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 operational phase 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 operational phase 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 operational phase 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.

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, 84% of physicians with patients in Medicare Advantage plans reported that their patients had difficulty understanding the plans. 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, 84% of physicians with patients in Medicare Advantage plans reported that their patients had difficulty understanding the plans. 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, 84% of physicians with patients in Medicare Advantage plans reported that their patients had difficulty understanding the plans. 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 federal legislation is a first step toward new funding to improve preparedness and care in the nation's trauma centers, experts in emergency medicine said.

In May, President Bush signed into law the Trauma Care Systems Planning and Development Act of 2007, reauthorizing the program through 2012 and authorizing $12 million in funding for fiscal year 2008, $10 million for fiscal year 2009, and $8 million annually for fiscal years 2010–2012.

The law resurrects the Department of Health and Human Services' Trauma-EMS Program, which was originally established by Congress in 1990 and has provided more than $31 million to states and territories to help develop and implement statewide trauma systems. However, over the years the program has struggled to receive adequate funding, and in fiscal years 2006 and 2007 it received no funding.

The law also authorizes funding for existing emergency medicine residency training programs at $400,000 annually during fiscal years 2008–2012.

The law is supported by the American College of Emergency Physicians and the American College of Surgeons, as well as other groups

"We view this as a critically important piece of legislation but only a first step," said Dr. Mary Pat McKay, director of the center for injury prevention and control at George Washington University, Washington. Dr. McKay also serves as chair of ACEP's trauma and injury control committee.

The next step is for Congress to appropriate the full amount, and for officials at HHS to quickly get the money down to the state level. There are likely to be some delays at the local level because in the 2 years that the program has been zero funded, local staff has left or been shifted to other duties, she said.

"The federal government has finally realized there's a crisis going on," Dr. McKay said. "People aren't getting to optimal care in every case."

In fact, only about one-fourth of the population in the United States lives in an area served by a trauma care system, according to the American College of Surgeons. And a recent series of reports from the Institute of Medicine found that the emergency care system is ill equipped to handle a major disaster.

The IOM found that with many emergency departments at or over their capacity, there is little surge capacity in the event of a natural or manmade disaster. Emergency medical technicians in non-fire-based services also lack needed training, receiving an average of less than 1 hour of training in disaster response. And both EMS and hospital personnel do not have the personal protective equipment that would be necessary to respond to a chemical, biological, or nuclear attack.

In addition to reauthorizing the Trauma-EMS Program, the law also creates a separate competitive grant program aimed at helping those states that are further along in developing statewide trauma care systems and who meet national standards and protocols.

The new law also provides for grants for research and demonstration projects in rural areas centering around innovative uses of communications technologies, the development of model training curricula, and the management of EMS systems.

Enactment of this law will have an effect not only in terms of the money available through grants, but also in terms of national leadership from officials in HHS's Health Resources and Services Administration (HRSA), which administers the program, said Dr. Robert R. Bass, director of the Maryland Institute for EMS Systems, Baltimore, and a member of the ACEP EMS and tactical emergency medicine section.

Through the program, HRSA has developed a model trauma plan, which has been very useful for states, Dr. Bass said. And since the program was first authorized in 1990, the number of states with statewide trauma systems has been increasing and existing programs have been improving, he said.

The passage of the Trauma Care Systems Planning and Development Act is an important first step, Dr. McKay said, because it allows for pilot projects at the state level to test new ideas and strategies, and will aid in the purchase of new equipment.

New federal legislation is a first step toward new funding to improve preparedness and care in the nation's trauma centers, experts in emergency medicine said.

In May, President Bush signed into law the Trauma Care Systems Planning and Development Act of 2007, reauthorizing the program through 2012 and authorizing $12 million in funding for fiscal year 2008, $10 million for fiscal year 2009, and $8 million annually for fiscal years 2010–2012.

The law resurrects the Department of Health and Human Services' Trauma-EMS Program, which was originally established by Congress in 1990 and has provided more than $31 million to states and territories to help develop and implement statewide trauma systems. However, over the years the program has struggled to receive adequate funding, and in fiscal years 2006 and 2007 it received no funding.

The law also authorizes funding for existing emergency medicine residency training programs at $400,000 annually during fiscal years 2008–2012.

The law is supported by the American College of Emergency Physicians and the American College of Surgeons, as well as other groups

"We view this as a critically important piece of legislation but only a first step," said Dr. Mary Pat McKay, director of the center for injury prevention and control at George Washington University, Washington. Dr. McKay also serves as chair of ACEP's trauma and injury control committee.

The next step is for Congress to appropriate the full amount, and for officials at HHS to quickly get the money down to the state level. There are likely to be some delays at the local level because in the 2 years that the program has been zero funded, local staff has left or been shifted to other duties, she said.

"The federal government has finally realized there's a crisis going on," Dr. McKay said. "People aren't getting to optimal care in every case."

In fact, only about one-fourth of the population in the United States lives in an area served by a trauma care system, according to the American College of Surgeons. And a recent series of reports from the Institute of Medicine found that the emergency care system is ill equipped to handle a major disaster.

The IOM found that with many emergency departments at or over their capacity, there is little surge capacity in the event of a natural or manmade disaster. Emergency medical technicians in non-fire-based services also lack needed training, receiving an average of less than 1 hour of training in disaster response. And both EMS and hospital personnel do not have the personal protective equipment that would be necessary to respond to a chemical, biological, or nuclear attack.

In addition to reauthorizing the Trauma-EMS Program, the law also creates a separate competitive grant program aimed at helping those states that are further along in developing statewide trauma care systems and who meet national standards and protocols.

The new law also provides for grants for research and demonstration projects in rural areas centering around innovative uses of communications technologies, the development of model training curricula, and the management of EMS systems.

Enactment of this law will have an effect not only in terms of the money available through grants, but also in terms of national leadership from officials in HHS's Health Resources and Services Administration (HRSA), which administers the program, said Dr. Robert R. Bass, director of the Maryland Institute for EMS Systems, Baltimore, and a member of the ACEP EMS and tactical emergency medicine section.

Through the program, HRSA has developed a model trauma plan, which has been very useful for states, Dr. Bass said. And since the program was first authorized in 1990, the number of states with statewide trauma systems has been increasing and existing programs have been improving, he said.

The passage of the Trauma Care Systems Planning and Development Act is an important first step, Dr. McKay said, because it allows for pilot projects at the state level to test new ideas and strategies, and will aid in the purchase of new equipment.

New federal legislation is a first step toward new funding to improve preparedness and care in the nation's trauma centers, experts in emergency medicine said.

In May, President Bush signed into law the Trauma Care Systems Planning and Development Act of 2007, reauthorizing the program through 2012 and authorizing $12 million in funding for fiscal year 2008, $10 million for fiscal year 2009, and $8 million annually for fiscal years 2010–2012.

The law resurrects the Department of Health and Human Services' Trauma-EMS Program, which was originally established by Congress in 1990 and has provided more than $31 million to states and territories to help develop and implement statewide trauma systems. However, over the years the program has struggled to receive adequate funding, and in fiscal years 2006 and 2007 it received no funding.

The law also authorizes funding for existing emergency medicine residency training programs at $400,000 annually during fiscal years 2008–2012.

The law is supported by the American College of Emergency Physicians and the American College of Surgeons, as well as other groups

"We view this as a critically important piece of legislation but only a first step," said Dr. Mary Pat McKay, director of the center for injury prevention and control at George Washington University, Washington. Dr. McKay also serves as chair of ACEP's trauma and injury control committee.

The next step is for Congress to appropriate the full amount, and for officials at HHS to quickly get the money down to the state level. There are likely to be some delays at the local level because in the 2 years that the program has been zero funded, local staff has left or been shifted to other duties, she said.

"The federal government has finally realized there's a crisis going on," Dr. McKay said. "People aren't getting to optimal care in every case."

In fact, only about one-fourth of the population in the United States lives in an area served by a trauma care system, according to the American College of Surgeons. And a recent series of reports from the Institute of Medicine found that the emergency care system is ill equipped to handle a major disaster.

The IOM found that with many emergency departments at or over their capacity, there is little surge capacity in the event of a natural or manmade disaster. Emergency medical technicians in non-fire-based services also lack needed training, receiving an average of less than 1 hour of training in disaster response. And both EMS and hospital personnel do not have the personal protective equipment that would be necessary to respond to a chemical, biological, or nuclear attack.

In addition to reauthorizing the Trauma-EMS Program, the law also creates a separate competitive grant program aimed at helping those states that are further along in developing statewide trauma care systems and who meet national standards and protocols.

The new law also provides for grants for research and demonstration projects in rural areas centering around innovative uses of communications technologies, the development of model training curricula, and the management of EMS systems.

Enactment of this law will have an effect not only in terms of the money available through grants, but also in terms of national leadership from officials in HHS's Health Resources and Services Administration (HRSA), which administers the program, said Dr. Robert R. Bass, director of the Maryland Institute for EMS Systems, Baltimore, and a member of the ACEP EMS and tactical emergency medicine section.

Through the program, HRSA has developed a model trauma plan, which has been very useful for states, Dr. Bass said. And since the program was first authorized in 1990, the number of states with statewide trauma systems has been increasing and existing programs have been improving, he said.

The passage of the Trauma Care Systems Planning and Development Act is an important first step, Dr. McKay said, because it allows for pilot projects at the state level to test new ideas and strategies, and will aid in the purchase of new equipment.

Egg-Donor Pay Less than $5K

Despite some advertisements offering $25,000-$50,000 for egg donations, a new national survey finds that the average compensation for an egg donor was $4,216 among clinics affiliated with the Society for Assisted Reproductive Technology (SART). The results are based on a survey of SART clinics conducted last year and published in the May issue of Fertility and Sterility. The highest payments were in the East, Northeast, and West, with the average compensation in those regions at about $5,000. However, some clinics reported much higher levels of compensation. One clinic in the West reported a maximum payment of $15,000 and two programs in the East/Northeast region reported payments as high as $10,000. The survey was completed by 207 of the 394 SART clinics; 16 of the responding clinics did not have an ovum donor program. In 2000, the American Society of Reproductive Medicine's ethics committee issued a position paper on financial incentives for oocyte donors which stated that compensation of more than $5,000 requires justification and payments of more than $10,000 are not appropriate. “As physicians, we want to help our patients get the therapies they need to overcome their infertility,” Dr. David Grainger, SART president, said in a statement. “But we also need to assure them we are following the highest ethical standards while providing that care.”

Contraceptive Coverage for oregon

With Gov. Ted Kulongoski's signature on a new piece of legislation, Oregon joined more than 20 other states in requiring coverage for contraceptives by employee health insurance plans. The new law, which will go into effect Jan. 1, 2008, exempts certain religious employers from the requirement. The law also requires hospitals to inform victims of sexual assault about the availability of emergency contraception and requires hospital staff to provide it upon request. “This fight is fundamentally about women being able to make the best health care decisions for themselves and their families,” Gov. Kulongosk, a Democrat, said in a statement. “With the signing of this bill into law, we continue our ongoing work to expand personal freedom and offer women full equality in our society.”

Stem Cell Victory in California

The California Supreme Court last month cleared the way for the state to use bond funding to pay for a large-scale stem cell research initiative. The state's highest court refused to hear an appeal challenging the constitutionality of Proposition 71, the 2004 ballot initiative that called for spending $3 billion for stem cell research. The California Institute for Regenerative Medicine, the state agency that is managing the initiative, has already issued $158 million in grants financed through state loans and private funds. With the Supreme Court action, the agency can now pay back those loans and move forward with the next round of funding.

Gender Differences in Care

Women with heart disease and diabetes are less likely to receive several types of routine outpatient care than are men who have similar health problems, according to a Rand Corporation study published in the May/June edition of the journal Women's Health Issues. Researchers studied more than 50,000 men and women, examining 11 different screening tests, treatments, or measurements of health status. Among people in commercial plans, women were significantly less likely than were men to receive the care evaluated in 6 of the 11 measures, while women enrolled in Medicare managed care plans were less likely to receive the care evaluated in 4 of the 11 measures. The largest disparity found by researchers was that women were less likely to lower their cholesterol to recommended levels after suffering a heart attack or other acute cardiac event, or if they had diabetes.

U.S. Scores Last on Health Care

The United States again ranked last among six nations studied by the Commonwealth Fund on health access, safety, efficiency, and equity measures of health care, the Washington think tank reported. The study, “Mirror, Mirror,” draws on survey responses from primary care physicians and from data from the Commonwealth Fund Commission on a High Performance Health System scorecard, and pits the U.S. health system against those in Australia, Canada, Germany, New Zealand, and the United Kingdom. The United States outperformed all other nations on preventive care delivery but lagged behind on health care information technology and on coordinating chronic disease care. In addition, U.S. patients were more likely than were their peers to forgo treatment because of high costs, the study found.

Adults Disregard MDs' Orders

Forty-four percent of U.S. adults say they or an immediate family member have ignored a doctor's course of treatment or sought a second opinion because they felt the doctor's orders were unnecessary or overly aggressive, according to a survey. Most adults reported that they didn't view disregarding a doctor's recommendations as problematic or consequential. Only 1 in 10 adults who chose to disregard a physician's instructions at some time believes that he, she, or a family member experienced problems because of this decision. The survey, conducted by Harris Interactive for the Wall Street Journal Online's health industry edition, also found that a large majority of adults think patients who have medical conditions often experience problems because of overtreatment as well as undertreatment by medical providers.

Egg-Donor Pay Less than $5K

Despite some advertisements offering $25,000-$50,000 for egg donations, a new national survey finds that the average compensation for an egg donor was $4,216 among clinics affiliated with the Society for Assisted Reproductive Technology (SART). The results are based on a survey of SART clinics conducted last year and published in the May issue of Fertility and Sterility. The highest payments were in the East, Northeast, and West, with the average compensation in those regions at about $5,000. However, some clinics reported much higher levels of compensation. One clinic in the West reported a maximum payment of $15,000 and two programs in the East/Northeast region reported payments as high as $10,000. The survey was completed by 207 of the 394 SART clinics; 16 of the responding clinics did not have an ovum donor program. In 2000, the American Society of Reproductive Medicine's ethics committee issued a position paper on financial incentives for oocyte donors which stated that compensation of more than $5,000 requires justification and payments of more than $10,000 are not appropriate. “As physicians, we want to help our patients get the therapies they need to overcome their infertility,” Dr. David Grainger, SART president, said in a statement. “But we also need to assure them we are following the highest ethical standards while providing that care.”

Contraceptive Coverage for oregon

With Gov. Ted Kulongoski's signature on a new piece of legislation, Oregon joined more than 20 other states in requiring coverage for contraceptives by employee health insurance plans. The new law, which will go into effect Jan. 1, 2008, exempts certain religious employers from the requirement. The law also requires hospitals to inform victims of sexual assault about the availability of emergency contraception and requires hospital staff to provide it upon request. “This fight is fundamentally about women being able to make the best health care decisions for themselves and their families,” Gov. Kulongosk, a Democrat, said in a statement. “With the signing of this bill into law, we continue our ongoing work to expand personal freedom and offer women full equality in our society.”

Stem Cell Victory in California

The California Supreme Court last month cleared the way for the state to use bond funding to pay for a large-scale stem cell research initiative. The state's highest court refused to hear an appeal challenging the constitutionality of Proposition 71, the 2004 ballot initiative that called for spending $3 billion for stem cell research. The California Institute for Regenerative Medicine, the state agency that is managing the initiative, has already issued $158 million in grants financed through state loans and private funds. With the Supreme Court action, the agency can now pay back those loans and move forward with the next round of funding.

Gender Differences in Care

Women with heart disease and diabetes are less likely to receive several types of routine outpatient care than are men who have similar health problems, according to a Rand Corporation study published in the May/June edition of the journal Women's Health Issues. Researchers studied more than 50,000 men and women, examining 11 different screening tests, treatments, or measurements of health status. Among people in commercial plans, women were significantly less likely than were men to receive the care evaluated in 6 of the 11 measures, while women enrolled in Medicare managed care plans were less likely to receive the care evaluated in 4 of the 11 measures. The largest disparity found by researchers was that women were less likely to lower their cholesterol to recommended levels after suffering a heart attack or other acute cardiac event, or if they had diabetes.

U.S. Scores Last on Health Care

The United States again ranked last among six nations studied by the Commonwealth Fund on health access, safety, efficiency, and equity measures of health care, the Washington think tank reported. The study, “Mirror, Mirror,” draws on survey responses from primary care physicians and from data from the Commonwealth Fund Commission on a High Performance Health System scorecard, and pits the U.S. health system against those in Australia, Canada, Germany, New Zealand, and the United Kingdom. The United States outperformed all other nations on preventive care delivery but lagged behind on health care information technology and on coordinating chronic disease care. In addition, U.S. patients were more likely than were their peers to forgo treatment because of high costs, the study found.

Adults Disregard MDs' Orders

Forty-four percent of U.S. adults say they or an immediate family member have ignored a doctor's course of treatment or sought a second opinion because they felt the doctor's orders were unnecessary or overly aggressive, according to a survey. Most adults reported that they didn't view disregarding a doctor's recommendations as problematic or consequential. Only 1 in 10 adults who chose to disregard a physician's instructions at some time believes that he, she, or a family member experienced problems because of this decision. The survey, conducted by Harris Interactive for the Wall Street Journal Online's health industry edition, also found that a large majority of adults think patients who have medical conditions often experience problems because of overtreatment as well as undertreatment by medical providers.

Egg-Donor Pay Less than $5K

Despite some advertisements offering $25,000-$50,000 for egg donations, a new national survey finds that the average compensation for an egg donor was $4,216 among clinics affiliated with the Society for Assisted Reproductive Technology (SART). The results are based on a survey of SART clinics conducted last year and published in the May issue of Fertility and Sterility. The highest payments were in the East, Northeast, and West, with the average compensation in those regions at about $5,000. However, some clinics reported much higher levels of compensation. One clinic in the West reported a maximum payment of $15,000 and two programs in the East/Northeast region reported payments as high as $10,000. The survey was completed by 207 of the 394 SART clinics; 16 of the responding clinics did not have an ovum donor program. In 2000, the American Society of Reproductive Medicine's ethics committee issued a position paper on financial incentives for oocyte donors which stated that compensation of more than $5,000 requires justification and payments of more than $10,000 are not appropriate. “As physicians, we want to help our patients get the therapies they need to overcome their infertility,” Dr. David Grainger, SART president, said in a statement. “But we also need to assure them we are following the highest ethical standards while providing that care.”

Contraceptive Coverage for oregon

With Gov. Ted Kulongoski's signature on a new piece of legislation, Oregon joined more than 20 other states in requiring coverage for contraceptives by employee health insurance plans. The new law, which will go into effect Jan. 1, 2008, exempts certain religious employers from the requirement. The law also requires hospitals to inform victims of sexual assault about the availability of emergency contraception and requires hospital staff to provide it upon request. “This fight is fundamentally about women being able to make the best health care decisions for themselves and their families,” Gov. Kulongosk, a Democrat, said in a statement. “With the signing of this bill into law, we continue our ongoing work to expand personal freedom and offer women full equality in our society.”

Stem Cell Victory in California

The California Supreme Court last month cleared the way for the state to use bond funding to pay for a large-scale stem cell research initiative. The state's highest court refused to hear an appeal challenging the constitutionality of Proposition 71, the 2004 ballot initiative that called for spending $3 billion for stem cell research. The California Institute for Regenerative Medicine, the state agency that is managing the initiative, has already issued $158 million in grants financed through state loans and private funds. With the Supreme Court action, the agency can now pay back those loans and move forward with the next round of funding.

Gender Differences in Care

Women with heart disease and diabetes are less likely to receive several types of routine outpatient care than are men who have similar health problems, according to a Rand Corporation study published in the May/June edition of the journal Women's Health Issues. Researchers studied more than 50,000 men and women, examining 11 different screening tests, treatments, or measurements of health status. Among people in commercial plans, women were significantly less likely than were men to receive the care evaluated in 6 of the 11 measures, while women enrolled in Medicare managed care plans were less likely to receive the care evaluated in 4 of the 11 measures. The largest disparity found by researchers was that women were less likely to lower their cholesterol to recommended levels after suffering a heart attack or other acute cardiac event, or if they had diabetes.

U.S. Scores Last on Health Care

The United States again ranked last among six nations studied by the Commonwealth Fund on health access, safety, efficiency, and equity measures of health care, the Washington think tank reported. The study, “Mirror, Mirror,” draws on survey responses from primary care physicians and from data from the Commonwealth Fund Commission on a High Performance Health System scorecard, and pits the U.S. health system against those in Australia, Canada, Germany, New Zealand, and the United Kingdom. The United States outperformed all other nations on preventive care delivery but lagged behind on health care information technology and on coordinating chronic disease care. In addition, U.S. patients were more likely than were their peers to forgo treatment because of high costs, the study found.

Adults Disregard MDs' Orders

Forty-four percent of U.S. adults say they or an immediate family member have ignored a doctor's course of treatment or sought a second opinion because they felt the doctor's orders were unnecessary or overly aggressive, according to a survey. Most adults reported that they didn't view disregarding a doctor's recommendations as problematic or consequential. Only 1 in 10 adults who chose to disregard a physician's instructions at some time believes that he, she, or a family member experienced problems because of this decision. The survey, conducted by Harris Interactive for the Wall Street Journal Online's health industry edition, also found that a large majority of adults think patients who have medical conditions often experience problems because of overtreatment as well as undertreatment by medical providers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 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 ACP Practice Management 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,” he said. “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.

“Accounts receivable management is another area that is critical to monitoring the financial status of your practice,” Ms. Williams said.

Accounts receivable 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. For most practices, the average number of days in accounts receivable is about 37, Ms. Williams said.

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.

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 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 ACP Practice Management 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,” he said. “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.

“Accounts receivable management is another area that is critical to monitoring the financial status of your practice,” Ms. Williams said.

Accounts receivable 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. For most practices, the average number of days in accounts receivable is about 37, Ms. Williams said.

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.

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 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 ACP Practice Management 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,” he said. “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.

“Accounts receivable management is another area that is critical to monitoring the financial status of your practice,” Ms. Williams said.

Accounts receivable 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. For most practices, the average number of days in accounts receivable is about 37, Ms. Williams said.

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.

NEW YORK — What physicians and researchers know for sure about physical activity during pregnancy hasn't changed much since the early 1900s, James M. Pivarnik, Ph.D., said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Recommendations from the Handbook for Prospective Mothers, published in 1913, advised pregnant women that the amount of exercise needed cannot be precisely stated, walking is the best kind of exercise, and all kinds of violent exertion should be avoided. While today's recommendations have been more thoroughly researched, they don't provide women with many more definitive answers, said Dr. Pivarnik, director of the Center for Physical Activity and Health at Michigan State University in East Lansing.

But professional medical societies are becoming less conservative in their recommendations about exercise for pregnant women. For example, the American College of Obstetricians and Gynecologists has revised its recommendations three times in the last 2 decades and has moved away from strict limits on physical activity.

In 1985, ACOG released its first exercise guidelines for pregnant women, which included time limits for exercise and recommended that a woman's heart rate not exceed 140 beats per minute. However, even these early guidelines included the disclaimer that physically fit pregnant woman may tolerate a more strenuous program.

“There was actually the dispensation way back then but a lot of people just did not follow that,” Dr. Pivarnik said.

In 1994, ACOG issued updated guidelines that were less cautious and emphasized the benefits of mild to moderate exercise at least 3 days a week. “There was more stress on the health benefits, rather than the fear,” he said.

The most recent ACOG guidelines on exercise in pregnancy were issued in 2002 and address activity in recreational and competitive athletes. The guidelines recommend that athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their routines as medically indicated. but because information on strenuous exercise is limited, they require close medical supervision.

And most pregnant women without medical or obstetric complications can aim to engage in 30 minutes or more of moderate exercise a day, say the guidelines.

Guidelines issued in Canada in 2003 by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology take an even more aggressive approach. The joint 2003 guidelines suggest that all women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises during pregnancy.

But some physicians and nurse-midwives who deal with obstetrics are not up to date on the guidelines and still recommend more conservative approaches, such as not exceeding a heart rate of 140 beats per minute, Dr. Pivarnik said. “There's no evidence that that's the way it should be done.”

Guidelines on exercise in pregnancy are moving away from strict activity limits. Stanford W. Carpenter

NEW YORK — What physicians and researchers know for sure about physical activity during pregnancy hasn't changed much since the early 1900s, James M. Pivarnik, Ph.D., said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Recommendations from the Handbook for Prospective Mothers, published in 1913, advised pregnant women that the amount of exercise needed cannot be precisely stated, walking is the best kind of exercise, and all kinds of violent exertion should be avoided. While today's recommendations have been more thoroughly researched, they don't provide women with many more definitive answers, said Dr. Pivarnik, director of the Center for Physical Activity and Health at Michigan State University in East Lansing.

But professional medical societies are becoming less conservative in their recommendations about exercise for pregnant women. For example, the American College of Obstetricians and Gynecologists has revised its recommendations three times in the last 2 decades and has moved away from strict limits on physical activity.

In 1985, ACOG released its first exercise guidelines for pregnant women, which included time limits for exercise and recommended that a woman's heart rate not exceed 140 beats per minute. However, even these early guidelines included the disclaimer that physically fit pregnant woman may tolerate a more strenuous program.

“There was actually the dispensation way back then but a lot of people just did not follow that,” Dr. Pivarnik said.

In 1994, ACOG issued updated guidelines that were less cautious and emphasized the benefits of mild to moderate exercise at least 3 days a week. “There was more stress on the health benefits, rather than the fear,” he said.

The most recent ACOG guidelines on exercise in pregnancy were issued in 2002 and address activity in recreational and competitive athletes. The guidelines recommend that athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their routines as medically indicated. but because information on strenuous exercise is limited, they require close medical supervision.

And most pregnant women without medical or obstetric complications can aim to engage in 30 minutes or more of moderate exercise a day, say the guidelines.

Guidelines issued in Canada in 2003 by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology take an even more aggressive approach. The joint 2003 guidelines suggest that all women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises during pregnancy.

But some physicians and nurse-midwives who deal with obstetrics are not up to date on the guidelines and still recommend more conservative approaches, such as not exceeding a heart rate of 140 beats per minute, Dr. Pivarnik said. “There's no evidence that that's the way it should be done.”

Guidelines on exercise in pregnancy are moving away from strict activity limits. Stanford W. Carpenter

NEW YORK — What physicians and researchers know for sure about physical activity during pregnancy hasn't changed much since the early 1900s, James M. Pivarnik, Ph.D., said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Recommendations from the Handbook for Prospective Mothers, published in 1913, advised pregnant women that the amount of exercise needed cannot be precisely stated, walking is the best kind of exercise, and all kinds of violent exertion should be avoided. While today's recommendations have been more thoroughly researched, they don't provide women with many more definitive answers, said Dr. Pivarnik, director of the Center for Physical Activity and Health at Michigan State University in East Lansing.

But professional medical societies are becoming less conservative in their recommendations about exercise for pregnant women. For example, the American College of Obstetricians and Gynecologists has revised its recommendations three times in the last 2 decades and has moved away from strict limits on physical activity.

In 1985, ACOG released its first exercise guidelines for pregnant women, which included time limits for exercise and recommended that a woman's heart rate not exceed 140 beats per minute. However, even these early guidelines included the disclaimer that physically fit pregnant woman may tolerate a more strenuous program.

“There was actually the dispensation way back then but a lot of people just did not follow that,” Dr. Pivarnik said.

In 1994, ACOG issued updated guidelines that were less cautious and emphasized the benefits of mild to moderate exercise at least 3 days a week. “There was more stress on the health benefits, rather than the fear,” he said.

The most recent ACOG guidelines on exercise in pregnancy were issued in 2002 and address activity in recreational and competitive athletes. The guidelines recommend that athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their routines as medically indicated. but because information on strenuous exercise is limited, they require close medical supervision.

And most pregnant women without medical or obstetric complications can aim to engage in 30 minutes or more of moderate exercise a day, say the guidelines.

Guidelines issued in Canada in 2003 by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology take an even more aggressive approach. The joint 2003 guidelines suggest that all women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises during pregnancy.

But some physicians and nurse-midwives who deal with obstetrics are not up to date on the guidelines and still recommend more conservative approaches, such as not exceeding a heart rate of 140 beats per minute, Dr. Pivarnik said. “There's no evidence that that's the way it should be done.”

Guidelines on exercise in pregnancy are moving away from strict activity limits. Stanford W. Carpenter

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

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

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

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

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

▸ Modifier −2P means the service was not provided for patient reasons, such as the patient declining or religious objections.

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

▸ Modifier −8P is used to indicate that the action was not performed and the reason has not been specified.

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

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

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

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

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

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

▸ Modifier −2P means the service was not provided for patient reasons, such as the patient declining or religious objections.

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

▸ Modifier −8P is used to indicate that the action was not performed and the reason has not been specified.

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

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

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

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

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

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

▸ Modifier −2P means the service was not provided for patient reasons, such as the patient declining or religious objections.

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

▸ Modifier −8P is used to indicate that the action was not performed and the reason has not been specified.

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

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

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

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

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

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

Physicians have some options in responding to these types of requests, he said. One approach is to explain to the family why it's desirable to provide the patient with more information. For example, some patients do better when they know their prognosis, because then they can make plans.

Telling patients about their medical condition also provides an opportunity to have a discussion about palliative care. And patients tend to learn about their prognosis anyway, especially in big hospitals, he said.

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

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

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

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

Providing culturally competent care at the end of life also means being aware of racial disparities, said Dr. LaVera Crawley, of the center for biomedical ethics at Stanford (Calif.) University.

A lack of access to aggressive treatments—or even a perceived lack of access—can affect the patient's willingness to receive palliative care later on, Dr. Crawley said.

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

For racial and ethnic groups that may have been subject to inequity in their health care, the idea of comfortably dying can be seen as a misplaced priority, Dr. Crawley said.

“Obviously, we have to start thinking about issues of trust,” she said. “For large patterns of disparities, you're not going to solve them in your office in that one visit with that one patient.”

However, when physicians encounter patients who may be reacting to past discrimination in their treatment, it's important to establish “trustworthiness,” she said. To determine if lack of trust is an issue, physicians can ask patients, “Have you ever felt unfairly treated by me or anyone else involved in your care?”

Physicians can also try to identify any behaviors by the medical staff that could be considered impolite or abusive.

Other possible factors in resistance to palliative care include communication issues between physicians and patients, and religious beliefs. For example, some patients see their suffering as noble and a test of their faith, she said.

Physicians can consult experts on the communities they serve to help bridge some of the communication gaps. But when in doubt, ask patients about their personal beliefs, values, and preferences, Dr. Crawley said.

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

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

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

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

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

Physicians have some options in responding to these types of requests, he said. One approach is to explain to the family why it's desirable to provide the patient with more information. For example, some patients do better when they know their prognosis, because then they can make plans.

Telling patients about their medical condition also provides an opportunity to have a discussion about palliative care. And patients tend to learn about their prognosis anyway, especially in big hospitals, he said.

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

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

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

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

Providing culturally competent care at the end of life also means being aware of racial disparities, said Dr. LaVera Crawley, of the center for biomedical ethics at Stanford (Calif.) University.

A lack of access to aggressive treatments—or even a perceived lack of access—can affect the patient's willingness to receive palliative care later on, Dr. Crawley said.

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

For racial and ethnic groups that may have been subject to inequity in their health care, the idea of comfortably dying can be seen as a misplaced priority, Dr. Crawley said.

“Obviously, we have to start thinking about issues of trust,” she said. “For large patterns of disparities, you're not going to solve them in your office in that one visit with that one patient.”

However, when physicians encounter patients who may be reacting to past discrimination in their treatment, it's important to establish “trustworthiness,” she said. To determine if lack of trust is an issue, physicians can ask patients, “Have you ever felt unfairly treated by me or anyone else involved in your care?”

Physicians can also try to identify any behaviors by the medical staff that could be considered impolite or abusive.

Other possible factors in resistance to palliative care include communication issues between physicians and patients, and religious beliefs. For example, some patients see their suffering as noble and a test of their faith, she said.

Physicians can consult experts on the communities they serve to help bridge some of the communication gaps. But when in doubt, ask patients about their personal beliefs, values, and preferences, Dr. Crawley said.

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

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

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

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

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

Physicians have some options in responding to these types of requests, he said. One approach is to explain to the family why it's desirable to provide the patient with more information. For example, some patients do better when they know their prognosis, because then they can make plans.

Telling patients about their medical condition also provides an opportunity to have a discussion about palliative care. And patients tend to learn about their prognosis anyway, especially in big hospitals, he said.

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

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

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

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

Providing culturally competent care at the end of life also means being aware of racial disparities, said Dr. LaVera Crawley, of the center for biomedical ethics at Stanford (Calif.) University.

A lack of access to aggressive treatments—or even a perceived lack of access—can affect the patient's willingness to receive palliative care later on, Dr. Crawley said.

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

For racial and ethnic groups that may have been subject to inequity in their health care, the idea of comfortably dying can be seen as a misplaced priority, Dr. Crawley said.

“Obviously, we have to start thinking about issues of trust,” she said. “For large patterns of disparities, you're not going to solve them in your office in that one visit with that one patient.”

However, when physicians encounter patients who may be reacting to past discrimination in their treatment, it's important to establish “trustworthiness,” she said. To determine if lack of trust is an issue, physicians can ask patients, “Have you ever felt unfairly treated by me or anyone else involved in your care?”

Physicians can also try to identify any behaviors by the medical staff that could be considered impolite or abusive.

Other possible factors in resistance to palliative care include communication issues between physicians and patients, and religious beliefs. For example, some patients see their suffering as noble and a test of their faith, she said.

Physicians can consult experts on the communities they serve to help bridge some of the communication gaps. But when in doubt, ask patients about their personal beliefs, values, and preferences, Dr. Crawley said.

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

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

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

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

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

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

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

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

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

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

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

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

'It really helps to know the theories and models and approaches that … help us understand why we do what we do.' DR. KUSHNER

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

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

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

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

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

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

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

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

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

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

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

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

'It really helps to know the theories and models and approaches that … help us understand why we do what we do.' DR. KUSHNER

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

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

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

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

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

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

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

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

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

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

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

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

'It really helps to know the theories and models and approaches that … help us understand why we do what we do.' DR. KUSHNER