Mary Ellen Schneider

Teenagers enrolled in abstinence-only education programs are about as likely to have abstained from sex as are teens in a control group, according to a report evaluating federal abstinence education programs.

The study, which was requested by Congress under the Balanced Budget Act of 1997, was conducted by Mathematica Policy Research Inc. on behalf of the Department of Health and Human Services. The study is based on the results of a survey of more than 2,000 teens who were assigned to an abstinence-education program or a control group. The sample included four abstinence education programs that focus on teaching abstinence from sexual activity outside of marriage.

Surveys from the teens involved in the study revealed that about 49% remained abstinent always regardless of whether they were enrolled in a program, and 56% of teens in a program were abstinent in the last 12 months, compared with 55% of teens in the control group.

The researchers found similar rates between the two groups when they asked about sex using a condom, age at first intercourse, and number of sexual partners.

One persistent criticism of abstinence-only education programs is that they contain medically inaccurate information. However, another report, also commissioned by the Health and Human Services department, found that most comprehensive sex education programs also include some inaccurate statements.

Of nine comprehensive sex education programs reviewed, six contained medically inaccurate statements, according to the report. For example, three programs promoted use of the spermicide nonoxynol-9, but the report states that recent research has shown that the spermicide is ineffective against sexually transmitted diseases and could increase the risk of transmission.

For the most part, the programs were medically accurate but tended to minimize condom failure rates, the report said. The report was requested in 2005 by former Sen. Rick Santorum (R-Pa.) and Sen. Tom Coburn (R-Okla.). The assessment was conducted by the Sagamore Institute for Policy Research and reviewed by the Medical Institute for Sexual Health.

The results of the Mathematica study appear to show that abstinence-only education doesn't live up to its promise, said Dr. David S. Rosen, professor of pediatrics and internal medicine at the University of Michigan, Ann Arbor. Teaching abstinence is appropriate, but teaching it exclusively doesn't seem to be effective based on the available literature.

He advises physicians to discuss sex with their adolescent patients in the context of preventive health visits, and to bring it up in the context of a confidential relationship, not with the parents in the room.

Teenagers enrolled in abstinence-only education programs are about as likely to have abstained from sex as are teens in a control group, according to a report evaluating federal abstinence education programs.

The study, which was requested by Congress under the Balanced Budget Act of 1997, was conducted by Mathematica Policy Research Inc. on behalf of the Department of Health and Human Services. The study is based on the results of a survey of more than 2,000 teens who were assigned to an abstinence-education program or a control group. The sample included four abstinence education programs that focus on teaching abstinence from sexual activity outside of marriage.

Surveys from the teens involved in the study revealed that about 49% remained abstinent always regardless of whether they were enrolled in a program, and 56% of teens in a program were abstinent in the last 12 months, compared with 55% of teens in the control group.

The researchers found similar rates between the two groups when they asked about sex using a condom, age at first intercourse, and number of sexual partners.

One persistent criticism of abstinence-only education programs is that they contain medically inaccurate information. However, another report, also commissioned by the Health and Human Services department, found that most comprehensive sex education programs also include some inaccurate statements.

Of nine comprehensive sex education programs reviewed, six contained medically inaccurate statements, according to the report. For example, three programs promoted use of the spermicide nonoxynol-9, but the report states that recent research has shown that the spermicide is ineffective against sexually transmitted diseases and could increase the risk of transmission.

For the most part, the programs were medically accurate but tended to minimize condom failure rates, the report said. The report was requested in 2005 by former Sen. Rick Santorum (R-Pa.) and Sen. Tom Coburn (R-Okla.). The assessment was conducted by the Sagamore Institute for Policy Research and reviewed by the Medical Institute for Sexual Health.

The results of the Mathematica study appear to show that abstinence-only education doesn't live up to its promise, said Dr. David S. Rosen, professor of pediatrics and internal medicine at the University of Michigan, Ann Arbor. Teaching abstinence is appropriate, but teaching it exclusively doesn't seem to be effective based on the available literature.

He advises physicians to discuss sex with their adolescent patients in the context of preventive health visits, and to bring it up in the context of a confidential relationship, not with the parents in the room.

Teenagers enrolled in abstinence-only education programs are about as likely to have abstained from sex as are teens in a control group, according to a report evaluating federal abstinence education programs.

The study, which was requested by Congress under the Balanced Budget Act of 1997, was conducted by Mathematica Policy Research Inc. on behalf of the Department of Health and Human Services. The study is based on the results of a survey of more than 2,000 teens who were assigned to an abstinence-education program or a control group. The sample included four abstinence education programs that focus on teaching abstinence from sexual activity outside of marriage.

Surveys from the teens involved in the study revealed that about 49% remained abstinent always regardless of whether they were enrolled in a program, and 56% of teens in a program were abstinent in the last 12 months, compared with 55% of teens in the control group.

The researchers found similar rates between the two groups when they asked about sex using a condom, age at first intercourse, and number of sexual partners.

One persistent criticism of abstinence-only education programs is that they contain medically inaccurate information. However, another report, also commissioned by the Health and Human Services department, found that most comprehensive sex education programs also include some inaccurate statements.

Of nine comprehensive sex education programs reviewed, six contained medically inaccurate statements, according to the report. For example, three programs promoted use of the spermicide nonoxynol-9, but the report states that recent research has shown that the spermicide is ineffective against sexually transmitted diseases and could increase the risk of transmission.

For the most part, the programs were medically accurate but tended to minimize condom failure rates, the report said. The report was requested in 2005 by former Sen. Rick Santorum (R-Pa.) and Sen. Tom Coburn (R-Okla.). The assessment was conducted by the Sagamore Institute for Policy Research and reviewed by the Medical Institute for Sexual Health.

The results of the Mathematica study appear to show that abstinence-only education doesn't live up to its promise, said Dr. David S. Rosen, professor of pediatrics and internal medicine at the University of Michigan, Ann Arbor. Teaching abstinence is appropriate, but teaching it exclusively doesn't seem to be effective based on the available literature.

He advises physicians to discuss sex with their adolescent patients in the context of preventive health visits, and to bring it up in the context of a confidential relationship, not with the parents in the room.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26 to 28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan into place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768-76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said. But diet and exercise alone would not make a significant difference in only 10 weeks, he warned. Although the results of the Diabetes Prevention Program and most other current studies show that lifestyle interventions produce the best results in preventing the development of diabetes, it is difficult to accomplish such results in a short time period, he said.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26 to 28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan into place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768-76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said. But diet and exercise alone would not make a significant difference in only 10 weeks, he warned. Although the results of the Diabetes Prevention Program and most other current studies show that lifestyle interventions produce the best results in preventing the development of diabetes, it is difficult to accomplish such results in a short time period, he said.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26 to 28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan into place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768-76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said. But diet and exercise alone would not make a significant difference in only 10 weeks, he warned. Although the results of the Diabetes Prevention Program and most other current studies show that lifestyle interventions produce the best results in preventing the development of diabetes, it is difficult to accomplish such results in a short time period, he said.

TORONTO – Political conditions still aren't ripe for significant U.S. government action on the obesity front, Michelle Mello, J.D., Ph.D., said at the annual meeting of the Endocrine Society.

Several highly active and influential public health groups support government action on obesity, but a well-funded lobby of food and beverage manufacturers and the restaurant industry has spent a lot of money trying to convince lawmakers that increased regulation of food products is unnecessary. “It's still a difficult row to hoe for a policy maker who would like to do something legally about obesity,” said Dr. Mello of the Harvard School of Public Health, Boston.

Legal authority is another obstacle to action at the federal level. The federal government's authority over public health policy is actually relatively limited, she said. Most of that authority is granted to the states; in order to get involved, the federal government has to find a “jurisdictional hook” relating to interstate commerce or federal spending, she said.

Another likely reason why politicians aren't eager to pursue policy related to obesity is that the public support isn't there yet.

In a 2004 survey of more than 1,000 adults, which looked at the issue of childhood obesity, only 17% said the government has a lot of responsibility to reduce childhood obesity. The lion's share of the responsibility rests with parents, according to 91% of survey respondents. About 30% of those surveyed said that the schools bear a lot of responsibility, too (Am. J. Prev. Med. 2005;28:26–32).

“The findings don't demonstrate broad support for interventions outside of the schools,” Dr. Mello said. Although the federal government has not taken action on obesity, there has been limited action at the state and local level. For example, some states have initiated financial disincentives by allowing some kinds of unhealthful foods to be taxable.

There have also been some attempts to condition the receipt of government benefits on individuals' making healthy lifestyle choices. In West Virginia, for example, the state Medicaid program offers an enhanced benefits package if beneficiaries sign a personal responsibility agreement. Food products are also being regulated directly in some places. Officials in New York City have banned the use of artificial trans fats in the city's restaurants after July 2008.

Dr. Mello predicted that future government actions regulating obesity are most likely to be supported if they focus on children.

“We can make all kinds of arguments about individual choice, but they make a lot less sense when we're talking about an 8-year-old than when we're talking about a 38-year-old,” Dr. Mello said.

TORONTO – Political conditions still aren't ripe for significant U.S. government action on the obesity front, Michelle Mello, J.D., Ph.D., said at the annual meeting of the Endocrine Society.

Several highly active and influential public health groups support government action on obesity, but a well-funded lobby of food and beverage manufacturers and the restaurant industry has spent a lot of money trying to convince lawmakers that increased regulation of food products is unnecessary. “It's still a difficult row to hoe for a policy maker who would like to do something legally about obesity,” said Dr. Mello of the Harvard School of Public Health, Boston.

Legal authority is another obstacle to action at the federal level. The federal government's authority over public health policy is actually relatively limited, she said. Most of that authority is granted to the states; in order to get involved, the federal government has to find a “jurisdictional hook” relating to interstate commerce or federal spending, she said.

Another likely reason why politicians aren't eager to pursue policy related to obesity is that the public support isn't there yet.

In a 2004 survey of more than 1,000 adults, which looked at the issue of childhood obesity, only 17% said the government has a lot of responsibility to reduce childhood obesity. The lion's share of the responsibility rests with parents, according to 91% of survey respondents. About 30% of those surveyed said that the schools bear a lot of responsibility, too (Am. J. Prev. Med. 2005;28:26–32).

“The findings don't demonstrate broad support for interventions outside of the schools,” Dr. Mello said. Although the federal government has not taken action on obesity, there has been limited action at the state and local level. For example, some states have initiated financial disincentives by allowing some kinds of unhealthful foods to be taxable.

There have also been some attempts to condition the receipt of government benefits on individuals' making healthy lifestyle choices. In West Virginia, for example, the state Medicaid program offers an enhanced benefits package if beneficiaries sign a personal responsibility agreement. Food products are also being regulated directly in some places. Officials in New York City have banned the use of artificial trans fats in the city's restaurants after July 2008.

Dr. Mello predicted that future government actions regulating obesity are most likely to be supported if they focus on children.

“We can make all kinds of arguments about individual choice, but they make a lot less sense when we're talking about an 8-year-old than when we're talking about a 38-year-old,” Dr. Mello said.

TORONTO – Political conditions still aren't ripe for significant U.S. government action on the obesity front, Michelle Mello, J.D., Ph.D., said at the annual meeting of the Endocrine Society.

Several highly active and influential public health groups support government action on obesity, but a well-funded lobby of food and beverage manufacturers and the restaurant industry has spent a lot of money trying to convince lawmakers that increased regulation of food products is unnecessary. “It's still a difficult row to hoe for a policy maker who would like to do something legally about obesity,” said Dr. Mello of the Harvard School of Public Health, Boston.

Legal authority is another obstacle to action at the federal level. The federal government's authority over public health policy is actually relatively limited, she said. Most of that authority is granted to the states; in order to get involved, the federal government has to find a “jurisdictional hook” relating to interstate commerce or federal spending, she said.

Another likely reason why politicians aren't eager to pursue policy related to obesity is that the public support isn't there yet.

In a 2004 survey of more than 1,000 adults, which looked at the issue of childhood obesity, only 17% said the government has a lot of responsibility to reduce childhood obesity. The lion's share of the responsibility rests with parents, according to 91% of survey respondents. About 30% of those surveyed said that the schools bear a lot of responsibility, too (Am. J. Prev. Med. 2005;28:26–32).

“The findings don't demonstrate broad support for interventions outside of the schools,” Dr. Mello said. Although the federal government has not taken action on obesity, there has been limited action at the state and local level. For example, some states have initiated financial disincentives by allowing some kinds of unhealthful foods to be taxable.

There have also been some attempts to condition the receipt of government benefits on individuals' making healthy lifestyle choices. In West Virginia, for example, the state Medicaid program offers an enhanced benefits package if beneficiaries sign a personal responsibility agreement. Food products are also being regulated directly in some places. Officials in New York City have banned the use of artificial trans fats in the city's restaurants after July 2008.

Dr. Mello predicted that future government actions regulating obesity are most likely to be supported if they focus on children.

“We can make all kinds of arguments about individual choice, but they make a lot less sense when we're talking about an 8-year-old than when we're talking about a 38-year-old,” Dr. Mello said.

HOLLYWOOD, FLA. – Common psychiatric disorders such as depression and dementia can be hard to distinguish in elderly patients, but there are some simple techniques that physicians can use to draw out the differences, Dr. Kevin Gray said at the annual symposium of the American Medical Director's Association.

“Dementia and depression can occur together or separately,” said Dr. Gray of the department of neurology at the University of Texas Southwestern Medical Center at Dallas.

One of the reasons that there is so much confusion about what is dementia and what is depression is that the symptoms can overlap to some degree, he said.

In a typical case, a family member will describe a patient's passivity, weight changes, sleep disturbances, sweet tooth, restlessness, declines in cognition, or lack of interest in favorite activities. All of these symptoms could be depression, he said.

The key elements in distinguishing between depression and dementia in that type of patient include the presence of true suicidality or feelings of worthlessness and guilt. These symptoms are characteristic of depressive syndrome but are rare in dementias such as Alzheimer's disease, he said.

When eliciting depression symptoms, Dr. Gray suggested using the mnemonic device SIG-E-CAPS, which represents the diagnostic elements of major depressive disorder: sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal ideation. Also look for changes in self-attitude, including helplessness, hopelessness, and worthlessness, he said.

It can be misleading to focus too much on some of the somatic issues related to depression, such as sleep problems and appetite, because these can be affected by so many of the conditions common in older adults, such as chronic pain, he said.

“The key is to tap into changes in self-attitude,” Dr. Gray said.

There are a variety of scales available and he uses the five-item version of the Short Geriatric Depression Scale since it can be performed quickly.

When depression is nonresponsive to treatment, confirm or refine your diagnosis, Dr. Gray advised. You could be dealing with patients with an underlying delirium or dementia, early parkinsonism, involuntary emotional expression disorder, or apathy syndromes. Performing a mental status exam in these patients is critical, he said.

Physicians also may run into difficulties distinguishing the symptoms of Alzheimer's disease from other types of dementia. Alzheimer's disease is characterized by an inability to learn new information that is in many ways unique, Dr. Gray said.

Physicians can demonstrate that a patient is “losing information” without having to have a PET scanner in the office, Dr. Gray said.

Instead, try a three-word cued recall test with patients. Ask the patient to try to remember three words, such as Oldsmobile, carrot, and piano. Wait a few minutes and ask the patient to try to recall the words. If they can't recall the words spontaneously, give them clues or choices to prompt them.

Impaired recall by itself enough isn't enough to indicate Alzheimer's disease, Dr. Gray said.

Many individuals without dementia of any kind can be forgetful.

However, the cued recall test, which includes providing hints to the patient, can help demonstrate whether the new information is available to be recalled.

Beware of making a diagnosis of Alzheimer's disease if memory loss is not a major feature, the recognition memory is intact, and there are early personality changes, Dr. Gray said.

Other dementias are generally characterized by executive impairment, mood and motor symptoms, and other impairments such as slow processing.

HOLLYWOOD, FLA. – Common psychiatric disorders such as depression and dementia can be hard to distinguish in elderly patients, but there are some simple techniques that physicians can use to draw out the differences, Dr. Kevin Gray said at the annual symposium of the American Medical Director's Association.

“Dementia and depression can occur together or separately,” said Dr. Gray of the department of neurology at the University of Texas Southwestern Medical Center at Dallas.

One of the reasons that there is so much confusion about what is dementia and what is depression is that the symptoms can overlap to some degree, he said.

In a typical case, a family member will describe a patient's passivity, weight changes, sleep disturbances, sweet tooth, restlessness, declines in cognition, or lack of interest in favorite activities. All of these symptoms could be depression, he said.

The key elements in distinguishing between depression and dementia in that type of patient include the presence of true suicidality or feelings of worthlessness and guilt. These symptoms are characteristic of depressive syndrome but are rare in dementias such as Alzheimer's disease, he said.

When eliciting depression symptoms, Dr. Gray suggested using the mnemonic device SIG-E-CAPS, which represents the diagnostic elements of major depressive disorder: sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal ideation. Also look for changes in self-attitude, including helplessness, hopelessness, and worthlessness, he said.

It can be misleading to focus too much on some of the somatic issues related to depression, such as sleep problems and appetite, because these can be affected by so many of the conditions common in older adults, such as chronic pain, he said.

“The key is to tap into changes in self-attitude,” Dr. Gray said.

There are a variety of scales available and he uses the five-item version of the Short Geriatric Depression Scale since it can be performed quickly.

When depression is nonresponsive to treatment, confirm or refine your diagnosis, Dr. Gray advised. You could be dealing with patients with an underlying delirium or dementia, early parkinsonism, involuntary emotional expression disorder, or apathy syndromes. Performing a mental status exam in these patients is critical, he said.

Physicians also may run into difficulties distinguishing the symptoms of Alzheimer's disease from other types of dementia. Alzheimer's disease is characterized by an inability to learn new information that is in many ways unique, Dr. Gray said.

Physicians can demonstrate that a patient is “losing information” without having to have a PET scanner in the office, Dr. Gray said.

Instead, try a three-word cued recall test with patients. Ask the patient to try to remember three words, such as Oldsmobile, carrot, and piano. Wait a few minutes and ask the patient to try to recall the words. If they can't recall the words spontaneously, give them clues or choices to prompt them.

Impaired recall by itself enough isn't enough to indicate Alzheimer's disease, Dr. Gray said.

Many individuals without dementia of any kind can be forgetful.

However, the cued recall test, which includes providing hints to the patient, can help demonstrate whether the new information is available to be recalled.

Beware of making a diagnosis of Alzheimer's disease if memory loss is not a major feature, the recognition memory is intact, and there are early personality changes, Dr. Gray said.

Other dementias are generally characterized by executive impairment, mood and motor symptoms, and other impairments such as slow processing.

HOLLYWOOD, FLA. – Common psychiatric disorders such as depression and dementia can be hard to distinguish in elderly patients, but there are some simple techniques that physicians can use to draw out the differences, Dr. Kevin Gray said at the annual symposium of the American Medical Director's Association.

“Dementia and depression can occur together or separately,” said Dr. Gray of the department of neurology at the University of Texas Southwestern Medical Center at Dallas.

One of the reasons that there is so much confusion about what is dementia and what is depression is that the symptoms can overlap to some degree, he said.

In a typical case, a family member will describe a patient's passivity, weight changes, sleep disturbances, sweet tooth, restlessness, declines in cognition, or lack of interest in favorite activities. All of these symptoms could be depression, he said.

The key elements in distinguishing between depression and dementia in that type of patient include the presence of true suicidality or feelings of worthlessness and guilt. These symptoms are characteristic of depressive syndrome but are rare in dementias such as Alzheimer's disease, he said.

When eliciting depression symptoms, Dr. Gray suggested using the mnemonic device SIG-E-CAPS, which represents the diagnostic elements of major depressive disorder: sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal ideation. Also look for changes in self-attitude, including helplessness, hopelessness, and worthlessness, he said.

It can be misleading to focus too much on some of the somatic issues related to depression, such as sleep problems and appetite, because these can be affected by so many of the conditions common in older adults, such as chronic pain, he said.

“The key is to tap into changes in self-attitude,” Dr. Gray said.

There are a variety of scales available and he uses the five-item version of the Short Geriatric Depression Scale since it can be performed quickly.

When depression is nonresponsive to treatment, confirm or refine your diagnosis, Dr. Gray advised. You could be dealing with patients with an underlying delirium or dementia, early parkinsonism, involuntary emotional expression disorder, or apathy syndromes. Performing a mental status exam in these patients is critical, he said.

Physicians also may run into difficulties distinguishing the symptoms of Alzheimer's disease from other types of dementia. Alzheimer's disease is characterized by an inability to learn new information that is in many ways unique, Dr. Gray said.

Physicians can demonstrate that a patient is “losing information” without having to have a PET scanner in the office, Dr. Gray said.

Instead, try a three-word cued recall test with patients. Ask the patient to try to remember three words, such as Oldsmobile, carrot, and piano. Wait a few minutes and ask the patient to try to recall the words. If they can't recall the words spontaneously, give them clues or choices to prompt them.

Impaired recall by itself enough isn't enough to indicate Alzheimer's disease, Dr. Gray said.

Many individuals without dementia of any kind can be forgetful.

However, the cued recall test, which includes providing hints to the patient, can help demonstrate whether the new information is available to be recalled.

Beware of making a diagnosis of Alzheimer's disease if memory loss is not a major feature, the recognition memory is intact, and there are early personality changes, Dr. Gray said.

Other dementias are generally characterized by executive impairment, mood and motor symptoms, and other impairments such as slow processing.

HOLLYWOOD, FLA. — Identifying nursing home residents with the greatest risk of dying, and offering them help with their advance planning, can improve the quality of care at the end of life, Dr. Cari R. Levy said at the annual symposium of the American Medical Directors Association.

Dr. Levy and her colleagues at the University of Colorado, Denver, compared end-of-life quality of care at a Denver nursing home before and after the implementation of an advance planning initiative. After implementation of the program, residents were less likely to die in the hospital and more likely to receive palliative care and hospice services. In addition, more residents had advance directives in place.

The researchers implemented the Making Advance Planning a Priority or MAPP program. The goal of the program is to encourage collaboration between nursing home staff with palliative care specialists to provide end-of-life planning to those residents who are at greatest risk of death.

To determine their risk of death, nursing home residents were assessed using the Flacker Mortality instrument, which assigns a score that translates into the chances of dying in the next year. For example, a Flacker mortality score of 0–2 means a 7% chance of dying, while a score of 11 or greater equals an 86% chance of dying in the next year.

The researchers targeted those residents with a score of 7 or greater, meaning they had a 50% chance of dying in the next year. “This person has a 50–50 chance of dying in the next year, so it's probably a good idea to get the advance planning in order,” Dr. Levy said.

After the residents were identified as high risk, the researchers informed the attending physicians of their mortality scores and helped them to obtain a palliative care or hospice consult if that was in line with the goals of the residents and their families.

The researchers performed a retrospective chart review of 96 patients who died in the year before intervention and 101 patients who died in the year after.

After the intervention, residents were less likely to die in the hospital. Before the implementation of the MAPP program, 48.2% of residents died in the hospital, versus 8.9% after the program. This was a statistically significant result. Palliative care referrals also increased with the program. Referrals rose from 7.4% before intervention to 31.1% post intervention. This also was a statistically significant finding.

All patients who died after the MAPP initiative was implemented had an advance directive in place, Dr. Levy said. Before the intervention, about 12% of residents died without having an advance directive.

In an effort to determine if the program would be applicable at other facilities, the researchers performed the same retrospective chart review at seven other community nursing homes in the Denver area but did not implement the MAPP program.

Across the seven nursing homes, the researchers found similar overall referral patterns among the 253 residents who had died in those facilities in the last year.

About 53% of residents had been referred to hospice before death, 8% were referred to a palliative care program, and 88% had do-not-resuscitate orders in place. About 10% of residents did not have an advance directive, Dr. Levy said.

HOLLYWOOD, FLA. — Identifying nursing home residents with the greatest risk of dying, and offering them help with their advance planning, can improve the quality of care at the end of life, Dr. Cari R. Levy said at the annual symposium of the American Medical Directors Association.

Dr. Levy and her colleagues at the University of Colorado, Denver, compared end-of-life quality of care at a Denver nursing home before and after the implementation of an advance planning initiative. After implementation of the program, residents were less likely to die in the hospital and more likely to receive palliative care and hospice services. In addition, more residents had advance directives in place.

The researchers implemented the Making Advance Planning a Priority or MAPP program. The goal of the program is to encourage collaboration between nursing home staff with palliative care specialists to provide end-of-life planning to those residents who are at greatest risk of death.

To determine their risk of death, nursing home residents were assessed using the Flacker Mortality instrument, which assigns a score that translates into the chances of dying in the next year. For example, a Flacker mortality score of 0–2 means a 7% chance of dying, while a score of 11 or greater equals an 86% chance of dying in the next year.

The researchers targeted those residents with a score of 7 or greater, meaning they had a 50% chance of dying in the next year. “This person has a 50–50 chance of dying in the next year, so it's probably a good idea to get the advance planning in order,” Dr. Levy said.

After the residents were identified as high risk, the researchers informed the attending physicians of their mortality scores and helped them to obtain a palliative care or hospice consult if that was in line with the goals of the residents and their families.

The researchers performed a retrospective chart review of 96 patients who died in the year before intervention and 101 patients who died in the year after.

After the intervention, residents were less likely to die in the hospital. Before the implementation of the MAPP program, 48.2% of residents died in the hospital, versus 8.9% after the program. This was a statistically significant result. Palliative care referrals also increased with the program. Referrals rose from 7.4% before intervention to 31.1% post intervention. This also was a statistically significant finding.

All patients who died after the MAPP initiative was implemented had an advance directive in place, Dr. Levy said. Before the intervention, about 12% of residents died without having an advance directive.

In an effort to determine if the program would be applicable at other facilities, the researchers performed the same retrospective chart review at seven other community nursing homes in the Denver area but did not implement the MAPP program.

Across the seven nursing homes, the researchers found similar overall referral patterns among the 253 residents who had died in those facilities in the last year.

About 53% of residents had been referred to hospice before death, 8% were referred to a palliative care program, and 88% had do-not-resuscitate orders in place. About 10% of residents did not have an advance directive, Dr. Levy said.

HOLLYWOOD, FLA. — Identifying nursing home residents with the greatest risk of dying, and offering them help with their advance planning, can improve the quality of care at the end of life, Dr. Cari R. Levy said at the annual symposium of the American Medical Directors Association.

Dr. Levy and her colleagues at the University of Colorado, Denver, compared end-of-life quality of care at a Denver nursing home before and after the implementation of an advance planning initiative. After implementation of the program, residents were less likely to die in the hospital and more likely to receive palliative care and hospice services. In addition, more residents had advance directives in place.

The researchers implemented the Making Advance Planning a Priority or MAPP program. The goal of the program is to encourage collaboration between nursing home staff with palliative care specialists to provide end-of-life planning to those residents who are at greatest risk of death.

To determine their risk of death, nursing home residents were assessed using the Flacker Mortality instrument, which assigns a score that translates into the chances of dying in the next year. For example, a Flacker mortality score of 0–2 means a 7% chance of dying, while a score of 11 or greater equals an 86% chance of dying in the next year.

The researchers targeted those residents with a score of 7 or greater, meaning they had a 50% chance of dying in the next year. “This person has a 50–50 chance of dying in the next year, so it's probably a good idea to get the advance planning in order,” Dr. Levy said.

After the residents were identified as high risk, the researchers informed the attending physicians of their mortality scores and helped them to obtain a palliative care or hospice consult if that was in line with the goals of the residents and their families.

The researchers performed a retrospective chart review of 96 patients who died in the year before intervention and 101 patients who died in the year after.

After the intervention, residents were less likely to die in the hospital. Before the implementation of the MAPP program, 48.2% of residents died in the hospital, versus 8.9% after the program. This was a statistically significant result. Palliative care referrals also increased with the program. Referrals rose from 7.4% before intervention to 31.1% post intervention. This also was a statistically significant finding.

All patients who died after the MAPP initiative was implemented had an advance directive in place, Dr. Levy said. Before the intervention, about 12% of residents died without having an advance directive.

In an effort to determine if the program would be applicable at other facilities, the researchers performed the same retrospective chart review at seven other community nursing homes in the Denver area but did not implement the MAPP program.

Across the seven nursing homes, the researchers found similar overall referral patterns among the 253 residents who had died in those facilities in the last year.

About 53% of residents had been referred to hospice before death, 8% were referred to a palliative care program, and 88% had do-not-resuscitate orders in place. About 10% of residents did not have an advance directive, Dr. Levy said.

Several Medicare Advantage fee-for-service plan sponsors have agreed to voluntarily suspend marketing of their plans until officials at the Centers for Medicare and Medicaid Services can verify that they are in compliance with certain management controls.

CMS officials announced this temporary marketing moratorium as part of an effort to halt deceptive marketing practices in the private fee-for-service Medicare market.

“It is our strong belief that while most agents and brokers are helpful and responsible in describing and explaining choices to beneficiaries, there are a few bad actors operating in the marketplace that need to be removed from the system,” Abby Block, director of the Center for Beneficiary Choices at the CMS, said during a press briefing. “This voluntary agreement demonstrates that the plans are stepping up to ensure that deceptive marketing practices end and that beneficiaries fully understand what they are purchasing.”

From last December through April, CMS officials received about 2,700 complaints from beneficiaries regarding Medicare Advantage plans, with many of those complaints relating to private fee-for-service plans.

However, Ms. Block pointed out that the 2,700 complaints account for a small fraction of the 1.3 million Medicare beneficiaries who have elected to enroll in such plans.

The problems reported range from agents encouraging the misperception that the private plans are just like traditional Medicare and are accepted by all providers who accept Medicare to more blatant cases of deception in which agents have told beneficiaries they are still enrolled in traditional Medicare and are purchasing a Medigap supplemental insurance policy.

The seven private fee-for-service Medicare plans that recently signed an agreement with the CMS to suspend their marketing efforts are United Healthcare, Humana, WellCare, Universal American Financial Corporation (Pyramid), Coventry, Sterling, and Blue Cross Blue Shield of Tennessee. Together, they account for about 90% of enrollment in private fee-for-service plans, according to the CMS. “These are clearly the major players in the industry,” Ms. Block said.

The plans were not singled out because of particular problems with their marketing practices, Ms. Block said. The real concern relates to actions by a small number of rogue brokers and agents with whom these and other organizations may contract, she said.

The temporary moratorium does not apply to enrollment among the plans and does not affect the employer market, where CMS has not received complaints of issues with marketing tactics.

The marketing moratorium will be lifted on a plan-by-plan basis when the CMS certifies that the plan has both systems and management controls in place that meet conditions spelled out by the agency in guidance earlier this year.

For example, plan sponsors will have to show that all of their advertising, marketing, and enrollment materials include model disclaimer language provided by the CMS that private fee-for-service Medicare plans are not the same as traditional Medicare or Medigap and that not all providers will accept the plan. All representatives selling products on behalf of a plan sponsor will have to pass a written test demonstrating familiarity with Medicare and fee-for-service plans.

Plans must also agree to provide a list of individuals who are marketing the plan upon request by the CMS or state agencies. The CMS will begin to review plans as soon as they indicate they are in compliance, Ms. Block said.

In addition, the CMS will be monitoring all private fee-for-service plans to ensure they are not engaging in deceptive marketing practices.

“We will be watching very carefully as the entire industry begins marketing in October for the 2008 benefit year,” Ms. Block said.

Several Medicare Advantage fee-for-service plan sponsors have agreed to voluntarily suspend marketing of their plans until officials at the Centers for Medicare and Medicaid Services can verify that they are in compliance with certain management controls.

CMS officials announced this temporary marketing moratorium as part of an effort to halt deceptive marketing practices in the private fee-for-service Medicare market.

“It is our strong belief that while most agents and brokers are helpful and responsible in describing and explaining choices to beneficiaries, there are a few bad actors operating in the marketplace that need to be removed from the system,” Abby Block, director of the Center for Beneficiary Choices at the CMS, said during a press briefing. “This voluntary agreement demonstrates that the plans are stepping up to ensure that deceptive marketing practices end and that beneficiaries fully understand what they are purchasing.”

From last December through April, CMS officials received about 2,700 complaints from beneficiaries regarding Medicare Advantage plans, with many of those complaints relating to private fee-for-service plans.

However, Ms. Block pointed out that the 2,700 complaints account for a small fraction of the 1.3 million Medicare beneficiaries who have elected to enroll in such plans.

The problems reported range from agents encouraging the misperception that the private plans are just like traditional Medicare and are accepted by all providers who accept Medicare to more blatant cases of deception in which agents have told beneficiaries they are still enrolled in traditional Medicare and are purchasing a Medigap supplemental insurance policy.

The seven private fee-for-service Medicare plans that recently signed an agreement with the CMS to suspend their marketing efforts are United Healthcare, Humana, WellCare, Universal American Financial Corporation (Pyramid), Coventry, Sterling, and Blue Cross Blue Shield of Tennessee. Together, they account for about 90% of enrollment in private fee-for-service plans, according to the CMS. “These are clearly the major players in the industry,” Ms. Block said.

The plans were not singled out because of particular problems with their marketing practices, Ms. Block said. The real concern relates to actions by a small number of rogue brokers and agents with whom these and other organizations may contract, she said.

The temporary moratorium does not apply to enrollment among the plans and does not affect the employer market, where CMS has not received complaints of issues with marketing tactics.

The marketing moratorium will be lifted on a plan-by-plan basis when the CMS certifies that the plan has both systems and management controls in place that meet conditions spelled out by the agency in guidance earlier this year.

For example, plan sponsors will have to show that all of their advertising, marketing, and enrollment materials include model disclaimer language provided by the CMS that private fee-for-service Medicare plans are not the same as traditional Medicare or Medigap and that not all providers will accept the plan. All representatives selling products on behalf of a plan sponsor will have to pass a written test demonstrating familiarity with Medicare and fee-for-service plans.

Plans must also agree to provide a list of individuals who are marketing the plan upon request by the CMS or state agencies. The CMS will begin to review plans as soon as they indicate they are in compliance, Ms. Block said.

In addition, the CMS will be monitoring all private fee-for-service plans to ensure they are not engaging in deceptive marketing practices.

“We will be watching very carefully as the entire industry begins marketing in October for the 2008 benefit year,” Ms. Block said.

Several Medicare Advantage fee-for-service plan sponsors have agreed to voluntarily suspend marketing of their plans until officials at the Centers for Medicare and Medicaid Services can verify that they are in compliance with certain management controls.

CMS officials announced this temporary marketing moratorium as part of an effort to halt deceptive marketing practices in the private fee-for-service Medicare market.

“It is our strong belief that while most agents and brokers are helpful and responsible in describing and explaining choices to beneficiaries, there are a few bad actors operating in the marketplace that need to be removed from the system,” Abby Block, director of the Center for Beneficiary Choices at the CMS, said during a press briefing. “This voluntary agreement demonstrates that the plans are stepping up to ensure that deceptive marketing practices end and that beneficiaries fully understand what they are purchasing.”

From last December through April, CMS officials received about 2,700 complaints from beneficiaries regarding Medicare Advantage plans, with many of those complaints relating to private fee-for-service plans.

However, Ms. Block pointed out that the 2,700 complaints account for a small fraction of the 1.3 million Medicare beneficiaries who have elected to enroll in such plans.

The problems reported range from agents encouraging the misperception that the private plans are just like traditional Medicare and are accepted by all providers who accept Medicare to more blatant cases of deception in which agents have told beneficiaries they are still enrolled in traditional Medicare and are purchasing a Medigap supplemental insurance policy.

The seven private fee-for-service Medicare plans that recently signed an agreement with the CMS to suspend their marketing efforts are United Healthcare, Humana, WellCare, Universal American Financial Corporation (Pyramid), Coventry, Sterling, and Blue Cross Blue Shield of Tennessee. Together, they account for about 90% of enrollment in private fee-for-service plans, according to the CMS. “These are clearly the major players in the industry,” Ms. Block said.

The plans were not singled out because of particular problems with their marketing practices, Ms. Block said. The real concern relates to actions by a small number of rogue brokers and agents with whom these and other organizations may contract, she said.

The temporary moratorium does not apply to enrollment among the plans and does not affect the employer market, where CMS has not received complaints of issues with marketing tactics.

The marketing moratorium will be lifted on a plan-by-plan basis when the CMS certifies that the plan has both systems and management controls in place that meet conditions spelled out by the agency in guidance earlier this year.

For example, plan sponsors will have to show that all of their advertising, marketing, and enrollment materials include model disclaimer language provided by the CMS that private fee-for-service Medicare plans are not the same as traditional Medicare or Medigap and that not all providers will accept the plan. All representatives selling products on behalf of a plan sponsor will have to pass a written test demonstrating familiarity with Medicare and fee-for-service plans.

Plans must also agree to provide a list of individuals who are marketing the plan upon request by the CMS or state agencies. The CMS will begin to review plans as soon as they indicate they are in compliance, Ms. Block said.

In addition, the CMS will be monitoring all private fee-for-service plans to ensure they are not engaging in deceptive marketing practices.

“We will be watching very carefully as the entire industry begins marketing in October for the 2008 benefit year,” Ms. Block said.

At the Spanish Catholic Center health clinics in the Washington area, patients can access one-stop shopping for their chronic medical care.

The health clinics have on-site laboratories and pharmacies so patients can come in for an exam, have blood work performed, and pick up their medicine in a single visit. This type of access, which is especially appealing for the clinic's mostly uninsured population, is one way that the organization strives to provide a "medical home" to its patients, said Dr. Anna Maria Izquierdo-Porrera, an internist who serves as medical director of the Spanish Catholic Center.

"A medical home improves the quality of service that you receive, and whether you're insured or not, there are ways that we can look at how we deliver care [in order] to improve," Dr. Izquierdo-Porrera said during a press briefing sponsored by the Commonwealth Fund. "It needs to be in a place where the patient trusts you and will come back."

This approach has been yielding positive results in diabetes control. Physicians at the Spanish Catholic Center, who provide mainly charity care, have seen a drop in the number of diabetes patients with poor control. From 2003 to 2005, the percentage of diabetes patients with poor control fell from 29.6% to 13.7%, and the percentage of those with good control rose from 29.6% to 46.3%, she said.

And now researchers are finding that having access to a medical home makes patients less likely to experience health disparities. In a report released in June, researchers at the Commonwealth Fund said that having a regular provider or place of care that is accessible after hours and is efficiently run can improve the quality of both preventive and chronic care.

The findings are based on a 2006 survey of 2,837 adults aged 18-64 years. The national sample was designed to target black, Hispanic, and Asian households. The sample specifically excluded adults aged 65 and older who are eligible to receive Medicare coverage.

The survey found that overall health disparities persist. However, according to the report, strategies such as providing patients with a medical home and increasing health insurance coverage can reduce or even eliminate disparities.

The researchers defined a medical home as a regular provider or source of care that is accessible both during the day and on evenings and weekends. The setting should also be well organized and efficiently run. Only 27% of the survey respondents reported that they have a place of care meeting that definition, Dr. Anne Beal, the lead study author and a pediatrician, said during the press briefing.

The uninsured are the least likely to have access to a medical home, the researchers found. About 16% of uninsured respondents receive their care through a medical home, whereas 45% do not have a regular source of care.

Safety net facilities, such as community health centers and public clinics, are crucial to providing the uninsured with a medical home, according to the Commonwealth Fund report. Currently, however, safety net facilities are less likely to meet the criteria for a medical home than are private physician offices.

In analyzing the impact of the medical home, the researchers found that having a regular place of care really does matter. Nearly three-quarters of adults with a medical home report being able to get the care they need when they need it, compared with 52% of those with a regular provider that is not a medical home. Only 38% of adults without any regular source of care say they can get the care they need when they need it.

And when patients had a medical home, there were no disparities in access to care based on race, Dr. Beal said. Among patients who had a medical home, the same percentage of whites, blacks, and Hispanics—nearly 75%–reported that they always get care when they need it. In addition, about 65% of patients with a medical home, regardless of race, reported that they receive reminders for preventive care visits.

"Whenever a patient said that they were in a medical home, we found that there were no disparities in the quality of care that they received," Dr. Beal said.

The medical home is also important in terms of providing chronic care, the researchers said. The survey found that adults with a medical home were more likely to have a plan to manage their chronic health conditions at home, compared with those without a regular source of care. For example, among adults with hypertension, 42% of those with a medical home reported that they regularly check their blood pressure and that it is well controlled. In contrast, only 25% of individuals with a regular source of care that is not a medical home reported regularly checking their blood pressure and keeping it under control.

The Commonwealth Fund report calls on all providers to take steps to create medical homes for patients, especially among safety net providers. The researchers also call on physicians and policy makers to establish standards for medical homes and promote public reporting of performance.

The American College of Physicians has also been selling the idea of the "patient-centered" medical home. The organization issued a joint principles statement with the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association in February outlining the elements of a patient-centered medical home. ACP and AAFP officials are also in discussions with employers and payers to begin pilot projects testing the concept of the medical home, some of which could launch this year.

The findings of the Commonwealth Fund report were praised by Dr. Rick Kellerman, AAFP president, who called the results "outstanding and not unexpected." The findings showcase how important the medical home is, and add to the long list of reasons for changing how care is provided and paid for, he said.

Demonstration projects are also in the works at the federal level. As part of the Tax Relief and Health Care Act of 2006, Congress has authorized a 3-year demonstration project in eight states that would provide a care management fee to physicians who coordinate care as part of a medical home. That Medicare demonstration project is expected to launch in 2009.

Other pieces of legislation being considered by Congress contain references to the medical home and the need to coordinate care, Dr. Dora L. Hughes, health policy adviser to senator and presidential candidate Barack Obama (D-Ill.), said at the press briefing. But the real barrier to making the medical home more widespread throughout medicine is the reimbursement system, she said.

Physicians aren't reimbursed for coordinating care, answering patient e-mails, conducting telephone consultations, managing chronic diseases, or implementing health information technology. And primary care is generally not well paid, she said.

ELSEVIER GLOBAL MEDICAL NEWS

At the Spanish Catholic Center health clinics in the Washington area, patients can access one-stop shopping for their chronic medical care.

The health clinics have on-site laboratories and pharmacies so patients can come in for an exam, have blood work performed, and pick up their medicine in a single visit. This type of access, which is especially appealing for the clinic's mostly uninsured population, is one way that the organization strives to provide a "medical home" to its patients, said Dr. Anna Maria Izquierdo-Porrera, an internist who serves as medical director of the Spanish Catholic Center.

"A medical home improves the quality of service that you receive, and whether you're insured or not, there are ways that we can look at how we deliver care [in order] to improve," Dr. Izquierdo-Porrera said during a press briefing sponsored by the Commonwealth Fund. "It needs to be in a place where the patient trusts you and will come back."

This approach has been yielding positive results in diabetes control. Physicians at the Spanish Catholic Center, who provide mainly charity care, have seen a drop in the number of diabetes patients with poor control. From 2003 to 2005, the percentage of diabetes patients with poor control fell from 29.6% to 13.7%, and the percentage of those with good control rose from 29.6% to 46.3%, she said.

And now researchers are finding that having access to a medical home makes patients less likely to experience health disparities. In a report released in June, researchers at the Commonwealth Fund said that having a regular provider or place of care that is accessible after hours and is efficiently run can improve the quality of both preventive and chronic care.

The findings are based on a 2006 survey of 2,837 adults aged 18-64 years. The national sample was designed to target black, Hispanic, and Asian households. The sample specifically excluded adults aged 65 and older who are eligible to receive Medicare coverage.

The survey found that overall health disparities persist. However, according to the report, strategies such as providing patients with a medical home and increasing health insurance coverage can reduce or even eliminate disparities.

The researchers defined a medical home as a regular provider or source of care that is accessible both during the day and on evenings and weekends. The setting should also be well organized and efficiently run. Only 27% of the survey respondents reported that they have a place of care meeting that definition, Dr. Anne Beal, the lead study author and a pediatrician, said during the press briefing.

The uninsured are the least likely to have access to a medical home, the researchers found. About 16% of uninsured respondents receive their care through a medical home, whereas 45% do not have a regular source of care.

Safety net facilities, such as community health centers and public clinics, are crucial to providing the uninsured with a medical home, according to the Commonwealth Fund report. Currently, however, safety net facilities are less likely to meet the criteria for a medical home than are private physician offices.

In analyzing the impact of the medical home, the researchers found that having a regular place of care really does matter. Nearly three-quarters of adults with a medical home report being able to get the care they need when they need it, compared with 52% of those with a regular provider that is not a medical home. Only 38% of adults without any regular source of care say they can get the care they need when they need it.

And when patients had a medical home, there were no disparities in access to care based on race, Dr. Beal said. Among patients who had a medical home, the same percentage of whites, blacks, and Hispanics—nearly 75%–reported that they always get care when they need it. In addition, about 65% of patients with a medical home, regardless of race, reported that they receive reminders for preventive care visits.

"Whenever a patient said that they were in a medical home, we found that there were no disparities in the quality of care that they received," Dr. Beal said.

The medical home is also important in terms of providing chronic care, the researchers said. The survey found that adults with a medical home were more likely to have a plan to manage their chronic health conditions at home, compared with those without a regular source of care. For example, among adults with hypertension, 42% of those with a medical home reported that they regularly check their blood pressure and that it is well controlled. In contrast, only 25% of individuals with a regular source of care that is not a medical home reported regularly checking their blood pressure and keeping it under control.

The Commonwealth Fund report calls on all providers to take steps to create medical homes for patients, especially among safety net providers. The researchers also call on physicians and policy makers to establish standards for medical homes and promote public reporting of performance.

The American College of Physicians has also been selling the idea of the "patient-centered" medical home. The organization issued a joint principles statement with the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association in February outlining the elements of a patient-centered medical home. ACP and AAFP officials are also in discussions with employers and payers to begin pilot projects testing the concept of the medical home, some of which could launch this year.

The findings of the Commonwealth Fund report were praised by Dr. Rick Kellerman, AAFP president, who called the results "outstanding and not unexpected." The findings showcase how important the medical home is, and add to the long list of reasons for changing how care is provided and paid for, he said.

Demonstration projects are also in the works at the federal level. As part of the Tax Relief and Health Care Act of 2006, Congress has authorized a 3-year demonstration project in eight states that would provide a care management fee to physicians who coordinate care as part of a medical home. That Medicare demonstration project is expected to launch in 2009.

Other pieces of legislation being considered by Congress contain references to the medical home and the need to coordinate care, Dr. Dora L. Hughes, health policy adviser to senator and presidential candidate Barack Obama (D-Ill.), said at the press briefing. But the real barrier to making the medical home more widespread throughout medicine is the reimbursement system, she said.

Physicians aren't reimbursed for coordinating care, answering patient e-mails, conducting telephone consultations, managing chronic diseases, or implementing health information technology. And primary care is generally not well paid, she said.

ELSEVIER GLOBAL MEDICAL NEWS

At the Spanish Catholic Center health clinics in the Washington area, patients can access one-stop shopping for their chronic medical care.

The health clinics have on-site laboratories and pharmacies so patients can come in for an exam, have blood work performed, and pick up their medicine in a single visit. This type of access, which is especially appealing for the clinic's mostly uninsured population, is one way that the organization strives to provide a "medical home" to its patients, said Dr. Anna Maria Izquierdo-Porrera, an internist who serves as medical director of the Spanish Catholic Center.

"A medical home improves the quality of service that you receive, and whether you're insured or not, there are ways that we can look at how we deliver care [in order] to improve," Dr. Izquierdo-Porrera said during a press briefing sponsored by the Commonwealth Fund. "It needs to be in a place where the patient trusts you and will come back."

This approach has been yielding positive results in diabetes control. Physicians at the Spanish Catholic Center, who provide mainly charity care, have seen a drop in the number of diabetes patients with poor control. From 2003 to 2005, the percentage of diabetes patients with poor control fell from 29.6% to 13.7%, and the percentage of those with good control rose from 29.6% to 46.3%, she said.

And now researchers are finding that having access to a medical home makes patients less likely to experience health disparities. In a report released in June, researchers at the Commonwealth Fund said that having a regular provider or place of care that is accessible after hours and is efficiently run can improve the quality of both preventive and chronic care.

The findings are based on a 2006 survey of 2,837 adults aged 18-64 years. The national sample was designed to target black, Hispanic, and Asian households. The sample specifically excluded adults aged 65 and older who are eligible to receive Medicare coverage.

The survey found that overall health disparities persist. However, according to the report, strategies such as providing patients with a medical home and increasing health insurance coverage can reduce or even eliminate disparities.

The researchers defined a medical home as a regular provider or source of care that is accessible both during the day and on evenings and weekends. The setting should also be well organized and efficiently run. Only 27% of the survey respondents reported that they have a place of care meeting that definition, Dr. Anne Beal, the lead study author and a pediatrician, said during the press briefing.

The uninsured are the least likely to have access to a medical home, the researchers found. About 16% of uninsured respondents receive their care through a medical home, whereas 45% do not have a regular source of care.

Safety net facilities, such as community health centers and public clinics, are crucial to providing the uninsured with a medical home, according to the Commonwealth Fund report. Currently, however, safety net facilities are less likely to meet the criteria for a medical home than are private physician offices.

In analyzing the impact of the medical home, the researchers found that having a regular place of care really does matter. Nearly three-quarters of adults with a medical home report being able to get the care they need when they need it, compared with 52% of those with a regular provider that is not a medical home. Only 38% of adults without any regular source of care say they can get the care they need when they need it.

And when patients had a medical home, there were no disparities in access to care based on race, Dr. Beal said. Among patients who had a medical home, the same percentage of whites, blacks, and Hispanics—nearly 75%–reported that they always get care when they need it. In addition, about 65% of patients with a medical home, regardless of race, reported that they receive reminders for preventive care visits.

"Whenever a patient said that they were in a medical home, we found that there were no disparities in the quality of care that they received," Dr. Beal said.

The medical home is also important in terms of providing chronic care, the researchers said. The survey found that adults with a medical home were more likely to have a plan to manage their chronic health conditions at home, compared with those without a regular source of care. For example, among adults with hypertension, 42% of those with a medical home reported that they regularly check their blood pressure and that it is well controlled. In contrast, only 25% of individuals with a regular source of care that is not a medical home reported regularly checking their blood pressure and keeping it under control.

The Commonwealth Fund report calls on all providers to take steps to create medical homes for patients, especially among safety net providers. The researchers also call on physicians and policy makers to establish standards for medical homes and promote public reporting of performance.

The American College of Physicians has also been selling the idea of the "patient-centered" medical home. The organization issued a joint principles statement with the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association in February outlining the elements of a patient-centered medical home. ACP and AAFP officials are also in discussions with employers and payers to begin pilot projects testing the concept of the medical home, some of which could launch this year.

The findings of the Commonwealth Fund report were praised by Dr. Rick Kellerman, AAFP president, who called the results "outstanding and not unexpected." The findings showcase how important the medical home is, and add to the long list of reasons for changing how care is provided and paid for, he said.

Demonstration projects are also in the works at the federal level. As part of the Tax Relief and Health Care Act of 2006, Congress has authorized a 3-year demonstration project in eight states that would provide a care management fee to physicians who coordinate care as part of a medical home. That Medicare demonstration project is expected to launch in 2009.

Other pieces of legislation being considered by Congress contain references to the medical home and the need to coordinate care, Dr. Dora L. Hughes, health policy adviser to senator and presidential candidate Barack Obama (D-Ill.), said at the press briefing. But the real barrier to making the medical home more widespread throughout medicine is the reimbursement system, she said.

Physicians aren't reimbursed for coordinating care, answering patient e-mails, conducting telephone consultations, managing chronic diseases, or implementing health information technology. And primary care is generally not well paid, she said.

ELSEVIER GLOBAL MEDICAL NEWS

Public health systems need more federal funding to respond to both day-to-day emergencies and mass-casualty events, according to disaster preparedness recommendations released by a coalition of 18 health organizations.

The coalition, which was led by the American Medical Association and the American Public Health Association, issued a report with 53 recommendations aimed at leaders in medicine and the government.

Other coalition members include the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Surgeons. The project was funded under a cooperative agreement from the Centers for Disease Control and Prevention.

"The only thing we can probably predict with any certainty about terrorism attacks and other mass casualty events is this—we're not going to know the time, location, and magnitude in advance," Dr. Ronald M. Davis, AMA president, said at a press conference to release the report. "But we have no excuse if our responses aren't known in advance."

The report identifies nine critical areas needing immediate action, including:

▸ Increased federal funding should be allocated to expand emergency medical care, trauma care, and disaster health preparedness systems across the United States.

▸ Governmental entities and health systems must develop and evaluate processes to ensure a return to readiness for routine health care and future mass casualty events following a disaster.

▸ Funding for economic recovery after a disaster must emphasize the reestablishment of public health and health care systems.

▸ The Institute of Medicine should perform a comprehensive study of health system surge capacity.

▸ Emergency and disaster preparedness must be integrated with public health and health care systems nationwide to provide effective emergency and trauma care.

▸ Public health and health care officials must participate directly in disaster preparedness planning, mitigation, response, and recovery operations.

▸ Health disaster communications and health information exchange networks must be fully integrated and interoperable at every level of government and health systems.

▸ The government, health systems, and professional organizations should develop and distribute information on the management of adult and pediatric patients in day-to-day emergencies and catastrophic events.

▸ Public health and health care responders must be given adequate legal protections for providing care during a disaster situation.

The full report is available at www.ama-assn.org/go/disasterpreparedness

Public health systems need more federal funding to respond to both day-to-day emergencies and mass-casualty events, according to disaster preparedness recommendations released by a coalition of 18 health organizations.

The coalition, which was led by the American Medical Association and the American Public Health Association, issued a report with 53 recommendations aimed at leaders in medicine and the government.

Other coalition members include the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Surgeons. The project was funded under a cooperative agreement from the Centers for Disease Control and Prevention.

"The only thing we can probably predict with any certainty about terrorism attacks and other mass casualty events is this—we're not going to know the time, location, and magnitude in advance," Dr. Ronald M. Davis, AMA president, said at a press conference to release the report. "But we have no excuse if our responses aren't known in advance."

The report identifies nine critical areas needing immediate action, including:

▸ Increased federal funding should be allocated to expand emergency medical care, trauma care, and disaster health preparedness systems across the United States.

▸ Governmental entities and health systems must develop and evaluate processes to ensure a return to readiness for routine health care and future mass casualty events following a disaster.

▸ Funding for economic recovery after a disaster must emphasize the reestablishment of public health and health care systems.

▸ The Institute of Medicine should perform a comprehensive study of health system surge capacity.

▸ Emergency and disaster preparedness must be integrated with public health and health care systems nationwide to provide effective emergency and trauma care.

▸ Public health and health care officials must participate directly in disaster preparedness planning, mitigation, response, and recovery operations.

▸ Health disaster communications and health information exchange networks must be fully integrated and interoperable at every level of government and health systems.

▸ The government, health systems, and professional organizations should develop and distribute information on the management of adult and pediatric patients in day-to-day emergencies and catastrophic events.

▸ Public health and health care responders must be given adequate legal protections for providing care during a disaster situation.

The full report is available at www.ama-assn.org/go/disasterpreparedness

Public health systems need more federal funding to respond to both day-to-day emergencies and mass-casualty events, according to disaster preparedness recommendations released by a coalition of 18 health organizations.

The coalition, which was led by the American Medical Association and the American Public Health Association, issued a report with 53 recommendations aimed at leaders in medicine and the government.

Other coalition members include the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Surgeons. The project was funded under a cooperative agreement from the Centers for Disease Control and Prevention.

"The only thing we can probably predict with any certainty about terrorism attacks and other mass casualty events is this—we're not going to know the time, location, and magnitude in advance," Dr. Ronald M. Davis, AMA president, said at a press conference to release the report. "But we have no excuse if our responses aren't known in advance."

The report identifies nine critical areas needing immediate action, including:

▸ Increased federal funding should be allocated to expand emergency medical care, trauma care, and disaster health preparedness systems across the United States.

▸ Governmental entities and health systems must develop and evaluate processes to ensure a return to readiness for routine health care and future mass casualty events following a disaster.

▸ Funding for economic recovery after a disaster must emphasize the reestablishment of public health and health care systems.

▸ The Institute of Medicine should perform a comprehensive study of health system surge capacity.

▸ Emergency and disaster preparedness must be integrated with public health and health care systems nationwide to provide effective emergency and trauma care.

▸ Public health and health care officials must participate directly in disaster preparedness planning, mitigation, response, and recovery operations.

▸ Health disaster communications and health information exchange networks must be fully integrated and interoperable at every level of government and health systems.

▸ The government, health systems, and professional organizations should develop and distribute information on the management of adult and pediatric patients in day-to-day emergencies and catastrophic events.

▸ Public health and health care responders must be given adequate legal protections for providing care during a disaster situation.

The full report is available at www.ama-assn.org/go/disasterpreparedness

With Congress returning from its August recess, the fate of the State Children's Health Insurance Program reauthorization is up in the air, and so is the fate of physician pay relief.

As a planned Oct. 6 adjournment looms, a House/Senate conference committee must reconcile the vastly different health bills passed by the two chambers and craft the legislation into something that might escape a threatened presidential veto.

Before breaking for the summer recess, the Senate overwhelmingly passed S. 1893, which includes a $35 billion increase for SCHIP. The funds would come from an increase in the federal tobacco tax.

The approved House legislation (H.R. 3162), meanwhile, contains a number of provisions unrelated to SCHIP. For example, the bill would halt next year's planned 10% cut in the Medicare physician fee schedule, instead putting in place a 0.5% increase for 2008 and another for 2009.

In terms of SCHIP funding, the House bill calls for a $50 billion increase in funding and would pay for it with both increases in the federal tobacco tax and cuts to subsidies given to Medicare Advantage plans.

The American Academy of Pediatrics praised the passage of the two pieces of legislation and called on Congress to create a compromise bill that includes at least $50 billion in new federal funding for SCHIP.

"While the $35 billion included in the Senate bill is a good start, it's not enough to cover the eligible but unenrolled children in SCHIP or Medicaid," AAP President Jay E. Berkelhamer said in a statement. "The American public, including pediatricians, wants every child and adolescent covered. Passing and signing into law a strong SCHIP bill gets us that much closer to our goal."

AAP officials also praised provisions of the two bills that ease citizenship and identification documentation requirements and establish a pediatric quality measurement program.

Other medical professional societies called on Congress to craft a final piece of legislation that would include increased funding for SCHIP and the House provisions that halt Medicare cuts to physicians for the next 2 years.

"Emergency departments are a health care safety net not only for the uninsured but for us all," Dr. Brian Keaton, president of the American College of Emergency Physicians, said in a statement. "But with millions of people uninsured, that safety net is breaking under the load. This legislation will help shore up the safety net by providing more resources for those children, as well as for older Americans."

Officials at the American Academy of Family Physicians favor a final bill that includes SCHIP funding that would cover as many children as possible, 2 years of positive updates to the Medicare physician fee schedule, and a commitment to fixing the sustainable growth rate formula, said Dr. Rick Kellerman, AAFP president.

Two years of positive updates are important, Dr. Kellerman said. Legislators are tired of physicians coming every year to Capitol Hill to talk about this issue.

"We think we've got a lot of other important health care issues to deal with," Dr. Kellerman said, adding that a 2-year fix will give Congress time to evaluate the sustainable growth rate (SGR) issue and formulate an alternative. "It's a transitional bill," he said. "This gets us through the next 2 years."

The American College of Physicians praised both the House and the Senate bills but said they would like to see final legislation that includes some of the Medicare provisions passed by the House, including the temporary pay fix for physicians.

The House bill also outlines a new physician payment structure under Medicare that would set a separate conversion factor for six service categories:

▸ Evaluation and management for primary care.

▸ Evaluation and management for other services.

▸ Imaging.

▸ Major procedures.

▸ Anesthesia services.

▸ Minor procedures.

The proposed formula would also take prescription drugs out of the spending targets and would take into account Medicare coverage decisions when setting targets, according to Rich Trachtman, American College of Physicians legislative affairs director. But the formula would still lead to deep payment cuts starting in 2010, so there is an understanding among legislators and leaders in medicine that the updates for 2010 and beyond would require additional action, Mr. Trachtman said.

Dr. Edward Langston, Board Chair of the American Medical Association, said the House legislation is encouraging and shows a willingness to come up with alternatives to the SGR. However, what the final formula will look like is still up in the air, he said.

But the American College of Cardiology expressed problems with the new structure for Medicare payments outlined in the House bill. The proposed payment structure would be based on a system of separate expenditure targets that ACC asserts would not take into account the appropriate growth in services, including many common cardiovascular services.

"While the ACC appreciates congressional efforts to stop Medicare physician payment cuts, it is critical that any new payment structure is fair to all physicians," the ACC said in a statement. "The ACC urges Congress to resolve this issue before any final legislation is passed."

The House bill also drew the ire of the insurance industry. America's Health Insurance Plans (AHIP) hailed the passage of the Senate legislation but is opposed to provisions in the House bill that would make cuts to the Medicare Advantage program. These cuts could result in more than 3 million seniors losing Medicare Advantage coverage and having to switch to fee-for-service Medicare, where they would likely pay higher out-of-pocket costs, according to the AHIP.

With Congress returning from its August recess, the fate of the State Children's Health Insurance Program reauthorization is up in the air, and so is the fate of physician pay relief.

As a planned Oct. 6 adjournment looms, a House/Senate conference committee must reconcile the vastly different health bills passed by the two chambers and craft the legislation into something that might escape a threatened presidential veto.

Before breaking for the summer recess, the Senate overwhelmingly passed S. 1893, which includes a $35 billion increase for SCHIP. The funds would come from an increase in the federal tobacco tax.

The approved House legislation (H.R. 3162), meanwhile, contains a number of provisions unrelated to SCHIP. For example, the bill would halt next year's planned 10% cut in the Medicare physician fee schedule, instead putting in place a 0.5% increase for 2008 and another for 2009.

In terms of SCHIP funding, the House bill calls for a $50 billion increase in funding and would pay for it with both increases in the federal tobacco tax and cuts to subsidies given to Medicare Advantage plans.

The American Academy of Pediatrics praised the passage of the two pieces of legislation and called on Congress to create a compromise bill that includes at least $50 billion in new federal funding for SCHIP.

"While the $35 billion included in the Senate bill is a good start, it's not enough to cover the eligible but unenrolled children in SCHIP or Medicaid," AAP President Jay E. Berkelhamer said in a statement. "The American public, including pediatricians, wants every child and adolescent covered. Passing and signing into law a strong SCHIP bill gets us that much closer to our goal."

AAP officials also praised provisions of the two bills that ease citizenship and identification documentation requirements and establish a pediatric quality measurement program.

Other medical professional societies called on Congress to craft a final piece of legislation that would include increased funding for SCHIP and the House provisions that halt Medicare cuts to physicians for the next 2 years.

"Emergency departments are a health care safety net not only for the uninsured but for us all," Dr. Brian Keaton, president of the American College of Emergency Physicians, said in a statement. "But with millions of people uninsured, that safety net is breaking under the load. This legislation will help shore up the safety net by providing more resources for those children, as well as for older Americans."

Officials at the American Academy of Family Physicians favor a final bill that includes SCHIP funding that would cover as many children as possible, 2 years of positive updates to the Medicare physician fee schedule, and a commitment to fixing the sustainable growth rate formula, said Dr. Rick Kellerman, AAFP president.

Two years of positive updates are important, Dr. Kellerman said. Legislators are tired of physicians coming every year to Capitol Hill to talk about this issue.

"We think we've got a lot of other important health care issues to deal with," Dr. Kellerman said, adding that a 2-year fix will give Congress time to evaluate the sustainable growth rate (SGR) issue and formulate an alternative. "It's a transitional bill," he said. "This gets us through the next 2 years."

The American College of Physicians praised both the House and the Senate bills but said they would like to see final legislation that includes some of the Medicare provisions passed by the House, including the temporary pay fix for physicians.

The House bill also outlines a new physician payment structure under Medicare that would set a separate conversion factor for six service categories:

▸ Evaluation and management for primary care.

▸ Evaluation and management for other services.

▸ Imaging.

▸ Major procedures.

▸ Anesthesia services.

▸ Minor procedures.

The proposed formula would also take prescription drugs out of the spending targets and would take into account Medicare coverage decisions when setting targets, according to Rich Trachtman, American College of Physicians legislative affairs director. But the formula would still lead to deep payment cuts starting in 2010, so there is an understanding among legislators and leaders in medicine that the updates for 2010 and beyond would require additional action, Mr. Trachtman said.

Dr. Edward Langston, Board Chair of the American Medical Association, said the House legislation is encouraging and shows a willingness to come up with alternatives to the SGR. However, what the final formula will look like is still up in the air, he said.

But the American College of Cardiology expressed problems with the new structure for Medicare payments outlined in the House bill. The proposed payment structure would be based on a system of separate expenditure targets that ACC asserts would not take into account the appropriate growth in services, including many common cardiovascular services.

"While the ACC appreciates congressional efforts to stop Medicare physician payment cuts, it is critical that any new payment structure is fair to all physicians," the ACC said in a statement. "The ACC urges Congress to resolve this issue before any final legislation is passed."

The House bill also drew the ire of the insurance industry. America's Health Insurance Plans (AHIP) hailed the passage of the Senate legislation but is opposed to provisions in the House bill that would make cuts to the Medicare Advantage program. These cuts could result in more than 3 million seniors losing Medicare Advantage coverage and having to switch to fee-for-service Medicare, where they would likely pay higher out-of-pocket costs, according to the AHIP.

With Congress returning from its August recess, the fate of the State Children's Health Insurance Program reauthorization is up in the air, and so is the fate of physician pay relief.

As a planned Oct. 6 adjournment looms, a House/Senate conference committee must reconcile the vastly different health bills passed by the two chambers and craft the legislation into something that might escape a threatened presidential veto.

Before breaking for the summer recess, the Senate overwhelmingly passed S. 1893, which includes a $35 billion increase for SCHIP. The funds would come from an increase in the federal tobacco tax.

The approved House legislation (H.R. 3162), meanwhile, contains a number of provisions unrelated to SCHIP. For example, the bill would halt next year's planned 10% cut in the Medicare physician fee schedule, instead putting in place a 0.5% increase for 2008 and another for 2009.

In terms of SCHIP funding, the House bill calls for a $50 billion increase in funding and would pay for it with both increases in the federal tobacco tax and cuts to subsidies given to Medicare Advantage plans.

The American Academy of Pediatrics praised the passage of the two pieces of legislation and called on Congress to create a compromise bill that includes at least $50 billion in new federal funding for SCHIP.

"While the $35 billion included in the Senate bill is a good start, it's not enough to cover the eligible but unenrolled children in SCHIP or Medicaid," AAP President Jay E. Berkelhamer said in a statement. "The American public, including pediatricians, wants every child and adolescent covered. Passing and signing into law a strong SCHIP bill gets us that much closer to our goal."

AAP officials also praised provisions of the two bills that ease citizenship and identification documentation requirements and establish a pediatric quality measurement program.

Other medical professional societies called on Congress to craft a final piece of legislation that would include increased funding for SCHIP and the House provisions that halt Medicare cuts to physicians for the next 2 years.

"Emergency departments are a health care safety net not only for the uninsured but for us all," Dr. Brian Keaton, president of the American College of Emergency Physicians, said in a statement. "But with millions of people uninsured, that safety net is breaking under the load. This legislation will help shore up the safety net by providing more resources for those children, as well as for older Americans."

Officials at the American Academy of Family Physicians favor a final bill that includes SCHIP funding that would cover as many children as possible, 2 years of positive updates to the Medicare physician fee schedule, and a commitment to fixing the sustainable growth rate formula, said Dr. Rick Kellerman, AAFP president.

Two years of positive updates are important, Dr. Kellerman said. Legislators are tired of physicians coming every year to Capitol Hill to talk about this issue.

"We think we've got a lot of other important health care issues to deal with," Dr. Kellerman said, adding that a 2-year fix will give Congress time to evaluate the sustainable growth rate (SGR) issue and formulate an alternative. "It's a transitional bill," he said. "This gets us through the next 2 years."

The American College of Physicians praised both the House and the Senate bills but said they would like to see final legislation that includes some of the Medicare provisions passed by the House, including the temporary pay fix for physicians.

The House bill also outlines a new physician payment structure under Medicare that would set a separate conversion factor for six service categories:

▸ Evaluation and management for primary care.

▸ Evaluation and management for other services.

▸ Imaging.

▸ Major procedures.

▸ Anesthesia services.

▸ Minor procedures.

The proposed formula would also take prescription drugs out of the spending targets and would take into account Medicare coverage decisions when setting targets, according to Rich Trachtman, American College of Physicians legislative affairs director. But the formula would still lead to deep payment cuts starting in 2010, so there is an understanding among legislators and leaders in medicine that the updates for 2010 and beyond would require additional action, Mr. Trachtman said.

Dr. Edward Langston, Board Chair of the American Medical Association, said the House legislation is encouraging and shows a willingness to come up with alternatives to the SGR. However, what the final formula will look like is still up in the air, he said.

But the American College of Cardiology expressed problems with the new structure for Medicare payments outlined in the House bill. The proposed payment structure would be based on a system of separate expenditure targets that ACC asserts would not take into account the appropriate growth in services, including many common cardiovascular services.

"While the ACC appreciates congressional efforts to stop Medicare physician payment cuts, it is critical that any new payment structure is fair to all physicians," the ACC said in a statement. "The ACC urges Congress to resolve this issue before any final legislation is passed."

The House bill also drew the ire of the insurance industry. America's Health Insurance Plans (AHIP) hailed the passage of the Senate legislation but is opposed to provisions in the House bill that would make cuts to the Medicare Advantage program. These cuts could result in more than 3 million seniors losing Medicare Advantage coverage and having to switch to fee-for-service Medicare, where they would likely pay higher out-of-pocket costs, according to the AHIP.

SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP. "Where the action is really taking place is at the state level," he said.

There are comprehensive plans in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP).

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and offering federal grants for state initiatives.

For now, these proposals are circulating in congressional committees and are likely to stay there, Mr. Ginsburg said.

SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP. "Where the action is really taking place is at the state level," he said.

There are comprehensive plans in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP).

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and offering federal grants for state initiatives.

For now, these proposals are circulating in congressional committees and are likely to stay there, Mr. Ginsburg said.

SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP. "Where the action is really taking place is at the state level," he said.

There are comprehensive plans in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP).

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and offering federal grants for state initiatives.

For now, these proposals are circulating in congressional committees and are likely to stay there, Mr. Ginsburg said.