Mary Ellen Schneider

Bush Issues Second Stem Cell Veto

President Bush for the second time has vetoed legislation that would have expanded federal funding for human embryonic stem cell research. The bill, the “Stem Cell Research Enhancement Act of 2007” (S. 5), would have allowed federal funding of human embryonic stem cell research if the embryos were donated from in vitro fertilization clinics and would otherwise have been discarded. In addition, the legislation called for the written, informed consent of individuals donating embryos, and prohibited financial inducements for donation. President Bush said he could not support legislation that would lead to the deliberate destruction of human embryos. Instead, the President supports efforts such as adult stem cell research and the use of umbilical cord blood. President Bush also issued an executive order directing the Health and Human Services department and the National Institutes of Health to ensure that any human pluripotent stem cell lines “produced in ways that do not create, destroy, or harm human embryos” are eligible for federal funding. The order also expands the NIH Human Embryonic Stem Cell Registry to include all types of pluripotent stem cells and renames it the Pluripotent Stem Cell Registry. The “executive order directing NIH to continue pursuing [alternative forms] of research is nothing new, since NIH has already been conducting this research for the past 20 years,” Sean Tipton, the president of the Coalition for the Advancement of Medical Research, said in a statement. “[He] isn't fooling anyone with this executive order, and the fact that it doesn't change the policy adds insult to injury for the millions of patients who suffer every day.”

Alzheimer's Programs Recognized

The Alzheimer's Foundation of America recently awarded “Excellence in Care” status to two dementia care programs that met standards for high performance. The two programs, both based in New York City, are the first to receive this designation from the group. The Alzheimer's Foundation of America began the program last November and to date has trained about 40 specialists to conducted on-site evaluations and to work with facilities to improve their performance and adopt best practices. The recognized facilities are the 80th Street Residence, an assisted living facility, and Ozanam Hall, a skilled geriatric and short-term rehabilitation facility. More information on the Excellence in Care recognition program is available online at

www.excellenceincare.org

Veterans Epilepsy Bill Introduced

New federal legislation would establish six centers of excellence aimed at treating epilepsy among veterans, including those who develop the condition following traumatic brain injury. The bill is the latest piece of legislation that calls for devoting more resources to address the consequences of traumatic brain injury in returning soldiers. The legislation (H.R. 2818) would establish epilepsy “centers for excellence” within the Department of Veterans Affairs that would focus on research, education, and clinical care. “Many of our brave veterans will develop epilepsy following a traumatic brain injury,” Eric R. Hargis, president and CEO of the Epilepsy Foundation, said in a statement. “The difficulty is that the epilepsy often will not become apparent for 3 to 5 years or more post injury. These centers [will ensure] that our veterans will still receive excellent care for a condition they developed as a consequence of military service.” The bill was introduced by Rep. Ed Perlmutter (D-Colo.) and was referred to the House Committee on Veterans' Affairs.

AMA: Investigate Store Clinics

The American Medical Association has called for investigations into potential conflicts of interest that are posed by joint ventures between store-based health clinics and pharmacy chains. Physicians at the AMA's House of Delegates in Chicago voted to ask state and federal agencies to determine whether these joint ventures pose a threat to patients' welfare. “There are clear incentives for retailers to participate in the implementation and operation of store-based health clinics,” said AMA board member Dr. Peter Carmel in a statement. “The nation's physicians want the AMA to ensure these incentives do not compromise the basic obligation of store-based clinics to provide patients with quality care.” Additionally, the AMA noted that some insurers are allowing store-based clinics to waive or lower their patients' copayments even as they are still requiring physicians to collect such payments. The House of Delegates, noting concerns that these lower copayments for in-store clinics could inappropriately steer patients to the clinics on the basis of cost rather than quality of care, voted to seek equal treatment for physicians regarding health insurers' copayment policies.

Bush Issues Second Stem Cell Veto

President Bush for the second time has vetoed legislation that would have expanded federal funding for human embryonic stem cell research. The bill, the “Stem Cell Research Enhancement Act of 2007” (S. 5), would have allowed federal funding of human embryonic stem cell research if the embryos were donated from in vitro fertilization clinics and would otherwise have been discarded. In addition, the legislation called for the written, informed consent of individuals donating embryos, and prohibited financial inducements for donation. President Bush said he could not support legislation that would lead to the deliberate destruction of human embryos. Instead, the President supports efforts such as adult stem cell research and the use of umbilical cord blood. President Bush also issued an executive order directing the Health and Human Services department and the National Institutes of Health to ensure that any human pluripotent stem cell lines “produced in ways that do not create, destroy, or harm human embryos” are eligible for federal funding. The order also expands the NIH Human Embryonic Stem Cell Registry to include all types of pluripotent stem cells and renames it the Pluripotent Stem Cell Registry. The “executive order directing NIH to continue pursuing [alternative forms] of research is nothing new, since NIH has already been conducting this research for the past 20 years,” Sean Tipton, the president of the Coalition for the Advancement of Medical Research, said in a statement. “[He] isn't fooling anyone with this executive order, and the fact that it doesn't change the policy adds insult to injury for the millions of patients who suffer every day.”

Alzheimer's Programs Recognized

The Alzheimer's Foundation of America recently awarded “Excellence in Care” status to two dementia care programs that met standards for high performance. The two programs, both based in New York City, are the first to receive this designation from the group. The Alzheimer's Foundation of America began the program last November and to date has trained about 40 specialists to conducted on-site evaluations and to work with facilities to improve their performance and adopt best practices. The recognized facilities are the 80th Street Residence, an assisted living facility, and Ozanam Hall, a skilled geriatric and short-term rehabilitation facility. More information on the Excellence in Care recognition program is available online at

www.excellenceincare.org

Veterans Epilepsy Bill Introduced

New federal legislation would establish six centers of excellence aimed at treating epilepsy among veterans, including those who develop the condition following traumatic brain injury. The bill is the latest piece of legislation that calls for devoting more resources to address the consequences of traumatic brain injury in returning soldiers. The legislation (H.R. 2818) would establish epilepsy “centers for excellence” within the Department of Veterans Affairs that would focus on research, education, and clinical care. “Many of our brave veterans will develop epilepsy following a traumatic brain injury,” Eric R. Hargis, president and CEO of the Epilepsy Foundation, said in a statement. “The difficulty is that the epilepsy often will not become apparent for 3 to 5 years or more post injury. These centers [will ensure] that our veterans will still receive excellent care for a condition they developed as a consequence of military service.” The bill was introduced by Rep. Ed Perlmutter (D-Colo.) and was referred to the House Committee on Veterans' Affairs.

AMA: Investigate Store Clinics

The American Medical Association has called for investigations into potential conflicts of interest that are posed by joint ventures between store-based health clinics and pharmacy chains. Physicians at the AMA's House of Delegates in Chicago voted to ask state and federal agencies to determine whether these joint ventures pose a threat to patients' welfare. “There are clear incentives for retailers to participate in the implementation and operation of store-based health clinics,” said AMA board member Dr. Peter Carmel in a statement. “The nation's physicians want the AMA to ensure these incentives do not compromise the basic obligation of store-based clinics to provide patients with quality care.” Additionally, the AMA noted that some insurers are allowing store-based clinics to waive or lower their patients' copayments even as they are still requiring physicians to collect such payments. The House of Delegates, noting concerns that these lower copayments for in-store clinics could inappropriately steer patients to the clinics on the basis of cost rather than quality of care, voted to seek equal treatment for physicians regarding health insurers' copayment policies.

Bush Issues Second Stem Cell Veto

President Bush for the second time has vetoed legislation that would have expanded federal funding for human embryonic stem cell research. The bill, the “Stem Cell Research Enhancement Act of 2007” (S. 5), would have allowed federal funding of human embryonic stem cell research if the embryos were donated from in vitro fertilization clinics and would otherwise have been discarded. In addition, the legislation called for the written, informed consent of individuals donating embryos, and prohibited financial inducements for donation. President Bush said he could not support legislation that would lead to the deliberate destruction of human embryos. Instead, the President supports efforts such as adult stem cell research and the use of umbilical cord blood. President Bush also issued an executive order directing the Health and Human Services department and the National Institutes of Health to ensure that any human pluripotent stem cell lines “produced in ways that do not create, destroy, or harm human embryos” are eligible for federal funding. The order also expands the NIH Human Embryonic Stem Cell Registry to include all types of pluripotent stem cells and renames it the Pluripotent Stem Cell Registry. The “executive order directing NIH to continue pursuing [alternative forms] of research is nothing new, since NIH has already been conducting this research for the past 20 years,” Sean Tipton, the president of the Coalition for the Advancement of Medical Research, said in a statement. “[He] isn't fooling anyone with this executive order, and the fact that it doesn't change the policy adds insult to injury for the millions of patients who suffer every day.”

Alzheimer's Programs Recognized

The Alzheimer's Foundation of America recently awarded “Excellence in Care” status to two dementia care programs that met standards for high performance. The two programs, both based in New York City, are the first to receive this designation from the group. The Alzheimer's Foundation of America began the program last November and to date has trained about 40 specialists to conducted on-site evaluations and to work with facilities to improve their performance and adopt best practices. The recognized facilities are the 80th Street Residence, an assisted living facility, and Ozanam Hall, a skilled geriatric and short-term rehabilitation facility. More information on the Excellence in Care recognition program is available online at

www.excellenceincare.org

Veterans Epilepsy Bill Introduced

New federal legislation would establish six centers of excellence aimed at treating epilepsy among veterans, including those who develop the condition following traumatic brain injury. The bill is the latest piece of legislation that calls for devoting more resources to address the consequences of traumatic brain injury in returning soldiers. The legislation (H.R. 2818) would establish epilepsy “centers for excellence” within the Department of Veterans Affairs that would focus on research, education, and clinical care. “Many of our brave veterans will develop epilepsy following a traumatic brain injury,” Eric R. Hargis, president and CEO of the Epilepsy Foundation, said in a statement. “The difficulty is that the epilepsy often will not become apparent for 3 to 5 years or more post injury. These centers [will ensure] that our veterans will still receive excellent care for a condition they developed as a consequence of military service.” The bill was introduced by Rep. Ed Perlmutter (D-Colo.) and was referred to the House Committee on Veterans' Affairs.

AMA: Investigate Store Clinics

The American Medical Association has called for investigations into potential conflicts of interest that are posed by joint ventures between store-based health clinics and pharmacy chains. Physicians at the AMA's House of Delegates in Chicago voted to ask state and federal agencies to determine whether these joint ventures pose a threat to patients' welfare. “There are clear incentives for retailers to participate in the implementation and operation of store-based health clinics,” said AMA board member Dr. Peter Carmel in a statement. “The nation's physicians want the AMA to ensure these incentives do not compromise the basic obligation of store-based clinics to provide patients with quality care.” Additionally, the AMA noted that some insurers are allowing store-based clinics to waive or lower their patients' copayments even as they are still requiring physicians to collect such payments. The House of Delegates, noting concerns that these lower copayments for in-store clinics could inappropriately steer patients to the clinics on the basis of cost rather than quality of care, voted to seek equal treatment for physicians regarding health insurers' copayment policies.

Approving Follow-On Biologics

Creating a regulatory pathway for approving generic or “follow-on” versions of biologic therapies would improve competition and curb rising biotech prices, according to an analysis from the Competitive Enterprise Institute. Congress is considering legislation that would allow an abbreviated approval process for so-called follow-on biologics. This pathway would be similar to the process currently in place for approving generic pharmaceuticals. Whether this regulatory pathway is created through legislation or out of the Food and Drug Administration's existing authority, the report maintains that the process could be done safely. Generic manufacturers have the capability to create safe follow-on biologics, and the FDA has the tools to recognize products that are comparable with existing drugs or interchangeable, wrote study author Gregory Conko, a senior fellow at the Competitive Enterprise Institute. “Consumers would see tremendous benefits from an abbreviated approval process for generic biotech prescription drugs,” Mr. Conko said in a statement. “In addition to the cost savings, the competition that these approvals would generate could spur even more improvements in the quality of biopharmaceuticals.” Find the report online at

www.cei.org/gencon/025,05933.cfm

Lupus Grants Awarded

The Department of Defense's Congressionally Directed Medical Research Program awarded over $2 million in the form of two grants for research on lupus and lupus biomarkers. The grants will fund investigations in mouse models, but the findings could lead to human advances. Researchers at the Medical University of South Carolina in Charleston will experiment with targeting a certain cascade of proteins in a mouse model to target certain areas where lupus causes tissue damage and to minimize immune suppression in other areas of the body. Grant recipients at the Feinstein Institute for Medical Research at the North Shore Medical Center in Manhasset, N.Y., will examine the estrogen's role in triggering lupus activity in certain mouse models but not in others. That research could have long-term implications for testing patients with lupus for hormonal disorders.

AMA Fights Medicare Cuts

Physicians report they will severely limit the numbers of Medicare patients they treat if Congress won't avert planned Medicare physician payment cuts, which will total 10% on Jan. 1, 2008, and will reach about 40% over the next 9 years, according to an American Medical Association survey of nearly 9,000 physicians. If Medicare payment rates are cut by 10% in January, 60% of physicians report they will limit new Medicare patients and 40% will limit established Medicare patients, the AMA survey found. “As physicians brace for 9 years of steep payment cuts, it will be extremely difficult for them to continue accepting new Medicare patients,” said Dr. Cecil Wilson, AMA board chair. “The baby boomers begin entering the program in 2010, and the Medicare cuts increase the likelihood that there may not be enough doctors to care for the huge influx.” MedPAC, Congress' advisory committee on Medicare, has recommended Congress halt next year's 10% cut and update payments 1.7% in line with practice cost increases.

State Variations in Care Cost, Quality

Cost, quality, and access to care vary widely depending on where you live, according to a report from the Commonwealth Fund. The report ranks states based on 32 indicators of access, quality, avoidable hospital use and costs, equity, and healthy lives. While no state ranked first across all indicators, in general states in the Northeast and Upper Midwest performed better, while southern states tended to score the lowest. “The differences we found between the top and bottom states were shocking, often a two- to threefold variation or greater,” study coauthor Cathy Schoen said in a statement. “Where you live clearly matters for access to care when you need it, the quality of care you receive, and opportunities to live healthier lives.”

New FDA Risk Panel

Following an Institute of Medicine recommendation, the FDA has created an advisory committee charged with helping the agency communicate the risks and benefits of pharmaceuticals and other products. In 2006, the IOM's report, The Future of Drug Safety: Promoting and Protecting the Health of the Public, urged Congress to establish a new advisory panel that would weigh in on the FDA's communications about safety and efficacy to health care providers and the public. The agency found an administrative process that let it establish the committee without congressional action. The FDA is now seeking 15 members to serve on the Risk Communication Advisory Committee, including experts on risk communication, social marketing, health literacy, journalism, bioethics, and cultural competency.

Approving Follow-On Biologics

Creating a regulatory pathway for approving generic or “follow-on” versions of biologic therapies would improve competition and curb rising biotech prices, according to an analysis from the Competitive Enterprise Institute. Congress is considering legislation that would allow an abbreviated approval process for so-called follow-on biologics. This pathway would be similar to the process currently in place for approving generic pharmaceuticals. Whether this regulatory pathway is created through legislation or out of the Food and Drug Administration's existing authority, the report maintains that the process could be done safely. Generic manufacturers have the capability to create safe follow-on biologics, and the FDA has the tools to recognize products that are comparable with existing drugs or interchangeable, wrote study author Gregory Conko, a senior fellow at the Competitive Enterprise Institute. “Consumers would see tremendous benefits from an abbreviated approval process for generic biotech prescription drugs,” Mr. Conko said in a statement. “In addition to the cost savings, the competition that these approvals would generate could spur even more improvements in the quality of biopharmaceuticals.” Find the report online at

www.cei.org/gencon/025,05933.cfm

Lupus Grants Awarded

The Department of Defense's Congressionally Directed Medical Research Program awarded over $2 million in the form of two grants for research on lupus and lupus biomarkers. The grants will fund investigations in mouse models, but the findings could lead to human advances. Researchers at the Medical University of South Carolina in Charleston will experiment with targeting a certain cascade of proteins in a mouse model to target certain areas where lupus causes tissue damage and to minimize immune suppression in other areas of the body. Grant recipients at the Feinstein Institute for Medical Research at the North Shore Medical Center in Manhasset, N.Y., will examine the estrogen's role in triggering lupus activity in certain mouse models but not in others. That research could have long-term implications for testing patients with lupus for hormonal disorders.

AMA Fights Medicare Cuts

Physicians report they will severely limit the numbers of Medicare patients they treat if Congress won't avert planned Medicare physician payment cuts, which will total 10% on Jan. 1, 2008, and will reach about 40% over the next 9 years, according to an American Medical Association survey of nearly 9,000 physicians. If Medicare payment rates are cut by 10% in January, 60% of physicians report they will limit new Medicare patients and 40% will limit established Medicare patients, the AMA survey found. “As physicians brace for 9 years of steep payment cuts, it will be extremely difficult for them to continue accepting new Medicare patients,” said Dr. Cecil Wilson, AMA board chair. “The baby boomers begin entering the program in 2010, and the Medicare cuts increase the likelihood that there may not be enough doctors to care for the huge influx.” MedPAC, Congress' advisory committee on Medicare, has recommended Congress halt next year's 10% cut and update payments 1.7% in line with practice cost increases.

State Variations in Care Cost, Quality

Cost, quality, and access to care vary widely depending on where you live, according to a report from the Commonwealth Fund. The report ranks states based on 32 indicators of access, quality, avoidable hospital use and costs, equity, and healthy lives. While no state ranked first across all indicators, in general states in the Northeast and Upper Midwest performed better, while southern states tended to score the lowest. “The differences we found between the top and bottom states were shocking, often a two- to threefold variation or greater,” study coauthor Cathy Schoen said in a statement. “Where you live clearly matters for access to care when you need it, the quality of care you receive, and opportunities to live healthier lives.”

New FDA Risk Panel

Following an Institute of Medicine recommendation, the FDA has created an advisory committee charged with helping the agency communicate the risks and benefits of pharmaceuticals and other products. In 2006, the IOM's report, The Future of Drug Safety: Promoting and Protecting the Health of the Public, urged Congress to establish a new advisory panel that would weigh in on the FDA's communications about safety and efficacy to health care providers and the public. The agency found an administrative process that let it establish the committee without congressional action. The FDA is now seeking 15 members to serve on the Risk Communication Advisory Committee, including experts on risk communication, social marketing, health literacy, journalism, bioethics, and cultural competency.

Approving Follow-On Biologics

Creating a regulatory pathway for approving generic or “follow-on” versions of biologic therapies would improve competition and curb rising biotech prices, according to an analysis from the Competitive Enterprise Institute. Congress is considering legislation that would allow an abbreviated approval process for so-called follow-on biologics. This pathway would be similar to the process currently in place for approving generic pharmaceuticals. Whether this regulatory pathway is created through legislation or out of the Food and Drug Administration's existing authority, the report maintains that the process could be done safely. Generic manufacturers have the capability to create safe follow-on biologics, and the FDA has the tools to recognize products that are comparable with existing drugs or interchangeable, wrote study author Gregory Conko, a senior fellow at the Competitive Enterprise Institute. “Consumers would see tremendous benefits from an abbreviated approval process for generic biotech prescription drugs,” Mr. Conko said in a statement. “In addition to the cost savings, the competition that these approvals would generate could spur even more improvements in the quality of biopharmaceuticals.” Find the report online at

www.cei.org/gencon/025,05933.cfm

Lupus Grants Awarded

The Department of Defense's Congressionally Directed Medical Research Program awarded over $2 million in the form of two grants for research on lupus and lupus biomarkers. The grants will fund investigations in mouse models, but the findings could lead to human advances. Researchers at the Medical University of South Carolina in Charleston will experiment with targeting a certain cascade of proteins in a mouse model to target certain areas where lupus causes tissue damage and to minimize immune suppression in other areas of the body. Grant recipients at the Feinstein Institute for Medical Research at the North Shore Medical Center in Manhasset, N.Y., will examine the estrogen's role in triggering lupus activity in certain mouse models but not in others. That research could have long-term implications for testing patients with lupus for hormonal disorders.

AMA Fights Medicare Cuts

Physicians report they will severely limit the numbers of Medicare patients they treat if Congress won't avert planned Medicare physician payment cuts, which will total 10% on Jan. 1, 2008, and will reach about 40% over the next 9 years, according to an American Medical Association survey of nearly 9,000 physicians. If Medicare payment rates are cut by 10% in January, 60% of physicians report they will limit new Medicare patients and 40% will limit established Medicare patients, the AMA survey found. “As physicians brace for 9 years of steep payment cuts, it will be extremely difficult for them to continue accepting new Medicare patients,” said Dr. Cecil Wilson, AMA board chair. “The baby boomers begin entering the program in 2010, and the Medicare cuts increase the likelihood that there may not be enough doctors to care for the huge influx.” MedPAC, Congress' advisory committee on Medicare, has recommended Congress halt next year's 10% cut and update payments 1.7% in line with practice cost increases.

State Variations in Care Cost, Quality

Cost, quality, and access to care vary widely depending on where you live, according to a report from the Commonwealth Fund. The report ranks states based on 32 indicators of access, quality, avoidable hospital use and costs, equity, and healthy lives. While no state ranked first across all indicators, in general states in the Northeast and Upper Midwest performed better, while southern states tended to score the lowest. “The differences we found between the top and bottom states were shocking, often a two- to threefold variation or greater,” study coauthor Cathy Schoen said in a statement. “Where you live clearly matters for access to care when you need it, the quality of care you receive, and opportunities to live healthier lives.”

New FDA Risk Panel

Following an Institute of Medicine recommendation, the FDA has created an advisory committee charged with helping the agency communicate the risks and benefits of pharmaceuticals and other products. In 2006, the IOM's report, The Future of Drug Safety: Promoting and Protecting the Health of the Public, urged Congress to establish a new advisory panel that would weigh in on the FDA's communications about safety and efficacy to health care providers and the public. The agency found an administrative process that let it establish the committee without congressional action. The FDA is now seeking 15 members to serve on the Risk Communication Advisory Committee, including experts on risk communication, social marketing, health literacy, journalism, bioethics, and cultural competency.

Physicians who participate in Medicare's pay-for-reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.

Under the Physician Quality Reporting Initiative (PQRI) that began July 1, reporting for certain measures will include adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.

The PQRI is a voluntary program that lets physicians earn a bonus payment of up to 1.5% of total allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures, and physicians are expected to report on between one and three, depending on how many apply to their patient populations.

When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT II code if the service was not provided. These modifiers are not used when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

▸ Modifier −1P is shows the service was not indicated or is contraindicated.

▸ Modifier −2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

▸ Modifier −3P is used to indicate that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.

▸ Modifier −8P is a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document are available online at www.cms.hhs.gov/pqri

Physicians who participate in Medicare's pay-for-reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.

Under the Physician Quality Reporting Initiative (PQRI) that began July 1, reporting for certain measures will include adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.

The PQRI is a voluntary program that lets physicians earn a bonus payment of up to 1.5% of total allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures, and physicians are expected to report on between one and three, depending on how many apply to their patient populations.

When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT II code if the service was not provided. These modifiers are not used when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

▸ Modifier −1P is shows the service was not indicated or is contraindicated.

▸ Modifier −2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

▸ Modifier −3P is used to indicate that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.

▸ Modifier −8P is a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document are available online at www.cms.hhs.gov/pqri

Physicians who participate in Medicare's pay-for-reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.

Under the Physician Quality Reporting Initiative (PQRI) that began July 1, reporting for certain measures will include adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.

The PQRI is a voluntary program that lets physicians earn a bonus payment of up to 1.5% of total allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures, and physicians are expected to report on between one and three, depending on how many apply to their patient populations.

When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT II code if the service was not provided. These modifiers are not used when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

▸ Modifier −1P is shows the service was not indicated or is contraindicated.

▸ Modifier −2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

▸ Modifier −3P is used to indicate that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.

▸ Modifier −8P is a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document are available online at www.cms.hhs.gov/pqri

Officials at the Centers for Medicare and Medicaid Services are proposing changes to the Medicare Part D prescription drug plans and Medicare Advantage plans in an effort to strengthen oversight of the programs.

The proposal includes mandatory self-reporting aimed at curbing potential fraud and misconduct by plans. The CMS proposal also includes changes to streamline the process of intermediate sanctions and contract determinations. In addition, the proposal clarifies the process for imposing civil money penalties.

“While the majority of Medicare Advantage and Medicare Prescription Drug Plans that offer important benefits to beneficiaries are conducting themselves professionally, it is important for CMS to be able to take swift action to safeguard beneficiaries from unlawful or questionable business practices,” Leslie Norwalk, acting CMS administrator, said in a statement.

But the Bush administration is falling short in policing the marketing practices of Medicare Advantage plans, according to Robert M. Hayes, president of the Medicare Rights Center. Mr. Hayes has called on Congress to establish clear safeguards against “abusive and deceptive” marketing practices and to give state governments the power to enforce those standards. He also called on Congress to establish minimum benefit standards and standardize benefit packages to allow for better consumer comparison of plans.

Officials at the American Medical Association are also reporting problems with Medicare Advantage plans. An online survey of more than 2,200 AMA member physicians conducted in March found that patients had difficulty understanding how the Medicare Advantage plans work or have experienced coverage denials for services that were typically covered under traditional Medicare plans.

For example, about 84% of physicians with patients in Medicare Advantage managed care plans said their patients had difficulty understanding how the plan works. About 80% of physicians with patients in Medicare Advantage private fee-for-service plans also reported confusion among their patients. More than half of physicians reported excessive hold times and documentation requested by payers with both types of Medicare Advantage plans.

CMS is accepting comments on the proposal through July 24.

Officials at the Centers for Medicare and Medicaid Services are proposing changes to the Medicare Part D prescription drug plans and Medicare Advantage plans in an effort to strengthen oversight of the programs.

The proposal includes mandatory self-reporting aimed at curbing potential fraud and misconduct by plans. The CMS proposal also includes changes to streamline the process of intermediate sanctions and contract determinations. In addition, the proposal clarifies the process for imposing civil money penalties.

“While the majority of Medicare Advantage and Medicare Prescription Drug Plans that offer important benefits to beneficiaries are conducting themselves professionally, it is important for CMS to be able to take swift action to safeguard beneficiaries from unlawful or questionable business practices,” Leslie Norwalk, acting CMS administrator, said in a statement.

But the Bush administration is falling short in policing the marketing practices of Medicare Advantage plans, according to Robert M. Hayes, president of the Medicare Rights Center. Mr. Hayes has called on Congress to establish clear safeguards against “abusive and deceptive” marketing practices and to give state governments the power to enforce those standards. He also called on Congress to establish minimum benefit standards and standardize benefit packages to allow for better consumer comparison of plans.

Officials at the American Medical Association are also reporting problems with Medicare Advantage plans. An online survey of more than 2,200 AMA member physicians conducted in March found that patients had difficulty understanding how the Medicare Advantage plans work or have experienced coverage denials for services that were typically covered under traditional Medicare plans.

For example, about 84% of physicians with patients in Medicare Advantage managed care plans said their patients had difficulty understanding how the plan works. About 80% of physicians with patients in Medicare Advantage private fee-for-service plans also reported confusion among their patients. More than half of physicians reported excessive hold times and documentation requested by payers with both types of Medicare Advantage plans.

CMS is accepting comments on the proposal through July 24.

Officials at the Centers for Medicare and Medicaid Services are proposing changes to the Medicare Part D prescription drug plans and Medicare Advantage plans in an effort to strengthen oversight of the programs.

The proposal includes mandatory self-reporting aimed at curbing potential fraud and misconduct by plans. The CMS proposal also includes changes to streamline the process of intermediate sanctions and contract determinations. In addition, the proposal clarifies the process for imposing civil money penalties.

“While the majority of Medicare Advantage and Medicare Prescription Drug Plans that offer important benefits to beneficiaries are conducting themselves professionally, it is important for CMS to be able to take swift action to safeguard beneficiaries from unlawful or questionable business practices,” Leslie Norwalk, acting CMS administrator, said in a statement.

But the Bush administration is falling short in policing the marketing practices of Medicare Advantage plans, according to Robert M. Hayes, president of the Medicare Rights Center. Mr. Hayes has called on Congress to establish clear safeguards against “abusive and deceptive” marketing practices and to give state governments the power to enforce those standards. He also called on Congress to establish minimum benefit standards and standardize benefit packages to allow for better consumer comparison of plans.

Officials at the American Medical Association are also reporting problems with Medicare Advantage plans. An online survey of more than 2,200 AMA member physicians conducted in March found that patients had difficulty understanding how the Medicare Advantage plans work or have experienced coverage denials for services that were typically covered under traditional Medicare plans.

For example, about 84% of physicians with patients in Medicare Advantage managed care plans said their patients had difficulty understanding how the plan works. About 80% of physicians with patients in Medicare Advantage private fee-for-service plans also reported confusion among their patients. More than half of physicians reported excessive hold times and documentation requested by payers with both types of Medicare Advantage plans.

CMS is accepting comments on the proposal through July 24.

A multiagency “strike force” targeting fraudulent Medicare billing related to infusion therapy and durable medical equipment recently made 38 arrests.

The arrests, all in south Florida, mark the first phase of operations for the team of federal, state, and local officials. The team began its investigations in March using real-time analysis of billing data from Medicare and claims data from the Health Care Information System. In May, the departments of Justice and Health and Human Services jointly announced the team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. Charges include conspiracy to defraud the Medicare program, criminal false claims, and violations of the antikickback statutes.

The antifraud efforts drew praise from Senate Finance Committee Chairman Max Baucus (D-Mont.).

“Federal health dollars are just too scarce to lose to fraud and abuse in Medicare,” he said in a statement. “I'm glad to see the Justice Department taking this new, more aggressive stance against scams that endanger Medicare patients and that rob all taxpayers who contribute to America's health care programs.”

Sen. Baucus recently expressed concern about reports of durable medical equipment fraud in South Florida. In one instance, the Health and Human Services inspector general found many device suppliers were not at their advertised addresses but were billing Medicare for millions of dollars in reimbursement.

A multiagency “strike force” targeting fraudulent Medicare billing related to infusion therapy and durable medical equipment recently made 38 arrests.

The arrests, all in south Florida, mark the first phase of operations for the team of federal, state, and local officials. The team began its investigations in March using real-time analysis of billing data from Medicare and claims data from the Health Care Information System. In May, the departments of Justice and Health and Human Services jointly announced the team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. Charges include conspiracy to defraud the Medicare program, criminal false claims, and violations of the antikickback statutes.

The antifraud efforts drew praise from Senate Finance Committee Chairman Max Baucus (D-Mont.).

“Federal health dollars are just too scarce to lose to fraud and abuse in Medicare,” he said in a statement. “I'm glad to see the Justice Department taking this new, more aggressive stance against scams that endanger Medicare patients and that rob all taxpayers who contribute to America's health care programs.”

Sen. Baucus recently expressed concern about reports of durable medical equipment fraud in South Florida. In one instance, the Health and Human Services inspector general found many device suppliers were not at their advertised addresses but were billing Medicare for millions of dollars in reimbursement.

A multiagency “strike force” targeting fraudulent Medicare billing related to infusion therapy and durable medical equipment recently made 38 arrests.

The arrests, all in south Florida, mark the first phase of operations for the team of federal, state, and local officials. The team began its investigations in March using real-time analysis of billing data from Medicare and claims data from the Health Care Information System. In May, the departments of Justice and Health and Human Services jointly announced the team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. Charges include conspiracy to defraud the Medicare program, criminal false claims, and violations of the antikickback statutes.

The antifraud efforts drew praise from Senate Finance Committee Chairman Max Baucus (D-Mont.).

“Federal health dollars are just too scarce to lose to fraud and abuse in Medicare,” he said in a statement. “I'm glad to see the Justice Department taking this new, more aggressive stance against scams that endanger Medicare patients and that rob all taxpayers who contribute to America's health care programs.”

Sen. Baucus recently expressed concern about reports of durable medical equipment fraud in South Florida. In one instance, the Health and Human Services inspector general found many device suppliers were not at their advertised addresses but were billing Medicare for millions of dollars in reimbursement.

Physicians who choose to participate in Medicare's pay for reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.

Under the Physician Quality Reporting Initiative (PQRI), which began July 1, reporting for certain measures includes adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.

PQRI, a voluntary program that allows physicians to earn a bonus payment of up to 1.5% of total allowed Medicare charges for reporting on certain quality measures, will run from July 1 through the end of the year. CMS officials have selected 74 quality measures and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.

When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT II code if the service was not provided. These modifiers are not used when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

P Modifier -1P is used to show that the service was not indicated or is contraindicated for medical reasons.

P Modifier -2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

P Modifier -3P is used to indicate that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.

P Modifier -8P is a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document, which is available online at www.cms.hhs.gov/pqri

Physicians who choose to participate in Medicare's pay for reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.

Under the Physician Quality Reporting Initiative (PQRI), which began July 1, reporting for certain measures includes adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.

PQRI, a voluntary program that allows physicians to earn a bonus payment of up to 1.5% of total allowed Medicare charges for reporting on certain quality measures, will run from July 1 through the end of the year. CMS officials have selected 74 quality measures and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.

When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT II code if the service was not provided. These modifiers are not used when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

P Modifier -1P is used to show that the service was not indicated or is contraindicated for medical reasons.

P Modifier -2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

P Modifier -3P is used to indicate that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.

P Modifier -8P is a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document, which is available online at www.cms.hhs.gov/pqri

Physicians who choose to participate in Medicare's pay for reporting program do not have to satisfy quality indicators to receive a bonus. But in some cases, they will need to cite why they did not follow evidence-based guidelines.

Under the Physician Quality Reporting Initiative (PQRI), which began July 1, reporting for certain measures includes adding a coding modifier explaining why a service was not performed. For example, the service may not have been provided because it was not medically indicated or the patient declined.

PQRI, a voluntary program that allows physicians to earn a bonus payment of up to 1.5% of total allowed Medicare charges for reporting on certain quality measures, will run from July 1 through the end of the year. CMS officials have selected 74 quality measures and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.

When reporting on measures, physicians must include a CPT-II code or G-code. Some measures may also require that physicians add a modifier to the CPT II code if the service was not provided. These modifiers are not used when reporting G codes. The CPT-II modifiers include performance measure exclusion modifiers and a performance measure reporting modifier. For example:

P Modifier -1P is used to show that the service was not indicated or is contraindicated for medical reasons.

P Modifier -2P is used to indicate that the service was not provided for patient reasons, such as the patient declining or religious objections.

P Modifier -3P is used to indicate that the service was not provided for systems reasons such as insurance coverage limitations or a lack of resources to provide the service.

P Modifier -8P is a performance measure reporting modifier and indicates that the action was not performed and the reason has not been specified.

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document, which is available online at www.cms.hhs.gov/pqri

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

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

“Where the action is really taking place is at the state level,” he said.

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

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

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

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

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

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

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

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

“Where the action is really taking place is at the state level,” he said.

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

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

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

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

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

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

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

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

“Where the action is really taking place is at the state level,” he said.

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

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

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

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

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

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

SAN DIEGO — Physicians are finding ways to redesign their practices and improve efficiency, both with and without the use of electronic medical records.

Dr. Kevin D. Egly of Sandwich, Ill., has used his comprehensive electronic medical record (EMR) system to practice in a scaled-down office without staff. Taking a lower-tech approach, Dr. Barbara E. Magera of Charleston, S.C., uses preprinted forms to accomplish many of the functions done by an electronic system but for a fraction of the cost.

The two physicians presented their different approaches at the annual meeting of the American College of Physicians. Both practices have been studied by the ACP's Center for Practice Innovation, a 2-year project created by the ACP to help small practices improve their work flow.

For Dr. Egly, the comprehensive EMR system, which performs chart documentation and billing, is what makes it possible for him to practice the way that he does. He and his wife Angela, also an internist, each work about 20 hours a week in their small practice. Since they don't employ any other staff, they answer the phones themselves and handle their own billing.

They have built the practice over the last 3 years, and each now sees about 400–500 patients. Dr. Egly and his wife started the practice after each working in a large multispecialty group for about 4 years, and they quickly realized that to be successful they would have to practice differently. “In opening our practice, we realized that resources are tough to come by,” Dr. Egly said.

They implemented the EMR system from the start, and they have tried to keep their overhead low. For 2007, Dr. Egly estimates that overhead for the practice will be about 36% of projected revenue, with the EMR and its network accounting for only about 2.5% of the overhead costs.

The benefits of the low overhead are that he and his wife can see a lower volume of patients and still support the practice. They estimate that it takes about four patients a day to cover their expenses. They can also provide generally longer patient appointments. For example, they routinely provide 60 minutes for a physical, 40 minutes for a chronic care appointment, and 20 minutes for an short-term care visit. “It provides a good work flow for the day and breathing room every day,” he said.

And the design of the practice also lends itself to better patient access, Dr. Egly said. Because he and his wife answer the phones themselves, patients can speak directly to their physician. They also provide 24/7 access to patients. After-hours calls to the office are put through to a pager, and the patient receives a call back in about 15 minutes. “By giving them the access, I actually get fewer calls, but the calls I get are the important ones,” he said.

To improve access, they are working on creating a patient portal that will allow patients to make online appointments, check lab results, and access their charts.

“This is a very satisfying way to practice medicine,” Dr. Egly said.

For Dr. Magera, an EMR system is still too expensive, and she hasn't been able to find one with the necessary functionality for her practice. Instead, she uses preprinted forms that are aimed at streamlining the work flow in her office and reducing callbacks from pharmacists, caregivers, other physicians, and insurers.

Dr. Magera, who has been in practice for about 10 years, sees both allergy and internal medicine patients at four offices in the Charleston area.

The preprinted forms she created have also made it easier for the staff to code correctly, she said. “We code it right the first time. Therefore, we get very few calls back,” she said.

For example, Dr. Magera uses preprinted prescription pads for each drug she prescribes with the drug name and dosage already printed. The prescriptions are compliant with state pharmacy laws and are color coded for patients with low literacy. The pads are relatively cheap but make prescribing much faster, Dr. Magera said. And she doesn't run into the handwriting problems or dosage mistakes that can plague handwritten prescriptions.

Dr. Magera and her staff also have created special forms for phone notes, allowing the staff to document any contact the patient has with office staff that doesn't happen during a visit.

The notes, which also cover contacts by e-mail, letter, fax, or handheld personal digital assistant, are given first to a nurse for review and then signed by the physician. All phone notes must be reviewed before the end of the work day, she said.

But those are just a few of the standardized forms that she uses in her practice. She also uses preprinted forms to request laboratory, x-ray, and CT studies.

Some of her forms help her to get paid, she said. Dr. Magera has a standard insurance verification form that asks for current demographic information on the patient and policy holder, deductibles and copays for the office visit and procedures, preexisting conditions, which facilities are covered for lab and x-ray procedures, and whether precertification is required.

Although the process was originally time consuming, the staff is now able to get some information online. Having the standardized form allows her billing staff to discuss financial responsibility with the patient before the first office visit.

So far, consistently using the form to collect information before the visit has helped increase revenues by 25%–40%, she said. And the process is popular with patients because there are no surprise bills later on, she said.

Having a paper-based office can work, Dr. Magera said, and her rule of thumb is that if she does a task more than once it qualifies for a preprinted form.

But she doesn't expect to be using paper forever. “These forms are really preparing us for when we get our EMR,” she said.

SAN DIEGO — Physicians are finding ways to redesign their practices and improve efficiency, both with and without the use of electronic medical records.

Dr. Kevin D. Egly of Sandwich, Ill., has used his comprehensive electronic medical record (EMR) system to practice in a scaled-down office without staff. Taking a lower-tech approach, Dr. Barbara E. Magera of Charleston, S.C., uses preprinted forms to accomplish many of the functions done by an electronic system but for a fraction of the cost.

The two physicians presented their different approaches at the annual meeting of the American College of Physicians. Both practices have been studied by the ACP's Center for Practice Innovation, a 2-year project created by the ACP to help small practices improve their work flow.

For Dr. Egly, the comprehensive EMR system, which performs chart documentation and billing, is what makes it possible for him to practice the way that he does. He and his wife Angela, also an internist, each work about 20 hours a week in their small practice. Since they don't employ any other staff, they answer the phones themselves and handle their own billing.

They have built the practice over the last 3 years, and each now sees about 400–500 patients. Dr. Egly and his wife started the practice after each working in a large multispecialty group for about 4 years, and they quickly realized that to be successful they would have to practice differently. “In opening our practice, we realized that resources are tough to come by,” Dr. Egly said.

They implemented the EMR system from the start, and they have tried to keep their overhead low. For 2007, Dr. Egly estimates that overhead for the practice will be about 36% of projected revenue, with the EMR and its network accounting for only about 2.5% of the overhead costs.

The benefits of the low overhead are that he and his wife can see a lower volume of patients and still support the practice. They estimate that it takes about four patients a day to cover their expenses. They can also provide generally longer patient appointments. For example, they routinely provide 60 minutes for a physical, 40 minutes for a chronic care appointment, and 20 minutes for an short-term care visit. “It provides a good work flow for the day and breathing room every day,” he said.

And the design of the practice also lends itself to better patient access, Dr. Egly said. Because he and his wife answer the phones themselves, patients can speak directly to their physician. They also provide 24/7 access to patients. After-hours calls to the office are put through to a pager, and the patient receives a call back in about 15 minutes. “By giving them the access, I actually get fewer calls, but the calls I get are the important ones,” he said.

To improve access, they are working on creating a patient portal that will allow patients to make online appointments, check lab results, and access their charts.

“This is a very satisfying way to practice medicine,” Dr. Egly said.

For Dr. Magera, an EMR system is still too expensive, and she hasn't been able to find one with the necessary functionality for her practice. Instead, she uses preprinted forms that are aimed at streamlining the work flow in her office and reducing callbacks from pharmacists, caregivers, other physicians, and insurers.

Dr. Magera, who has been in practice for about 10 years, sees both allergy and internal medicine patients at four offices in the Charleston area.

The preprinted forms she created have also made it easier for the staff to code correctly, she said. “We code it right the first time. Therefore, we get very few calls back,” she said.

For example, Dr. Magera uses preprinted prescription pads for each drug she prescribes with the drug name and dosage already printed. The prescriptions are compliant with state pharmacy laws and are color coded for patients with low literacy. The pads are relatively cheap but make prescribing much faster, Dr. Magera said. And she doesn't run into the handwriting problems or dosage mistakes that can plague handwritten prescriptions.

Dr. Magera and her staff also have created special forms for phone notes, allowing the staff to document any contact the patient has with office staff that doesn't happen during a visit.

The notes, which also cover contacts by e-mail, letter, fax, or handheld personal digital assistant, are given first to a nurse for review and then signed by the physician. All phone notes must be reviewed before the end of the work day, she said.

But those are just a few of the standardized forms that she uses in her practice. She also uses preprinted forms to request laboratory, x-ray, and CT studies.

Some of her forms help her to get paid, she said. Dr. Magera has a standard insurance verification form that asks for current demographic information on the patient and policy holder, deductibles and copays for the office visit and procedures, preexisting conditions, which facilities are covered for lab and x-ray procedures, and whether precertification is required.

Although the process was originally time consuming, the staff is now able to get some information online. Having the standardized form allows her billing staff to discuss financial responsibility with the patient before the first office visit.

So far, consistently using the form to collect information before the visit has helped increase revenues by 25%–40%, she said. And the process is popular with patients because there are no surprise bills later on, she said.

Having a paper-based office can work, Dr. Magera said, and her rule of thumb is that if she does a task more than once it qualifies for a preprinted form.

But she doesn't expect to be using paper forever. “These forms are really preparing us for when we get our EMR,” she said.

SAN DIEGO — Physicians are finding ways to redesign their practices and improve efficiency, both with and without the use of electronic medical records.

Dr. Kevin D. Egly of Sandwich, Ill., has used his comprehensive electronic medical record (EMR) system to practice in a scaled-down office without staff. Taking a lower-tech approach, Dr. Barbara E. Magera of Charleston, S.C., uses preprinted forms to accomplish many of the functions done by an electronic system but for a fraction of the cost.

The two physicians presented their different approaches at the annual meeting of the American College of Physicians. Both practices have been studied by the ACP's Center for Practice Innovation, a 2-year project created by the ACP to help small practices improve their work flow.

For Dr. Egly, the comprehensive EMR system, which performs chart documentation and billing, is what makes it possible for him to practice the way that he does. He and his wife Angela, also an internist, each work about 20 hours a week in their small practice. Since they don't employ any other staff, they answer the phones themselves and handle their own billing.

They have built the practice over the last 3 years, and each now sees about 400–500 patients. Dr. Egly and his wife started the practice after each working in a large multispecialty group for about 4 years, and they quickly realized that to be successful they would have to practice differently. “In opening our practice, we realized that resources are tough to come by,” Dr. Egly said.

They implemented the EMR system from the start, and they have tried to keep their overhead low. For 2007, Dr. Egly estimates that overhead for the practice will be about 36% of projected revenue, with the EMR and its network accounting for only about 2.5% of the overhead costs.

The benefits of the low overhead are that he and his wife can see a lower volume of patients and still support the practice. They estimate that it takes about four patients a day to cover their expenses. They can also provide generally longer patient appointments. For example, they routinely provide 60 minutes for a physical, 40 minutes for a chronic care appointment, and 20 minutes for an short-term care visit. “It provides a good work flow for the day and breathing room every day,” he said.

And the design of the practice also lends itself to better patient access, Dr. Egly said. Because he and his wife answer the phones themselves, patients can speak directly to their physician. They also provide 24/7 access to patients. After-hours calls to the office are put through to a pager, and the patient receives a call back in about 15 minutes. “By giving them the access, I actually get fewer calls, but the calls I get are the important ones,” he said.

To improve access, they are working on creating a patient portal that will allow patients to make online appointments, check lab results, and access their charts.

“This is a very satisfying way to practice medicine,” Dr. Egly said.

For Dr. Magera, an EMR system is still too expensive, and she hasn't been able to find one with the necessary functionality for her practice. Instead, she uses preprinted forms that are aimed at streamlining the work flow in her office and reducing callbacks from pharmacists, caregivers, other physicians, and insurers.

Dr. Magera, who has been in practice for about 10 years, sees both allergy and internal medicine patients at four offices in the Charleston area.

The preprinted forms she created have also made it easier for the staff to code correctly, she said. “We code it right the first time. Therefore, we get very few calls back,” she said.

For example, Dr. Magera uses preprinted prescription pads for each drug she prescribes with the drug name and dosage already printed. The prescriptions are compliant with state pharmacy laws and are color coded for patients with low literacy. The pads are relatively cheap but make prescribing much faster, Dr. Magera said. And she doesn't run into the handwriting problems or dosage mistakes that can plague handwritten prescriptions.

Dr. Magera and her staff also have created special forms for phone notes, allowing the staff to document any contact the patient has with office staff that doesn't happen during a visit.

The notes, which also cover contacts by e-mail, letter, fax, or handheld personal digital assistant, are given first to a nurse for review and then signed by the physician. All phone notes must be reviewed before the end of the work day, she said.

But those are just a few of the standardized forms that she uses in her practice. She also uses preprinted forms to request laboratory, x-ray, and CT studies.

Some of her forms help her to get paid, she said. Dr. Magera has a standard insurance verification form that asks for current demographic information on the patient and policy holder, deductibles and copays for the office visit and procedures, preexisting conditions, which facilities are covered for lab and x-ray procedures, and whether precertification is required.

Although the process was originally time consuming, the staff is now able to get some information online. Having the standardized form allows her billing staff to discuss financial responsibility with the patient before the first office visit.

So far, consistently using the form to collect information before the visit has helped increase revenues by 25%–40%, she said. And the process is popular with patients because there are no surprise bills later on, she said.

Having a paper-based office can work, Dr. Magera said, and her rule of thumb is that if she does a task more than once it qualifies for a preprinted form.

But she doesn't expect to be using paper forever. “These forms are really preparing us for when we get our EMR,” she said.

TORONTO — Diet and exercise remain the first-line treatment for overweight and obese children, according to guidelines on the diagnosis, treatment, and prevention of pediatric obesity developed by the Endocrine Society.

Although selective patients may be candidates for pharmacotherapy or bariatric surgery, lifestyle modification remains the basic treatment modality, said Dr. Gilbert P. August, chair of the expert panel that developed the guidelines.

“Prevention of obesity should be the prime directive,” said Dr. August, a pediatric endocrinologist and professor emeritus of pediatrics at George Washington University, Washington.

At press time, the pediatric obesity guidelines had been submitted for publication. The guidelines include both recommendations and suggestions; suggestions are given in cases where the evidence is weaker. Dr. August offered a preview of the guidelines at the annual meeting of the Endocrine Society.

The prevalence of obesity, defined as having a body mass index (BMI) over the 95th percentile for age and sex, is about 17%, representing a fourfold increase among 6- to 11-year-olds, a threefold increase among 12- to 19-year-olds, and nearly a threefold increase among 2- to 5-year-olds, versus a survey done from 1963 to 1970.

“It is important to look at childhood obesity as a possible precursor of adult obesity and institute corrective measures as soon as possible,” Dr. August said.

The diagnostic recommendations include using the normative percentiles for BMI developed by the Centers for Disease Control and Prevention. The panel also recommended against a routine endocrine evaluation in obese or overweight children unless the growth rate of the child is attenuated.

However, the panel is recommending a referral to a geneticist when the obesity is associated with neurodevelopmental abnormalities. The panel is also suggesting that parents be informed about the possibility of MC4R genetic testing if the child has gained weight from early infancy and is over the 97th percentile for weight at 3 years of age. But keep in mind that test results are positive in only 2%–4% of such children and will not change the treatment, Dr. August said.

Children whose BMIs are above the 85th percentile should be evaluated for comorbidities, according to the guidelines. Screening tests and measurements should include fasting plasma glucose, fasting lipid profiles, blood pressure, and waist circumference.

In terms of treatment, the committee is recommending lifestyle modification as the “cornerstone” for treatment of overweight and obesity in children.

The approach of diet and exercise has a bad reputation, Dr. August acknowledged. There are a number of obstacles to implementing lifestyle approaches effectively, including denial on the part of the family.

Pharmacotherapy can be added after failure of a 6-month trial of diet and exercise in overweight and obese children, the committee suggests. But when considering pharmacotherapy in the overweight child, the child should have significant comorbidities to justify the risk. In addition, the family needs to understand that the medications available have waning effectiveness after 6 months.

The expert panel also suggests the use of bariatric surgery only after failure of a 6-month trial of lifestyle modification with or without a trial of pharmacotherapy in adolescents who have a BMI of over 40 and severe comorbidities. This treatment also can be considered in adolescents with a BMI over 50, Dr. August said.

But the panel adds a number of caveats. For example, the family must undergo psychological evaluation and the surgical team must have adequate pediatric experience and have personnel available capable of handling the metabolic and psychosocial needs of the entire family.

The committee members also suggest that primary care physicians offer more education on obesity and healthy eating.

TORONTO — Diet and exercise remain the first-line treatment for overweight and obese children, according to guidelines on the diagnosis, treatment, and prevention of pediatric obesity developed by the Endocrine Society.

Although selective patients may be candidates for pharmacotherapy or bariatric surgery, lifestyle modification remains the basic treatment modality, said Dr. Gilbert P. August, chair of the expert panel that developed the guidelines.

“Prevention of obesity should be the prime directive,” said Dr. August, a pediatric endocrinologist and professor emeritus of pediatrics at George Washington University, Washington.

At press time, the pediatric obesity guidelines had been submitted for publication. The guidelines include both recommendations and suggestions; suggestions are given in cases where the evidence is weaker. Dr. August offered a preview of the guidelines at the annual meeting of the Endocrine Society.

The prevalence of obesity, defined as having a body mass index (BMI) over the 95th percentile for age and sex, is about 17%, representing a fourfold increase among 6- to 11-year-olds, a threefold increase among 12- to 19-year-olds, and nearly a threefold increase among 2- to 5-year-olds, versus a survey done from 1963 to 1970.

“It is important to look at childhood obesity as a possible precursor of adult obesity and institute corrective measures as soon as possible,” Dr. August said.

The diagnostic recommendations include using the normative percentiles for BMI developed by the Centers for Disease Control and Prevention. The panel also recommended against a routine endocrine evaluation in obese or overweight children unless the growth rate of the child is attenuated.

However, the panel is recommending a referral to a geneticist when the obesity is associated with neurodevelopmental abnormalities. The panel is also suggesting that parents be informed about the possibility of MC4R genetic testing if the child has gained weight from early infancy and is over the 97th percentile for weight at 3 years of age. But keep in mind that test results are positive in only 2%–4% of such children and will not change the treatment, Dr. August said.

Children whose BMIs are above the 85th percentile should be evaluated for comorbidities, according to the guidelines. Screening tests and measurements should include fasting plasma glucose, fasting lipid profiles, blood pressure, and waist circumference.

In terms of treatment, the committee is recommending lifestyle modification as the “cornerstone” for treatment of overweight and obesity in children.

The approach of diet and exercise has a bad reputation, Dr. August acknowledged. There are a number of obstacles to implementing lifestyle approaches effectively, including denial on the part of the family.

Pharmacotherapy can be added after failure of a 6-month trial of diet and exercise in overweight and obese children, the committee suggests. But when considering pharmacotherapy in the overweight child, the child should have significant comorbidities to justify the risk. In addition, the family needs to understand that the medications available have waning effectiveness after 6 months.

The expert panel also suggests the use of bariatric surgery only after failure of a 6-month trial of lifestyle modification with or without a trial of pharmacotherapy in adolescents who have a BMI of over 40 and severe comorbidities. This treatment also can be considered in adolescents with a BMI over 50, Dr. August said.

But the panel adds a number of caveats. For example, the family must undergo psychological evaluation and the surgical team must have adequate pediatric experience and have personnel available capable of handling the metabolic and psychosocial needs of the entire family.

The committee members also suggest that primary care physicians offer more education on obesity and healthy eating.

TORONTO — Diet and exercise remain the first-line treatment for overweight and obese children, according to guidelines on the diagnosis, treatment, and prevention of pediatric obesity developed by the Endocrine Society.

Although selective patients may be candidates for pharmacotherapy or bariatric surgery, lifestyle modification remains the basic treatment modality, said Dr. Gilbert P. August, chair of the expert panel that developed the guidelines.

“Prevention of obesity should be the prime directive,” said Dr. August, a pediatric endocrinologist and professor emeritus of pediatrics at George Washington University, Washington.

At press time, the pediatric obesity guidelines had been submitted for publication. The guidelines include both recommendations and suggestions; suggestions are given in cases where the evidence is weaker. Dr. August offered a preview of the guidelines at the annual meeting of the Endocrine Society.

The prevalence of obesity, defined as having a body mass index (BMI) over the 95th percentile for age and sex, is about 17%, representing a fourfold increase among 6- to 11-year-olds, a threefold increase among 12- to 19-year-olds, and nearly a threefold increase among 2- to 5-year-olds, versus a survey done from 1963 to 1970.

“It is important to look at childhood obesity as a possible precursor of adult obesity and institute corrective measures as soon as possible,” Dr. August said.

The diagnostic recommendations include using the normative percentiles for BMI developed by the Centers for Disease Control and Prevention. The panel also recommended against a routine endocrine evaluation in obese or overweight children unless the growth rate of the child is attenuated.

However, the panel is recommending a referral to a geneticist when the obesity is associated with neurodevelopmental abnormalities. The panel is also suggesting that parents be informed about the possibility of MC4R genetic testing if the child has gained weight from early infancy and is over the 97th percentile for weight at 3 years of age. But keep in mind that test results are positive in only 2%–4% of such children and will not change the treatment, Dr. August said.

Children whose BMIs are above the 85th percentile should be evaluated for comorbidities, according to the guidelines. Screening tests and measurements should include fasting plasma glucose, fasting lipid profiles, blood pressure, and waist circumference.

In terms of treatment, the committee is recommending lifestyle modification as the “cornerstone” for treatment of overweight and obesity in children.

The approach of diet and exercise has a bad reputation, Dr. August acknowledged. There are a number of obstacles to implementing lifestyle approaches effectively, including denial on the part of the family.

Pharmacotherapy can be added after failure of a 6-month trial of diet and exercise in overweight and obese children, the committee suggests. But when considering pharmacotherapy in the overweight child, the child should have significant comorbidities to justify the risk. In addition, the family needs to understand that the medications available have waning effectiveness after 6 months.

The expert panel also suggests the use of bariatric surgery only after failure of a 6-month trial of lifestyle modification with or without a trial of pharmacotherapy in adolescents who have a BMI of over 40 and severe comorbidities. This treatment also can be considered in adolescents with a BMI over 50, Dr. August said.

But the panel adds a number of caveats. For example, the family must undergo psychological evaluation and the surgical team must have adequate pediatric experience and have personnel available capable of handling the metabolic and psychosocial needs of the entire family.

The committee members also suggest that primary care physicians offer more education on obesity and healthy eating.

SAN DIEGO – Counseling patients about end-of-life care is often a difficult task, but it can be more complicated when the patient has an ethnic or cultural background that differs from your own.

Asking open-ended questions about the patient's concerns and fears is often the best way to elicit information, experts said at the annual meeting of the American College of Physicians.

Open-ended questions can be used even if you are unfamiliar with the culture of the patient. “You don't have to know the details of every culture,” said Dr. Bernard Lo, professor of medicine and director of the program in medical ethics at the University of California, San Francisco.

One of the issues that sometimes come up in treating patients from traditional cultures, such as Asian Americans, is withholding information from the patient. For example, a family member may ask the medical staff to limit the information provided to the patient about the prognosis of their cancer.

Many families believe that explicitly telling the patient bad news will cause unnecessary suffering or cause the patient to lose hope, Dr. Lo said.

There are some options in responding to these types of requests, he said. One approach is to explain to the family why it's desirable to give the patient more information. For example, some patients do better when they know their prognosis because they can make plans. Telling patients about their condition also provides an opportunity to discuss palliative care. And patients tend to find out anyway, especially in big hospitals, he said.

In addition to talking to family members, Dr. Lo said that finding out what the patient wants is critical. In some cases, what the patient wants and what the family wants may differ. Give the patient a chance to choose how much information he or she wants to hear, he said.

“I think it's good to offer information,” Dr. Lo said.

Sometimes cultural issues can also affect how the patient expresses pain. For instance, Dr. Lo recently had a case in which the children of a patient complained that their father's pain was not being adequately addressed. It turned out that the patient, a 56-year-old Chinese-American man, was underreporting his pain because he didn't want to bother the nurses.

In that case, patient-controlled analgesia was helpful because he no longer had to ask the nurses for pain relief, Dr. Lo said.

Providing culturally competent care at the end of life also means being aware of racial disparities, said Dr. LaVera Crawley, of the Center for Biomedical Ethics at Stanford (Calif.) University. A lack of access to aggressive treatments–or even a perceived lack of access–can affect the patient's willingness to receive palliative care later on, Dr. Crawley said.

Documented racial and ethnic disparities in accessing treatment may be one explanation for the general underuse of hospice and other palliative care services among African-American patients, she said. This group tends to prefer resource-intensive care, such as aggressive interventions. Similar trends are also seen in Hispanic and Asian-American families.

For groups that may have been subject to inequity in their health care, the idea of comfortably dying can be seen as a misplaced priority, Dr. Crawley said. “Obviously, we have to start thinking about issues of trust,” she said.

SAN DIEGO – Counseling patients about end-of-life care is often a difficult task, but it can be more complicated when the patient has an ethnic or cultural background that differs from your own.

Asking open-ended questions about the patient's concerns and fears is often the best way to elicit information, experts said at the annual meeting of the American College of Physicians.

Open-ended questions can be used even if you are unfamiliar with the culture of the patient. “You don't have to know the details of every culture,” said Dr. Bernard Lo, professor of medicine and director of the program in medical ethics at the University of California, San Francisco.

One of the issues that sometimes come up in treating patients from traditional cultures, such as Asian Americans, is withholding information from the patient. For example, a family member may ask the medical staff to limit the information provided to the patient about the prognosis of their cancer.

Many families believe that explicitly telling the patient bad news will cause unnecessary suffering or cause the patient to lose hope, Dr. Lo said.

There are some options in responding to these types of requests, he said. One approach is to explain to the family why it's desirable to give the patient more information. For example, some patients do better when they know their prognosis because they can make plans. Telling patients about their condition also provides an opportunity to discuss palliative care. And patients tend to find out anyway, especially in big hospitals, he said.

In addition to talking to family members, Dr. Lo said that finding out what the patient wants is critical. In some cases, what the patient wants and what the family wants may differ. Give the patient a chance to choose how much information he or she wants to hear, he said.

“I think it's good to offer information,” Dr. Lo said.

Sometimes cultural issues can also affect how the patient expresses pain. For instance, Dr. Lo recently had a case in which the children of a patient complained that their father's pain was not being adequately addressed. It turned out that the patient, a 56-year-old Chinese-American man, was underreporting his pain because he didn't want to bother the nurses.

In that case, patient-controlled analgesia was helpful because he no longer had to ask the nurses for pain relief, Dr. Lo said.

Providing culturally competent care at the end of life also means being aware of racial disparities, said Dr. LaVera Crawley, of the Center for Biomedical Ethics at Stanford (Calif.) University. A lack of access to aggressive treatments–or even a perceived lack of access–can affect the patient's willingness to receive palliative care later on, Dr. Crawley said.

Documented racial and ethnic disparities in accessing treatment may be one explanation for the general underuse of hospice and other palliative care services among African-American patients, she said. This group tends to prefer resource-intensive care, such as aggressive interventions. Similar trends are also seen in Hispanic and Asian-American families.

For groups that may have been subject to inequity in their health care, the idea of comfortably dying can be seen as a misplaced priority, Dr. Crawley said. “Obviously, we have to start thinking about issues of trust,” she said.

SAN DIEGO – Counseling patients about end-of-life care is often a difficult task, but it can be more complicated when the patient has an ethnic or cultural background that differs from your own.

Asking open-ended questions about the patient's concerns and fears is often the best way to elicit information, experts said at the annual meeting of the American College of Physicians.

Open-ended questions can be used even if you are unfamiliar with the culture of the patient. “You don't have to know the details of every culture,” said Dr. Bernard Lo, professor of medicine and director of the program in medical ethics at the University of California, San Francisco.

One of the issues that sometimes come up in treating patients from traditional cultures, such as Asian Americans, is withholding information from the patient. For example, a family member may ask the medical staff to limit the information provided to the patient about the prognosis of their cancer.

Many families believe that explicitly telling the patient bad news will cause unnecessary suffering or cause the patient to lose hope, Dr. Lo said.

There are some options in responding to these types of requests, he said. One approach is to explain to the family why it's desirable to give the patient more information. For example, some patients do better when they know their prognosis because they can make plans. Telling patients about their condition also provides an opportunity to discuss palliative care. And patients tend to find out anyway, especially in big hospitals, he said.

In addition to talking to family members, Dr. Lo said that finding out what the patient wants is critical. In some cases, what the patient wants and what the family wants may differ. Give the patient a chance to choose how much information he or she wants to hear, he said.

“I think it's good to offer information,” Dr. Lo said.

Sometimes cultural issues can also affect how the patient expresses pain. For instance, Dr. Lo recently had a case in which the children of a patient complained that their father's pain was not being adequately addressed. It turned out that the patient, a 56-year-old Chinese-American man, was underreporting his pain because he didn't want to bother the nurses.

In that case, patient-controlled analgesia was helpful because he no longer had to ask the nurses for pain relief, Dr. Lo said.

Providing culturally competent care at the end of life also means being aware of racial disparities, said Dr. LaVera Crawley, of the Center for Biomedical Ethics at Stanford (Calif.) University. A lack of access to aggressive treatments–or even a perceived lack of access–can affect the patient's willingness to receive palliative care later on, Dr. Crawley said.

Documented racial and ethnic disparities in accessing treatment may be one explanation for the general underuse of hospice and other palliative care services among African-American patients, she said. This group tends to prefer resource-intensive care, such as aggressive interventions. Similar trends are also seen in Hispanic and Asian-American families.

For groups that may have been subject to inequity in their health care, the idea of comfortably dying can be seen as a misplaced priority, Dr. Crawley said. “Obviously, we have to start thinking about issues of trust,” she said.