Mary Ellen Schneider

Assessing Pediatric Seizure Drugs

Officials at the National Institutes of Health are launching a large national trial to assess the safety and efficacy of two common seizure medications in the treatment of children with status epilepticus in the emergency department. Currently, diazepam (Valium) and lorazepam (Ativan) are prescribed based on the physician's judgment, but few data indicate which medication has the best safety and efficacy profile in children. “The Pediatric Seizure Study seeks to provide the most definitive information possible,” Dr. Duane Alexander, director of the NIH's National Institute of Child Health and Human Development, said in a statement. Researchers at 11 hospitals will randomly assign children in status epilepticus to either lorazepam or diazepam. Because the medication must be administered within minutes of the patient's arrival at the ED, it will not be possible to obtain parental consent until the patients are stable, according to the NIH. The researchers will collect blood samples, and parents will be interviewed by phone after 48 hours and 30 days. Currently, diazepam is approved for use in adults and children. Lorazepam is approved to treat seizures in adults, but is prescribed off label for children. The study is being funded by the National Institute of Child Health and Human Development.

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 state Supreme Court action, the agency can now pay back those loans and move forward with the next round of funding.

ALS Registry Legislation Introduced

Senate Majority Leader Harry Reid (D-Nev.) introduced legislation that would create a single, national patient registry to collect data on amyotrophic lateral sclerosis (ALS). Under the legislation, the “Amyotrophic Lateral Sclerosis (ALS) Registry Act” (S. 1382), the registry would be housed at the Centers for Disease Control and Prevention. “Creating a national registry is crucial to understand patterns and examine causes of this debilitating disease,” Sen. Reid said in a statement. If passed, it would authorize $25 million in funding for fiscal year 2008 and additional funds to sustain the registry from 2009 through 2012. Sen. Reid originally introduced this legislation in the last session of Congress but it failed to gain traction. Meanwhile, Congress has provided funds to the CDC for pilot programs to support the development of an ALS registry. Rep. Eliot Engel (D-N.Y.) introduced companion legislation (H.R. 2295) in the House.

OxyContin Maker Pays Fine

Purdue Pharma L.P. and three current and former executives pleaded guilty last month in federal court to criminal charges that they misbranded the company's product, OxyContin (oxycodone). The company agreed to pay about $600 million in fines and other payments, while three top executives, including the company's president and its top attorney, agreed to pay a total of $34.5 million in fines. Misbranding involves promoting a drug in unauthorized ways, potentially for unintended and unapproved uses. U.S. Attorney John Brownlee said that Purdue and its executives had deliberately downplayed OxyContin's potential for addiction when promoting it, and persuaded physicians to prescribe it.

Costs Grow for Medicare Drugs

Prices for 10 of the most prescribed brand-name medications have risen nearly 7% since December under Medicare Part D, though wholesale prices for the same drugs rose just 3%, investigators from the House Oversight and Government Reform Committee reported. The increases may indicate that despite initial success in containing prices, Part D may be losing leverage over drug makers, said to the investigators, who added Part D premiums rose 13% over the past year. Meanwhile, the rebates insurers get from drug manufacturers are less than expected. The committee looked at prices for the top 10 drugs of 2004, most of which have no generic alternatives. The cost of a month's supply of Lipitor (atorvastatin), for example, rose nearly 10% to over $84 in mid-April, up from about $77 in mid-December. Wholesale prices climbed 5% in that time. Pharmaceutical industry representatives disputed the panel's conclusions. “There is one big glaring omission in the Government Reform Committee's report: The Medicare prescription drug program continues to provide large cost savings to tens of millions of seniors and disabled Americans,” PhRMA Senior Vice President Ken Johnson said in a statement. “The committee's report focuses on just a handful of medicines and tries to draw sweeping conclusions.”

Hospital CEOs See MD Shortage

More than two-thirds of hospital CEOs responding to a survey identified physician shortages as a serious problem that must be addressed. Over three-quarters said the nurse shortage is a serious problem, according to the Council on Physician and Nurse Supply, which commissioned the survey from health care staffing company AMN Healthcare Inc. Almost all of the 400 CEOs said recruiting physicians was difficult or challenging, and almost all favored an expansion of physician training. In all, 86% are currently recruiting physicians; 80% of those are looking for primary care physicians, and 74% seek specialists.

Assessing Pediatric Seizure Drugs

Officials at the National Institutes of Health are launching a large national trial to assess the safety and efficacy of two common seizure medications in the treatment of children with status epilepticus in the emergency department. Currently, diazepam (Valium) and lorazepam (Ativan) are prescribed based on the physician's judgment, but few data indicate which medication has the best safety and efficacy profile in children. “The Pediatric Seizure Study seeks to provide the most definitive information possible,” Dr. Duane Alexander, director of the NIH's National Institute of Child Health and Human Development, said in a statement. Researchers at 11 hospitals will randomly assign children in status epilepticus to either lorazepam or diazepam. Because the medication must be administered within minutes of the patient's arrival at the ED, it will not be possible to obtain parental consent until the patients are stable, according to the NIH. The researchers will collect blood samples, and parents will be interviewed by phone after 48 hours and 30 days. Currently, diazepam is approved for use in adults and children. Lorazepam is approved to treat seizures in adults, but is prescribed off label for children. The study is being funded by the National Institute of Child Health and Human Development.

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 state Supreme Court action, the agency can now pay back those loans and move forward with the next round of funding.

ALS Registry Legislation Introduced

Senate Majority Leader Harry Reid (D-Nev.) introduced legislation that would create a single, national patient registry to collect data on amyotrophic lateral sclerosis (ALS). Under the legislation, the “Amyotrophic Lateral Sclerosis (ALS) Registry Act” (S. 1382), the registry would be housed at the Centers for Disease Control and Prevention. “Creating a national registry is crucial to understand patterns and examine causes of this debilitating disease,” Sen. Reid said in a statement. If passed, it would authorize $25 million in funding for fiscal year 2008 and additional funds to sustain the registry from 2009 through 2012. Sen. Reid originally introduced this legislation in the last session of Congress but it failed to gain traction. Meanwhile, Congress has provided funds to the CDC for pilot programs to support the development of an ALS registry. Rep. Eliot Engel (D-N.Y.) introduced companion legislation (H.R. 2295) in the House.

OxyContin Maker Pays Fine

Purdue Pharma L.P. and three current and former executives pleaded guilty last month in federal court to criminal charges that they misbranded the company's product, OxyContin (oxycodone). The company agreed to pay about $600 million in fines and other payments, while three top executives, including the company's president and its top attorney, agreed to pay a total of $34.5 million in fines. Misbranding involves promoting a drug in unauthorized ways, potentially for unintended and unapproved uses. U.S. Attorney John Brownlee said that Purdue and its executives had deliberately downplayed OxyContin's potential for addiction when promoting it, and persuaded physicians to prescribe it.

Costs Grow for Medicare Drugs

Prices for 10 of the most prescribed brand-name medications have risen nearly 7% since December under Medicare Part D, though wholesale prices for the same drugs rose just 3%, investigators from the House Oversight and Government Reform Committee reported. The increases may indicate that despite initial success in containing prices, Part D may be losing leverage over drug makers, said to the investigators, who added Part D premiums rose 13% over the past year. Meanwhile, the rebates insurers get from drug manufacturers are less than expected. The committee looked at prices for the top 10 drugs of 2004, most of which have no generic alternatives. The cost of a month's supply of Lipitor (atorvastatin), for example, rose nearly 10% to over $84 in mid-April, up from about $77 in mid-December. Wholesale prices climbed 5% in that time. Pharmaceutical industry representatives disputed the panel's conclusions. “There is one big glaring omission in the Government Reform Committee's report: The Medicare prescription drug program continues to provide large cost savings to tens of millions of seniors and disabled Americans,” PhRMA Senior Vice President Ken Johnson said in a statement. “The committee's report focuses on just a handful of medicines and tries to draw sweeping conclusions.”

Hospital CEOs See MD Shortage

More than two-thirds of hospital CEOs responding to a survey identified physician shortages as a serious problem that must be addressed. Over three-quarters said the nurse shortage is a serious problem, according to the Council on Physician and Nurse Supply, which commissioned the survey from health care staffing company AMN Healthcare Inc. Almost all of the 400 CEOs said recruiting physicians was difficult or challenging, and almost all favored an expansion of physician training. In all, 86% are currently recruiting physicians; 80% of those are looking for primary care physicians, and 74% seek specialists.

Assessing Pediatric Seizure Drugs

Officials at the National Institutes of Health are launching a large national trial to assess the safety and efficacy of two common seizure medications in the treatment of children with status epilepticus in the emergency department. Currently, diazepam (Valium) and lorazepam (Ativan) are prescribed based on the physician's judgment, but few data indicate which medication has the best safety and efficacy profile in children. “The Pediatric Seizure Study seeks to provide the most definitive information possible,” Dr. Duane Alexander, director of the NIH's National Institute of Child Health and Human Development, said in a statement. Researchers at 11 hospitals will randomly assign children in status epilepticus to either lorazepam or diazepam. Because the medication must be administered within minutes of the patient's arrival at the ED, it will not be possible to obtain parental consent until the patients are stable, according to the NIH. The researchers will collect blood samples, and parents will be interviewed by phone after 48 hours and 30 days. Currently, diazepam is approved for use in adults and children. Lorazepam is approved to treat seizures in adults, but is prescribed off label for children. The study is being funded by the National Institute of Child Health and Human Development.

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 state Supreme Court action, the agency can now pay back those loans and move forward with the next round of funding.

ALS Registry Legislation Introduced

Senate Majority Leader Harry Reid (D-Nev.) introduced legislation that would create a single, national patient registry to collect data on amyotrophic lateral sclerosis (ALS). Under the legislation, the “Amyotrophic Lateral Sclerosis (ALS) Registry Act” (S. 1382), the registry would be housed at the Centers for Disease Control and Prevention. “Creating a national registry is crucial to understand patterns and examine causes of this debilitating disease,” Sen. Reid said in a statement. If passed, it would authorize $25 million in funding for fiscal year 2008 and additional funds to sustain the registry from 2009 through 2012. Sen. Reid originally introduced this legislation in the last session of Congress but it failed to gain traction. Meanwhile, Congress has provided funds to the CDC for pilot programs to support the development of an ALS registry. Rep. Eliot Engel (D-N.Y.) introduced companion legislation (H.R. 2295) in the House.

OxyContin Maker Pays Fine

Purdue Pharma L.P. and three current and former executives pleaded guilty last month in federal court to criminal charges that they misbranded the company's product, OxyContin (oxycodone). The company agreed to pay about $600 million in fines and other payments, while three top executives, including the company's president and its top attorney, agreed to pay a total of $34.5 million in fines. Misbranding involves promoting a drug in unauthorized ways, potentially for unintended and unapproved uses. U.S. Attorney John Brownlee said that Purdue and its executives had deliberately downplayed OxyContin's potential for addiction when promoting it, and persuaded physicians to prescribe it.

Costs Grow for Medicare Drugs

Prices for 10 of the most prescribed brand-name medications have risen nearly 7% since December under Medicare Part D, though wholesale prices for the same drugs rose just 3%, investigators from the House Oversight and Government Reform Committee reported. The increases may indicate that despite initial success in containing prices, Part D may be losing leverage over drug makers, said to the investigators, who added Part D premiums rose 13% over the past year. Meanwhile, the rebates insurers get from drug manufacturers are less than expected. The committee looked at prices for the top 10 drugs of 2004, most of which have no generic alternatives. The cost of a month's supply of Lipitor (atorvastatin), for example, rose nearly 10% to over $84 in mid-April, up from about $77 in mid-December. Wholesale prices climbed 5% in that time. Pharmaceutical industry representatives disputed the panel's conclusions. “There is one big glaring omission in the Government Reform Committee's report: The Medicare prescription drug program continues to provide large cost savings to tens of millions of seniors and disabled Americans,” PhRMA Senior Vice President Ken Johnson said in a statement. “The committee's report focuses on just a handful of medicines and tries to draw sweeping conclusions.”

Hospital CEOs See MD Shortage

More than two-thirds of hospital CEOs responding to a survey identified physician shortages as a serious problem that must be addressed. Over three-quarters said the nurse shortage is a serious problem, according to the Council on Physician and Nurse Supply, which commissioned the survey from health care staffing company AMN Healthcare Inc. Almost all of the 400 CEOs said recruiting physicians was difficult or challenging, and almost all favored an expansion of physician training. In all, 86% are currently recruiting physicians; 80% of those are looking for primary care physicians, and 74% seek specialists.

Arthritis Prevalence Still Climbing

Physician-diagnosed arthritis is expected to increase an average of 16% in 48 states from 2005 to 2030, according to a CDC estimate. In 14 states, the increase could be between 30% and 87%. The projections are based on estimates from the 2005 Behavioral Risk Factor Surveillance System survey and state population data for the year 2030. Only North Dakota, West Virginia, and the District of Columbia are projected to have decreases in the number of adults with physician-diagnosed arthritis and arthritis-attributable limitations due to expected population drops. The estimates were published in the May 4 issue of the Morbidity and Mortality Weekly Report. Arthritis and other rheumatologic conditions, including gout, lupus, and fibromyalgia, affect about 46 million adults in the United States, the report said. “Greater use of existing evidence-based interventions and development of new interventions aimed at decreasing pain, improving function, and delaying disability associated with arthritis are needed… particularly in those states that will be most heavily affected,” the CDC researchers wrote.

IVIG Pay, Access Issues Confirmed

Two new reports from the Department of Health and Human Services confirm that Medicare payments for intravenous immunoglobulin are severely lagging price increases from manufacturers, making it difficult for hospitals and physicians to offer the therapy. In an April report, the HHS Office of Inspector General found that in the third quarter of 2006, 56% of hospitals and 59% of physicians bought IVIG at prices below the Medicare reimbursement amount, which means they were able to marginally profit on the therapy. That means 44% of hospitals and 41% of physicians paid more for IVIG than Medicare reimbursed, said Marcia Boyle, president of the Immune Deficiency Foundation, in an interview. And, the Inspector General found that most physicians and hospitals were underpaid by Medicare relative to IVIG price for the first two quarters of the year. The agency acknowledged that the market was fragile because of tight supplies and price increases, and that physicians in hospitals would face the same in 2007 as they had in the first two quarters of 2006. Another report by the HHS Assistant Secretary for Planning and Evaluation agreed prices are exceeding reimbursement, and noted “current IVIG supplies are being rationed,” and prices are substantially higher in secondary markets that have developed as a result of problems in the official supply chain.

Osteoporosis Audit in the Works

European experts are planning an audit to determine the status of osteoporosis in Europe. Current estimates are that in the European Union, an osteoporosis-related fracture occurs every 30 seconds, and with an aging population, the number of osteoporosis-related hip fractures is expected to double to 1 million annually over the next 50 years, according to the International Osteoporosis Foundation. The foundation supports the EU Osteoporosis Consultation Panel, the group planning the audit. “We need this new [audit] to evaluate current standards of osteoporosis management in Europe,” said Juliet Compston, chair of the consultation panel.

New Medicare Leadership

President Bush recently nominated Kerry N. Weems, a 24-year veteran of the Department of Health and Human Services, to lead the CMS. Mr. Weems currently serves as deputy chief of staff to HHS Secretary Mike Leavitt. “He understands the large fiscal challenges facing Medicare and Medicaid,” Mr. Leavitt said in a statement. “He has been a leader in this department's efforts to accelerate adoption of health information technology and better financial management systems.” If confirmed by the Senate, Mr. Weems would fill the vacancy left by Dr. Mark B. McClellan who resigned from CMS last year. Leslie V. Norwalk is the current acting CMS administrator.

IRS Allows for Subsidy of EHRs

Not-for-profit hospitals can provide subsidies to physicians for the adoption of electronic health records (EHRs) without fear of losing their tax exempt status, according to a memo from the Internal Revenue Service. But officials are setting conditions. The subsidies can be provided only to physicians with staff privileges, and must be made available to all staff physicians. The hospital should also be able to access all of the EHRs created by the physician with the subsidized products, to the extent allowed under the law. Both hospitals and physicians will have to comply with HHS regulations issued last August. The IRS memo is available online at

www.irs.gov/pub/irs-tege/ehrdirective.pdf

Arthritis Prevalence Still Climbing

Physician-diagnosed arthritis is expected to increase an average of 16% in 48 states from 2005 to 2030, according to a CDC estimate. In 14 states, the increase could be between 30% and 87%. The projections are based on estimates from the 2005 Behavioral Risk Factor Surveillance System survey and state population data for the year 2030. Only North Dakota, West Virginia, and the District of Columbia are projected to have decreases in the number of adults with physician-diagnosed arthritis and arthritis-attributable limitations due to expected population drops. The estimates were published in the May 4 issue of the Morbidity and Mortality Weekly Report. Arthritis and other rheumatologic conditions, including gout, lupus, and fibromyalgia, affect about 46 million adults in the United States, the report said. “Greater use of existing evidence-based interventions and development of new interventions aimed at decreasing pain, improving function, and delaying disability associated with arthritis are needed… particularly in those states that will be most heavily affected,” the CDC researchers wrote.

IVIG Pay, Access Issues Confirmed

Two new reports from the Department of Health and Human Services confirm that Medicare payments for intravenous immunoglobulin are severely lagging price increases from manufacturers, making it difficult for hospitals and physicians to offer the therapy. In an April report, the HHS Office of Inspector General found that in the third quarter of 2006, 56% of hospitals and 59% of physicians bought IVIG at prices below the Medicare reimbursement amount, which means they were able to marginally profit on the therapy. That means 44% of hospitals and 41% of physicians paid more for IVIG than Medicare reimbursed, said Marcia Boyle, president of the Immune Deficiency Foundation, in an interview. And, the Inspector General found that most physicians and hospitals were underpaid by Medicare relative to IVIG price for the first two quarters of the year. The agency acknowledged that the market was fragile because of tight supplies and price increases, and that physicians in hospitals would face the same in 2007 as they had in the first two quarters of 2006. Another report by the HHS Assistant Secretary for Planning and Evaluation agreed prices are exceeding reimbursement, and noted “current IVIG supplies are being rationed,” and prices are substantially higher in secondary markets that have developed as a result of problems in the official supply chain.

Osteoporosis Audit in the Works

European experts are planning an audit to determine the status of osteoporosis in Europe. Current estimates are that in the European Union, an osteoporosis-related fracture occurs every 30 seconds, and with an aging population, the number of osteoporosis-related hip fractures is expected to double to 1 million annually over the next 50 years, according to the International Osteoporosis Foundation. The foundation supports the EU Osteoporosis Consultation Panel, the group planning the audit. “We need this new [audit] to evaluate current standards of osteoporosis management in Europe,” said Juliet Compston, chair of the consultation panel.

New Medicare Leadership

President Bush recently nominated Kerry N. Weems, a 24-year veteran of the Department of Health and Human Services, to lead the CMS. Mr. Weems currently serves as deputy chief of staff to HHS Secretary Mike Leavitt. “He understands the large fiscal challenges facing Medicare and Medicaid,” Mr. Leavitt said in a statement. “He has been a leader in this department's efforts to accelerate adoption of health information technology and better financial management systems.” If confirmed by the Senate, Mr. Weems would fill the vacancy left by Dr. Mark B. McClellan who resigned from CMS last year. Leslie V. Norwalk is the current acting CMS administrator.

IRS Allows for Subsidy of EHRs

Not-for-profit hospitals can provide subsidies to physicians for the adoption of electronic health records (EHRs) without fear of losing their tax exempt status, according to a memo from the Internal Revenue Service. But officials are setting conditions. The subsidies can be provided only to physicians with staff privileges, and must be made available to all staff physicians. The hospital should also be able to access all of the EHRs created by the physician with the subsidized products, to the extent allowed under the law. Both hospitals and physicians will have to comply with HHS regulations issued last August. The IRS memo is available online at

www.irs.gov/pub/irs-tege/ehrdirective.pdf

Arthritis Prevalence Still Climbing

Physician-diagnosed arthritis is expected to increase an average of 16% in 48 states from 2005 to 2030, according to a CDC estimate. In 14 states, the increase could be between 30% and 87%. The projections are based on estimates from the 2005 Behavioral Risk Factor Surveillance System survey and state population data for the year 2030. Only North Dakota, West Virginia, and the District of Columbia are projected to have decreases in the number of adults with physician-diagnosed arthritis and arthritis-attributable limitations due to expected population drops. The estimates were published in the May 4 issue of the Morbidity and Mortality Weekly Report. Arthritis and other rheumatologic conditions, including gout, lupus, and fibromyalgia, affect about 46 million adults in the United States, the report said. “Greater use of existing evidence-based interventions and development of new interventions aimed at decreasing pain, improving function, and delaying disability associated with arthritis are needed… particularly in those states that will be most heavily affected,” the CDC researchers wrote.

IVIG Pay, Access Issues Confirmed

Two new reports from the Department of Health and Human Services confirm that Medicare payments for intravenous immunoglobulin are severely lagging price increases from manufacturers, making it difficult for hospitals and physicians to offer the therapy. In an April report, the HHS Office of Inspector General found that in the third quarter of 2006, 56% of hospitals and 59% of physicians bought IVIG at prices below the Medicare reimbursement amount, which means they were able to marginally profit on the therapy. That means 44% of hospitals and 41% of physicians paid more for IVIG than Medicare reimbursed, said Marcia Boyle, president of the Immune Deficiency Foundation, in an interview. And, the Inspector General found that most physicians and hospitals were underpaid by Medicare relative to IVIG price for the first two quarters of the year. The agency acknowledged that the market was fragile because of tight supplies and price increases, and that physicians in hospitals would face the same in 2007 as they had in the first two quarters of 2006. Another report by the HHS Assistant Secretary for Planning and Evaluation agreed prices are exceeding reimbursement, and noted “current IVIG supplies are being rationed,” and prices are substantially higher in secondary markets that have developed as a result of problems in the official supply chain.

Osteoporosis Audit in the Works

European experts are planning an audit to determine the status of osteoporosis in Europe. Current estimates are that in the European Union, an osteoporosis-related fracture occurs every 30 seconds, and with an aging population, the number of osteoporosis-related hip fractures is expected to double to 1 million annually over the next 50 years, according to the International Osteoporosis Foundation. The foundation supports the EU Osteoporosis Consultation Panel, the group planning the audit. “We need this new [audit] to evaluate current standards of osteoporosis management in Europe,” said Juliet Compston, chair of the consultation panel.

New Medicare Leadership

President Bush recently nominated Kerry N. Weems, a 24-year veteran of the Department of Health and Human Services, to lead the CMS. Mr. Weems currently serves as deputy chief of staff to HHS Secretary Mike Leavitt. “He understands the large fiscal challenges facing Medicare and Medicaid,” Mr. Leavitt said in a statement. “He has been a leader in this department's efforts to accelerate adoption of health information technology and better financial management systems.” If confirmed by the Senate, Mr. Weems would fill the vacancy left by Dr. Mark B. McClellan who resigned from CMS last year. Leslie V. Norwalk is the current acting CMS administrator.

IRS Allows for Subsidy of EHRs

Not-for-profit hospitals can provide subsidies to physicians for the adoption of electronic health records (EHRs) without fear of losing their tax exempt status, according to a memo from the Internal Revenue Service. But officials are setting conditions. The subsidies can be provided only to physicians with staff privileges, and must be made available to all staff physicians. The hospital should also be able to access all of the EHRs created by the physician with the subsidized products, to the extent allowed under the law. Both hospitals and physicians will have to comply with HHS regulations issued last August. The IRS memo is available online at

www.irs.gov/pub/irs-tege/ehrdirective.pdf

Newly enacted 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 from 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.

But in the long run, much more work is needed to get all states and territories to the same level of trauma system development. Right now, development is variable; some states have advanced information systems in place, whereas others still use paper and pencil systems, she said.

Variations in the way EMS operates in this country remain an unmet challenge, Dr. McKay said. In some places, EMS is a third municipal service, or it could be run by a private company, or it may be part of the local fire department.

Newly enacted 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 from 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.

But in the long run, much more work is needed to get all states and territories to the same level of trauma system development. Right now, development is variable; some states have advanced information systems in place, whereas others still use paper and pencil systems, she said.

Variations in the way EMS operates in this country remain an unmet challenge, Dr. McKay said. In some places, EMS is a third municipal service, or it could be run by a private company, or it may be part of the local fire department.

Newly enacted 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 from 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.

But in the long run, much more work is needed to get all states and territories to the same level of trauma system development. Right now, development is variable; some states have advanced information systems in place, whereas others still use paper and pencil systems, she said.

Variations in the way EMS operates in this country remain an unmet challenge, Dr. McKay said. In some places, EMS is a third municipal service, or it could be run by a private company, or it may be part of the local fire department.

SAN DIEGO — Nearly two-thirds of internists provide care for patients with limited English proficiency, according to a national survey conducted by the American College of Physicians.

That language barrier can create challenges for patients and physicians, because patients who are not proficient in English tend to have a worse understanding of basic health information, have difficulty asking questions of clinical and administrative staff, and may not follow through on treatment recommendations, the survey showed.

ACP officials conducted the survey of 4,000 of its members in fall 2006 and received responses from 2,022 internists. The analysis was based on the 1,261 respondents who work at least 20 hours weekly.

The results were released at the annual meeting of the ACP in conjunction with the organization's new position paper on language services for patients with limited English proficiency (LEP).

In its position paper, the ACP called for language services to be available to improve health services for patients with LEP, and recommended that Medicare directly reimburse physicians for the added expense of language services and the extra time involved in providing care for patients with LEP.

The ACP is also pushing for the establishment of a national clearinghouse to provide translated documents and patient education materials.

“If we're unable to communicate with our patients—either understand what they are telling us or help them to understand how best to take care of themselves—we certainly aren't practicing patient-centered care,” Dr. Lynne Kirk, ACP immediate past president, said at a press briefing.

Internists who care for limited English proficiency patients estimated that these patients make up an average of about 12% of their practice.

Physicians often devote additional time to their limited English proficiency patients, said Dr. William Golden, immediate past chair of the ACP board of regents.

For example, 51% of physicians who see LEP patients in their practice said they devote an average of 5–15 minutes of additional time during a visit with an LEP patient.

Another 26% report spending an extra 16–30 minutes on average, according to the survey of ACP members.

“That is time that is sometimes difficult to carve out, and at the same time [is] often unreimbursed,” Dr. Golden said.

Spanish topped the list of most frequently encountered languages, but physicians reported seeing patients who spoke nearly 80 different languages or dialects, from Chinese to German. (See box.)

About 52% of respondents said they thought their practices could determine the top three languages spoken by their LEP patients, whereas 48% could not or were uncertain.

Many practices do not have processes in place for obtaining information about a patient's primary language, the survey of ACP members found.

About 28% of physicians said their practice recorded the patient's primary language in the medical record, whereas others cited informal monitoring or data provided on check-in or patient registration forms.

About 64% of survey respondents said they provide some type of language services to their LEP patients.

Those language services are usually provided by a bilingual health care provider, bilingual staff, or ad hoc interpreters.

Of those physicians who reported providing language services to their limited English proficiency patients, about 64% also provided translated documents or forms to patients.

Medical practices vary in the cost they assign to providing language services to limited English proficiency patients, with cost estimates ranging from zero to $25,000 annually.

Physicians absorb most of the costs, with 75% of respondents saying they received no direct reimbursement, 24% reporting they were uncertain, and 1% reporting direct reimbursement for language services provided.

Providing payment either to physicians or translators for language services for limited English proficiency patients eventually could save a significant amount of money in direct medical costs, Dr. Golden commented.

The provision of adequate language services can lower medical costs by helping to avoid medical errors and unnecessary tests and hospitalizations.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Nearly two-thirds of internists provide care for patients with limited English proficiency, according to a national survey conducted by the American College of Physicians.

That language barrier can create challenges for patients and physicians, because patients who are not proficient in English tend to have a worse understanding of basic health information, have difficulty asking questions of clinical and administrative staff, and may not follow through on treatment recommendations, the survey showed.

ACP officials conducted the survey of 4,000 of its members in fall 2006 and received responses from 2,022 internists. The analysis was based on the 1,261 respondents who work at least 20 hours weekly.

The results were released at the annual meeting of the ACP in conjunction with the organization's new position paper on language services for patients with limited English proficiency (LEP).

In its position paper, the ACP called for language services to be available to improve health services for patients with LEP, and recommended that Medicare directly reimburse physicians for the added expense of language services and the extra time involved in providing care for patients with LEP.

The ACP is also pushing for the establishment of a national clearinghouse to provide translated documents and patient education materials.

“If we're unable to communicate with our patients—either understand what they are telling us or help them to understand how best to take care of themselves—we certainly aren't practicing patient-centered care,” Dr. Lynne Kirk, ACP immediate past president, said at a press briefing.

Internists who care for limited English proficiency patients estimated that these patients make up an average of about 12% of their practice.

Physicians often devote additional time to their limited English proficiency patients, said Dr. William Golden, immediate past chair of the ACP board of regents.

For example, 51% of physicians who see LEP patients in their practice said they devote an average of 5–15 minutes of additional time during a visit with an LEP patient.

Another 26% report spending an extra 16–30 minutes on average, according to the survey of ACP members.

“That is time that is sometimes difficult to carve out, and at the same time [is] often unreimbursed,” Dr. Golden said.

Spanish topped the list of most frequently encountered languages, but physicians reported seeing patients who spoke nearly 80 different languages or dialects, from Chinese to German. (See box.)

About 52% of respondents said they thought their practices could determine the top three languages spoken by their LEP patients, whereas 48% could not or were uncertain.

Many practices do not have processes in place for obtaining information about a patient's primary language, the survey of ACP members found.

About 28% of physicians said their practice recorded the patient's primary language in the medical record, whereas others cited informal monitoring or data provided on check-in or patient registration forms.

About 64% of survey respondents said they provide some type of language services to their LEP patients.

Those language services are usually provided by a bilingual health care provider, bilingual staff, or ad hoc interpreters.

Of those physicians who reported providing language services to their limited English proficiency patients, about 64% also provided translated documents or forms to patients.

Medical practices vary in the cost they assign to providing language services to limited English proficiency patients, with cost estimates ranging from zero to $25,000 annually.

Physicians absorb most of the costs, with 75% of respondents saying they received no direct reimbursement, 24% reporting they were uncertain, and 1% reporting direct reimbursement for language services provided.

Providing payment either to physicians or translators for language services for limited English proficiency patients eventually could save a significant amount of money in direct medical costs, Dr. Golden commented.

The provision of adequate language services can lower medical costs by helping to avoid medical errors and unnecessary tests and hospitalizations.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Nearly two-thirds of internists provide care for patients with limited English proficiency, according to a national survey conducted by the American College of Physicians.

That language barrier can create challenges for patients and physicians, because patients who are not proficient in English tend to have a worse understanding of basic health information, have difficulty asking questions of clinical and administrative staff, and may not follow through on treatment recommendations, the survey showed.

ACP officials conducted the survey of 4,000 of its members in fall 2006 and received responses from 2,022 internists. The analysis was based on the 1,261 respondents who work at least 20 hours weekly.

The results were released at the annual meeting of the ACP in conjunction with the organization's new position paper on language services for patients with limited English proficiency (LEP).

In its position paper, the ACP called for language services to be available to improve health services for patients with LEP, and recommended that Medicare directly reimburse physicians for the added expense of language services and the extra time involved in providing care for patients with LEP.

The ACP is also pushing for the establishment of a national clearinghouse to provide translated documents and patient education materials.

“If we're unable to communicate with our patients—either understand what they are telling us or help them to understand how best to take care of themselves—we certainly aren't practicing patient-centered care,” Dr. Lynne Kirk, ACP immediate past president, said at a press briefing.

Internists who care for limited English proficiency patients estimated that these patients make up an average of about 12% of their practice.

Physicians often devote additional time to their limited English proficiency patients, said Dr. William Golden, immediate past chair of the ACP board of regents.

For example, 51% of physicians who see LEP patients in their practice said they devote an average of 5–15 minutes of additional time during a visit with an LEP patient.

Another 26% report spending an extra 16–30 minutes on average, according to the survey of ACP members.

“That is time that is sometimes difficult to carve out, and at the same time [is] often unreimbursed,” Dr. Golden said.

Spanish topped the list of most frequently encountered languages, but physicians reported seeing patients who spoke nearly 80 different languages or dialects, from Chinese to German. (See box.)

About 52% of respondents said they thought their practices could determine the top three languages spoken by their LEP patients, whereas 48% could not or were uncertain.

Many practices do not have processes in place for obtaining information about a patient's primary language, the survey of ACP members found.

About 28% of physicians said their practice recorded the patient's primary language in the medical record, whereas others cited informal monitoring or data provided on check-in or patient registration forms.

About 64% of survey respondents said they provide some type of language services to their LEP patients.

Those language services are usually provided by a bilingual health care provider, bilingual staff, or ad hoc interpreters.

Of those physicians who reported providing language services to their limited English proficiency patients, about 64% also provided translated documents or forms to patients.

Medical practices vary in the cost they assign to providing language services to limited English proficiency patients, with cost estimates ranging from zero to $25,000 annually.

Physicians absorb most of the costs, with 75% of respondents saying they received no direct reimbursement, 24% reporting they were uncertain, and 1% reporting direct reimbursement for language services provided.

Providing payment either to physicians or translators for language services for limited English proficiency patients eventually could save a significant amount of money in direct medical costs, Dr. Golden commented.

The provision of adequate language services can lower medical costs by helping to avoid medical errors and unnecessary tests and hospitalizations.

ELSEVIER GLOBAL MEDICAL NEWS

Starting July 1, physicians who report on selected quality measures will have a chance to earn a small bonus payment from Medicare.

The program, called the Physician Quality Reporting Initiative, was mandated by Congress and offers incentive payments to physicians who report on one to three quality measures. By doing so, physicians can earn a bonus of up to 1.5% of their total allowed Medicare charges during the 6-month reporting period.

Although even the maximum compensation isn't enough to make anyone rich, some physician organizations are advising their members to take a good look at the program because it may be the first step toward a performance-based payment system. “By involving ourselves in the process we can have feedback,” said Dr. James Stevens, a neurologist in Fort Wayne, Ind., and a member of the medical economics and management committee of the American Academy of Neurology.

Deciding whether participation makes sense is a calculation that has to be made by each practice, Dr. Stevens said. Those who give it a try will get a confidential report from the Centers for Medicare and Medicaid Services about how they are doing and have a chance to provide information on what works and what doesn't.

“This experience will likely be helpful in the future,” said Brett Baker, director of regulatory affairs at the American College of Physicians, adding that although the bonus payment is not significant, having some type of financial incentive attached may be enough to get people's attention.

To get started, physicians must familiarize themselves with the program and the measures and figure out for how many patients they will be able to gather and report data, Mr. Baker said. They also should consider the technical issues involved in reporting and how feasible it will be to make those changes. “It's certainly a challenge for everyone to ramp up to do this in a short period of time,” he said.

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

Although payments will be provided to the holder of the tax identification number, the results will be analyzed at the physician level, the CMS said. As a result, Medicare officials are requiring that the National Provider Identifier number be used on all claims.

The reporting period will run from July 1 through Dec. 31, 2007, and all claims must reach the National Claims History File by Feb. 29, 2008.

Any Medicare-enrolled eligible professional can participate in the program, regardless of whether they have signed a participation agreement with Medicare to accept assignment on all claims. In addition, physicians are not required to register to participate in the Physician Quality Reporting Initiative. Medicare will use a claims-based reporting system for the program and will require practices to enter either CPT Category II codes or temporary G-codes where CPT-II codes are not available.

The codes can be reported on either paper-based CMS 1500 forms or electronic 837-P claims. The quality codes should be reported with a $0.00 charge.

The bonus payments will be made in a lump sum in mid-2008, CMS officials said. Physicians can earn up to a 1.5% bonus, subject to a cap. The cap is structured to ensure that physicians who do more reporting will receive higher payments.

Under the law that established the Physician Quality Reporting Initiative, the program is excluded from a formal appeals process. However, CMS officials said they plan to establish some type of informal inquiry process. In addition, they are currently developing a validation procedure for the reporting process that is likely to involve sampling.

In addition to the bonus payment, physicians who participate will receive a confidential feedback report from the CMS sometime in 2008. Those reports are expected to include reporting and performance rates. However, the quality data reported in 2007 will not be publicly released.

For 2008, the CMS is required under statute to propose the new measures in August 2007 and finalize them by Nov. 15, 2007. Next year's measures are likely to include structural measures, such as the use of electronic health records or electronic prescribing technology. CMS officials are also working on the possibility of allowing physicians to report using either registry-based systems or electronic records systems in 2008.

Of the 74 measures released by the CMS, 21 apply to family medicine, said Dr. Rick Kellerman, president of the American Academy of Family Physicians. In an effort to make the process more user friendly, AAFP officials are strongly urging family physicians to report on the three diabetes measures available. This will make it easier for physicians to report because they can concentrate on a single diagnosis, Dr. Kellerman said.

The AAFP is developing a data collection sheet for physicians and another for the back office staff, he said. The academy also is developing tools to help physicians calculate their potential bonus payment under the program.

Because the CMS has selected measures that have been vetted by physician organizations and reflect current medical practice, most physicians should not have a problem with that aspect of the program, said Dr. Janet Wright, a cardiologist in Chico, Calif., and chair of the performance assessment task force of the American College of Cardiology.

The hurdle will be in changing the workflow in the office, she said. For some, the bonus payment will not be enough to offset the cost of making these administrative changes. The ACC is developing a special coding form that can be attached to the visit encounter form in an effort to streamline the process. In addition, participation in the program will help provide the CMS with information on the real-life experiences of cardiologists, Dr. Wright said.

More information on the Physician Quality Reporting Initiative is available online at www.cms.hhs.gov/PQRI

Starting July 1, physicians who report on selected quality measures will have a chance to earn a small bonus payment from Medicare.

The program, called the Physician Quality Reporting Initiative, was mandated by Congress and offers incentive payments to physicians who report on one to three quality measures. By doing so, physicians can earn a bonus of up to 1.5% of their total allowed Medicare charges during the 6-month reporting period.

Although even the maximum compensation isn't enough to make anyone rich, some physician organizations are advising their members to take a good look at the program because it may be the first step toward a performance-based payment system. “By involving ourselves in the process we can have feedback,” said Dr. James Stevens, a neurologist in Fort Wayne, Ind., and a member of the medical economics and management committee of the American Academy of Neurology.

Deciding whether participation makes sense is a calculation that has to be made by each practice, Dr. Stevens said. Those who give it a try will get a confidential report from the Centers for Medicare and Medicaid Services about how they are doing and have a chance to provide information on what works and what doesn't.

“This experience will likely be helpful in the future,” said Brett Baker, director of regulatory affairs at the American College of Physicians, adding that although the bonus payment is not significant, having some type of financial incentive attached may be enough to get people's attention.

To get started, physicians must familiarize themselves with the program and the measures and figure out for how many patients they will be able to gather and report data, Mr. Baker said. They also should consider the technical issues involved in reporting and how feasible it will be to make those changes. “It's certainly a challenge for everyone to ramp up to do this in a short period of time,” he said.

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

Although payments will be provided to the holder of the tax identification number, the results will be analyzed at the physician level, the CMS said. As a result, Medicare officials are requiring that the National Provider Identifier number be used on all claims.

The reporting period will run from July 1 through Dec. 31, 2007, and all claims must reach the National Claims History File by Feb. 29, 2008.

Any Medicare-enrolled eligible professional can participate in the program, regardless of whether they have signed a participation agreement with Medicare to accept assignment on all claims. In addition, physicians are not required to register to participate in the Physician Quality Reporting Initiative. Medicare will use a claims-based reporting system for the program and will require practices to enter either CPT Category II codes or temporary G-codes where CPT-II codes are not available.

The codes can be reported on either paper-based CMS 1500 forms or electronic 837-P claims. The quality codes should be reported with a $0.00 charge.

The bonus payments will be made in a lump sum in mid-2008, CMS officials said. Physicians can earn up to a 1.5% bonus, subject to a cap. The cap is structured to ensure that physicians who do more reporting will receive higher payments.

Under the law that established the Physician Quality Reporting Initiative, the program is excluded from a formal appeals process. However, CMS officials said they plan to establish some type of informal inquiry process. In addition, they are currently developing a validation procedure for the reporting process that is likely to involve sampling.

In addition to the bonus payment, physicians who participate will receive a confidential feedback report from the CMS sometime in 2008. Those reports are expected to include reporting and performance rates. However, the quality data reported in 2007 will not be publicly released.

For 2008, the CMS is required under statute to propose the new measures in August 2007 and finalize them by Nov. 15, 2007. Next year's measures are likely to include structural measures, such as the use of electronic health records or electronic prescribing technology. CMS officials are also working on the possibility of allowing physicians to report using either registry-based systems or electronic records systems in 2008.

Of the 74 measures released by the CMS, 21 apply to family medicine, said Dr. Rick Kellerman, president of the American Academy of Family Physicians. In an effort to make the process more user friendly, AAFP officials are strongly urging family physicians to report on the three diabetes measures available. This will make it easier for physicians to report because they can concentrate on a single diagnosis, Dr. Kellerman said.

The AAFP is developing a data collection sheet for physicians and another for the back office staff, he said. The academy also is developing tools to help physicians calculate their potential bonus payment under the program.

Because the CMS has selected measures that have been vetted by physician organizations and reflect current medical practice, most physicians should not have a problem with that aspect of the program, said Dr. Janet Wright, a cardiologist in Chico, Calif., and chair of the performance assessment task force of the American College of Cardiology.

The hurdle will be in changing the workflow in the office, she said. For some, the bonus payment will not be enough to offset the cost of making these administrative changes. The ACC is developing a special coding form that can be attached to the visit encounter form in an effort to streamline the process. In addition, participation in the program will help provide the CMS with information on the real-life experiences of cardiologists, Dr. Wright said.

More information on the Physician Quality Reporting Initiative is available online at www.cms.hhs.gov/PQRI

Starting July 1, physicians who report on selected quality measures will have a chance to earn a small bonus payment from Medicare.

The program, called the Physician Quality Reporting Initiative, was mandated by Congress and offers incentive payments to physicians who report on one to three quality measures. By doing so, physicians can earn a bonus of up to 1.5% of their total allowed Medicare charges during the 6-month reporting period.

Although even the maximum compensation isn't enough to make anyone rich, some physician organizations are advising their members to take a good look at the program because it may be the first step toward a performance-based payment system. “By involving ourselves in the process we can have feedback,” said Dr. James Stevens, a neurologist in Fort Wayne, Ind., and a member of the medical economics and management committee of the American Academy of Neurology.

Deciding whether participation makes sense is a calculation that has to be made by each practice, Dr. Stevens said. Those who give it a try will get a confidential report from the Centers for Medicare and Medicaid Services about how they are doing and have a chance to provide information on what works and what doesn't.

“This experience will likely be helpful in the future,” said Brett Baker, director of regulatory affairs at the American College of Physicians, adding that although the bonus payment is not significant, having some type of financial incentive attached may be enough to get people's attention.

To get started, physicians must familiarize themselves with the program and the measures and figure out for how many patients they will be able to gather and report data, Mr. Baker said. They also should consider the technical issues involved in reporting and how feasible it will be to make those changes. “It's certainly a challenge for everyone to ramp up to do this in a short period of time,” he said.

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

Although payments will be provided to the holder of the tax identification number, the results will be analyzed at the physician level, the CMS said. As a result, Medicare officials are requiring that the National Provider Identifier number be used on all claims.

The reporting period will run from July 1 through Dec. 31, 2007, and all claims must reach the National Claims History File by Feb. 29, 2008.

Any Medicare-enrolled eligible professional can participate in the program, regardless of whether they have signed a participation agreement with Medicare to accept assignment on all claims. In addition, physicians are not required to register to participate in the Physician Quality Reporting Initiative. Medicare will use a claims-based reporting system for the program and will require practices to enter either CPT Category II codes or temporary G-codes where CPT-II codes are not available.

The codes can be reported on either paper-based CMS 1500 forms or electronic 837-P claims. The quality codes should be reported with a $0.00 charge.

The bonus payments will be made in a lump sum in mid-2008, CMS officials said. Physicians can earn up to a 1.5% bonus, subject to a cap. The cap is structured to ensure that physicians who do more reporting will receive higher payments.

Under the law that established the Physician Quality Reporting Initiative, the program is excluded from a formal appeals process. However, CMS officials said they plan to establish some type of informal inquiry process. In addition, they are currently developing a validation procedure for the reporting process that is likely to involve sampling.

In addition to the bonus payment, physicians who participate will receive a confidential feedback report from the CMS sometime in 2008. Those reports are expected to include reporting and performance rates. However, the quality data reported in 2007 will not be publicly released.

For 2008, the CMS is required under statute to propose the new measures in August 2007 and finalize them by Nov. 15, 2007. Next year's measures are likely to include structural measures, such as the use of electronic health records or electronic prescribing technology. CMS officials are also working on the possibility of allowing physicians to report using either registry-based systems or electronic records systems in 2008.

Of the 74 measures released by the CMS, 21 apply to family medicine, said Dr. Rick Kellerman, president of the American Academy of Family Physicians. In an effort to make the process more user friendly, AAFP officials are strongly urging family physicians to report on the three diabetes measures available. This will make it easier for physicians to report because they can concentrate on a single diagnosis, Dr. Kellerman said.

The AAFP is developing a data collection sheet for physicians and another for the back office staff, he said. The academy also is developing tools to help physicians calculate their potential bonus payment under the program.

Because the CMS has selected measures that have been vetted by physician organizations and reflect current medical practice, most physicians should not have a problem with that aspect of the program, said Dr. Janet Wright, a cardiologist in Chico, Calif., and chair of the performance assessment task force of the American College of Cardiology.

The hurdle will be in changing the workflow in the office, she said. For some, the bonus payment will not be enough to offset the cost of making these administrative changes. The ACC is developing a special coding form that can be attached to the visit encounter form in an effort to streamline the process. In addition, participation in the program will help provide the CMS with information on the real-life experiences of cardiologists, Dr. Wright said.

More information on the Physician Quality Reporting Initiative is available online at www.cms.hhs.gov/PQRI

SAN DIEGO — In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, of the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said.

Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said.

When you are faced with prior authorization, Dr. Mitchell suggested, save time by having the patient collect the authorization forms and bring them into the office. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said

Over the course of Part D implementation, Dr. Mitchell learned that insurers may ask for documentation justifying a switch in medications. To simplify that process, she recommends, keep a sheet in the front of the chart with information on medication changes and the reasons for the switch.

SAN DIEGO — In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, of the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said.

Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said.

When you are faced with prior authorization, Dr. Mitchell suggested, save time by having the patient collect the authorization forms and bring them into the office. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said

Over the course of Part D implementation, Dr. Mitchell learned that insurers may ask for documentation justifying a switch in medications. To simplify that process, she recommends, keep a sheet in the front of the chart with information on medication changes and the reasons for the switch.

SAN DIEGO — In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, of the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said.

Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said.

When you are faced with prior authorization, Dr. Mitchell suggested, save time by having the patient collect the authorization forms and bring them into the office. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said

Over the course of Part D implementation, Dr. Mitchell learned that insurers may ask for documentation justifying a switch in medications. To simplify that process, she recommends, keep a sheet in the front of the chart with information on medication changes and the reasons for the switch.

Nearly all physicians have ties to the pharmaceutical or device industries ranging from accepting drug samples to serving on a speakers' bureau, according to a survey of physicians across six specialties.

The study found that 94% of physicians surveyed reported some type of relationship with industry. The most frequently cited interaction (83%) was receiving food in the workplace. A majority of physicians surveyed (78%) also reported accepting drug samples.

Fewer physicians, about 35%, reported accepting reimbursement for admission to continuing medical education meetings or other meeting-related expenses, and 28% said they received payments from industry for professional services such as consulting, speaking, serving on an advisory board, or enrolling patients in clinical trials (N. Engl. J. Med. 2007;356:1742–50).

But the study fails to give a clear picture of the relationship between industry and pediatricians, said Dr. Richard Lander, a pediatrician in Livingston, N.J., and chairman of the section on administration and practice management for the American Academy of Pediatrics.

The nature of pediatric practice, from the time constraints to the office-based setting of the practice, tends to mean that pediatricians are less likely to be involved with industry than other specialties, Dr. Lander said. And because most drugs aren't designed with the pediatric patient in mind, the pharmaceutical industry doesn't spend as much time trying to reach pediatricians. “They're not going to make money off of us,” he said.

Eric G. Campbell, Ph.D., of the Institute for Health Policy at Massachusetts General Hospital-Partners Health Care System in Boston, and his colleagues surveyed 3,167 physicians working in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. Of those surveyed, 1,662 completed the questionnaire for an overall response rate of about 52%. The study was supported by a grant from the Institute on Medicine as a Profession.

The type and extent of reported interaction with representatives of the pharmaceutical and device industries varied by specialty, the researchers found. For example, cardiologists were significantly more likely than pediatricians, anesthesiologists, or surgeons to receive payments for professional services, such as consulting or work on clinical trials.

Family physicians held the most meetings with industry representatives, on average about 16 meetings per month, according to the study. In contrast, pediatricians held 8 meetings per month with industry representatives.

Practice setting also played a role in the interaction. Physicians in group practice were six times more likely to receive drug samples than were those working in hospitals, clinics, or staff-model health maintenance organizations. Physicians in group practice were also three times as likely to receive gifts and nearly four times as likely to receive payments for professional services.

The study did not assess the appropriateness of the relationships with industry, however, the researchers concluded that the variations in relationships by specialty may indicate a need for guidelines that are specific to specialties and practice settings.

Dr. Lander said he hoped that the article's findings would not create the misimpression that physicians are influenced by a free lunch, pens, or even drug samples. “We're doing it because we really care about the kids.”

Dr. James King, president-elect of the American Academy of Family Physicians, agreed that the study findings were not a major cause for concern. In particular, it is a common practice for physicians to accept drug samples in an effort to save their patients money.

Most practices are likely operating within the guidelines set out by the American Medical Association, he said.

The AMA guidelines recommend that gifts should primarily have a benefit to patients and should not be of substantial value. For example, modest meals and textbooks are acceptable under the AMA guidelines, but cash payments should not be accepted.

The main responsibility of physicians who do have relationships with industry is to ensure that patients' interests always come first and to disclose any financial conflicts, Dr. Jack Lewin, CEO of the American College of Cardiology, said in an interview.

ACC has a policy requiring disclosure of industry relationships for anyone involved in the group's activities, he said. “We really do have a firewall.”

However, many of the relationships between cardiologists and industry are necessary and appropriate, he said, because industry is the main source of research on new treatments.

But more can be done to reduce concerns about potential conflict of interest, Dr. Lewin said.

For example, an increase in the number of publicly funded independent reviews of drugs and devices and increases in federal research funding would help to clarify some of the grey areas of cardiovascular care, he said.

Nearly all physicians have ties to the pharmaceutical or device industries ranging from accepting drug samples to serving on a speakers' bureau, according to a survey of physicians across six specialties.

The study found that 94% of physicians surveyed reported some type of relationship with industry. The most frequently cited interaction (83%) was receiving food in the workplace. A majority of physicians surveyed (78%) also reported accepting drug samples.

Fewer physicians, about 35%, reported accepting reimbursement for admission to continuing medical education meetings or other meeting-related expenses, and 28% said they received payments from industry for professional services such as consulting, speaking, serving on an advisory board, or enrolling patients in clinical trials (N. Engl. J. Med. 2007;356:1742–50).

But the study fails to give a clear picture of the relationship between industry and pediatricians, said Dr. Richard Lander, a pediatrician in Livingston, N.J., and chairman of the section on administration and practice management for the American Academy of Pediatrics.

The nature of pediatric practice, from the time constraints to the office-based setting of the practice, tends to mean that pediatricians are less likely to be involved with industry than other specialties, Dr. Lander said. And because most drugs aren't designed with the pediatric patient in mind, the pharmaceutical industry doesn't spend as much time trying to reach pediatricians. “They're not going to make money off of us,” he said.

Eric G. Campbell, Ph.D., of the Institute for Health Policy at Massachusetts General Hospital-Partners Health Care System in Boston, and his colleagues surveyed 3,167 physicians working in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. Of those surveyed, 1,662 completed the questionnaire for an overall response rate of about 52%. The study was supported by a grant from the Institute on Medicine as a Profession.

The type and extent of reported interaction with representatives of the pharmaceutical and device industries varied by specialty, the researchers found. For example, cardiologists were significantly more likely than pediatricians, anesthesiologists, or surgeons to receive payments for professional services, such as consulting or work on clinical trials.

Family physicians held the most meetings with industry representatives, on average about 16 meetings per month, according to the study. In contrast, pediatricians held 8 meetings per month with industry representatives.

Practice setting also played a role in the interaction. Physicians in group practice were six times more likely to receive drug samples than were those working in hospitals, clinics, or staff-model health maintenance organizations. Physicians in group practice were also three times as likely to receive gifts and nearly four times as likely to receive payments for professional services.

The study did not assess the appropriateness of the relationships with industry, however, the researchers concluded that the variations in relationships by specialty may indicate a need for guidelines that are specific to specialties and practice settings.

Dr. Lander said he hoped that the article's findings would not create the misimpression that physicians are influenced by a free lunch, pens, or even drug samples. “We're doing it because we really care about the kids.”

Dr. James King, president-elect of the American Academy of Family Physicians, agreed that the study findings were not a major cause for concern. In particular, it is a common practice for physicians to accept drug samples in an effort to save their patients money.

Most practices are likely operating within the guidelines set out by the American Medical Association, he said.

The AMA guidelines recommend that gifts should primarily have a benefit to patients and should not be of substantial value. For example, modest meals and textbooks are acceptable under the AMA guidelines, but cash payments should not be accepted.

The main responsibility of physicians who do have relationships with industry is to ensure that patients' interests always come first and to disclose any financial conflicts, Dr. Jack Lewin, CEO of the American College of Cardiology, said in an interview.

ACC has a policy requiring disclosure of industry relationships for anyone involved in the group's activities, he said. “We really do have a firewall.”

However, many of the relationships between cardiologists and industry are necessary and appropriate, he said, because industry is the main source of research on new treatments.

But more can be done to reduce concerns about potential conflict of interest, Dr. Lewin said.

For example, an increase in the number of publicly funded independent reviews of drugs and devices and increases in federal research funding would help to clarify some of the grey areas of cardiovascular care, he said.

Nearly all physicians have ties to the pharmaceutical or device industries ranging from accepting drug samples to serving on a speakers' bureau, according to a survey of physicians across six specialties.

The study found that 94% of physicians surveyed reported some type of relationship with industry. The most frequently cited interaction (83%) was receiving food in the workplace. A majority of physicians surveyed (78%) also reported accepting drug samples.

Fewer physicians, about 35%, reported accepting reimbursement for admission to continuing medical education meetings or other meeting-related expenses, and 28% said they received payments from industry for professional services such as consulting, speaking, serving on an advisory board, or enrolling patients in clinical trials (N. Engl. J. Med. 2007;356:1742–50).

But the study fails to give a clear picture of the relationship between industry and pediatricians, said Dr. Richard Lander, a pediatrician in Livingston, N.J., and chairman of the section on administration and practice management for the American Academy of Pediatrics.

The nature of pediatric practice, from the time constraints to the office-based setting of the practice, tends to mean that pediatricians are less likely to be involved with industry than other specialties, Dr. Lander said. And because most drugs aren't designed with the pediatric patient in mind, the pharmaceutical industry doesn't spend as much time trying to reach pediatricians. “They're not going to make money off of us,” he said.

Eric G. Campbell, Ph.D., of the Institute for Health Policy at Massachusetts General Hospital-Partners Health Care System in Boston, and his colleagues surveyed 3,167 physicians working in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. Of those surveyed, 1,662 completed the questionnaire for an overall response rate of about 52%. The study was supported by a grant from the Institute on Medicine as a Profession.

The type and extent of reported interaction with representatives of the pharmaceutical and device industries varied by specialty, the researchers found. For example, cardiologists were significantly more likely than pediatricians, anesthesiologists, or surgeons to receive payments for professional services, such as consulting or work on clinical trials.

Family physicians held the most meetings with industry representatives, on average about 16 meetings per month, according to the study. In contrast, pediatricians held 8 meetings per month with industry representatives.

Practice setting also played a role in the interaction. Physicians in group practice were six times more likely to receive drug samples than were those working in hospitals, clinics, or staff-model health maintenance organizations. Physicians in group practice were also three times as likely to receive gifts and nearly four times as likely to receive payments for professional services.

The study did not assess the appropriateness of the relationships with industry, however, the researchers concluded that the variations in relationships by specialty may indicate a need for guidelines that are specific to specialties and practice settings.

Dr. Lander said he hoped that the article's findings would not create the misimpression that physicians are influenced by a free lunch, pens, or even drug samples. “We're doing it because we really care about the kids.”

Dr. James King, president-elect of the American Academy of Family Physicians, agreed that the study findings were not a major cause for concern. In particular, it is a common practice for physicians to accept drug samples in an effort to save their patients money.

Most practices are likely operating within the guidelines set out by the American Medical Association, he said.

The AMA guidelines recommend that gifts should primarily have a benefit to patients and should not be of substantial value. For example, modest meals and textbooks are acceptable under the AMA guidelines, but cash payments should not be accepted.

The main responsibility of physicians who do have relationships with industry is to ensure that patients' interests always come first and to disclose any financial conflicts, Dr. Jack Lewin, CEO of the American College of Cardiology, said in an interview.

ACC has a policy requiring disclosure of industry relationships for anyone involved in the group's activities, he said. “We really do have a firewall.”

However, many of the relationships between cardiologists and industry are necessary and appropriate, he said, because industry is the main source of research on new treatments.

But more can be done to reduce concerns about potential conflict of interest, Dr. Lewin said.

For example, an increase in the number of publicly funded independent reviews of drugs and devices and increases in federal research funding would help to clarify some of the grey areas of cardiovascular care, he said.

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

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

ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper focuses on what the programs should accomplish, what physicians should do if participating in them, and the potential unintended consequences of these programs.

For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A_1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing. Other unintended consequences include the potential for gaming the system by physicians, and an increase in unnecessary care and costs.

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

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

The limited data in the literature has provided mixed results on pay for performance. One study compared the performance of California physicians enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. It assessed outcomes on cervical cancer screening, mammography, and hemoglobin A_1c testing. The California physicians achieved greater quality improvement only in cervical cancer screening. The authors found there was little gain in quality, and the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).

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

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

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

ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper focuses on what the programs should accomplish, what physicians should do if participating in them, and the potential unintended consequences of these programs.

For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A_1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing. Other unintended consequences include the potential for gaming the system by physicians, and an increase in unnecessary care and costs.

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

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

The limited data in the literature has provided mixed results on pay for performance. One study compared the performance of California physicians enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. It assessed outcomes on cervical cancer screening, mammography, and hemoglobin A_1c testing. The California physicians achieved greater quality improvement only in cervical cancer screening. The authors found there was little gain in quality, and the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).

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

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

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

ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper focuses on what the programs should accomplish, what physicians should do if participating in them, and the potential unintended consequences of these programs.

For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A_1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing. Other unintended consequences include the potential for gaming the system by physicians, and an increase in unnecessary care and costs.

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

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

The limited data in the literature has provided mixed results on pay for performance. One study compared the performance of California physicians enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. It assessed outcomes on cervical cancer screening, mammography, and hemoglobin A_1c testing. The California physicians achieved greater quality improvement only in cervical cancer screening. The authors found there was little gain in quality, and the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).

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

SAN DIEGO – In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, a geriatrician and a professor in the department of community internal medicine at the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said. Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said. CMS officials announced that prior authorizations and exceptions approved by a drug plan in 2006 are expected to continue this year if the beneficiary remains in the same plan and the expiration date hasn't occurred by Dec. 31, 2006. However, if the beneficiary changes plans, physicians might have to go through the same process again. And even when patients remain in the same plan, some physicians have still received prior authorization requests, she said.

When you are faced with prior authorization, Dr. Mitchell suggested, save time by having the patient collect the authorization forms and bring them into the office. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said. Some physicians use general office staff while others use nursing staff. Dr. Mitchell said she prefers to have one of her nurses work on Part D issues because she is already familiar with the patients and their medications.

Dr. Mitchell also recommended that staff members who are working on Part D issues attend continuing medical education meetings that focus on Part D.

Because insurers may ask for documentation justifying a switch in medications, she recommends keeping a sheet in the front of the chart with information on medication changes and the reasons for the switch.

SAN DIEGO – In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, a geriatrician and a professor in the department of community internal medicine at the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said. Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said. CMS officials announced that prior authorizations and exceptions approved by a drug plan in 2006 are expected to continue this year if the beneficiary remains in the same plan and the expiration date hasn't occurred by Dec. 31, 2006. However, if the beneficiary changes plans, physicians might have to go through the same process again. And even when patients remain in the same plan, some physicians have still received prior authorization requests, she said.

When you are faced with prior authorization, Dr. Mitchell suggested, save time by having the patient collect the authorization forms and bring them into the office. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said. Some physicians use general office staff while others use nursing staff. Dr. Mitchell said she prefers to have one of her nurses work on Part D issues because she is already familiar with the patients and their medications.

Dr. Mitchell also recommended that staff members who are working on Part D issues attend continuing medical education meetings that focus on Part D.

Because insurers may ask for documentation justifying a switch in medications, she recommends keeping a sheet in the front of the chart with information on medication changes and the reasons for the switch.

SAN DIEGO – In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, a geriatrician and a professor in the department of community internal medicine at the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said. Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said. CMS officials announced that prior authorizations and exceptions approved by a drug plan in 2006 are expected to continue this year if the beneficiary remains in the same plan and the expiration date hasn't occurred by Dec. 31, 2006. However, if the beneficiary changes plans, physicians might have to go through the same process again. And even when patients remain in the same plan, some physicians have still received prior authorization requests, she said.

When you are faced with prior authorization, Dr. Mitchell suggested, save time by having the patient collect the authorization forms and bring them into the office. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said. Some physicians use general office staff while others use nursing staff. Dr. Mitchell said she prefers to have one of her nurses work on Part D issues because she is already familiar with the patients and their medications.

Dr. Mitchell also recommended that staff members who are working on Part D issues attend continuing medical education meetings that focus on Part D.

Because insurers may ask for documentation justifying a switch in medications, she recommends keeping a sheet in the front of the chart with information on medication changes and the reasons for the switch.

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 total allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.

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

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

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

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

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

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document, 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 total allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.

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

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

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

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

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

Specific instructions on when to use a modifier in the 2007 PQRI Specifications Document, 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 total allowed Medicare charges for reporting on certain quality measures. The program will run from July 1 through the end of the year. CMS officials have selected 74 quality measures and physicians are expected to report on between one and three measures, depending on how many apply to their patient populations.

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

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

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

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

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

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