Mary Ellen Schneider

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 have 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.

Future success will also depend on improving the evidence base. For example, scientists need to show not only that sugary beverages contribute to obesity but also that specific regulation of these drinks will reduce obesity, she said.

“All of these things have to advance incrementally as culture evolves, as our own public opinions of obesity and the food industry change over time,” 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 have 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.

Future success will also depend on improving the evidence base. For example, scientists need to show not only that sugary beverages contribute to obesity but also that specific regulation of these drinks will reduce obesity, she said.

“All of these things have to advance incrementally as culture evolves, as our own public opinions of obesity and the food industry change over time,” 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 have 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.

Future success will also depend on improving the evidence base. For example, scientists need to show not only that sugary beverages contribute to obesity but also that specific regulation of these drinks will reduce obesity, she said.

“All of these things have to advance incrementally as culture evolves, as our own public opinions of obesity and the food industry change over time,” Dr. Mello said.

As Congress returns from its August recess, the fate of reauthorization of the State Children's Health Insurance Program as well as physician pay relief are both up in the air.

In a month's short time, a House/Senate conference committee must reconcile the vastly different bills passed by each house, and craft the legislation into something that might escape a promised presidential veto.

Before breaking for its August 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) 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 bill contains provisions unrelated to SCHIP, including a halt to next year's planned 10% cut in the Medicare physician fee schedule; instead, a 0.5% increase would be put in place for 2008 and another for 2009.

The American College of Physicians praised both the House and the Senate bills but said that the college 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 American Academy of Pediatrics also praised the bills 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. 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.

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.

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 find alternatives to the SGR. But 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.

“The House bill shreds the safety net for millions of seniors who depend on Medicare Advantage,” Karen Ignagni, AHIP president and CEO, said in a statement.

The House bill also includes some protections for Medicare beneficiaries. For example, the bill would codify protection for six drug classes under Medicare Part D. Starting in 2009, Medicare drug plans would be required to include all or substantially all Part D drugs in each of the following classes: anticonvulsants, antineoplastics, antiretrovirals, antidepressants, antipsychotics, and immunosuppressants.

The bill would also waive cost sharing for Medicare beneficiaries for certain preventive services including diabetes outpatient self-management training services, cardiovascular screening blood tests, diabetes screening tests, screening mammography, screening Pap smear and pelvic exam, and bone mass measurement.

As Congress returns from its August recess, the fate of reauthorization of the State Children's Health Insurance Program as well as physician pay relief are both up in the air.

In a month's short time, a House/Senate conference committee must reconcile the vastly different bills passed by each house, and craft the legislation into something that might escape a promised presidential veto.

Before breaking for its August 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) 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 bill contains provisions unrelated to SCHIP, including a halt to next year's planned 10% cut in the Medicare physician fee schedule; instead, a 0.5% increase would be put in place for 2008 and another for 2009.

The American College of Physicians praised both the House and the Senate bills but said that the college 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 American Academy of Pediatrics also praised the bills 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. 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.

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.

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 find alternatives to the SGR. But 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.

“The House bill shreds the safety net for millions of seniors who depend on Medicare Advantage,” Karen Ignagni, AHIP president and CEO, said in a statement.

The House bill also includes some protections for Medicare beneficiaries. For example, the bill would codify protection for six drug classes under Medicare Part D. Starting in 2009, Medicare drug plans would be required to include all or substantially all Part D drugs in each of the following classes: anticonvulsants, antineoplastics, antiretrovirals, antidepressants, antipsychotics, and immunosuppressants.

The bill would also waive cost sharing for Medicare beneficiaries for certain preventive services including diabetes outpatient self-management training services, cardiovascular screening blood tests, diabetes screening tests, screening mammography, screening Pap smear and pelvic exam, and bone mass measurement.

As Congress returns from its August recess, the fate of reauthorization of the State Children's Health Insurance Program as well as physician pay relief are both up in the air.

In a month's short time, a House/Senate conference committee must reconcile the vastly different bills passed by each house, and craft the legislation into something that might escape a promised presidential veto.

Before breaking for its August 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) 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 bill contains provisions unrelated to SCHIP, including a halt to next year's planned 10% cut in the Medicare physician fee schedule; instead, a 0.5% increase would be put in place for 2008 and another for 2009.

The American College of Physicians praised both the House and the Senate bills but said that the college 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 American Academy of Pediatrics also praised the bills 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. 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.

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.

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 find alternatives to the SGR. But 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.

“The House bill shreds the safety net for millions of seniors who depend on Medicare Advantage,” Karen Ignagni, AHIP president and CEO, said in a statement.

The House bill also includes some protections for Medicare beneficiaries. For example, the bill would codify protection for six drug classes under Medicare Part D. Starting in 2009, Medicare drug plans would be required to include all or substantially all Part D drugs in each of the following classes: anticonvulsants, antineoplastics, antiretrovirals, antidepressants, antipsychotics, and immunosuppressants.

The bill would also waive cost sharing for Medicare beneficiaries for certain preventive services including diabetes outpatient self-management training services, cardiovascular screening blood tests, diabetes screening tests, screening mammography, screening Pap smear and pelvic exam, and bone mass measurement.

Preliminary results of a demonstration project that allows physician groups to share in savings they earn for the Medicare program has also resulted in quality gains, according to the Centers for Medicare and Medicaid Services.

The Medicare Physician Group Practice Demonstration is a 3-year project that encourages group practices to improve coordination of care for patients with chronic diseases. The project offers the practices financial incentives that meet clinical targets and save the Medicare program money above a certain threshold. In the first year, 10 participating practices were assessed based on their performance on evidence-based diabetes measures.

In the first year (April 2005-March 2006), all participating practices improved their clinical management of diabetes and met targets on at least 7 of 10 measures; two practices improved on all 10 measures.

Measures for the first year included hemoglobin A1c management and control, blood pressure management, lipid measurement, LDL cholesterol level, urine protein testing, eye exam, foot exam, influenza vaccination, and pneumonia vaccination.

In addition to improving care, the demonstration saved the Medicare program about $9.5 million, Herb Kuhn, CMS acting deputy administrator, said during a press conference to announce the first-year results. “We are seeing substantial and verifiable improvements in the quality of care for patients and improved efficiency in the delivery of that care,” Mr. Kuhn said.

The results show that Medicare is “on the right track” in terms of providing incentives for coordinating care, he said.

The demonstration includes 10 large, multispecialty group practices with a total of about 224,000 Medicare beneficiaries. The 10 group practices are Dartmouth-Hitchcock Clinic, Bedford, N.H.; Deaconess Billings (Mont.) Clinic; the Everett (Wash.) Clinic; Geisinger Health System, Danville, Pa.; Middlesex Health System, Middletown, Conn.; Marshfield (Wisc.) Clinic; Forsyth Medical Group, Winston-Salem, N.C.; Park Nicollet Health Services, St. Louis Park, Minn.; St. John's Health System, Springfield, Mo.; and University of Michigan Faculty Group Practice, Ann Arbor.

The demonstration encourages physicians to coordinate Part A and Part B Medicare services, invest in new care management programs, and redesign care processes. If these investments save money for the Medicare program, the physician groups are able to share in a portion of the savings. These performance payments are in addition to the regular fee-for-service Medicare payments received. Physician groups may share up to 80% of the savings, which are distributed based on financial performance and achievement of benchmarks in care quality measures, Mr. Kuhn said.

To receive a performance payment, the practices' total Medicare spending growth rate must be more than 2 percentage points lower than a comparison population of Medicare beneficiaries in their local market area.

Although all the practices met clinical targets for at least seven diabetes measures, only two practices received performance payments.

The Marshfield Clinic, and the University of Michigan Faculty Group Practice earned performance payments for quality and efficiency improvements. In total, the two groups earned $7.3 million in payments; however, the two practices that met benchmarks in every clinical area—St. John's Health System and the Forsyth Medical Group—did not receive payments.

While other participating practices did achieve lower Medicare spending growth rates than comparison populations in their local markets, their savings did not meet the 2% threshold to share in the Medicare savings, Mr. Kuhn said.

Part of the problem may be that not all practices were able to fully deploy their initiatives in the first year, Mr. Kuhn said. “I think, overall, it's trending in a very positive way.”

The first-year evaluation has revealed an emphasis among the practices on care coordination, chronic disease management, efforts to avoid unnecessary hospitalizations, proactive case management, timely follow-up after hospital stays, and the use of health information technology. For example, St. John's Health System is using a Web-based patient registry aimed at helping physicians to plan patient visits.

In the second and third years of the program, the group practices will be assessed on additional measures related to heart failure, coronary artery disease, hypertension, and cancer screening.

Preliminary results of a demonstration project that allows physician groups to share in savings they earn for the Medicare program has also resulted in quality gains, according to the Centers for Medicare and Medicaid Services.

The Medicare Physician Group Practice Demonstration is a 3-year project that encourages group practices to improve coordination of care for patients with chronic diseases. The project offers the practices financial incentives that meet clinical targets and save the Medicare program money above a certain threshold. In the first year, 10 participating practices were assessed based on their performance on evidence-based diabetes measures.

In the first year (April 2005-March 2006), all participating practices improved their clinical management of diabetes and met targets on at least 7 of 10 measures; two practices improved on all 10 measures.

Measures for the first year included hemoglobin A1c management and control, blood pressure management, lipid measurement, LDL cholesterol level, urine protein testing, eye exam, foot exam, influenza vaccination, and pneumonia vaccination.

In addition to improving care, the demonstration saved the Medicare program about $9.5 million, Herb Kuhn, CMS acting deputy administrator, said during a press conference to announce the first-year results. “We are seeing substantial and verifiable improvements in the quality of care for patients and improved efficiency in the delivery of that care,” Mr. Kuhn said.

The results show that Medicare is “on the right track” in terms of providing incentives for coordinating care, he said.

The demonstration includes 10 large, multispecialty group practices with a total of about 224,000 Medicare beneficiaries. The 10 group practices are Dartmouth-Hitchcock Clinic, Bedford, N.H.; Deaconess Billings (Mont.) Clinic; the Everett (Wash.) Clinic; Geisinger Health System, Danville, Pa.; Middlesex Health System, Middletown, Conn.; Marshfield (Wisc.) Clinic; Forsyth Medical Group, Winston-Salem, N.C.; Park Nicollet Health Services, St. Louis Park, Minn.; St. John's Health System, Springfield, Mo.; and University of Michigan Faculty Group Practice, Ann Arbor.

The demonstration encourages physicians to coordinate Part A and Part B Medicare services, invest in new care management programs, and redesign care processes. If these investments save money for the Medicare program, the physician groups are able to share in a portion of the savings. These performance payments are in addition to the regular fee-for-service Medicare payments received. Physician groups may share up to 80% of the savings, which are distributed based on financial performance and achievement of benchmarks in care quality measures, Mr. Kuhn said.

To receive a performance payment, the practices' total Medicare spending growth rate must be more than 2 percentage points lower than a comparison population of Medicare beneficiaries in their local market area.

Although all the practices met clinical targets for at least seven diabetes measures, only two practices received performance payments.

The Marshfield Clinic, and the University of Michigan Faculty Group Practice earned performance payments for quality and efficiency improvements. In total, the two groups earned $7.3 million in payments; however, the two practices that met benchmarks in every clinical area—St. John's Health System and the Forsyth Medical Group—did not receive payments.

While other participating practices did achieve lower Medicare spending growth rates than comparison populations in their local markets, their savings did not meet the 2% threshold to share in the Medicare savings, Mr. Kuhn said.

Part of the problem may be that not all practices were able to fully deploy their initiatives in the first year, Mr. Kuhn said. “I think, overall, it's trending in a very positive way.”

The first-year evaluation has revealed an emphasis among the practices on care coordination, chronic disease management, efforts to avoid unnecessary hospitalizations, proactive case management, timely follow-up after hospital stays, and the use of health information technology. For example, St. John's Health System is using a Web-based patient registry aimed at helping physicians to plan patient visits.

In the second and third years of the program, the group practices will be assessed on additional measures related to heart failure, coronary artery disease, hypertension, and cancer screening.

Preliminary results of a demonstration project that allows physician groups to share in savings they earn for the Medicare program has also resulted in quality gains, according to the Centers for Medicare and Medicaid Services.

The Medicare Physician Group Practice Demonstration is a 3-year project that encourages group practices to improve coordination of care for patients with chronic diseases. The project offers the practices financial incentives that meet clinical targets and save the Medicare program money above a certain threshold. In the first year, 10 participating practices were assessed based on their performance on evidence-based diabetes measures.

In the first year (April 2005-March 2006), all participating practices improved their clinical management of diabetes and met targets on at least 7 of 10 measures; two practices improved on all 10 measures.

Measures for the first year included hemoglobin A1c management and control, blood pressure management, lipid measurement, LDL cholesterol level, urine protein testing, eye exam, foot exam, influenza vaccination, and pneumonia vaccination.

In addition to improving care, the demonstration saved the Medicare program about $9.5 million, Herb Kuhn, CMS acting deputy administrator, said during a press conference to announce the first-year results. “We are seeing substantial and verifiable improvements in the quality of care for patients and improved efficiency in the delivery of that care,” Mr. Kuhn said.

The results show that Medicare is “on the right track” in terms of providing incentives for coordinating care, he said.

The demonstration includes 10 large, multispecialty group practices with a total of about 224,000 Medicare beneficiaries. The 10 group practices are Dartmouth-Hitchcock Clinic, Bedford, N.H.; Deaconess Billings (Mont.) Clinic; the Everett (Wash.) Clinic; Geisinger Health System, Danville, Pa.; Middlesex Health System, Middletown, Conn.; Marshfield (Wisc.) Clinic; Forsyth Medical Group, Winston-Salem, N.C.; Park Nicollet Health Services, St. Louis Park, Minn.; St. John's Health System, Springfield, Mo.; and University of Michigan Faculty Group Practice, Ann Arbor.

The demonstration encourages physicians to coordinate Part A and Part B Medicare services, invest in new care management programs, and redesign care processes. If these investments save money for the Medicare program, the physician groups are able to share in a portion of the savings. These performance payments are in addition to the regular fee-for-service Medicare payments received. Physician groups may share up to 80% of the savings, which are distributed based on financial performance and achievement of benchmarks in care quality measures, Mr. Kuhn said.

To receive a performance payment, the practices' total Medicare spending growth rate must be more than 2 percentage points lower than a comparison population of Medicare beneficiaries in their local market area.

Although all the practices met clinical targets for at least seven diabetes measures, only two practices received performance payments.

The Marshfield Clinic, and the University of Michigan Faculty Group Practice earned performance payments for quality and efficiency improvements. In total, the two groups earned $7.3 million in payments; however, the two practices that met benchmarks in every clinical area—St. John's Health System and the Forsyth Medical Group—did not receive payments.

While other participating practices did achieve lower Medicare spending growth rates than comparison populations in their local markets, their savings did not meet the 2% threshold to share in the Medicare savings, Mr. Kuhn said.

Part of the problem may be that not all practices were able to fully deploy their initiatives in the first year, Mr. Kuhn said. “I think, overall, it's trending in a very positive way.”

The first-year evaluation has revealed an emphasis among the practices on care coordination, chronic disease management, efforts to avoid unnecessary hospitalizations, proactive case management, timely follow-up after hospital stays, and the use of health information technology. For example, St. John's Health System is using a Web-based patient registry aimed at helping physicians to plan patient visits.

In the second and third years of the program, the group practices will be assessed on additional measures related to heart failure, coronary artery disease, hypertension, and cancer screening.

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.

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.

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.

TORONTO — Higher free testosterone levels appear to be associated with metabolic dysfunction in women from the general population, according to a cross-sectional study of more than 1,600 women in the Framingham Heart Study Offspring Cohort.

Free testosterone was positively associated with body mass index (BMI), waist circumference, diabetes, metabolic syndrome, and systolic and diastolic blood pressure in a community-based sample of women.

The findings raise questions about whether higher testosterone levels predispose women to increased cardiovascular risks, lead investigator Dr. Andrea Coviello of Boston University said at the annual meeting of the Endocrine Society.

Studies have shown that women with polycystic ovary syndrome (PCOS) are at a fourfold increased risk for developing diabetes and a twofold increased risk for developing metabolic syndrome. But there are a lot of unanswered questions about the clinical consequences of androgen excess in women who have mild to moderate hyperandrogenism without accompanying PCOS, Dr. Coviello said.

Dr. Coviello and her colleagues measured circulating testosterone levels in 1,678 women from the Framingham Heart Study Offspring Cohort in an effort to find out if healthy women with higher testosterone levels face risks for metabolic problems. The study was funded by grants from the National Institutes of Health.

The investigators assessed circulating testosterone levels using liquid chromatography tandem mass spectrometry, which has a sensitivity of about 2 ng/dL, and measured sex hormone-binding globulin (SHBG) through immunoflourometric assay. They also evaluated the relationship between testosterone and metabolic dysfunction, particularly metabolic syndrome and diabetes.

The women in the sample ranged in age from 33 to 87, with a mean age of 61. Most of the group was postmenopausal, Dr. Coviello said.

The study subjects had a mean SHBG of 92 nmol/L, a mean total testosterone of 30 ng/dL, and a mean free testosterone of 3 pg/mL.

The investigators found that free testosterone was positively correlated with BMI, waist circumference, both systolic and diastolic blood pressure, triglycerides, total cholesterol, LDL cholesterol, and fasting glucose. Free testosterone was inversely associated with HDL cholesterol.

The study also found that women with diabetes had higher free testosterone and lower SHBG levels than women without diabetes.

SHBG was inversely correlated with most of the components of metabolic syndrome. For example, higher BMI and waist circumference was associated with lower SHBG. Higher blood pressure, higher total cholesterol, higher triglycerides, and higher LDL cholesterol were all associated with lower SHBG. Higher fasting glucose was associated with a lower SHBG.

When examining total testosterone, only HDL cholesterol and triglycerides were significantly correlated. HDL cholesterol was positively correlated with total testosterone, and triglycerides were negatively correlated.

Free testosterone was positively correlated with BMI, waist circumference, both systolic and diastolic blood pressure, triglycerides, total cholesterol, LDL cholesterol, and fasting glucose. Free testosterone was inversely associated with HDL cholesterol.

The study also found that women with diabetes had lower SHBG levels and higher free testosterone than women without diabetes.

The study had a number of limitations, Dr. Coviello said. The sample included only Caucasian individuals, and there was no information on the timing of the blood draws in relation to menstrual cycle among the premenopausal women. In addition, the reproductive histories were not adequate to determine whether women in the sample had PCOS, she said.

TORONTO — Higher free testosterone levels appear to be associated with metabolic dysfunction in women from the general population, according to a cross-sectional study of more than 1,600 women in the Framingham Heart Study Offspring Cohort.

Free testosterone was positively associated with body mass index (BMI), waist circumference, diabetes, metabolic syndrome, and systolic and diastolic blood pressure in a community-based sample of women.

The findings raise questions about whether higher testosterone levels predispose women to increased cardiovascular risks, lead investigator Dr. Andrea Coviello of Boston University said at the annual meeting of the Endocrine Society.

Studies have shown that women with polycystic ovary syndrome (PCOS) are at a fourfold increased risk for developing diabetes and a twofold increased risk for developing metabolic syndrome. But there are a lot of unanswered questions about the clinical consequences of androgen excess in women who have mild to moderate hyperandrogenism without accompanying PCOS, Dr. Coviello said.

Dr. Coviello and her colleagues measured circulating testosterone levels in 1,678 women from the Framingham Heart Study Offspring Cohort in an effort to find out if healthy women with higher testosterone levels face risks for metabolic problems. The study was funded by grants from the National Institutes of Health.

The investigators assessed circulating testosterone levels using liquid chromatography tandem mass spectrometry, which has a sensitivity of about 2 ng/dL, and measured sex hormone-binding globulin (SHBG) through immunoflourometric assay. They also evaluated the relationship between testosterone and metabolic dysfunction, particularly metabolic syndrome and diabetes.

The women in the sample ranged in age from 33 to 87, with a mean age of 61. Most of the group was postmenopausal, Dr. Coviello said.

The study subjects had a mean SHBG of 92 nmol/L, a mean total testosterone of 30 ng/dL, and a mean free testosterone of 3 pg/mL.

The investigators found that free testosterone was positively correlated with BMI, waist circumference, both systolic and diastolic blood pressure, triglycerides, total cholesterol, LDL cholesterol, and fasting glucose. Free testosterone was inversely associated with HDL cholesterol.

The study also found that women with diabetes had higher free testosterone and lower SHBG levels than women without diabetes.

SHBG was inversely correlated with most of the components of metabolic syndrome. For example, higher BMI and waist circumference was associated with lower SHBG. Higher blood pressure, higher total cholesterol, higher triglycerides, and higher LDL cholesterol were all associated with lower SHBG. Higher fasting glucose was associated with a lower SHBG.

When examining total testosterone, only HDL cholesterol and triglycerides were significantly correlated. HDL cholesterol was positively correlated with total testosterone, and triglycerides were negatively correlated.

Free testosterone was positively correlated with BMI, waist circumference, both systolic and diastolic blood pressure, triglycerides, total cholesterol, LDL cholesterol, and fasting glucose. Free testosterone was inversely associated with HDL cholesterol.

The study also found that women with diabetes had lower SHBG levels and higher free testosterone than women without diabetes.

The study had a number of limitations, Dr. Coviello said. The sample included only Caucasian individuals, and there was no information on the timing of the blood draws in relation to menstrual cycle among the premenopausal women. In addition, the reproductive histories were not adequate to determine whether women in the sample had PCOS, she said.

TORONTO — Higher free testosterone levels appear to be associated with metabolic dysfunction in women from the general population, according to a cross-sectional study of more than 1,600 women in the Framingham Heart Study Offspring Cohort.

Free testosterone was positively associated with body mass index (BMI), waist circumference, diabetes, metabolic syndrome, and systolic and diastolic blood pressure in a community-based sample of women.

The findings raise questions about whether higher testosterone levels predispose women to increased cardiovascular risks, lead investigator Dr. Andrea Coviello of Boston University said at the annual meeting of the Endocrine Society.

Studies have shown that women with polycystic ovary syndrome (PCOS) are at a fourfold increased risk for developing diabetes and a twofold increased risk for developing metabolic syndrome. But there are a lot of unanswered questions about the clinical consequences of androgen excess in women who have mild to moderate hyperandrogenism without accompanying PCOS, Dr. Coviello said.

Dr. Coviello and her colleagues measured circulating testosterone levels in 1,678 women from the Framingham Heart Study Offspring Cohort in an effort to find out if healthy women with higher testosterone levels face risks for metabolic problems. The study was funded by grants from the National Institutes of Health.

The investigators assessed circulating testosterone levels using liquid chromatography tandem mass spectrometry, which has a sensitivity of about 2 ng/dL, and measured sex hormone-binding globulin (SHBG) through immunoflourometric assay. They also evaluated the relationship between testosterone and metabolic dysfunction, particularly metabolic syndrome and diabetes.

The women in the sample ranged in age from 33 to 87, with a mean age of 61. Most of the group was postmenopausal, Dr. Coviello said.

The study subjects had a mean SHBG of 92 nmol/L, a mean total testosterone of 30 ng/dL, and a mean free testosterone of 3 pg/mL.

The investigators found that free testosterone was positively correlated with BMI, waist circumference, both systolic and diastolic blood pressure, triglycerides, total cholesterol, LDL cholesterol, and fasting glucose. Free testosterone was inversely associated with HDL cholesterol.

The study also found that women with diabetes had higher free testosterone and lower SHBG levels than women without diabetes.

SHBG was inversely correlated with most of the components of metabolic syndrome. For example, higher BMI and waist circumference was associated with lower SHBG. Higher blood pressure, higher total cholesterol, higher triglycerides, and higher LDL cholesterol were all associated with lower SHBG. Higher fasting glucose was associated with a lower SHBG.

When examining total testosterone, only HDL cholesterol and triglycerides were significantly correlated. HDL cholesterol was positively correlated with total testosterone, and triglycerides were negatively correlated.

Free testosterone was positively correlated with BMI, waist circumference, both systolic and diastolic blood pressure, triglycerides, total cholesterol, LDL cholesterol, and fasting glucose. Free testosterone was inversely associated with HDL cholesterol.

The study also found that women with diabetes had lower SHBG levels and higher free testosterone than women without diabetes.

The study had a number of limitations, Dr. Coviello said. The sample included only Caucasian individuals, and there was no information on the timing of the blood draws in relation to menstrual cycle among the premenopausal women. In addition, the reproductive histories were not adequate to determine whether women in the sample had PCOS, she said.

TORONTO — Although physicians commonly prescribe oral contraceptives for women with anorexia nervosa, new research presented at the annual meeting of the Endocrine Society suggests that androgen levels are already low in these women and are further reduced by the use of oral contraceptives.

But the jury is still out on the long-term consequences for skeletal health and body composition among women with the disease, said Dr. Karen K. Miller of Massachusetts General Hospital, Boston.

Dr. Miller and her colleagues performed a study analyzing androgen levels among 217 community-dwelling women in an effort to determine the physiologic consequences of prescribing oral contraceptives to women with anorexia nervosa.

The study included four arms comprised of 137 women with anorexia nervosa who were not receiving oral contraceptives; 32 women with anorexia nervosa who were receiving oral contraceptives; 21 women of normal weight with hypothalamic amenorrhea; and 27 healthy eumenorrheic controls.

Women with anorexia nervosa all met DSM-IV criteria for anorexia nervosa, were less than 85% of ideal body weight, and all had an intense fear of gaining weight or denial of low weight.

Anorectic women not receiving oral contraceptives had been amenorrheic for at least 3 consecutive months and had not received hormonal contraceptives within the previous 3 months. Anorectic women who received oral contraceptives had to have been receiving them for at least 3 months.

All women with hypothalamic amenorrhea were 90%–110% of ideal body weight; amenorrheic for at least 3 months; had normal FSH, prolactin, testosterone, and free testosterone levels; an LH-to-FSH ratio of less than 2.5; absence of hirsutism; and no history of an eating disorder.

Healthy controls were 90%–110% of ideal body weight and eumenorrheic. Controls were excluded from the study if they had a history of amenorrhea or an eating disorder, had a history of any major medical illness, or had used oral contraceptives within the last 3 months.

The mean body mass index (BMI), percent ideal body weight, percent fat, total fat mass, and fat-free mass were all lower in the anorexia nervosa groups, compared with women who had hypothalamic amenorrhea and healthy controls.

An analysis of the androgen levels among the four groups found that total testosterone levels were lower in women with anorexia nervosa than in healthy controls. The levels of total testosterone were similar in anorectic women who received oral contraceptives and those who did not. The total testosterone levels were normal in women with hypothalamic amenorrhea, Dr. Miller said.

Free testosterone levels were lower in women with anorexia nervosa than in healthy controls, and the lowest levels occurred among women with anorexia nervosa who were receiving oral contraceptives. The levels were normal in women with hypothalamic amenorrhea.

The researchers also found that dehydroepiandrosterone (DHEAS) levels were lower only in women with anorexia nervosa receiving oral contraceptives, compared with healthy controls. DHEAS levels were normal in women with anorexia nervosa not receiving contraceptives and in women with hypothalamic amenorrhea.

Free testosterone levels were found to be predictors of bone mineral density and body composition in women with anorexia nervosa, hypothalamic amenorrhea, and healthy controls. DHEAS levels also predicted bone density, but were weaker predictors than free testosterone and did not predict fat-free mass, Dr. Miller said.

Intervention studies are now needed to determine the relationship between androgens and bone density and body composition among women with anorexia nervosa, Dr. Miller said. Studies are also needed to determine whether oral contraceptive use is harmful to skeletal health in these women, she said.

TORONTO — Although physicians commonly prescribe oral contraceptives for women with anorexia nervosa, new research presented at the annual meeting of the Endocrine Society suggests that androgen levels are already low in these women and are further reduced by the use of oral contraceptives.

But the jury is still out on the long-term consequences for skeletal health and body composition among women with the disease, said Dr. Karen K. Miller of Massachusetts General Hospital, Boston.

Dr. Miller and her colleagues performed a study analyzing androgen levels among 217 community-dwelling women in an effort to determine the physiologic consequences of prescribing oral contraceptives to women with anorexia nervosa.

The study included four arms comprised of 137 women with anorexia nervosa who were not receiving oral contraceptives; 32 women with anorexia nervosa who were receiving oral contraceptives; 21 women of normal weight with hypothalamic amenorrhea; and 27 healthy eumenorrheic controls.

Women with anorexia nervosa all met DSM-IV criteria for anorexia nervosa, were less than 85% of ideal body weight, and all had an intense fear of gaining weight or denial of low weight.

Anorectic women not receiving oral contraceptives had been amenorrheic for at least 3 consecutive months and had not received hormonal contraceptives within the previous 3 months. Anorectic women who received oral contraceptives had to have been receiving them for at least 3 months.

All women with hypothalamic amenorrhea were 90%–110% of ideal body weight; amenorrheic for at least 3 months; had normal FSH, prolactin, testosterone, and free testosterone levels; an LH-to-FSH ratio of less than 2.5; absence of hirsutism; and no history of an eating disorder.

Healthy controls were 90%–110% of ideal body weight and eumenorrheic. Controls were excluded from the study if they had a history of amenorrhea or an eating disorder, had a history of any major medical illness, or had used oral contraceptives within the last 3 months.

The mean body mass index (BMI), percent ideal body weight, percent fat, total fat mass, and fat-free mass were all lower in the anorexia nervosa groups, compared with women who had hypothalamic amenorrhea and healthy controls.

An analysis of the androgen levels among the four groups found that total testosterone levels were lower in women with anorexia nervosa than in healthy controls. The levels of total testosterone were similar in anorectic women who received oral contraceptives and those who did not. The total testosterone levels were normal in women with hypothalamic amenorrhea, Dr. Miller said.

Free testosterone levels were lower in women with anorexia nervosa than in healthy controls, and the lowest levels occurred among women with anorexia nervosa who were receiving oral contraceptives. The levels were normal in women with hypothalamic amenorrhea.

The researchers also found that dehydroepiandrosterone (DHEAS) levels were lower only in women with anorexia nervosa receiving oral contraceptives, compared with healthy controls. DHEAS levels were normal in women with anorexia nervosa not receiving contraceptives and in women with hypothalamic amenorrhea.

Free testosterone levels were found to be predictors of bone mineral density and body composition in women with anorexia nervosa, hypothalamic amenorrhea, and healthy controls. DHEAS levels also predicted bone density, but were weaker predictors than free testosterone and did not predict fat-free mass, Dr. Miller said.

Intervention studies are now needed to determine the relationship between androgens and bone density and body composition among women with anorexia nervosa, Dr. Miller said. Studies are also needed to determine whether oral contraceptive use is harmful to skeletal health in these women, she said.

TORONTO — Although physicians commonly prescribe oral contraceptives for women with anorexia nervosa, new research presented at the annual meeting of the Endocrine Society suggests that androgen levels are already low in these women and are further reduced by the use of oral contraceptives.

But the jury is still out on the long-term consequences for skeletal health and body composition among women with the disease, said Dr. Karen K. Miller of Massachusetts General Hospital, Boston.

Dr. Miller and her colleagues performed a study analyzing androgen levels among 217 community-dwelling women in an effort to determine the physiologic consequences of prescribing oral contraceptives to women with anorexia nervosa.

The study included four arms comprised of 137 women with anorexia nervosa who were not receiving oral contraceptives; 32 women with anorexia nervosa who were receiving oral contraceptives; 21 women of normal weight with hypothalamic amenorrhea; and 27 healthy eumenorrheic controls.

Women with anorexia nervosa all met DSM-IV criteria for anorexia nervosa, were less than 85% of ideal body weight, and all had an intense fear of gaining weight or denial of low weight.

Anorectic women not receiving oral contraceptives had been amenorrheic for at least 3 consecutive months and had not received hormonal contraceptives within the previous 3 months. Anorectic women who received oral contraceptives had to have been receiving them for at least 3 months.

All women with hypothalamic amenorrhea were 90%–110% of ideal body weight; amenorrheic for at least 3 months; had normal FSH, prolactin, testosterone, and free testosterone levels; an LH-to-FSH ratio of less than 2.5; absence of hirsutism; and no history of an eating disorder.

Healthy controls were 90%–110% of ideal body weight and eumenorrheic. Controls were excluded from the study if they had a history of amenorrhea or an eating disorder, had a history of any major medical illness, or had used oral contraceptives within the last 3 months.

The mean body mass index (BMI), percent ideal body weight, percent fat, total fat mass, and fat-free mass were all lower in the anorexia nervosa groups, compared with women who had hypothalamic amenorrhea and healthy controls.

An analysis of the androgen levels among the four groups found that total testosterone levels were lower in women with anorexia nervosa than in healthy controls. The levels of total testosterone were similar in anorectic women who received oral contraceptives and those who did not. The total testosterone levels were normal in women with hypothalamic amenorrhea, Dr. Miller said.

Free testosterone levels were lower in women with anorexia nervosa than in healthy controls, and the lowest levels occurred among women with anorexia nervosa who were receiving oral contraceptives. The levels were normal in women with hypothalamic amenorrhea.

The researchers also found that dehydroepiandrosterone (DHEAS) levels were lower only in women with anorexia nervosa receiving oral contraceptives, compared with healthy controls. DHEAS levels were normal in women with anorexia nervosa not receiving contraceptives and in women with hypothalamic amenorrhea.

Free testosterone levels were found to be predictors of bone mineral density and body composition in women with anorexia nervosa, hypothalamic amenorrhea, and healthy controls. DHEAS levels also predicted bone density, but were weaker predictors than free testosterone and did not predict fat-free mass, Dr. Miller said.

Intervention studies are now needed to determine the relationship between androgens and bone density and body composition among women with anorexia nervosa, Dr. Miller said. Studies are also needed to determine whether oral contraceptive use is harmful to skeletal health in these women, she said.

SAN DIEGO – As pay for performance becomes more common, patient adherence could become a pocketbook issue for physicians, Dr. Robert F. Kushner said at the annual meeting of the American College of Physicians.

“A patient's behavior is shaped by their environment, lifestyle, and life experiences. People do what they do for a reason. No one is a bad patient,” said Dr. Kushner, a professor of medicine at Northwestern University, Chicago. “Your role is to find out why they're doing what they're doing.”

The first step is assessing the patient's readiness for change. But just asking a patient if he or she is ready isn't enough. “Very few patients want to be bad patients in front of your eyes,” he said. “Very few patients will say, 'No, I'm not ready, doctor.'”

Go deeper in understanding their readiness by evaluating their reasons and motivation to change behavior, previous attempts at change, the level of support expected from family and friends, and potential barriers. In addition, assessing whether patients have the time available to make the change is critical.

There are some tools available to help physicians make that assessment, Dr. Kushner said. Five models for understanding and changing behavior have been around since the 1970s: the health belief model, self-determination, motivational interviewing, social cognitive theory/ecological models, and stages of change.

“Intuition is not enough,” he said. “It really helps to know the theories and models and approaches that have been developed to help us understand why we do what we do.”

▸ Health belief model. Under this model, the patient might not understand the importance of making a behavioral or lifestyle change, or might be ignoring health risks. It is often helpful to educate this type of patient about susceptibility to risks, Dr. Kushner said.

▸ Self-determination. This involves the goal of helping patients find their own personal motivation for making a change. In general, patients are more likely to adopt healthy behaviors because they want to, not because they should or they have to. Dr. Kushner said he often evaluates patient motivation by asking them to assess, on a scale of 0-10, how hard it is to make the change. Patients who respond that the difficulty is about a 10 are unlikely to be able to maintain the change, he said.

▸ Motivational interviewing. With motivational interviewing, physicians can assess a patient's readiness to change by asking two questions: How important is this change on a scale of 0-10? How confident are you that you can make the change on a scale of 0-10? Typically, the confidence number will be lower than the importance number. That opens up a dialogue for the physician to ask what can be done to improve confidence.

The goal with motivational interviewing is to support the patients' own belief that change is possible, Dr. Kushner said, but not to get angry or argue with the patient.

▸ Social cognitive theory/ecological models. These look at the resources for or barriers to the patient making the change. “This is the most important theory I use on a daily basis,” he said. “It looks at the patient in the context of their life, their community, and their environment.” For example, can the patient afford to make changes to his or her diet? This model also depends on the patient's self-efficacy and the degree to which the patient believes that making changes will lead to a positive outcome.

▸ Stages of change. Under the stages of change model, the physician assesses the patients' readiness for change and tries to support movement to the next stage. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. The stages of change can be very helpful in choosing the most effective way to approach the patient, he said. For example, when patients are in the precontemplation stage, provide education and move on.

'Intuition is not enough. It really helps to know the … models and approaches that have been developed.' DR. KUSHNER

SAN DIEGO – As pay for performance becomes more common, patient adherence could become a pocketbook issue for physicians, Dr. Robert F. Kushner said at the annual meeting of the American College of Physicians.

“A patient's behavior is shaped by their environment, lifestyle, and life experiences. People do what they do for a reason. No one is a bad patient,” said Dr. Kushner, a professor of medicine at Northwestern University, Chicago. “Your role is to find out why they're doing what they're doing.”

The first step is assessing the patient's readiness for change. But just asking a patient if he or she is ready isn't enough. “Very few patients want to be bad patients in front of your eyes,” he said. “Very few patients will say, 'No, I'm not ready, doctor.'”

Go deeper in understanding their readiness by evaluating their reasons and motivation to change behavior, previous attempts at change, the level of support expected from family and friends, and potential barriers. In addition, assessing whether patients have the time available to make the change is critical.

There are some tools available to help physicians make that assessment, Dr. Kushner said. Five models for understanding and changing behavior have been around since the 1970s: the health belief model, self-determination, motivational interviewing, social cognitive theory/ecological models, and stages of change.

“Intuition is not enough,” he said. “It really helps to know the theories and models and approaches that have been developed to help us understand why we do what we do.”

▸ Health belief model. Under this model, the patient might not understand the importance of making a behavioral or lifestyle change, or might be ignoring health risks. It is often helpful to educate this type of patient about susceptibility to risks, Dr. Kushner said.

▸ Self-determination. This involves the goal of helping patients find their own personal motivation for making a change. In general, patients are more likely to adopt healthy behaviors because they want to, not because they should or they have to. Dr. Kushner said he often evaluates patient motivation by asking them to assess, on a scale of 0-10, how hard it is to make the change. Patients who respond that the difficulty is about a 10 are unlikely to be able to maintain the change, he said.

▸ Motivational interviewing. With motivational interviewing, physicians can assess a patient's readiness to change by asking two questions: How important is this change on a scale of 0-10? How confident are you that you can make the change on a scale of 0-10? Typically, the confidence number will be lower than the importance number. That opens up a dialogue for the physician to ask what can be done to improve confidence.

The goal with motivational interviewing is to support the patients' own belief that change is possible, Dr. Kushner said, but not to get angry or argue with the patient.

▸ Social cognitive theory/ecological models. These look at the resources for or barriers to the patient making the change. “This is the most important theory I use on a daily basis,” he said. “It looks at the patient in the context of their life, their community, and their environment.” For example, can the patient afford to make changes to his or her diet? This model also depends on the patient's self-efficacy and the degree to which the patient believes that making changes will lead to a positive outcome.

▸ Stages of change. Under the stages of change model, the physician assesses the patients' readiness for change and tries to support movement to the next stage. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. The stages of change can be very helpful in choosing the most effective way to approach the patient, he said. For example, when patients are in the precontemplation stage, provide education and move on.

'Intuition is not enough. It really helps to know the … models and approaches that have been developed.' DR. KUSHNER

SAN DIEGO – As pay for performance becomes more common, patient adherence could become a pocketbook issue for physicians, Dr. Robert F. Kushner said at the annual meeting of the American College of Physicians.

“A patient's behavior is shaped by their environment, lifestyle, and life experiences. People do what they do for a reason. No one is a bad patient,” said Dr. Kushner, a professor of medicine at Northwestern University, Chicago. “Your role is to find out why they're doing what they're doing.”

The first step is assessing the patient's readiness for change. But just asking a patient if he or she is ready isn't enough. “Very few patients want to be bad patients in front of your eyes,” he said. “Very few patients will say, 'No, I'm not ready, doctor.'”

Go deeper in understanding their readiness by evaluating their reasons and motivation to change behavior, previous attempts at change, the level of support expected from family and friends, and potential barriers. In addition, assessing whether patients have the time available to make the change is critical.

There are some tools available to help physicians make that assessment, Dr. Kushner said. Five models for understanding and changing behavior have been around since the 1970s: the health belief model, self-determination, motivational interviewing, social cognitive theory/ecological models, and stages of change.

“Intuition is not enough,” he said. “It really helps to know the theories and models and approaches that have been developed to help us understand why we do what we do.”

▸ Health belief model. Under this model, the patient might not understand the importance of making a behavioral or lifestyle change, or might be ignoring health risks. It is often helpful to educate this type of patient about susceptibility to risks, Dr. Kushner said.

▸ Self-determination. This involves the goal of helping patients find their own personal motivation for making a change. In general, patients are more likely to adopt healthy behaviors because they want to, not because they should or they have to. Dr. Kushner said he often evaluates patient motivation by asking them to assess, on a scale of 0-10, how hard it is to make the change. Patients who respond that the difficulty is about a 10 are unlikely to be able to maintain the change, he said.

▸ Motivational interviewing. With motivational interviewing, physicians can assess a patient's readiness to change by asking two questions: How important is this change on a scale of 0-10? How confident are you that you can make the change on a scale of 0-10? Typically, the confidence number will be lower than the importance number. That opens up a dialogue for the physician to ask what can be done to improve confidence.

The goal with motivational interviewing is to support the patients' own belief that change is possible, Dr. Kushner said, but not to get angry or argue with the patient.

▸ Social cognitive theory/ecological models. These look at the resources for or barriers to the patient making the change. “This is the most important theory I use on a daily basis,” he said. “It looks at the patient in the context of their life, their community, and their environment.” For example, can the patient afford to make changes to his or her diet? This model also depends on the patient's self-efficacy and the degree to which the patient believes that making changes will lead to a positive outcome.

▸ Stages of change. Under the stages of change model, the physician assesses the patients' readiness for change and tries to support movement to the next stage. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. The stages of change can be very helpful in choosing the most effective way to approach the patient, he said. For example, when patients are in the precontemplation stage, provide education and move on.

'Intuition is not enough. It really helps to know the … models and approaches that have been developed.' DR. KUSHNER

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.

Women Miss Pap Tests

About 14% of women aged 18-64 years had not receive a Pap smear in the last 3 years, according to 2005 data from the Agency for Healthcare Research and Quality. Health insurance was one factor: About 25% of women without health insurance failed to receive a Pap test in the last 3 years, compared with 11% of women covered by private insurance and nearly 15% of women with public insurance. Women with lower levels of education and single women also are more likely to go without a Pap test, according to the AHRQ data. The data are from the Medical Expenditure Panel Survey, which includes information on how Americans use health services. The U.S. Preventive Services Task Force recommends that all women aged 21-64 years receive a Pap test every 3 years to detect cervical cancer and abnormal cells.

N.H. Repeals Parental Notification Law

New Hampshire's parental notification law, which had been pending in the courts, has now been repealed. Gov. John Lynch (D) signed into law a bill officially repealing the requirement that physicians contact parents at least 48 hours before performing an abortion on a minor. The original parental notification requirement was enacted in 2003 and challenged by the American Civil Liberties Union and Planned Parenthood Federation of America. The case made its way to the U.S. Supreme Court and in 2006 the justices found that the law was unconstitutional because it lacked an exemption for medical emergencies. But the Supreme Court stopped short of striking down the law and instead sent it back to the lower court. The law was still being considered at the lower court level when it was repealed. “We are thrilled that New Hampshire has recognized the importance of protecting teenagers' health,” Corinne Schiff, a lawyer with the ACLU's Reproductive Freedom Project, said in a statement.

Breast-Feeding Protections in Pa.

Pennsylvania Gov. Ed Rendell (D) signed a bill into law that ensures that women who breast-feed in public cannot be charged with violating any state law or public ordinance. Under the “Freedom to Breastfeed Act,” breast-feeding cannot be considered indecent exposure, open lewdness, obscenity or sexual conduct, or a public nuisance. Pennsylvania is now one of 39 states with laws that specifically allow women to breast-feed in any public or private location, according to the National Conference of State Legislatures.

Ethics of Sterilization

Women considering sterilization should receive comprehensive counseling on the potential for future regret and the estimated failure rates and the risk of ectopic pregnancy, according to an opinion from the American College of Obstetricians and Gynecologists' Committee on Ethics. Women also should be encouraged to discuss the issue with their partners, the committee recommended. The committee opinion, which updates ACOG's position on sterilization, was published in the July issue of Obstetrics and Gynecology. However, physicians should be cautious in offering advice and making recommendations that go beyond the health issues, ACOG said, since nonmedical issues may be difficult to address without bias. The ethical issues become more complicated in women with mental disabilities. The presence of a mental disability alone does not justify either sterilization or the denial of the procedure, ACOG advised. However, physicians must evaluate the patient's ability to give informed consent. In those cases where informed consent cannot be obtained from the patient, the physician should try to ascertain the patient's views on reproduction and be aware of the possibility of undue pressure by family members. “Though sterilization is technically fairly straightforward, it can present serious ethical issues, especially when it comes to women with limited mental capacity,” Dr. Anne D. Lyerly, chair of the ACOG Committee on Ethics, said in a statement. “Physicians need to proceed with great care when they consider performing sterilization.”

CDC: 43 Million Lack Coverage

Nearly 15% of Americans–43.6 million–lacked health insurance in 2006, according to the Centers for Disease Control and Prevention. Among Americans aged 18 through 64, nearly 20% lacked health insurance in 2006, a slight increase from about 19% in 2005, the CDC said. About 9% of children did not have health coverage in 2006, a marked drop from 14% in 1997, the year the State Children's Health Insurance Program (SCHIP) was enacted. The CDC noted that the percentage of uninsured Americans in the 20 largest states varied from less than 8% in Michigan to nearly 24% in Texas. The CDC study was based on data collected from interviews in more than 100,000 households nationwide.

Women Miss Pap Tests

About 14% of women aged 18-64 years had not receive a Pap smear in the last 3 years, according to 2005 data from the Agency for Healthcare Research and Quality. Health insurance was one factor: About 25% of women without health insurance failed to receive a Pap test in the last 3 years, compared with 11% of women covered by private insurance and nearly 15% of women with public insurance. Women with lower levels of education and single women also are more likely to go without a Pap test, according to the AHRQ data. The data are from the Medical Expenditure Panel Survey, which includes information on how Americans use health services. The U.S. Preventive Services Task Force recommends that all women aged 21-64 years receive a Pap test every 3 years to detect cervical cancer and abnormal cells.

N.H. Repeals Parental Notification Law

New Hampshire's parental notification law, which had been pending in the courts, has now been repealed. Gov. John Lynch (D) signed into law a bill officially repealing the requirement that physicians contact parents at least 48 hours before performing an abortion on a minor. The original parental notification requirement was enacted in 2003 and challenged by the American Civil Liberties Union and Planned Parenthood Federation of America. The case made its way to the U.S. Supreme Court and in 2006 the justices found that the law was unconstitutional because it lacked an exemption for medical emergencies. But the Supreme Court stopped short of striking down the law and instead sent it back to the lower court. The law was still being considered at the lower court level when it was repealed. “We are thrilled that New Hampshire has recognized the importance of protecting teenagers' health,” Corinne Schiff, a lawyer with the ACLU's Reproductive Freedom Project, said in a statement.

Breast-Feeding Protections in Pa.

Pennsylvania Gov. Ed Rendell (D) signed a bill into law that ensures that women who breast-feed in public cannot be charged with violating any state law or public ordinance. Under the “Freedom to Breastfeed Act,” breast-feeding cannot be considered indecent exposure, open lewdness, obscenity or sexual conduct, or a public nuisance. Pennsylvania is now one of 39 states with laws that specifically allow women to breast-feed in any public or private location, according to the National Conference of State Legislatures.

Ethics of Sterilization

Women considering sterilization should receive comprehensive counseling on the potential for future regret and the estimated failure rates and the risk of ectopic pregnancy, according to an opinion from the American College of Obstetricians and Gynecologists' Committee on Ethics. Women also should be encouraged to discuss the issue with their partners, the committee recommended. The committee opinion, which updates ACOG's position on sterilization, was published in the July issue of Obstetrics and Gynecology. However, physicians should be cautious in offering advice and making recommendations that go beyond the health issues, ACOG said, since nonmedical issues may be difficult to address without bias. The ethical issues become more complicated in women with mental disabilities. The presence of a mental disability alone does not justify either sterilization or the denial of the procedure, ACOG advised. However, physicians must evaluate the patient's ability to give informed consent. In those cases where informed consent cannot be obtained from the patient, the physician should try to ascertain the patient's views on reproduction and be aware of the possibility of undue pressure by family members. “Though sterilization is technically fairly straightforward, it can present serious ethical issues, especially when it comes to women with limited mental capacity,” Dr. Anne D. Lyerly, chair of the ACOG Committee on Ethics, said in a statement. “Physicians need to proceed with great care when they consider performing sterilization.”

CDC: 43 Million Lack Coverage

Nearly 15% of Americans–43.6 million–lacked health insurance in 2006, according to the Centers for Disease Control and Prevention. Among Americans aged 18 through 64, nearly 20% lacked health insurance in 2006, a slight increase from about 19% in 2005, the CDC said. About 9% of children did not have health coverage in 2006, a marked drop from 14% in 1997, the year the State Children's Health Insurance Program (SCHIP) was enacted. The CDC noted that the percentage of uninsured Americans in the 20 largest states varied from less than 8% in Michigan to nearly 24% in Texas. The CDC study was based on data collected from interviews in more than 100,000 households nationwide.

Women Miss Pap Tests

About 14% of women aged 18-64 years had not receive a Pap smear in the last 3 years, according to 2005 data from the Agency for Healthcare Research and Quality. Health insurance was one factor: About 25% of women without health insurance failed to receive a Pap test in the last 3 years, compared with 11% of women covered by private insurance and nearly 15% of women with public insurance. Women with lower levels of education and single women also are more likely to go without a Pap test, according to the AHRQ data. The data are from the Medical Expenditure Panel Survey, which includes information on how Americans use health services. The U.S. Preventive Services Task Force recommends that all women aged 21-64 years receive a Pap test every 3 years to detect cervical cancer and abnormal cells.

N.H. Repeals Parental Notification Law

New Hampshire's parental notification law, which had been pending in the courts, has now been repealed. Gov. John Lynch (D) signed into law a bill officially repealing the requirement that physicians contact parents at least 48 hours before performing an abortion on a minor. The original parental notification requirement was enacted in 2003 and challenged by the American Civil Liberties Union and Planned Parenthood Federation of America. The case made its way to the U.S. Supreme Court and in 2006 the justices found that the law was unconstitutional because it lacked an exemption for medical emergencies. But the Supreme Court stopped short of striking down the law and instead sent it back to the lower court. The law was still being considered at the lower court level when it was repealed. “We are thrilled that New Hampshire has recognized the importance of protecting teenagers' health,” Corinne Schiff, a lawyer with the ACLU's Reproductive Freedom Project, said in a statement.

Breast-Feeding Protections in Pa.

Pennsylvania Gov. Ed Rendell (D) signed a bill into law that ensures that women who breast-feed in public cannot be charged with violating any state law or public ordinance. Under the “Freedom to Breastfeed Act,” breast-feeding cannot be considered indecent exposure, open lewdness, obscenity or sexual conduct, or a public nuisance. Pennsylvania is now one of 39 states with laws that specifically allow women to breast-feed in any public or private location, according to the National Conference of State Legislatures.

Ethics of Sterilization

Women considering sterilization should receive comprehensive counseling on the potential for future regret and the estimated failure rates and the risk of ectopic pregnancy, according to an opinion from the American College of Obstetricians and Gynecologists' Committee on Ethics. Women also should be encouraged to discuss the issue with their partners, the committee recommended. The committee opinion, which updates ACOG's position on sterilization, was published in the July issue of Obstetrics and Gynecology. However, physicians should be cautious in offering advice and making recommendations that go beyond the health issues, ACOG said, since nonmedical issues may be difficult to address without bias. The ethical issues become more complicated in women with mental disabilities. The presence of a mental disability alone does not justify either sterilization or the denial of the procedure, ACOG advised. However, physicians must evaluate the patient's ability to give informed consent. In those cases where informed consent cannot be obtained from the patient, the physician should try to ascertain the patient's views on reproduction and be aware of the possibility of undue pressure by family members. “Though sterilization is technically fairly straightforward, it can present serious ethical issues, especially when it comes to women with limited mental capacity,” Dr. Anne D. Lyerly, chair of the ACOG Committee on Ethics, said in a statement. “Physicians need to proceed with great care when they consider performing sterilization.”

CDC: 43 Million Lack Coverage

Nearly 15% of Americans–43.6 million–lacked health insurance in 2006, according to the Centers for Disease Control and Prevention. Among Americans aged 18 through 64, nearly 20% lacked health insurance in 2006, a slight increase from about 19% in 2005, the CDC said. About 9% of children did not have health coverage in 2006, a marked drop from 14% in 1997, the year the State Children's Health Insurance Program (SCHIP) was enacted. The CDC noted that the percentage of uninsured Americans in the 20 largest states varied from less than 8% in Michigan to nearly 24% in Texas. The CDC study was based on data collected from interviews in more than 100,000 households nationwide.

TORONTO – Aromatase inhibitors could someday replace clomiphene citrate as the first-line treatment for infertility in patients with polycystic ovary syndrome, Dr. Robert F. Casper said at the annual meeting of the Endocrine Society.

Aromatase inhibitors don't suffer from some of the drawbacks of clomiphene citrate such as a long tissue half-life, high multiple pregnancy rates, and peripheral antiestrogenic effects, he said.

“All of these problems result in a lower pregnancy and live birth rate than you'd expect from the very good efficacy of clomiphene citrate for ovulation induction,” said Dr. Casper, professor of obstetrics and gynecology at the University of Toronto.

Aromatase inhibitors such as letrozole, on the other hand, have a relatively short half-life and result in predominantly monofollicular ovulation when used alone. The drug also results in increased follicular sensitivity to follicle-stimulating hormone (FSH) and does not have adverse effects on the endometrium or cervical mucus.

Moreover, aromatase inhibitors are safe for use in ovulation induction, despite a well-publicized report in 2005 that letrozole results in an increased risk of congenital abnormalities, he said.

Dr. Casper has a licensing agreement with EMD Serono, of Geneva, which is currently testing an aromatase inhibitor for use in treating infertility.

Many physicians may be reluctant to prescribe letrozole off-label for the treatment of infertility in patients with polycystic ovary syndrome (PCOS), Dr. Casper said, because of warnings from the drug's maker. In November 2005, Novartis, which markets letrozole as Femara for the treatment of breast cancer, issued a letter to physicians warning that that the drug is contraindicated in women with premenopausal endocrine status, in pregnancy, and during lactation because of the potential for maternal and fetal toxicity and fetal malformations.

The warning was based largely on a study presented at the American Society of Reproductive Medicine meeting in 2005 in which researchers examined the outcomes of 150 babies who were born following treatment with letrozole, or letrozole and gonadotropins, compared with a database of about 36,000 deliveries in a low-risk maternity hospital. The researchers, led by Dr. Marinko M. Biljan of the Montreal Fertility Center, found no difference in overall malformations but an increased incidence of locomotor and cardiac malformations in the letrozole group, which was statistically significant.

But there are some problems with the design of the study that call the results into question, Dr. Casper said. For example, the control group was composed of spontaneously conceiving patients without infertility. “It is actually well known that women with infertility, especially women with unexplained infertility, have a higher malformation rate in their babies than women who conceive naturally,” he said.

In addition, two recent studies appear to contradict the findings presented in 2005, according to Dr. Casper. Between 2003 and 2005, Dr. Casper and his colleagues examined 911 pregnancies at five clinics in Canada. The four-arm study included patients who received letrozole, letrozole plus FSH, clomiphene citrate, or clomiphene plus FSH. All of the women in the study were undergoing either intrauterine insemination or timed intercourse, and all were monitored in the same fashion.

“This is now comparing infertility patients with infertility patients,” he said.

The researchers found no difference in the overall malformation rate between clomiphene citrate and letrozole. However, they did find a higher rate of cardiac abnormalities in the babies born to the group of women receiving clomiphene citrate. The children of women in the two clomiphene citrate groups had a combined 1.8% rate of cardiac abnormalities, compared with a combined 0.2% rate among women in both letrozole groups, which was statistically significant (Fertil. Steril. 2006;85:1761-5).

In a follow-up study at the McGill Reproductive Centre and the Toronto Centre for Advanced Reproductive Technology, Dr. Casper and colleagues looked at pregnancies occurring after patients received letrozole and clomiphene for ovulation induction.

TORONTO – Aromatase inhibitors could someday replace clomiphene citrate as the first-line treatment for infertility in patients with polycystic ovary syndrome, Dr. Robert F. Casper said at the annual meeting of the Endocrine Society.

Aromatase inhibitors don't suffer from some of the drawbacks of clomiphene citrate such as a long tissue half-life, high multiple pregnancy rates, and peripheral antiestrogenic effects, he said.

“All of these problems result in a lower pregnancy and live birth rate than you'd expect from the very good efficacy of clomiphene citrate for ovulation induction,” said Dr. Casper, professor of obstetrics and gynecology at the University of Toronto.

Aromatase inhibitors such as letrozole, on the other hand, have a relatively short half-life and result in predominantly monofollicular ovulation when used alone. The drug also results in increased follicular sensitivity to follicle-stimulating hormone (FSH) and does not have adverse effects on the endometrium or cervical mucus.

Moreover, aromatase inhibitors are safe for use in ovulation induction, despite a well-publicized report in 2005 that letrozole results in an increased risk of congenital abnormalities, he said.

Dr. Casper has a licensing agreement with EMD Serono, of Geneva, which is currently testing an aromatase inhibitor for use in treating infertility.

Many physicians may be reluctant to prescribe letrozole off-label for the treatment of infertility in patients with polycystic ovary syndrome (PCOS), Dr. Casper said, because of warnings from the drug's maker. In November 2005, Novartis, which markets letrozole as Femara for the treatment of breast cancer, issued a letter to physicians warning that that the drug is contraindicated in women with premenopausal endocrine status, in pregnancy, and during lactation because of the potential for maternal and fetal toxicity and fetal malformations.

The warning was based largely on a study presented at the American Society of Reproductive Medicine meeting in 2005 in which researchers examined the outcomes of 150 babies who were born following treatment with letrozole, or letrozole and gonadotropins, compared with a database of about 36,000 deliveries in a low-risk maternity hospital. The researchers, led by Dr. Marinko M. Biljan of the Montreal Fertility Center, found no difference in overall malformations but an increased incidence of locomotor and cardiac malformations in the letrozole group, which was statistically significant.

But there are some problems with the design of the study that call the results into question, Dr. Casper said. For example, the control group was composed of spontaneously conceiving patients without infertility. “It is actually well known that women with infertility, especially women with unexplained infertility, have a higher malformation rate in their babies than women who conceive naturally,” he said.

In addition, two recent studies appear to contradict the findings presented in 2005, according to Dr. Casper. Between 2003 and 2005, Dr. Casper and his colleagues examined 911 pregnancies at five clinics in Canada. The four-arm study included patients who received letrozole, letrozole plus FSH, clomiphene citrate, or clomiphene plus FSH. All of the women in the study were undergoing either intrauterine insemination or timed intercourse, and all were monitored in the same fashion.

“This is now comparing infertility patients with infertility patients,” he said.

The researchers found no difference in the overall malformation rate between clomiphene citrate and letrozole. However, they did find a higher rate of cardiac abnormalities in the babies born to the group of women receiving clomiphene citrate. The children of women in the two clomiphene citrate groups had a combined 1.8% rate of cardiac abnormalities, compared with a combined 0.2% rate among women in both letrozole groups, which was statistically significant (Fertil. Steril. 2006;85:1761-5).

In a follow-up study at the McGill Reproductive Centre and the Toronto Centre for Advanced Reproductive Technology, Dr. Casper and colleagues looked at pregnancies occurring after patients received letrozole and clomiphene for ovulation induction.

TORONTO – Aromatase inhibitors could someday replace clomiphene citrate as the first-line treatment for infertility in patients with polycystic ovary syndrome, Dr. Robert F. Casper said at the annual meeting of the Endocrine Society.

Aromatase inhibitors don't suffer from some of the drawbacks of clomiphene citrate such as a long tissue half-life, high multiple pregnancy rates, and peripheral antiestrogenic effects, he said.

“All of these problems result in a lower pregnancy and live birth rate than you'd expect from the very good efficacy of clomiphene citrate for ovulation induction,” said Dr. Casper, professor of obstetrics and gynecology at the University of Toronto.

Aromatase inhibitors such as letrozole, on the other hand, have a relatively short half-life and result in predominantly monofollicular ovulation when used alone. The drug also results in increased follicular sensitivity to follicle-stimulating hormone (FSH) and does not have adverse effects on the endometrium or cervical mucus.

Moreover, aromatase inhibitors are safe for use in ovulation induction, despite a well-publicized report in 2005 that letrozole results in an increased risk of congenital abnormalities, he said.

Dr. Casper has a licensing agreement with EMD Serono, of Geneva, which is currently testing an aromatase inhibitor for use in treating infertility.

Many physicians may be reluctant to prescribe letrozole off-label for the treatment of infertility in patients with polycystic ovary syndrome (PCOS), Dr. Casper said, because of warnings from the drug's maker. In November 2005, Novartis, which markets letrozole as Femara for the treatment of breast cancer, issued a letter to physicians warning that that the drug is contraindicated in women with premenopausal endocrine status, in pregnancy, and during lactation because of the potential for maternal and fetal toxicity and fetal malformations.

The warning was based largely on a study presented at the American Society of Reproductive Medicine meeting in 2005 in which researchers examined the outcomes of 150 babies who were born following treatment with letrozole, or letrozole and gonadotropins, compared with a database of about 36,000 deliveries in a low-risk maternity hospital. The researchers, led by Dr. Marinko M. Biljan of the Montreal Fertility Center, found no difference in overall malformations but an increased incidence of locomotor and cardiac malformations in the letrozole group, which was statistically significant.

But there are some problems with the design of the study that call the results into question, Dr. Casper said. For example, the control group was composed of spontaneously conceiving patients without infertility. “It is actually well known that women with infertility, especially women with unexplained infertility, have a higher malformation rate in their babies than women who conceive naturally,” he said.

In addition, two recent studies appear to contradict the findings presented in 2005, according to Dr. Casper. Between 2003 and 2005, Dr. Casper and his colleagues examined 911 pregnancies at five clinics in Canada. The four-arm study included patients who received letrozole, letrozole plus FSH, clomiphene citrate, or clomiphene plus FSH. All of the women in the study were undergoing either intrauterine insemination or timed intercourse, and all were monitored in the same fashion.

“This is now comparing infertility patients with infertility patients,” he said.

The researchers found no difference in the overall malformation rate between clomiphene citrate and letrozole. However, they did find a higher rate of cardiac abnormalities in the babies born to the group of women receiving clomiphene citrate. The children of women in the two clomiphene citrate groups had a combined 1.8% rate of cardiac abnormalities, compared with a combined 0.2% rate among women in both letrozole groups, which was statistically significant (Fertil. Steril. 2006;85:1761-5).

In a follow-up study at the McGill Reproductive Centre and the Toronto Centre for Advanced Reproductive Technology, Dr. Casper and colleagues looked at pregnancies occurring after patients received letrozole and clomiphene for ovulation induction.