treatment of erectile dysfunction.

But for those men who are willing to broach the subject with their physicians, the visit offers an opportunity to assess other aspects of their health, experts said.

“The new interest in erectile dysfunction is bringing men to see their physicians who might not otherwise have gone, giving us an opportunity to assess a man's overall health far beyond the presenting complaint,” said Dr. Jean Bonhomme, a member of the board of directors of the Men's Health Network.

Disturbances in the circulatory or nervous systems or hormonal systems can all result in or contribute to erectile dysfunction, Dr. Bonhomme said.

In fact, new research indicates that erectile dysfunction may offer physicians an early warning about coronary artery disease, diabetes, and metabolic syndrome, said Dr. Ridwan Shabsigh, director of the division of urology at Maimonides Medical Center in Brooklyn, N.Y. Dr. Shabsigh received honorarium from Eli Lilly for participating in the Webcast and has served as a consultant to Eli Lilly and other companies that market erectile dysfunction medications, including Pfizer Inc., Bayer Healthcare Pharmaceuticals, and Schering-Plough Corp.

In a study recently published in the Journal of the American College of Cardiology, researchers found that among men with type 2 diabetes, those who also had erectile dysfunction were more likely than men without the condition to have symptoms of coronary heart disease and that erectile dysfunction was an independent predictor for coronary heart disease events (J. Am. Coll. Cardiol. 2008;51:2045-50).

The process of atherosclerosis and coronary heart disease is frequently silent until the first heart attack, Dr. Shabsigh said. As a result, it is important that middle-aged men with erectile dysfunction who are otherwise asymptomatic see their physician. And physicians who see these otherwise asymptomatic patients should try to intervene early with disease and behavioral modification, Dr. Shabsigh said. Conversely, physicians should ask about erectile dysfunction in patients with hypertension, he said.

“This presents an opportunity for erectile dysfunction to be an early warning marker of otherwise dangerous silent diseases,” he said.

Conversations about erectile dysfunction vary in his practice, Dr. Shabsigh said, depending on the comfort level of the patient. Some men will initially avoid a long conversation about erectile dysfunction even when they have questions. However, they usually open up once they feel more comfortable. Other patients are more comfortable from the start and will ask a lot of questions about what causes the condition.

The first step in helping a patient become more comfortable communicating about sexual issues is for the physician to be comfortable themselves, Dr. Shabsigh said, and there are continuing medical education courses and other resources available to help.

Once the physician is comfortable, he or she should raise the topic in the context of overall health, Dr. Shabsigh advised. For example, physicians can include erectile dysfunction in the review of systems. Signaling to the patient that sexual function is just part of overall health removes some of the stigma associated with the conversation, he said.

Physicians can also consider dedicating an entire visit to discussing sexual health issues. If a patient brings up the issue and there's limited time for a discussion, the physician can schedule another visit to work out those issues, he said.

More than 80% of men with erectile dysfunction know that the condition can be an indicator of other serious diseases, but 38% of men with the condition still haven't spoken to their physician about it, according to a survey sponsored by Eli Lilly & Co.

Many men cited their own discomfort as the main barrier to discussing their sexual health, but they also said that they didn't know what to ask, or thought that other health topics were more important to discuss during the visit.

The online survey of 300 men aged 45 and older who reported experiencing erectile dysfunction at least occasionally was presented during a Webcast sponsored by the Men's Health Network and Eli Lilly, which markets tadalafil (Cialis) for the treatment of erectile dysfunction.

But for those men who are willing to broach the subject with their physicians, the visit offers an opportunity to assess other aspects of their health, experts said.

“The new interest in erectile dysfunction is bringing men to see their physicians who might not otherwise have gone, giving us an opportunity to assess a man's overall health far beyond the presenting complaint,” said Dr. Jean Bonhomme, a member of the board of directors of the Men's Health Network.

Disturbances in the circulatory or nervous systems or hormonal systems can all result in or contribute to erectile dysfunction, Dr. Bonhomme said.

In fact, new research indicates that erectile dysfunction may offer physicians an early warning about coronary artery disease, diabetes, and metabolic syndrome, said Dr. Ridwan Shabsigh, director of the division of urology at Maimonides Medical Center in Brooklyn, N.Y. Dr. Shabsigh received honorarium from Eli Lilly for participating in the Webcast and has served as a consultant to Eli Lilly and other companies that market erectile dysfunction medications, including Pfizer Inc., Bayer Healthcare Pharmaceuticals, and Schering-Plough Corp.

In a study recently published in the Journal of the American College of Cardiology, researchers found that among men with type 2 diabetes, those who also had erectile dysfunction were more likely than men without the condition to have symptoms of coronary heart disease and that erectile dysfunction was an independent predictor for coronary heart disease events (J. Am. Coll. Cardiol. 2008;51:2045-50).

The process of atherosclerosis and coronary heart disease is frequently silent until the first heart attack, Dr. Shabsigh said. As a result, it is important that middle-aged men with erectile dysfunction who are otherwise asymptomatic see their physician. And physicians who see these otherwise asymptomatic patients should try to intervene early with disease and behavioral modification, Dr. Shabsigh said. Conversely, physicians should ask about erectile dysfunction in patients with hypertension, he said.

“This presents an opportunity for erectile dysfunction to be an early warning marker of otherwise dangerous silent diseases,” he said.

Conversations about erectile dysfunction vary in his practice, Dr. Shabsigh said, depending on the comfort level of the patient. Some men will initially avoid a long conversation about erectile dysfunction even when they have questions. However, they usually open up once they feel more comfortable. Other patients are more comfortable from the start and will ask a lot of questions about what causes the condition.

The first step in helping a patient become more comfortable communicating about sexual issues is for the physician to be comfortable themselves, Dr. Shabsigh said, and there are continuing medical education courses and other resources available to help.

Once the physician is comfortable, he or she should raise the topic in the context of overall health, Dr. Shabsigh advised. For example, physicians can include erectile dysfunction in the review of systems. Signaling to the patient that sexual function is just part of overall health removes some of the stigma associated with the conversation, he said.

Physicians can also consider dedicating an entire visit to discussing sexual health issues. If a patient brings up the issue and there's limited time for a discussion, the physician can schedule another visit to work out those issues, he said.

More than 80% of men with erectile dysfunction know that the condition can be an indicator of other serious diseases, but 38% of men with the condition still haven't spoken to their physician about it, according to a survey sponsored by Eli Lilly & Co.

Many men cited their own discomfort as the main barrier to discussing their sexual health, but they also said that they didn't know what to ask, or thought that other health topics were more important to discuss during the visit.

The online survey of 300 men aged 45 and older who reported experiencing erectile dysfunction at least occasionally was presented during a Webcast sponsored by the Men's Health Network and Eli Lilly, which markets tadalafil (Cialis) for the treatment of erectile dysfunction.

But for those men who are willing to broach the subject with their physicians, the visit offers an opportunity to assess other aspects of their health, experts said.

“The new interest in erectile dysfunction is bringing men to see their physicians who might not otherwise have gone, giving us an opportunity to assess a man's overall health far beyond the presenting complaint,” said Dr. Jean Bonhomme, a member of the board of directors of the Men's Health Network.

Disturbances in the circulatory or nervous systems or hormonal systems can all result in or contribute to erectile dysfunction, Dr. Bonhomme said.

In fact, new research indicates that erectile dysfunction may offer physicians an early warning about coronary artery disease, diabetes, and metabolic syndrome, said Dr. Ridwan Shabsigh, director of the division of urology at Maimonides Medical Center in Brooklyn, N.Y. Dr. Shabsigh received honorarium from Eli Lilly for participating in the Webcast and has served as a consultant to Eli Lilly and other companies that market erectile dysfunction medications, including Pfizer Inc., Bayer Healthcare Pharmaceuticals, and Schering-Plough Corp.

In a study recently published in the Journal of the American College of Cardiology, researchers found that among men with type 2 diabetes, those who also had erectile dysfunction were more likely than men without the condition to have symptoms of coronary heart disease and that erectile dysfunction was an independent predictor for coronary heart disease events (J. Am. Coll. Cardiol. 2008;51:2045-50).

The process of atherosclerosis and coronary heart disease is frequently silent until the first heart attack, Dr. Shabsigh said. As a result, it is important that middle-aged men with erectile dysfunction who are otherwise asymptomatic see their physician. And physicians who see these otherwise asymptomatic patients should try to intervene early with disease and behavioral modification, Dr. Shabsigh said. Conversely, physicians should ask about erectile dysfunction in patients with hypertension, he said.

“This presents an opportunity for erectile dysfunction to be an early warning marker of otherwise dangerous silent diseases,” he said.

Conversations about erectile dysfunction vary in his practice, Dr. Shabsigh said, depending on the comfort level of the patient. Some men will initially avoid a long conversation about erectile dysfunction even when they have questions. However, they usually open up once they feel more comfortable. Other patients are more comfortable from the start and will ask a lot of questions about what causes the condition.

The first step in helping a patient become more comfortable communicating about sexual issues is for the physician to be comfortable themselves, Dr. Shabsigh said, and there are continuing medical education courses and other resources available to help.

Once the physician is comfortable, he or she should raise the topic in the context of overall health, Dr. Shabsigh advised. For example, physicians can include erectile dysfunction in the review of systems. Signaling to the patient that sexual function is just part of overall health removes some of the stigma associated with the conversation, he said.

Physicians can also consider dedicating an entire visit to discussing sexual health issues. If a patient brings up the issue and there's limited time for a discussion, the physician can schedule another visit to work out those issues, he said.