Mary Ellen Schneider

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 of the team of federal, state, and local investigators. The team began its operations in March using both real-time analysis of billing data from Medicare and claims data extracted from the Health Care Information System.

In May, the departments of Justice and Health and Human Services jointly announced that the multiagency team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. The 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 had recently expressed concern about reports of durable medical equipment fraud in South Florida. In one recent case, the Health and Human Services inspector general found that many medical device suppliers were not at their advertised addresses and were still 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 of the team of federal, state, and local investigators. The team began its operations in March using both real-time analysis of billing data from Medicare and claims data extracted from the Health Care Information System.

In May, the departments of Justice and Health and Human Services jointly announced that the multiagency team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. The 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 had recently expressed concern about reports of durable medical equipment fraud in South Florida. In one recent case, the Health and Human Services inspector general found that many medical device suppliers were not at their advertised addresses and were still 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 of the team of federal, state, and local investigators. The team began its operations in March using both real-time analysis of billing data from Medicare and claims data extracted from the Health Care Information System.

In May, the departments of Justice and Health and Human Services jointly announced that the multiagency team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. The 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 had recently expressed concern about reports of durable medical equipment fraud in South Florida. In one recent case, the Health and Human Services inspector general found that many medical device suppliers were not at their advertised addresses and were still billing Medicare for millions of dollars in reimbursement.

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 reported that 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 also reported excessive hold times and excessive 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 reported that 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 also reported excessive hold times and excessive 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 reported that 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 also reported excessive hold times and excessive documentation requested by payers with both types of Medicare Advantage plans.

CMS is accepting comments on the proposal through July 24.

NEW ORLEANS – Antidepressants and antiepileptics are both effective in treating neuropathic pain, but a combination performs best, according to Dr. Damon Robinson.

Dr. Robinson and colleagues found that nearly 80% of patients who took a combination of antiepileptics and antidepressant medications had a greater than 50% visual analogue scale (VAS) improvement, a statistically significant finding. The results were presented as a poster at the annual meeting of the American Academy of Pain Medicine.

Whereas clinical trials have shown clear evidence in favor of using antidepressants and antiepileptic medications alone in treating chronic pain, no studies have been designed to focus on the effect of combining antidepressants and antiepileptics for the treatment of neuropathic pain, wrote Dr. Robinson of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and his colleagues.

Over a 2-year period, the researchers reviewed 6,129 charts with an initial encounter and a diagnosis of neuropathic pain. They also analyzed VAS, medical procedures, and antidepressant and antiepileptic use and dosage at each visit. Patients who had a 50% or greater improvement in their VAS score were considered to have a favorable response.

Of the charts reviewed, 3,370 patients had at least one antidepressant or antiepileptic prescribed. All of the antidepressant and antiepileptic drugs analyzed had favorable responses in more than 70% of patients. There was a statistically significant level of improvement among patients prescribed tertiary amines and among those prescribed a combination of antiepileptics and antidepressants. A total of 939 patients received the combination, with 79.4% reporting a VAS score improvement of 50% or greater. About 19.4% of patients who received combination therapy had no response, and 1.2% had an unknown response.

While retrospective studies have limits, the results are encouraging and indicate the need for prospective studies, Dr. Robinson said in an interview.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS – Antidepressants and antiepileptics are both effective in treating neuropathic pain, but a combination performs best, according to Dr. Damon Robinson.

Dr. Robinson and colleagues found that nearly 80% of patients who took a combination of antiepileptics and antidepressant medications had a greater than 50% visual analogue scale (VAS) improvement, a statistically significant finding. The results were presented as a poster at the annual meeting of the American Academy of Pain Medicine.

Whereas clinical trials have shown clear evidence in favor of using antidepressants and antiepileptic medications alone in treating chronic pain, no studies have been designed to focus on the effect of combining antidepressants and antiepileptics for the treatment of neuropathic pain, wrote Dr. Robinson of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and his colleagues.

Over a 2-year period, the researchers reviewed 6,129 charts with an initial encounter and a diagnosis of neuropathic pain. They also analyzed VAS, medical procedures, and antidepressant and antiepileptic use and dosage at each visit. Patients who had a 50% or greater improvement in their VAS score were considered to have a favorable response.

Of the charts reviewed, 3,370 patients had at least one antidepressant or antiepileptic prescribed. All of the antidepressant and antiepileptic drugs analyzed had favorable responses in more than 70% of patients. There was a statistically significant level of improvement among patients prescribed tertiary amines and among those prescribed a combination of antiepileptics and antidepressants. A total of 939 patients received the combination, with 79.4% reporting a VAS score improvement of 50% or greater. About 19.4% of patients who received combination therapy had no response, and 1.2% had an unknown response.

While retrospective studies have limits, the results are encouraging and indicate the need for prospective studies, Dr. Robinson said in an interview.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS – Antidepressants and antiepileptics are both effective in treating neuropathic pain, but a combination performs best, according to Dr. Damon Robinson.

Dr. Robinson and colleagues found that nearly 80% of patients who took a combination of antiepileptics and antidepressant medications had a greater than 50% visual analogue scale (VAS) improvement, a statistically significant finding. The results were presented as a poster at the annual meeting of the American Academy of Pain Medicine.

Whereas clinical trials have shown clear evidence in favor of using antidepressants and antiepileptic medications alone in treating chronic pain, no studies have been designed to focus on the effect of combining antidepressants and antiepileptics for the treatment of neuropathic pain, wrote Dr. Robinson of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and his colleagues.

Over a 2-year period, the researchers reviewed 6,129 charts with an initial encounter and a diagnosis of neuropathic pain. They also analyzed VAS, medical procedures, and antidepressant and antiepileptic use and dosage at each visit. Patients who had a 50% or greater improvement in their VAS score were considered to have a favorable response.

Of the charts reviewed, 3,370 patients had at least one antidepressant or antiepileptic prescribed. All of the antidepressant and antiepileptic drugs analyzed had favorable responses in more than 70% of patients. There was a statistically significant level of improvement among patients prescribed tertiary amines and among those prescribed a combination of antiepileptics and antidepressants. A total of 939 patients received the combination, with 79.4% reporting a VAS score improvement of 50% or greater. About 19.4% of patients who received combination therapy had no response, and 1.2% had an unknown response.

While retrospective studies have limits, the results are encouraging and indicate the need for prospective studies, Dr. Robinson said in an interview.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS – Most opioid abusers report that they get their drugs from dealers, friends, and relatives, according to a survey of individuals entering methadone maintenance treatment programs.

But prescriptions from physicians still rank third on that list, and about 30% of opioid abusers cite physicians as a source for the painkillers. Researchers at the American Association for the Treatment of Opioid Dependence, the National Development and Research Institutes, and Purdue Pharma L.P. evaluated the prevalence of prescription opioid abuse among 8,039 individuals who were admitted to 73 methadone maintenance programs in 33 states.

About 60% of the respondents were men; 95% were white. The respondents' mean age was 32 years.

About 12% reported public assistance as their major source of income, but approximately 56% of them said they were employed.

The study was presented as a poster by researcher Ann T. Kline of Purdue Pharma, which supported the research, at the annual meeting of the American Academy of Pain Medicine.

About 40% of the respondents reported that a prescription opioid analgesic was their primary drug of abuse in the month before entering the methadone program. Of the 3,294 respondents who said that prescription opioids were their primary drug of abuse, only 2.9% of respondents said the Internet was a source for opioids.

Respondents could name more than one source.

A physician's prescription was cited by 30.1% of opioid abusers. Emergency department visits were a source for another 13.5%, and a much smaller group, about 2.5% of opioid abusers surveyed, cited forged prescriptions as their source. The survey did not differentiate between prescriptions issued for legitimate medical uses and those that were not.

The most frequently cited sources for illegally obtained prescription opioid analgesics were dealers (79.9%), followed by friends and relatives (51.3%), the researchers reported

About 6.4% of the respondents in the survey cited theft as a way in which they had obtained their primary drug of abuse.

NEW ORLEANS – Most opioid abusers report that they get their drugs from dealers, friends, and relatives, according to a survey of individuals entering methadone maintenance treatment programs.

But prescriptions from physicians still rank third on that list, and about 30% of opioid abusers cite physicians as a source for the painkillers. Researchers at the American Association for the Treatment of Opioid Dependence, the National Development and Research Institutes, and Purdue Pharma L.P. evaluated the prevalence of prescription opioid abuse among 8,039 individuals who were admitted to 73 methadone maintenance programs in 33 states.

About 60% of the respondents were men; 95% were white. The respondents' mean age was 32 years.

About 12% reported public assistance as their major source of income, but approximately 56% of them said they were employed.

The study was presented as a poster by researcher Ann T. Kline of Purdue Pharma, which supported the research, at the annual meeting of the American Academy of Pain Medicine.

About 40% of the respondents reported that a prescription opioid analgesic was their primary drug of abuse in the month before entering the methadone program. Of the 3,294 respondents who said that prescription opioids were their primary drug of abuse, only 2.9% of respondents said the Internet was a source for opioids.

Respondents could name more than one source.

A physician's prescription was cited by 30.1% of opioid abusers. Emergency department visits were a source for another 13.5%, and a much smaller group, about 2.5% of opioid abusers surveyed, cited forged prescriptions as their source. The survey did not differentiate between prescriptions issued for legitimate medical uses and those that were not.

The most frequently cited sources for illegally obtained prescription opioid analgesics were dealers (79.9%), followed by friends and relatives (51.3%), the researchers reported

About 6.4% of the respondents in the survey cited theft as a way in which they had obtained their primary drug of abuse.

NEW ORLEANS – Most opioid abusers report that they get their drugs from dealers, friends, and relatives, according to a survey of individuals entering methadone maintenance treatment programs.

But prescriptions from physicians still rank third on that list, and about 30% of opioid abusers cite physicians as a source for the painkillers. Researchers at the American Association for the Treatment of Opioid Dependence, the National Development and Research Institutes, and Purdue Pharma L.P. evaluated the prevalence of prescription opioid abuse among 8,039 individuals who were admitted to 73 methadone maintenance programs in 33 states.

About 60% of the respondents were men; 95% were white. The respondents' mean age was 32 years.

About 12% reported public assistance as their major source of income, but approximately 56% of them said they were employed.

The study was presented as a poster by researcher Ann T. Kline of Purdue Pharma, which supported the research, at the annual meeting of the American Academy of Pain Medicine.

About 40% of the respondents reported that a prescription opioid analgesic was their primary drug of abuse in the month before entering the methadone program. Of the 3,294 respondents who said that prescription opioids were their primary drug of abuse, only 2.9% of respondents said the Internet was a source for opioids.

Respondents could name more than one source.

A physician's prescription was cited by 30.1% of opioid abusers. Emergency department visits were a source for another 13.5%, and a much smaller group, about 2.5% of opioid abusers surveyed, cited forged prescriptions as their source. The survey did not differentiate between prescriptions issued for legitimate medical uses and those that were not.

The most frequently cited sources for illegally obtained prescription opioid analgesics were dealers (79.9%), followed by friends and relatives (51.3%), the researchers reported

About 6.4% of the respondents in the survey cited theft as a way in which they had obtained their primary drug of abuse.

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 of the team of federal, state, and local investigators. The team began its operations in March using both real-time analysis of billing data from Medicare and claims data extracted from the Health Care Information System.

In May, the departments of Justice and Health and Human Services jointly announced that the multiagency team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. The 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 had recently expressed concern about reports of durable medical equipment fraud in South Florida. In one recent instance, the Health and Human Services inspector general found that many medical device suppliers were not at their advertised addresses but were still 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 of the team of federal, state, and local investigators. The team began its operations in March using both real-time analysis of billing data from Medicare and claims data extracted from the Health Care Information System.

In May, the departments of Justice and Health and Human Services jointly announced that the multiagency team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. The 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 had recently expressed concern about reports of durable medical equipment fraud in South Florida. In one recent instance, the Health and Human Services inspector general found that many medical device suppliers were not at their advertised addresses but were still 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 of the team of federal, state, and local investigators. The team began its operations in March using both real-time analysis of billing data from Medicare and claims data extracted from the Health Care Information System.

In May, the departments of Justice and Health and Human Services jointly announced that the multiagency team had obtained indictments of individuals and health care companies alleged to have collectively billed the Medicare program for more than $142 million. The 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 had recently expressed concern about reports of durable medical equipment fraud in South Florida. In one recent instance, the Health and Human Services inspector general found that many medical device suppliers were not at their advertised addresses but were still billing Medicare for millions of dollars in reimbursement.

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.

Dr. Egly and his wife started the practice after each working in a large multispecialty group, and they quickly realized that to be successful they would have to practice differently.

They implemented the EMR system from the start and have tried to keep 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%.

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 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 allergy and internal medicine patients at four offices. The preprinted forms she created have 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 does not 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. The office rule is that all phone notes must be reviewed before the end of the work day, she said.

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, pre-existing 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.

Dr. Egly and his wife started the practice after each working in a large multispecialty group, and they quickly realized that to be successful they would have to practice differently.

They implemented the EMR system from the start and have tried to keep 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%.

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 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 allergy and internal medicine patients at four offices. The preprinted forms she created have 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 does not 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. The office rule is that all phone notes must be reviewed before the end of the work day, she said.

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, pre-existing 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.

Dr. Egly and his wife started the practice after each working in a large multispecialty group, and they quickly realized that to be successful they would have to practice differently.

They implemented the EMR system from the start and have tried to keep 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%.

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 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 allergy and internal medicine patients at four offices. The preprinted forms she created have 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 does not 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. The office rule is that all phone notes must be reviewed before the end of the work day, she said.

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, pre-existing 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.

Over the next several months, officials at the American Board of Internal Medicine will be developing requirements for enhanced certification in comprehensive internal medicine.

The new optional certification would be called Recognition of Focused Practice, a designation that ABIM officials have been developing in order to recognize the special skills gained during practice, said Dr. Richard J. Baron, chair-elect of the ABIM Board of Directors. The added certification would be an optional part of the regular maintenance of certification process.

ABIM is developing a similar Recognition of Focused Practice certification pathway for hospital medicine (INTERNAL MEDICINE NEWS, June 15, 2007, p. 1). Before either of the two certification options can go forward, however, the Recognition of Focused Practice pathway must be approved by the American Board of Medical Specialties. Those discussions are ongoing, Dr. Baron said.

“It's very much a work in progress,” he said.

In the meantime, the ABIM Board of Directors has endorsed the idea that comprehensive internal medicine is a form of practice that is different from what is recognized by the underlying general internal medicine certificate. The board also recently asked a committee to develop requirements for such recognition. That group will report back to ABIM in February 2008.

Officials at the American College of Physicians are supportive of the concept of an added optional certification for the comprehensive internist.

“It's a healthy proposal to acknowledge that there are different ways doctors tend to spend their time or focus their practice,” said Dr. David C. Dale, ACP president.

The idea also complements the concept of the advanced medical home, which ACP and other primary care organizations have been advancing in Congress and throughout organized medicine.

Recertifying as a “comprehensive” internist would be a good fit for an internist working in the advanced medical home, because it would recognize the special skills of the internist who oversees patients with complicated illnesses across various care settings, Dr. Dale said.

The decision by ABIM to move forward with designing the requirements for a comprehensive internal medicine certification comes after a number of months of discussions held by an ABIM work group.

Led by Dr. Baron, the work group convened a series of roundtable discussions with a variety of health care practitioners and other stakeholders, including physicians, insurers, purchasers, and members of the health care team, including nurse practitioners and pharmacists. Members of the work group also consulted with chronic care patients.

What came out of those discussions was a “remarkably consistent vision” of what people wanted from a comprehensive internist, Dr. Baron said.

For example, there was strong consensus among the discussion participants that the comprehensive internist should communicate with patients efficiently and provide access not just for visits but also for questions and for follow-up between visits.

The groups also agreed that the comprehensive internist should have a deep knowledge of medicine and of the patient, Dr. Baron said.

If ABIM officials are successful in establishing a Recognition of Focused Practice certification in comprehensive internal medicine, it would be optional for physicians, he said.

The process could be valuable for internists because payers may see the added value of the services provided by a comprehensive internist and could choose to pay more to physicians with such certification, he said.

Over the next several months, officials at the American Board of Internal Medicine will be developing requirements for enhanced certification in comprehensive internal medicine.

The new optional certification would be called Recognition of Focused Practice, a designation that ABIM officials have been developing in order to recognize the special skills gained during practice, said Dr. Richard J. Baron, chair-elect of the ABIM Board of Directors. The added certification would be an optional part of the regular maintenance of certification process.

ABIM is developing a similar Recognition of Focused Practice certification pathway for hospital medicine (INTERNAL MEDICINE NEWS, June 15, 2007, p. 1). Before either of the two certification options can go forward, however, the Recognition of Focused Practice pathway must be approved by the American Board of Medical Specialties. Those discussions are ongoing, Dr. Baron said.

“It's very much a work in progress,” he said.

In the meantime, the ABIM Board of Directors has endorsed the idea that comprehensive internal medicine is a form of practice that is different from what is recognized by the underlying general internal medicine certificate. The board also recently asked a committee to develop requirements for such recognition. That group will report back to ABIM in February 2008.

Officials at the American College of Physicians are supportive of the concept of an added optional certification for the comprehensive internist.

“It's a healthy proposal to acknowledge that there are different ways doctors tend to spend their time or focus their practice,” said Dr. David C. Dale, ACP president.

The idea also complements the concept of the advanced medical home, which ACP and other primary care organizations have been advancing in Congress and throughout organized medicine.

Recertifying as a “comprehensive” internist would be a good fit for an internist working in the advanced medical home, because it would recognize the special skills of the internist who oversees patients with complicated illnesses across various care settings, Dr. Dale said.

The decision by ABIM to move forward with designing the requirements for a comprehensive internal medicine certification comes after a number of months of discussions held by an ABIM work group.

Led by Dr. Baron, the work group convened a series of roundtable discussions with a variety of health care practitioners and other stakeholders, including physicians, insurers, purchasers, and members of the health care team, including nurse practitioners and pharmacists. Members of the work group also consulted with chronic care patients.

What came out of those discussions was a “remarkably consistent vision” of what people wanted from a comprehensive internist, Dr. Baron said.

For example, there was strong consensus among the discussion participants that the comprehensive internist should communicate with patients efficiently and provide access not just for visits but also for questions and for follow-up between visits.

The groups also agreed that the comprehensive internist should have a deep knowledge of medicine and of the patient, Dr. Baron said.

If ABIM officials are successful in establishing a Recognition of Focused Practice certification in comprehensive internal medicine, it would be optional for physicians, he said.

The process could be valuable for internists because payers may see the added value of the services provided by a comprehensive internist and could choose to pay more to physicians with such certification, he said.

Over the next several months, officials at the American Board of Internal Medicine will be developing requirements for enhanced certification in comprehensive internal medicine.

The new optional certification would be called Recognition of Focused Practice, a designation that ABIM officials have been developing in order to recognize the special skills gained during practice, said Dr. Richard J. Baron, chair-elect of the ABIM Board of Directors. The added certification would be an optional part of the regular maintenance of certification process.

ABIM is developing a similar Recognition of Focused Practice certification pathway for hospital medicine (INTERNAL MEDICINE NEWS, June 15, 2007, p. 1). Before either of the two certification options can go forward, however, the Recognition of Focused Practice pathway must be approved by the American Board of Medical Specialties. Those discussions are ongoing, Dr. Baron said.

“It's very much a work in progress,” he said.

In the meantime, the ABIM Board of Directors has endorsed the idea that comprehensive internal medicine is a form of practice that is different from what is recognized by the underlying general internal medicine certificate. The board also recently asked a committee to develop requirements for such recognition. That group will report back to ABIM in February 2008.

Officials at the American College of Physicians are supportive of the concept of an added optional certification for the comprehensive internist.

“It's a healthy proposal to acknowledge that there are different ways doctors tend to spend their time or focus their practice,” said Dr. David C. Dale, ACP president.

The idea also complements the concept of the advanced medical home, which ACP and other primary care organizations have been advancing in Congress and throughout organized medicine.

Recertifying as a “comprehensive” internist would be a good fit for an internist working in the advanced medical home, because it would recognize the special skills of the internist who oversees patients with complicated illnesses across various care settings, Dr. Dale said.

The decision by ABIM to move forward with designing the requirements for a comprehensive internal medicine certification comes after a number of months of discussions held by an ABIM work group.

Led by Dr. Baron, the work group convened a series of roundtable discussions with a variety of health care practitioners and other stakeholders, including physicians, insurers, purchasers, and members of the health care team, including nurse practitioners and pharmacists. Members of the work group also consulted with chronic care patients.

What came out of those discussions was a “remarkably consistent vision” of what people wanted from a comprehensive internist, Dr. Baron said.

For example, there was strong consensus among the discussion participants that the comprehensive internist should communicate with patients efficiently and provide access not just for visits but also for questions and for follow-up between visits.

The groups also agreed that the comprehensive internist should have a deep knowledge of medicine and of the patient, Dr. Baron said.

If ABIM officials are successful in establishing a Recognition of Focused Practice certification in comprehensive internal medicine, it would be optional for physicians, he said.

The process could be valuable for internists because payers may see the added value of the services provided by a comprehensive internist and could choose to pay more to physicians with such certification, he said.

SAN DIEGO — Pay-for-performance programs must be carefully designed to avoid putting some of the most vulnerable patient populations at risk, officials with the American College of Physicians warned at the organization's annual meeting.

Although pay for performance has the potential to improve medical care, it could also endanger the physician-patient relationship, the financial stability of the health care system, and the elderly and the chronically ill, said Dr. Frederick E. Turton, chair of ACP's Ethics, Professionalism and Human Rights Committee.

To this end, ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper, "Ethics Manifesto: Pay for Performance Principles that Ensure the Promotion of Patient Centered Care," focuses on what pay-for-performance programs should accomplish, what physicians should do if participating in these programs, and the potential unintended consequences of these incentive programs.

"We already have one system that is broken," Dr. Turton said during a panel session on the topic. "We don't want pay for performance to initiate yet another broken system."

Pay-for-performance programs should be designed to promote evidence-based care, encourage collaboration among providers, support patient autonomy, protect patient privacy, and include full disclosure of financial incentives. A well-designed program also should address the comprehensive needs of patients, not single-disease states, according to the ACP position paper.

For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A_1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing during the meeting.

For their part, physicians should be aware of the potential influences on their clinical judgment and strive to avoid discrimination. And physicians need to put medical considerations ahead of both their own and the payer's financial interests, Dr. Turton said.

Some of the unintended consequences highlighted by ACP in its upcoming ethics paper include the potential deselection of patients, gaming of the system by physicians, and an increase in unnecessary care and costs.

Pay-for-performance programs also have the potential to encourage physicians to perform to the measure, rather than thoughtfully evaluating the individual needs of the patients, Dr. Alan R. Nelson, a member of the Institute of Medicine's study committee on pay for performance. And quality measures may not lead to reductions in cost, he said. In the short term, in fact, pay for performance will probably increase utilization of services and cost, he said during the panel session.

Exploring the ethical implications of pay-for-performance programs is new territory, according to Dr. Matthew K. Wynia, director of the Institute for Ethics of the American Medical Association.

Limited data are available about pay-for- performance ethical concerns, in part because these programs are so new and researchers need more time to study their effects, he said. The programs are also variable, complex, and are often proprietary and confidential, making them hard to study. And pay for performance is generally not well understood by either patients or physicians at this point, Dr. Wynia said.

The limited information in the literature on pay-for-performance and public reporting programs has provided mixed results on the question of whether pay for performance will simply reward those who are already high performers.

For example, one study compared the performance of California physicians who were enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. The study assessed outcomes on cervical cancer screening, mammography, and hemoglobin A_1c testing and found that the California physicians achieved greater quality improvement only in the area of cervical cancer screening. The researchers concluded that there was little gain in quality, and that the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).

However, in another study, 207 hospitals involved in a Medicare-sponsored pay-for-performance demonstration showed greater improvement in a composite of 10 quality measures, compared with 406 hospitals involved in voluntary public reporting only. And among the pay-for-performance hospitals, those that had the worst baseline quality performance improved the most (16.1%), while those with the highest baseline quality improved the least (1.9%) across the measures (N. Engl. J. Med. 2007;356:486–96).

There are data on both sides of this, Dr. Wynia said.

A recent study also calls into question how a pay-for-performance program under Medicare could reliably assign responsibility for a patient's care. For example, an analysis of Medicare claims from 2000 to 2002 among 1.79 million fee-for-service Medicare beneficiaries showed that, on average, beneficiaries saw two primary care physicians and five specialists across four practices. And about a third of Medicare patients also switched assigned physicians each year (N. Engl. J. Med. 2007;356:1130–9).

In light of these results, it could be difficult to assign rewards for care, Dr. Wynia said.

SAN DIEGO — Pay-for-performance programs must be carefully designed to avoid putting some of the most vulnerable patient populations at risk, officials with the American College of Physicians warned at the organization's annual meeting.

Although pay for performance has the potential to improve medical care, it could also endanger the physician-patient relationship, the financial stability of the health care system, and the elderly and the chronically ill, said Dr. Frederick E. Turton, chair of ACP's Ethics, Professionalism and Human Rights Committee.

To this end, ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper, "Ethics Manifesto: Pay for Performance Principles that Ensure the Promotion of Patient Centered Care," focuses on what pay-for-performance programs should accomplish, what physicians should do if participating in these programs, and the potential unintended consequences of these incentive programs.

"We already have one system that is broken," Dr. Turton said during a panel session on the topic. "We don't want pay for performance to initiate yet another broken system."

Pay-for-performance programs should be designed to promote evidence-based care, encourage collaboration among providers, support patient autonomy, protect patient privacy, and include full disclosure of financial incentives. A well-designed program also should address the comprehensive needs of patients, not single-disease states, according to the ACP position paper.

For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A_1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing during the meeting.

For their part, physicians should be aware of the potential influences on their clinical judgment and strive to avoid discrimination. And physicians need to put medical considerations ahead of both their own and the payer's financial interests, Dr. Turton said.

Some of the unintended consequences highlighted by ACP in its upcoming ethics paper include the potential deselection of patients, gaming of the system by physicians, and an increase in unnecessary care and costs.

Pay-for-performance programs also have the potential to encourage physicians to perform to the measure, rather than thoughtfully evaluating the individual needs of the patients, Dr. Alan R. Nelson, a member of the Institute of Medicine's study committee on pay for performance. And quality measures may not lead to reductions in cost, he said. In the short term, in fact, pay for performance will probably increase utilization of services and cost, he said during the panel session.

Exploring the ethical implications of pay-for-performance programs is new territory, according to Dr. Matthew K. Wynia, director of the Institute for Ethics of the American Medical Association.

Limited data are available about pay-for- performance ethical concerns, in part because these programs are so new and researchers need more time to study their effects, he said. The programs are also variable, complex, and are often proprietary and confidential, making them hard to study. And pay for performance is generally not well understood by either patients or physicians at this point, Dr. Wynia said.

The limited information in the literature on pay-for-performance and public reporting programs has provided mixed results on the question of whether pay for performance will simply reward those who are already high performers.

For example, one study compared the performance of California physicians who were enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. The study assessed outcomes on cervical cancer screening, mammography, and hemoglobin A_1c testing and found that the California physicians achieved greater quality improvement only in the area of cervical cancer screening. The researchers concluded that there was little gain in quality, and that the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).

However, in another study, 207 hospitals involved in a Medicare-sponsored pay-for-performance demonstration showed greater improvement in a composite of 10 quality measures, compared with 406 hospitals involved in voluntary public reporting only. And among the pay-for-performance hospitals, those that had the worst baseline quality performance improved the most (16.1%), while those with the highest baseline quality improved the least (1.9%) across the measures (N. Engl. J. Med. 2007;356:486–96).

There are data on both sides of this, Dr. Wynia said.

A recent study also calls into question how a pay-for-performance program under Medicare could reliably assign responsibility for a patient's care. For example, an analysis of Medicare claims from 2000 to 2002 among 1.79 million fee-for-service Medicare beneficiaries showed that, on average, beneficiaries saw two primary care physicians and five specialists across four practices. And about a third of Medicare patients also switched assigned physicians each year (N. Engl. J. Med. 2007;356:1130–9).

In light of these results, it could be difficult to assign rewards for care, Dr. Wynia said.

SAN DIEGO — Pay-for-performance programs must be carefully designed to avoid putting some of the most vulnerable patient populations at risk, officials with the American College of Physicians warned at the organization's annual meeting.

Although pay for performance has the potential to improve medical care, it could also endanger the physician-patient relationship, the financial stability of the health care system, and the elderly and the chronically ill, said Dr. Frederick E. Turton, chair of ACP's Ethics, Professionalism and Human Rights Committee.

To this end, ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper, "Ethics Manifesto: Pay for Performance Principles that Ensure the Promotion of Patient Centered Care," focuses on what pay-for-performance programs should accomplish, what physicians should do if participating in these programs, and the potential unintended consequences of these incentive programs.

"We already have one system that is broken," Dr. Turton said during a panel session on the topic. "We don't want pay for performance to initiate yet another broken system."

Pay-for-performance programs should be designed to promote evidence-based care, encourage collaboration among providers, support patient autonomy, protect patient privacy, and include full disclosure of financial incentives. A well-designed program also should address the comprehensive needs of patients, not single-disease states, according to the ACP position paper.

For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A_1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing during the meeting.

For their part, physicians should be aware of the potential influences on their clinical judgment and strive to avoid discrimination. And physicians need to put medical considerations ahead of both their own and the payer's financial interests, Dr. Turton said.

Some of the unintended consequences highlighted by ACP in its upcoming ethics paper include the potential deselection of patients, gaming of the system by physicians, and an increase in unnecessary care and costs.

Pay-for-performance programs also have the potential to encourage physicians to perform to the measure, rather than thoughtfully evaluating the individual needs of the patients, Dr. Alan R. Nelson, a member of the Institute of Medicine's study committee on pay for performance. And quality measures may not lead to reductions in cost, he said. In the short term, in fact, pay for performance will probably increase utilization of services and cost, he said during the panel session.

Exploring the ethical implications of pay-for-performance programs is new territory, according to Dr. Matthew K. Wynia, director of the Institute for Ethics of the American Medical Association.

Limited data are available about pay-for- performance ethical concerns, in part because these programs are so new and researchers need more time to study their effects, he said. The programs are also variable, complex, and are often proprietary and confidential, making them hard to study. And pay for performance is generally not well understood by either patients or physicians at this point, Dr. Wynia said.

The limited information in the literature on pay-for-performance and public reporting programs has provided mixed results on the question of whether pay for performance will simply reward those who are already high performers.

For example, one study compared the performance of California physicians who were enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. The study assessed outcomes on cervical cancer screening, mammography, and hemoglobin A_1c testing and found that the California physicians achieved greater quality improvement only in the area of cervical cancer screening. The researchers concluded that there was little gain in quality, and that the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).

However, in another study, 207 hospitals involved in a Medicare-sponsored pay-for-performance demonstration showed greater improvement in a composite of 10 quality measures, compared with 406 hospitals involved in voluntary public reporting only. And among the pay-for-performance hospitals, those that had the worst baseline quality performance improved the most (16.1%), while those with the highest baseline quality improved the least (1.9%) across the measures (N. Engl. J. Med. 2007;356:486–96).

There are data on both sides of this, Dr. Wynia said.

A recent study also calls into question how a pay-for-performance program under Medicare could reliably assign responsibility for a patient's care. For example, an analysis of Medicare claims from 2000 to 2002 among 1.79 million fee-for-service Medicare beneficiaries showed that, on average, beneficiaries saw two primary care physicians and five specialists across four practices. And about a third of Medicare patients also switched assigned physicians each year (N. Engl. J. Med. 2007;356:1130–9).

In light of these results, it could be difficult to assign rewards for care, Dr. Wynia said.

SAN DIEGO — Within the next few years, Medicare is likely to move from a system of pay for reporting to pay for performance, Jeff Flick, a regional administrator for the Centers for Medicare and Medicaid Services, said at the annual meeting of the American College of Physicians.

Mr. Flick, who is based in San Francisco, predicted that Congress is likely to approve funds to continue the Medicare Physician Quality Reporting Initiative (PQRI) in 2008. However, in future years the program is likely to convert to a pay-for-performance system, he said, which could be similar to the system being developed for hospital value-based purchasing.

"I believe we're not going to move away from this," he said.

PQRI is a voluntary program that will let physicians earn a bonus of up to 1.5% of their total allowed Medicare charges during the last 6 months of 2007 for reporting on certain quality measures.

Congress authorized the establishment of the 6-month pay-for-reporting program last December as part of the Tax Relief and Health Care Act of 2006. Changes to PQRI—and actual implementation of a pay-for-performance system—would require additional legislation from Congress.

Officials at the Centers for Medicare and Medicaid Services have selected 74 quality measures that can be used by physicians across specialties. If four or more measures apply, physicians must report on at least three measures for at least 80% of cases in which the measure was reportable. If no more than three measures apply, each measure must be reported for at least 80% of the cases in which a measure was reportable, according to CMS.

ACP has estimated that the typical internist will be able to earn about $1,500 for reporting over the 6-month period. But the amount earned will depend on the case mix of the practice, said Robert Doherty, senior vice president for governmental affairs and public policy at ACP.

"If you look at this program, it's one that can teach us a lot for the future. It's not the answer," Mr. Doherty said. "But if you do participate, you'll learn a lot about the program."

But physicians who choose to participate in the program will have a chance to learn about the quality of care they are providing and to get ready for pay for performance, Mr. Flick said. Physicians will also be sending the message to Congress that they are not afraid of quality, he said.

What is fundamentally driving the program is the need to move toward value, he said. CMS is currently receiving data on hospital, home health, and nursing home quality, but not on physicians. "We need data. We need to begin to understand information on quality of care," Mr. Flick said.

SAN DIEGO — Within the next few years, Medicare is likely to move from a system of pay for reporting to pay for performance, Jeff Flick, a regional administrator for the Centers for Medicare and Medicaid Services, said at the annual meeting of the American College of Physicians.

Mr. Flick, who is based in San Francisco, predicted that Congress is likely to approve funds to continue the Medicare Physician Quality Reporting Initiative (PQRI) in 2008. However, in future years the program is likely to convert to a pay-for-performance system, he said, which could be similar to the system being developed for hospital value-based purchasing.

"I believe we're not going to move away from this," he said.

PQRI is a voluntary program that will let physicians earn a bonus of up to 1.5% of their total allowed Medicare charges during the last 6 months of 2007 for reporting on certain quality measures.

Congress authorized the establishment of the 6-month pay-for-reporting program last December as part of the Tax Relief and Health Care Act of 2006. Changes to PQRI—and actual implementation of a pay-for-performance system—would require additional legislation from Congress.

Officials at the Centers for Medicare and Medicaid Services have selected 74 quality measures that can be used by physicians across specialties. If four or more measures apply, physicians must report on at least three measures for at least 80% of cases in which the measure was reportable. If no more than three measures apply, each measure must be reported for at least 80% of the cases in which a measure was reportable, according to CMS.

ACP has estimated that the typical internist will be able to earn about $1,500 for reporting over the 6-month period. But the amount earned will depend on the case mix of the practice, said Robert Doherty, senior vice president for governmental affairs and public policy at ACP.

"If you look at this program, it's one that can teach us a lot for the future. It's not the answer," Mr. Doherty said. "But if you do participate, you'll learn a lot about the program."

But physicians who choose to participate in the program will have a chance to learn about the quality of care they are providing and to get ready for pay for performance, Mr. Flick said. Physicians will also be sending the message to Congress that they are not afraid of quality, he said.

What is fundamentally driving the program is the need to move toward value, he said. CMS is currently receiving data on hospital, home health, and nursing home quality, but not on physicians. "We need data. We need to begin to understand information on quality of care," Mr. Flick said.

SAN DIEGO — Within the next few years, Medicare is likely to move from a system of pay for reporting to pay for performance, Jeff Flick, a regional administrator for the Centers for Medicare and Medicaid Services, said at the annual meeting of the American College of Physicians.

Mr. Flick, who is based in San Francisco, predicted that Congress is likely to approve funds to continue the Medicare Physician Quality Reporting Initiative (PQRI) in 2008. However, in future years the program is likely to convert to a pay-for-performance system, he said, which could be similar to the system being developed for hospital value-based purchasing.

"I believe we're not going to move away from this," he said.

PQRI is a voluntary program that will let physicians earn a bonus of up to 1.5% of their total allowed Medicare charges during the last 6 months of 2007 for reporting on certain quality measures.

Congress authorized the establishment of the 6-month pay-for-reporting program last December as part of the Tax Relief and Health Care Act of 2006. Changes to PQRI—and actual implementation of a pay-for-performance system—would require additional legislation from Congress.

Officials at the Centers for Medicare and Medicaid Services have selected 74 quality measures that can be used by physicians across specialties. If four or more measures apply, physicians must report on at least three measures for at least 80% of cases in which the measure was reportable. If no more than three measures apply, each measure must be reported for at least 80% of the cases in which a measure was reportable, according to CMS.

ACP has estimated that the typical internist will be able to earn about $1,500 for reporting over the 6-month period. But the amount earned will depend on the case mix of the practice, said Robert Doherty, senior vice president for governmental affairs and public policy at ACP.

"If you look at this program, it's one that can teach us a lot for the future. It's not the answer," Mr. Doherty said. "But if you do participate, you'll learn a lot about the program."

But physicians who choose to participate in the program will have a chance to learn about the quality of care they are providing and to get ready for pay for performance, Mr. Flick said. Physicians will also be sending the message to Congress that they are not afraid of quality, he said.

What is fundamentally driving the program is the need to move toward value, he said. CMS is currently receiving data on hospital, home health, and nursing home quality, but not on physicians. "We need data. We need to begin to understand information on quality of care," Mr. Flick said.

SAN DIEGO — Preparing a budget and regularly compiling financial reports are critical for any physician practice to maintain a healthy bottom line, financial experts said at the annual meeting of the American College of Physicians.

"It's important to keep your eye on your cash flow," said Margo J. Williams of the ACP's Practice Management Center in Washington. A number of standard financial monitoring tools—balance sheets, income statements, budgets, and accounts receivable reports—can help give physicians an overall picture of how the practice is doing and provide early warning of potential problems.

The balance sheet is often misunderstood, said Carl B. Cunningham, director of the center. For the average physician practice, the balance sheet is mainly useful when trying to sell the practice because it lists the accumulated assets and liabilities. However, because the balance sheet is really just a snapshot of one point in time, it's not very useful in managing the practice day to day, he said.

A better tool for daily management of the practice is the income statement, Mr. Cunningham said. This allows physicians to measure, over a specific period, their revenues and expenses. He recommends analyzing the income statement monthly.

But the income statement also has a drawback: It describes the financial state of the practice, but it doesn't help determine how the practice should be performing. That's where having a budget comes in, Mr. Cunningham said. "An awful lot of practices never bother to prepare a budget. I would strongly encourage you to do so because what it does is provide a planned income statement."

By preparing a budget, physicians can sit down in advance and figure out where they want to be financially and what types of expenses and revenue will be needed to get there. This type of budgeting exercise can be done for the whole practice, as well as when evaluating new ancillary services. And because the budget is there to serve as the guideline, it can also help physicians delegate some financial tasks to other staff, Mr. Cunningham said.

For those physicians who are ACP members, the staff at the Practice Management Center can provide a one-page summary of the practice's key financial data. The one-page report includes charges, patient visits, and accounts receivable by month and year-to-date. This tool can be an easy way for a busy physician to quickly evaluate his or her practice, he said.

"Accounts receivable management is another area that is critical to monitoring the financial status of your practice," Ms. Williams said. Accounts receivable, which is the money that is due but has not yet been received, is an area where everyone from the front desk receptionist to the physician can play a role, she said. The goal should be to get things right the first time in terms of getting out clean claims, staying on top of denials, and finding out why claims are being denied.

Continuous monitoring of accounts receivable also is important. Some of the tools that physicians and their staff can use to oversee this area include tracking the days in accounts receivable, to find out how long it takes to collect, and calculating gross and net collection ratios, which show how much is being collected.

The average number of days that charges spend in accounts receivable can be calculated in two steps. First, take the total charges and divide by 365 days to get the average daily charges. Then, take the total accounts receivable balance and divide by the average daily charges.

Collection ratios can be helpful in determining the share of the accounts receivable that has actually been collected. But when calculating collection ratios, keep in mind that the gross collection ratio is easy to figure out but is influenced by the fee discount contracted with payers, and so, it is not a pure measure of collections performance.

The net collection ratio is a better indicator of performance because it is based on contracted fees that can actually be collected. However, this number is difficult to calculate without a sophisticated practice management system that builds accurate payer fee schedules into the computer, Ms. Williams said.

Information on the ACP Practice Management Center is available online at www.acponline.org/pmc

SAN DIEGO — Preparing a budget and regularly compiling financial reports are critical for any physician practice to maintain a healthy bottom line, financial experts said at the annual meeting of the American College of Physicians.

"It's important to keep your eye on your cash flow," said Margo J. Williams of the ACP's Practice Management Center in Washington. A number of standard financial monitoring tools—balance sheets, income statements, budgets, and accounts receivable reports—can help give physicians an overall picture of how the practice is doing and provide early warning of potential problems.

The balance sheet is often misunderstood, said Carl B. Cunningham, director of the center. For the average physician practice, the balance sheet is mainly useful when trying to sell the practice because it lists the accumulated assets and liabilities. However, because the balance sheet is really just a snapshot of one point in time, it's not very useful in managing the practice day to day, he said.

A better tool for daily management of the practice is the income statement, Mr. Cunningham said. This allows physicians to measure, over a specific period, their revenues and expenses. He recommends analyzing the income statement monthly.

But the income statement also has a drawback: It describes the financial state of the practice, but it doesn't help determine how the practice should be performing. That's where having a budget comes in, Mr. Cunningham said. "An awful lot of practices never bother to prepare a budget. I would strongly encourage you to do so because what it does is provide a planned income statement."

By preparing a budget, physicians can sit down in advance and figure out where they want to be financially and what types of expenses and revenue will be needed to get there. This type of budgeting exercise can be done for the whole practice, as well as when evaluating new ancillary services. And because the budget is there to serve as the guideline, it can also help physicians delegate some financial tasks to other staff, Mr. Cunningham said.

For those physicians who are ACP members, the staff at the Practice Management Center can provide a one-page summary of the practice's key financial data. The one-page report includes charges, patient visits, and accounts receivable by month and year-to-date. This tool can be an easy way for a busy physician to quickly evaluate his or her practice, he said.

"Accounts receivable management is another area that is critical to monitoring the financial status of your practice," Ms. Williams said. Accounts receivable, which is the money that is due but has not yet been received, is an area where everyone from the front desk receptionist to the physician can play a role, she said. The goal should be to get things right the first time in terms of getting out clean claims, staying on top of denials, and finding out why claims are being denied.

Continuous monitoring of accounts receivable also is important. Some of the tools that physicians and their staff can use to oversee this area include tracking the days in accounts receivable, to find out how long it takes to collect, and calculating gross and net collection ratios, which show how much is being collected.

The average number of days that charges spend in accounts receivable can be calculated in two steps. First, take the total charges and divide by 365 days to get the average daily charges. Then, take the total accounts receivable balance and divide by the average daily charges.

Collection ratios can be helpful in determining the share of the accounts receivable that has actually been collected. But when calculating collection ratios, keep in mind that the gross collection ratio is easy to figure out but is influenced by the fee discount contracted with payers, and so, it is not a pure measure of collections performance.

The net collection ratio is a better indicator of performance because it is based on contracted fees that can actually be collected. However, this number is difficult to calculate without a sophisticated practice management system that builds accurate payer fee schedules into the computer, Ms. Williams said.

Information on the ACP Practice Management Center is available online at www.acponline.org/pmc

SAN DIEGO — Preparing a budget and regularly compiling financial reports are critical for any physician practice to maintain a healthy bottom line, financial experts said at the annual meeting of the American College of Physicians.

"It's important to keep your eye on your cash flow," said Margo J. Williams of the ACP's Practice Management Center in Washington. A number of standard financial monitoring tools—balance sheets, income statements, budgets, and accounts receivable reports—can help give physicians an overall picture of how the practice is doing and provide early warning of potential problems.

The balance sheet is often misunderstood, said Carl B. Cunningham, director of the center. For the average physician practice, the balance sheet is mainly useful when trying to sell the practice because it lists the accumulated assets and liabilities. However, because the balance sheet is really just a snapshot of one point in time, it's not very useful in managing the practice day to day, he said.

A better tool for daily management of the practice is the income statement, Mr. Cunningham said. This allows physicians to measure, over a specific period, their revenues and expenses. He recommends analyzing the income statement monthly.

But the income statement also has a drawback: It describes the financial state of the practice, but it doesn't help determine how the practice should be performing. That's where having a budget comes in, Mr. Cunningham said. "An awful lot of practices never bother to prepare a budget. I would strongly encourage you to do so because what it does is provide a planned income statement."

By preparing a budget, physicians can sit down in advance and figure out where they want to be financially and what types of expenses and revenue will be needed to get there. This type of budgeting exercise can be done for the whole practice, as well as when evaluating new ancillary services. And because the budget is there to serve as the guideline, it can also help physicians delegate some financial tasks to other staff, Mr. Cunningham said.

For those physicians who are ACP members, the staff at the Practice Management Center can provide a one-page summary of the practice's key financial data. The one-page report includes charges, patient visits, and accounts receivable by month and year-to-date. This tool can be an easy way for a busy physician to quickly evaluate his or her practice, he said.

"Accounts receivable management is another area that is critical to monitoring the financial status of your practice," Ms. Williams said. Accounts receivable, which is the money that is due but has not yet been received, is an area where everyone from the front desk receptionist to the physician can play a role, she said. The goal should be to get things right the first time in terms of getting out clean claims, staying on top of denials, and finding out why claims are being denied.

Continuous monitoring of accounts receivable also is important. Some of the tools that physicians and their staff can use to oversee this area include tracking the days in accounts receivable, to find out how long it takes to collect, and calculating gross and net collection ratios, which show how much is being collected.

The average number of days that charges spend in accounts receivable can be calculated in two steps. First, take the total charges and divide by 365 days to get the average daily charges. Then, take the total accounts receivable balance and divide by the average daily charges.

Collection ratios can be helpful in determining the share of the accounts receivable that has actually been collected. But when calculating collection ratios, keep in mind that the gross collection ratio is easy to figure out but is influenced by the fee discount contracted with payers, and so, it is not a pure measure of collections performance.

The net collection ratio is a better indicator of performance because it is based on contracted fees that can actually be collected. However, this number is difficult to calculate without a sophisticated practice management system that builds accurate payer fee schedules into the computer, Ms. Williams said.

Information on the ACP Practice Management Center is available online at www.acponline.org/pmc