Mary Ellen Schneider

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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since 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, since 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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since 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, since 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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since 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, since 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 carefully designed to avoid putting some of the most vulnerable patient populations at risk, officials with the American College of Physicians warned at the organization's annual meeting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other federal legislative proposals span the policy spectrum and include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and offering federal grants for state initiatives.

For now, these proposals are circulating in congressional committees, Mr. Ginsburg said. In the meantime, most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

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

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

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

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

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

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

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

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

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

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

Other federal legislative proposals span the policy spectrum and include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and offering federal grants for state initiatives.

For now, these proposals are circulating in congressional committees, Mr. Ginsburg said. In the meantime, most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

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

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

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

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

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

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

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

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

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

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

Other federal legislative proposals span the policy spectrum and include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and offering federal grants for state initiatives.

For now, these proposals are circulating in congressional committees, Mr. Ginsburg said. In the meantime, most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

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

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

Officials at the Centers for Medicare and Medicaid Services have reversed a proposal to expand coverage for carotid artery stenting in asymptomatic patients.

Instead, Medicare will continue to cover percutaneous transluminal angioplasty of the carotid artery concurrent with stenting, mainly in patients who are at high risk for carotid endarterectomy (CEA) and who also have symptomatic carotid artery stenosis of 70% or greater.

Medicare also will continue to cover the procedure in patients at high risk for CEA with symptomatic carotid artery stenosis between 50% and 70% in Category B Investigational Device Exemption (IDE) trials and in postapproval studies. The procedure will be covered only in asymptomatic patients under limited circumstances. Medicare will cover patients who are at high risk for CEA and have asymptomatic carotid artery stenosis of 80% or greater as part of a Category B IDE trial or a postapproval study.

The proposed decision to expand coverage of carotid artery stenting in asymptomatic patients outside of the protection of clinical trials and postapproval studies was “premature,” CMS said in its decision memo. However, officials also noted that registry and postapproval studies show a trend toward improving outcomes, and so they have continued coverage for patients who are enrolled in clinical trials or are part of postapproval studies.

Reversals of CMS-proposed coverage decisions are rare, a CMS spokesman said.

The policy reversal means that the agency will not proceed with plans to restrict coverage for patients 80 years of age or older to clinical trials and postapproval studies. And CMS also will not go forward with its proposal to require a surgeon to perform a consultation to ascertain a patient's high-risk status before undergoing carotid artery stenting (INTERNAL MEDICINE NEWS, March 1, 2007, p. 27).

Although CMS has rolled back most of the provisions of its February 2007 carotid artery stenting proposal, some aspects will remain in place. For example, CMS plans to implement the clarifications regarding embolic protection devices and the facility certification and recertification process.

Under the coverage decision, carotid artery stenting is covered only when used with an embolic protection device. The procedure will not be covered if the deployment of the distal embolic protection device is not possible.

Overall, the CMS coverage demo is fair and evidence based, said Dr. Eric R. Bates, a cardiologist and professor of internal medicine at the University of Michigan in Ann Arbor. “Everybody gets a little something out of it,” he said.

The decision not to expand coverage to asymptomatic patients makes sense and is based on the available evidence, he said. However, since it continues to cover the procedure in clinical trials and postapproval studies, it still leaves the door open for improvements in the technology, case selection, and operator skills, he said.

“I don't think you can be too critical of the decision,” Dr. Bates said.

But although CMS has done a good job of requiring evidence before expanding coverage, Dr. Bates said he is concerned that too many hospitals have been approved to perform carotid artery stenting for high-risk patients. Currently, 1,057 hospitals have met CMS minimum facility standards to perform the procedure in high-risk patients.

The coverage decision reversal is good news in the eyes of many in the neurology community who had urged CMS officials to be cautious in expanding coverage in this area. Both the American Academy of Neurology and the American Association of Neurological Surgeons submitted comments to CMS in which they said that available evidence did not warrant expansion.

The groups noted that the CMS proposal was based on case series data and company registries, which can be biased and are not helpful in determining efficacy.

In comments to the agency, officials at AANS recommended that CMS review its policies regarding carotid endarterectomy in high-risk asymptomatic patients. Both carotid artery stenting and CEA should be evaluated among those patients in a randomized clinical trial statistically powered to determine efficacy, AANS said.

“There is insufficient evidence regarding the relative risk of [carotid artery stenting] versus CEA in all asymptomatic high-risk subgroups to suggest that either procedure is superior to best medical therapy,” AANS wrote in comments to CMS. “Accordingly, it would be inappropriate and not in the best interest of patient care to change the [carotid artery stenting National Coverage Determination] to include asymptomatic high-risk patients in any age group at this time.”

Efforts to expand coverage now would make the development and completion of a randomized trial comparing CEA, carotid artery stenting, and medical therapy difficult, if not impossible, the American Stroke Association said in comments to CMS.

However, in comments to CMS, the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions supported efforts to expand carotid artery stenting to asymptomatic patients at high risk for CEA.

Expanded coverage was requested in March 2006 by Abbott Laboratories, which manufactures two carotid artery stent products, based on new evidence, including four Abbott-sponsored studies.

“This is a disappointing decision for carotid artery disease patients who are at high risk for surgery and who don't have symptoms of stroke,” the company said in a statement. “However, these patients will still have access to carotid artery stenting as a treatment option if they are enrolled in FDA-approved postmarketing clinical trials.”

Officials at the Centers for Medicare and Medicaid Services have reversed a proposal to expand coverage for carotid artery stenting in asymptomatic patients.

Instead, Medicare will continue to cover percutaneous transluminal angioplasty of the carotid artery concurrent with stenting, mainly in patients who are at high risk for carotid endarterectomy (CEA) and who also have symptomatic carotid artery stenosis of 70% or greater.

Medicare also will continue to cover the procedure in patients at high risk for CEA with symptomatic carotid artery stenosis between 50% and 70% in Category B Investigational Device Exemption (IDE) trials and in postapproval studies. The procedure will be covered only in asymptomatic patients under limited circumstances. Medicare will cover patients who are at high risk for CEA and have asymptomatic carotid artery stenosis of 80% or greater as part of a Category B IDE trial or a postapproval study.

The proposed decision to expand coverage of carotid artery stenting in asymptomatic patients outside of the protection of clinical trials and postapproval studies was “premature,” CMS said in its decision memo. However, officials also noted that registry and postapproval studies show a trend toward improving outcomes, and so they have continued coverage for patients who are enrolled in clinical trials or are part of postapproval studies.

Reversals of CMS-proposed coverage decisions are rare, a CMS spokesman said.

The policy reversal means that the agency will not proceed with plans to restrict coverage for patients 80 years of age or older to clinical trials and postapproval studies. And CMS also will not go forward with its proposal to require a surgeon to perform a consultation to ascertain a patient's high-risk status before undergoing carotid artery stenting (INTERNAL MEDICINE NEWS, March 1, 2007, p. 27).

Although CMS has rolled back most of the provisions of its February 2007 carotid artery stenting proposal, some aspects will remain in place. For example, CMS plans to implement the clarifications regarding embolic protection devices and the facility certification and recertification process.

Under the coverage decision, carotid artery stenting is covered only when used with an embolic protection device. The procedure will not be covered if the deployment of the distal embolic protection device is not possible.

Overall, the CMS coverage demo is fair and evidence based, said Dr. Eric R. Bates, a cardiologist and professor of internal medicine at the University of Michigan in Ann Arbor. “Everybody gets a little something out of it,” he said.

The decision not to expand coverage to asymptomatic patients makes sense and is based on the available evidence, he said. However, since it continues to cover the procedure in clinical trials and postapproval studies, it still leaves the door open for improvements in the technology, case selection, and operator skills, he said.

“I don't think you can be too critical of the decision,” Dr. Bates said.

But although CMS has done a good job of requiring evidence before expanding coverage, Dr. Bates said he is concerned that too many hospitals have been approved to perform carotid artery stenting for high-risk patients. Currently, 1,057 hospitals have met CMS minimum facility standards to perform the procedure in high-risk patients.

The coverage decision reversal is good news in the eyes of many in the neurology community who had urged CMS officials to be cautious in expanding coverage in this area. Both the American Academy of Neurology and the American Association of Neurological Surgeons submitted comments to CMS in which they said that available evidence did not warrant expansion.

The groups noted that the CMS proposal was based on case series data and company registries, which can be biased and are not helpful in determining efficacy.

In comments to the agency, officials at AANS recommended that CMS review its policies regarding carotid endarterectomy in high-risk asymptomatic patients. Both carotid artery stenting and CEA should be evaluated among those patients in a randomized clinical trial statistically powered to determine efficacy, AANS said.

“There is insufficient evidence regarding the relative risk of [carotid artery stenting] versus CEA in all asymptomatic high-risk subgroups to suggest that either procedure is superior to best medical therapy,” AANS wrote in comments to CMS. “Accordingly, it would be inappropriate and not in the best interest of patient care to change the [carotid artery stenting National Coverage Determination] to include asymptomatic high-risk patients in any age group at this time.”

Efforts to expand coverage now would make the development and completion of a randomized trial comparing CEA, carotid artery stenting, and medical therapy difficult, if not impossible, the American Stroke Association said in comments to CMS.

However, in comments to CMS, the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions supported efforts to expand carotid artery stenting to asymptomatic patients at high risk for CEA.

Expanded coverage was requested in March 2006 by Abbott Laboratories, which manufactures two carotid artery stent products, based on new evidence, including four Abbott-sponsored studies.

“This is a disappointing decision for carotid artery disease patients who are at high risk for surgery and who don't have symptoms of stroke,” the company said in a statement. “However, these patients will still have access to carotid artery stenting as a treatment option if they are enrolled in FDA-approved postmarketing clinical trials.”

Officials at the Centers for Medicare and Medicaid Services have reversed a proposal to expand coverage for carotid artery stenting in asymptomatic patients.

Instead, Medicare will continue to cover percutaneous transluminal angioplasty of the carotid artery concurrent with stenting, mainly in patients who are at high risk for carotid endarterectomy (CEA) and who also have symptomatic carotid artery stenosis of 70% or greater.

Medicare also will continue to cover the procedure in patients at high risk for CEA with symptomatic carotid artery stenosis between 50% and 70% in Category B Investigational Device Exemption (IDE) trials and in postapproval studies. The procedure will be covered only in asymptomatic patients under limited circumstances. Medicare will cover patients who are at high risk for CEA and have asymptomatic carotid artery stenosis of 80% or greater as part of a Category B IDE trial or a postapproval study.

The proposed decision to expand coverage of carotid artery stenting in asymptomatic patients outside of the protection of clinical trials and postapproval studies was “premature,” CMS said in its decision memo. However, officials also noted that registry and postapproval studies show a trend toward improving outcomes, and so they have continued coverage for patients who are enrolled in clinical trials or are part of postapproval studies.

Reversals of CMS-proposed coverage decisions are rare, a CMS spokesman said.

The policy reversal means that the agency will not proceed with plans to restrict coverage for patients 80 years of age or older to clinical trials and postapproval studies. And CMS also will not go forward with its proposal to require a surgeon to perform a consultation to ascertain a patient's high-risk status before undergoing carotid artery stenting (INTERNAL MEDICINE NEWS, March 1, 2007, p. 27).

Although CMS has rolled back most of the provisions of its February 2007 carotid artery stenting proposal, some aspects will remain in place. For example, CMS plans to implement the clarifications regarding embolic protection devices and the facility certification and recertification process.

Under the coverage decision, carotid artery stenting is covered only when used with an embolic protection device. The procedure will not be covered if the deployment of the distal embolic protection device is not possible.

Overall, the CMS coverage demo is fair and evidence based, said Dr. Eric R. Bates, a cardiologist and professor of internal medicine at the University of Michigan in Ann Arbor. “Everybody gets a little something out of it,” he said.

The decision not to expand coverage to asymptomatic patients makes sense and is based on the available evidence, he said. However, since it continues to cover the procedure in clinical trials and postapproval studies, it still leaves the door open for improvements in the technology, case selection, and operator skills, he said.

“I don't think you can be too critical of the decision,” Dr. Bates said.

But although CMS has done a good job of requiring evidence before expanding coverage, Dr. Bates said he is concerned that too many hospitals have been approved to perform carotid artery stenting for high-risk patients. Currently, 1,057 hospitals have met CMS minimum facility standards to perform the procedure in high-risk patients.

The coverage decision reversal is good news in the eyes of many in the neurology community who had urged CMS officials to be cautious in expanding coverage in this area. Both the American Academy of Neurology and the American Association of Neurological Surgeons submitted comments to CMS in which they said that available evidence did not warrant expansion.

The groups noted that the CMS proposal was based on case series data and company registries, which can be biased and are not helpful in determining efficacy.

In comments to the agency, officials at AANS recommended that CMS review its policies regarding carotid endarterectomy in high-risk asymptomatic patients. Both carotid artery stenting and CEA should be evaluated among those patients in a randomized clinical trial statistically powered to determine efficacy, AANS said.

“There is insufficient evidence regarding the relative risk of [carotid artery stenting] versus CEA in all asymptomatic high-risk subgroups to suggest that either procedure is superior to best medical therapy,” AANS wrote in comments to CMS. “Accordingly, it would be inappropriate and not in the best interest of patient care to change the [carotid artery stenting National Coverage Determination] to include asymptomatic high-risk patients in any age group at this time.”

Efforts to expand coverage now would make the development and completion of a randomized trial comparing CEA, carotid artery stenting, and medical therapy difficult, if not impossible, the American Stroke Association said in comments to CMS.

However, in comments to CMS, the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions supported efforts to expand carotid artery stenting to asymptomatic patients at high risk for CEA.

Expanded coverage was requested in March 2006 by Abbott Laboratories, which manufactures two carotid artery stent products, based on new evidence, including four Abbott-sponsored studies.

“This is a disappointing decision for carotid artery disease patients who are at high risk for surgery and who don't have symptoms of stroke,” the company said in a statement. “However, these patients will still have access to carotid artery stenting as a treatment option if they are enrolled in FDA-approved postmarketing clinical trials.”

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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, "I don't think it's a major cause for concern."

Dr. King said he was not surprised by the survey findings, especially since 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 relationship with industry should continue to be watched and addressed, said Dr. King, and he recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

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, since 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 gray 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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, "I don't think it's a major cause for concern."

Dr. King said he was not surprised by the survey findings, especially since 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 relationship with industry should continue to be watched and addressed, said Dr. King, and he recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

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, since 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 gray 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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, "I don't think it's a major cause for concern."

Dr. King said he was not surprised by the survey findings, especially since 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 relationship with industry should continue to be watched and addressed, said Dr. King, and he recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

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, since 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 gray areas of cardiovascular care, he said.

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.

During the course of Part D implementation, Dr. Mitchell also 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, 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.

During the course of Part D implementation, Dr. Mitchell also 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, 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.

During the course of Part D implementation, Dr. Mitchell also 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.

NEW ORLEANS — Get educated about state and federal regulations and policies on the prescription of controlled substances, advised David Joranson, director of the Pain and Policy Studies Group at the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center in Madison.

Mr. Joranson, who spoke at the annual meeting of the American Academy of Pain Medicine, said that understanding current regulations is critical to avoiding unnecessary fears over the risk of sanctions from prescribing pain medication.

In recent years there has been increasing agreement reached between pain medicine specialists, law enforcement, and regulators, he said.

For example, from 2003 to 2006, 19 states either repealed or added language to their state's controlled substances prescribing policies to take a more balanced approach—recognizing opioids are necessary but also pose risks and need to be controlled.

“The state policies are becoming more balanced,” he said.

Importantly, 39 states have adopted a policy aimed at directly addressing physicians' concerns about regulatory scrutiny, he added.

Nearly 10 years ago, the Federation of State Medical Boards made it clear that physicians should recognize that tolerance and physical dependence are the normal consequences of the sustained use of opioid analgesics and are not synonymous with addiction. As a result, many state medical board guidelines now reflect that statement, Mr. Joranson said.

Last year, at the federal level the Drug Enforcement Administration issued a statement that nearly every prescription issued in the United States is for a legitimate medical purpose and that the amount of dosage units per prescription will never be a basis for investigation for the overwhelming majority of physicians.

“Here again it looks like we're pretty much on the same page,” he said.

Research findings indicated, however, that physicians may not be paying attention to this policy shift. In a study published in the Journal of Family Practice in 2001, investigators from the University of California, San Francisco/Stanford Collaborative Research Network surveyed 230 primary care physicians on pain treatment, the use of opioids, and their familiarity with state prescribing and documentation guidelines.

Specifically, the investigation focused on whether physicians were aware of guidelines on prescribing opioids for chronic nonmalignant pain that were issued by the Medical Board of California in 1994. The guidelines were aimed in part at reducing physicians' fear of regulatory scrutiny. The guidelines were mailed to all licensed physician in the state three times between 1994 and 1996.

Of the 161 physicians who completed the survey, only 39% remembered reading the guidelines 1 year after the third mailing. And 40% of respondents said that fear of legal investigation influenced their opioid prescribing habits.

“It can be an uphill battle to get physicians to pay attention to policy,” Mr. Joranson said.

NEW ORLEANS — Get educated about state and federal regulations and policies on the prescription of controlled substances, advised David Joranson, director of the Pain and Policy Studies Group at the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center in Madison.

Mr. Joranson, who spoke at the annual meeting of the American Academy of Pain Medicine, said that understanding current regulations is critical to avoiding unnecessary fears over the risk of sanctions from prescribing pain medication.

In recent years there has been increasing agreement reached between pain medicine specialists, law enforcement, and regulators, he said.

For example, from 2003 to 2006, 19 states either repealed or added language to their state's controlled substances prescribing policies to take a more balanced approach—recognizing opioids are necessary but also pose risks and need to be controlled.

“The state policies are becoming more balanced,” he said.

Importantly, 39 states have adopted a policy aimed at directly addressing physicians' concerns about regulatory scrutiny, he added.

Nearly 10 years ago, the Federation of State Medical Boards made it clear that physicians should recognize that tolerance and physical dependence are the normal consequences of the sustained use of opioid analgesics and are not synonymous with addiction. As a result, many state medical board guidelines now reflect that statement, Mr. Joranson said.

Last year, at the federal level the Drug Enforcement Administration issued a statement that nearly every prescription issued in the United States is for a legitimate medical purpose and that the amount of dosage units per prescription will never be a basis for investigation for the overwhelming majority of physicians.

“Here again it looks like we're pretty much on the same page,” he said.

Research findings indicated, however, that physicians may not be paying attention to this policy shift. In a study published in the Journal of Family Practice in 2001, investigators from the University of California, San Francisco/Stanford Collaborative Research Network surveyed 230 primary care physicians on pain treatment, the use of opioids, and their familiarity with state prescribing and documentation guidelines.

Specifically, the investigation focused on whether physicians were aware of guidelines on prescribing opioids for chronic nonmalignant pain that were issued by the Medical Board of California in 1994. The guidelines were aimed in part at reducing physicians' fear of regulatory scrutiny. The guidelines were mailed to all licensed physician in the state three times between 1994 and 1996.

Of the 161 physicians who completed the survey, only 39% remembered reading the guidelines 1 year after the third mailing. And 40% of respondents said that fear of legal investigation influenced their opioid prescribing habits.

“It can be an uphill battle to get physicians to pay attention to policy,” Mr. Joranson said.

NEW ORLEANS — Get educated about state and federal regulations and policies on the prescription of controlled substances, advised David Joranson, director of the Pain and Policy Studies Group at the University of Wisconsin Paul P. Carbone Comprehensive Cancer Center in Madison.

Mr. Joranson, who spoke at the annual meeting of the American Academy of Pain Medicine, said that understanding current regulations is critical to avoiding unnecessary fears over the risk of sanctions from prescribing pain medication.

In recent years there has been increasing agreement reached between pain medicine specialists, law enforcement, and regulators, he said.

For example, from 2003 to 2006, 19 states either repealed or added language to their state's controlled substances prescribing policies to take a more balanced approach—recognizing opioids are necessary but also pose risks and need to be controlled.

“The state policies are becoming more balanced,” he said.

Importantly, 39 states have adopted a policy aimed at directly addressing physicians' concerns about regulatory scrutiny, he added.

Nearly 10 years ago, the Federation of State Medical Boards made it clear that physicians should recognize that tolerance and physical dependence are the normal consequences of the sustained use of opioid analgesics and are not synonymous with addiction. As a result, many state medical board guidelines now reflect that statement, Mr. Joranson said.

Last year, at the federal level the Drug Enforcement Administration issued a statement that nearly every prescription issued in the United States is for a legitimate medical purpose and that the amount of dosage units per prescription will never be a basis for investigation for the overwhelming majority of physicians.

“Here again it looks like we're pretty much on the same page,” he said.

Research findings indicated, however, that physicians may not be paying attention to this policy shift. In a study published in the Journal of Family Practice in 2001, investigators from the University of California, San Francisco/Stanford Collaborative Research Network surveyed 230 primary care physicians on pain treatment, the use of opioids, and their familiarity with state prescribing and documentation guidelines.

Specifically, the investigation focused on whether physicians were aware of guidelines on prescribing opioids for chronic nonmalignant pain that were issued by the Medical Board of California in 1994. The guidelines were aimed in part at reducing physicians' fear of regulatory scrutiny. The guidelines were mailed to all licensed physician in the state three times between 1994 and 1996.

Of the 161 physicians who completed the survey, only 39% remembered reading the guidelines 1 year after the third mailing. And 40% of respondents said that fear of legal investigation influenced their opioid prescribing habits.

“It can be an uphill battle to get physicians to pay attention to policy,” Mr. Joranson said.

Women Often Forgo Care

More women than men skip needed health care services because of cost, even when they have insurance coverage, according to a study issued by The Commonwealth Fund. About 43% of women reported having difficulty accessing health care, compared with 30% of men. Among the uninsured the problem is more pronounced with 68% of women reporting access issues, compared with 49% of men. Women are more likely than men to report not filling a prescription, not seeing a specialist when needed, and skipping medical tests or treatments, according to the report. The report data are from three surveys conducted in 2004 and 2005. “These findings show that comprehensive health care coverage that doesn't require high out-of-pocket costs is vital to ensuring that women get the care they need to be healthy,” Sara Collins, assistant vice president for the Program on the Future of Health Insurance at The Commonwealth Fund, said in a statement.

Breast, Cervical Cancer Screening

President Bush recently signed into law the National Breast and Cervical Cancer Early Detection Program Reauthorization Act, which will continue the screening program for low-income and uninsured women. Since 1991, the program has provide nearly 7 million cancer-screening exams to more than 2.9 million women. This year an additional 700,000 screenings are expected to be done. Through the program, women can receive clinical breast exams, mammograms, and Pap tests, as well surgical consultation, referrals to treatment, and diagnostics for those whose screening results are abnormal. “When breast cancer or cervical cancer is caught early, the survival rate is more than 90%,” President Bush said at the bill signing.

Codifying Roe v. Wade

One day after the U.S. Supreme Court upheld federal legislation banning the so-called partial birth abortion procedure, some members of Congress introduced legislation that would codify Roe v. Wade. Rep. Jerrold Nadler (D-N.Y.) and Sen. Barbara Boxer (D-Calif.) reintroduced the “Freedom of Choice Act,” which, if enacted would prohibit the government from interfering with a woman's right to bear a child, to terminate a pregnancy prior to viability, or to terminate a pregnancy after viability in order to protect her life or health. The legislation defines viability as the stage of pregnancy when, in the medical judgment of the attending physician, there is a reasonable likelihood that the fetus can survive outside of the woman's body. “Many members of Congress say they support preserving Roe v. Wade,” Rep. Nadler said in a statement. “This bill is a binding codification of that decision. It is time for members to step up to the plate and go on record in support of legislation that will provide meaningful protection for women.”

Grading Abstinence-Only Education

Teenagers enrolled in abstinence-only education programs are about as likely to have abstained from sex as teens in a control group, according to a report evaluating federal abstinence education programs. The study, which was requested by Congress under the Balanced Budget Act of 1997, was conducted by Mathematica Policy Research Inc., on behalf of the Department of Health and Human Services. The study is based on the results of a survey of more than 2,000 teens who were either assigned to an abstinence-education program or a control group. The sample includes four abstinence education programs that focus on teaching abstinence from sexual activity outside of marriage. Surveys from the teens involved in the study revealed that about 49% remained abstinent always regardless of whether they were enrolled in a program, and 56% of teens in a program were abstinent in the last 12 months, compared with 55% of teens in the control group. The researchers found similar rates among the two groups when they asked about sex using a condom, age at first intercourse, and number of sexual partners.

Juries Side With MDs

Contrary to popular belief, juries in malpractice cases usually sympathize more with physicians and less with their patients, according to a law professor who performed an extensive review of studies involving malpractice cases from 1989 to 2006. University of Missouri-Columbia School of Law professor Philip Peters found that plaintiffs rarely win weak cases, although they have more success in cases viewed as a “toss-up” and better outcomes in cases with strong evidence of medical negligence. Peters, whose study appeared in the May edition of the Michigan Law Review, said that several factors systemically favor medical defendants in the courtroom, including the defendant's superior resources, physicians' social standing, social norms against “profiting” by injury, and the jury's willingness to give physicians the benefit of the doubt when evidence conflicts.

Women Often Forgo Care

More women than men skip needed health care services because of cost, even when they have insurance coverage, according to a study issued by The Commonwealth Fund. About 43% of women reported having difficulty accessing health care, compared with 30% of men. Among the uninsured the problem is more pronounced with 68% of women reporting access issues, compared with 49% of men. Women are more likely than men to report not filling a prescription, not seeing a specialist when needed, and skipping medical tests or treatments, according to the report. The report data are from three surveys conducted in 2004 and 2005. “These findings show that comprehensive health care coverage that doesn't require high out-of-pocket costs is vital to ensuring that women get the care they need to be healthy,” Sara Collins, assistant vice president for the Program on the Future of Health Insurance at The Commonwealth Fund, said in a statement.

Breast, Cervical Cancer Screening

President Bush recently signed into law the National Breast and Cervical Cancer Early Detection Program Reauthorization Act, which will continue the screening program for low-income and uninsured women. Since 1991, the program has provide nearly 7 million cancer-screening exams to more than 2.9 million women. This year an additional 700,000 screenings are expected to be done. Through the program, women can receive clinical breast exams, mammograms, and Pap tests, as well surgical consultation, referrals to treatment, and diagnostics for those whose screening results are abnormal. “When breast cancer or cervical cancer is caught early, the survival rate is more than 90%,” President Bush said at the bill signing.

Codifying Roe v. Wade

One day after the U.S. Supreme Court upheld federal legislation banning the so-called partial birth abortion procedure, some members of Congress introduced legislation that would codify Roe v. Wade. Rep. Jerrold Nadler (D-N.Y.) and Sen. Barbara Boxer (D-Calif.) reintroduced the “Freedom of Choice Act,” which, if enacted would prohibit the government from interfering with a woman's right to bear a child, to terminate a pregnancy prior to viability, or to terminate a pregnancy after viability in order to protect her life or health. The legislation defines viability as the stage of pregnancy when, in the medical judgment of the attending physician, there is a reasonable likelihood that the fetus can survive outside of the woman's body. “Many members of Congress say they support preserving Roe v. Wade,” Rep. Nadler said in a statement. “This bill is a binding codification of that decision. It is time for members to step up to the plate and go on record in support of legislation that will provide meaningful protection for women.”

Grading Abstinence-Only Education

Teenagers enrolled in abstinence-only education programs are about as likely to have abstained from sex as teens in a control group, according to a report evaluating federal abstinence education programs. The study, which was requested by Congress under the Balanced Budget Act of 1997, was conducted by Mathematica Policy Research Inc., on behalf of the Department of Health and Human Services. The study is based on the results of a survey of more than 2,000 teens who were either assigned to an abstinence-education program or a control group. The sample includes four abstinence education programs that focus on teaching abstinence from sexual activity outside of marriage. Surveys from the teens involved in the study revealed that about 49% remained abstinent always regardless of whether they were enrolled in a program, and 56% of teens in a program were abstinent in the last 12 months, compared with 55% of teens in the control group. The researchers found similar rates among the two groups when they asked about sex using a condom, age at first intercourse, and number of sexual partners.

Juries Side With MDs

Contrary to popular belief, juries in malpractice cases usually sympathize more with physicians and less with their patients, according to a law professor who performed an extensive review of studies involving malpractice cases from 1989 to 2006. University of Missouri-Columbia School of Law professor Philip Peters found that plaintiffs rarely win weak cases, although they have more success in cases viewed as a “toss-up” and better outcomes in cases with strong evidence of medical negligence. Peters, whose study appeared in the May edition of the Michigan Law Review, said that several factors systemically favor medical defendants in the courtroom, including the defendant's superior resources, physicians' social standing, social norms against “profiting” by injury, and the jury's willingness to give physicians the benefit of the doubt when evidence conflicts.

Women Often Forgo Care

More women than men skip needed health care services because of cost, even when they have insurance coverage, according to a study issued by The Commonwealth Fund. About 43% of women reported having difficulty accessing health care, compared with 30% of men. Among the uninsured the problem is more pronounced with 68% of women reporting access issues, compared with 49% of men. Women are more likely than men to report not filling a prescription, not seeing a specialist when needed, and skipping medical tests or treatments, according to the report. The report data are from three surveys conducted in 2004 and 2005. “These findings show that comprehensive health care coverage that doesn't require high out-of-pocket costs is vital to ensuring that women get the care they need to be healthy,” Sara Collins, assistant vice president for the Program on the Future of Health Insurance at The Commonwealth Fund, said in a statement.

Breast, Cervical Cancer Screening

President Bush recently signed into law the National Breast and Cervical Cancer Early Detection Program Reauthorization Act, which will continue the screening program for low-income and uninsured women. Since 1991, the program has provide nearly 7 million cancer-screening exams to more than 2.9 million women. This year an additional 700,000 screenings are expected to be done. Through the program, women can receive clinical breast exams, mammograms, and Pap tests, as well surgical consultation, referrals to treatment, and diagnostics for those whose screening results are abnormal. “When breast cancer or cervical cancer is caught early, the survival rate is more than 90%,” President Bush said at the bill signing.

Codifying Roe v. Wade

One day after the U.S. Supreme Court upheld federal legislation banning the so-called partial birth abortion procedure, some members of Congress introduced legislation that would codify Roe v. Wade. Rep. Jerrold Nadler (D-N.Y.) and Sen. Barbara Boxer (D-Calif.) reintroduced the “Freedom of Choice Act,” which, if enacted would prohibit the government from interfering with a woman's right to bear a child, to terminate a pregnancy prior to viability, or to terminate a pregnancy after viability in order to protect her life or health. The legislation defines viability as the stage of pregnancy when, in the medical judgment of the attending physician, there is a reasonable likelihood that the fetus can survive outside of the woman's body. “Many members of Congress say they support preserving Roe v. Wade,” Rep. Nadler said in a statement. “This bill is a binding codification of that decision. It is time for members to step up to the plate and go on record in support of legislation that will provide meaningful protection for women.”

Grading Abstinence-Only Education

Teenagers enrolled in abstinence-only education programs are about as likely to have abstained from sex as teens in a control group, according to a report evaluating federal abstinence education programs. The study, which was requested by Congress under the Balanced Budget Act of 1997, was conducted by Mathematica Policy Research Inc., on behalf of the Department of Health and Human Services. The study is based on the results of a survey of more than 2,000 teens who were either assigned to an abstinence-education program or a control group. The sample includes four abstinence education programs that focus on teaching abstinence from sexual activity outside of marriage. Surveys from the teens involved in the study revealed that about 49% remained abstinent always regardless of whether they were enrolled in a program, and 56% of teens in a program were abstinent in the last 12 months, compared with 55% of teens in the control group. The researchers found similar rates among the two groups when they asked about sex using a condom, age at first intercourse, and number of sexual partners.

Juries Side With MDs

Contrary to popular belief, juries in malpractice cases usually sympathize more with physicians and less with their patients, according to a law professor who performed an extensive review of studies involving malpractice cases from 1989 to 2006. University of Missouri-Columbia School of Law professor Philip Peters found that plaintiffs rarely win weak cases, although they have more success in cases viewed as a “toss-up” and better outcomes in cases with strong evidence of medical negligence. Peters, whose study appeared in the May edition of the Michigan Law Review, said that several factors systemically favor medical defendants in the courtroom, including the defendant's superior resources, physicians' social standing, social norms against “profiting” by injury, and the jury's willingness to give physicians the benefit of the doubt when evidence conflicts.

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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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 industr; 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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians, said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since 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 relationship with industry should continue to be watched and addressed, said Dr. King, and he recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

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, Dr. Lewin said, since industry is the main source of research on new treatments. But more can be done to reduce concerns about potential conflict of interest, he noted. 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 gray 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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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 industr; 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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians, said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since 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 relationship with industry should continue to be watched and addressed, said Dr. King, and he recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

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, Dr. Lewin said, since industry is the main source of research on new treatments. But more can be done to reduce concerns about potential conflict of interest, he noted. 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 gray 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).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

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 more than twice as likely as family physicians 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.

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 industr; 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.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians, said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since 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 relationship with industry should continue to be watched and addressed, said Dr. King, and he recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

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, Dr. Lewin said, since industry is the main source of research on new treatments. But more can be done to reduce concerns about potential conflict of interest, he noted. 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 gray areas of cardiovascular care, he said.

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

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

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

PQRI is a voluntary program that will let physicians earn a bonus of up to 1.5% of their total allowed Medicare charges during the last 6 months of 2007 for reporting on certain quality measures. Congress authorized the establishment of the 6-month pay-for-reporting program last December as part of the Tax Relief and Health Care Act of 2006. Changes to PQRI—and actual implementation of a pay-for-performance system—would require additional legislation from Congress.

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

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

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

ACP officials would rather see a “weighted” performance payment that would take into consideration the impact and the additional work related to measures for chronic diseases, he said.

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

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

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

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

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

PQRI is a voluntary program that will let physicians earn a bonus of up to 1.5% of their total allowed Medicare charges during the last 6 months of 2007 for reporting on certain quality measures. Congress authorized the establishment of the 6-month pay-for-reporting program last December as part of the Tax Relief and Health Care Act of 2006. Changes to PQRI—and actual implementation of a pay-for-performance system—would require additional legislation from Congress.

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

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

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

ACP officials would rather see a “weighted” performance payment that would take into consideration the impact and the additional work related to measures for chronic diseases, he said.

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

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

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

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

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

PQRI is a voluntary program that will let physicians earn a bonus of up to 1.5% of their total allowed Medicare charges during the last 6 months of 2007 for reporting on certain quality measures. Congress authorized the establishment of the 6-month pay-for-reporting program last December as part of the Tax Relief and Health Care Act of 2006. Changes to PQRI—and actual implementation of a pay-for-performance system—would require additional legislation from Congress.

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

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

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

ACP officials would rather see a “weighted” performance payment that would take into consideration the impact and the additional work related to measures for chronic diseases, he said.

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

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