Mary Ellen Schneider

If a 14-year-old girl walks into an indoor tanning facility in California, she would need parental consent to get a tan. But in Wisconsin, that same teen would be turned away at the door.

Twenty-one states and some counties restrict minors' access to indoor tanning facilities in some way, according to a recent analysis (Arch. Dermatol. 2005;141:524–5).

But restrictions vary widely, with some areas requiring written parental consent that can be signed outside of the presence of an operator, others requiring parental accompaniment, and still others prohibiting access for individuals under age 14 years.

Six states—Texas, Illinois, Wisconsin, California, North Carolina, and New Hampshire—have minimum age limits for indoor UV tanning. And over the past few years, there has been a growing interest in this area from state-level policy makers.

“The effectiveness of even the most stringent regulations is measurable only as far as enforcement is enacted on a local level,” said Jessica Krant, M.D., of the dermatology department at the State University of New York Downstate Medical Center in Brooklyn, N.Y.

Where written parental consent is required, teens may forge their parent's signature, Dr. Krant said. And a new study shows that compliance with age limits and requirements for parental accompaniment vary. For example, in Wisconsin and Illinois, where restrictions have been in place for a number of years, compliance with age limits is about 89% and 74%, respectively. But in Texas, where age restrictions are newer, compliance is about 23% (Arch. Dermatol. 2005;141:959–62).

Uniform federal legislation could be helpful, said Jack Resneck Jr., M.D., president-elect of the California Society of Dermatology and Dermatologic Surgery. Without an overall federal policy, state dermatological societies have to fight this “one state house at a time,” he said.

The American Medical Association recently approved a policy that calls for federal legislation to prohibit the use of indoor tanning equipment by individuals under age 18 years. The policy also supports the creation of a U.S. surgeon general's warning on all indoor tanning equipment about the correlation between UV radiation, the use of indoor tanning equipment, and the incidence of skin cancer.

“Children and teens are still growing and undergoing rapid development, so it's particularly critical that we take the necessary steps to help ensure their long-term health and well-being,” AMA Trustee Ronald M. Davis, M.D., said in a statement.

Currently, there is no pending federal legislation or regulation that would prohibit access to tanning facilities by minors.

The growing public awareness and physician involvement in this area will eventually lead to proposed legislation at the federal level, Dr. Krant said, but it will be a tough political battle. Any effort would meet resistance from a strong corporate lobby of tanning bed makers and UV bulb producers, she said.

“Time will tell in terms of what we are able to accomplish on the national stage, but with so many national and world medical organizations behind our efforts, I am optimistic,” said Dr. Krant.

But action is most likely to continue on the state level, unless members of Congress take an interest in this issue, said James Spencer, M.D., professor of clinical dermatology at the Mount Sinai School of Medicine, New York. “The momentum is there at the state level.”

But John Overstreet, executive director of the Indoor Tanning Association, said the problem of teen tanning is overblown. Industry estimates are that less than 5% of indoor tanning customers are under age 18. And it's truly a nonissue for children under age 14, Mr. Overstreet said.

He predicted that the federal government would not act to further restrict the industry since the Food and Drug Administration already requires a warning statement on each device.

In addition to working with policy makers, doctors need to reach out to teens, Dr. Spencer said. The reality is that tanning is very popular among young people; they may know that it's not a good idea but they value looking good for the prom over the risk of skin cancer years down the road, he said.

“I think we have gotten the word out, but they just don't care,” said Dr. Spencer, who is a former cochair of the National Council for Skin Cancer Prevention.

One way to make the message stronger is to limit the use of indoor tanning facilities by minors, Dr. Spencer said.

A mix of regulation and education is appropriate, said Daniel Krowchuk, M.D., professor of pediatrics and dermatology at Wake Forest University in Winston-Salem, N.C. Physicians have been trying to educate the public about sun exposure for many years and have been only modestly successful, he said. So Dr. Krowchuk thinks it makes sense to regulate an unhealthy behavior like tanning similar to the way many states have mandated the use of seatbelts.

If a 14-year-old girl walks into an indoor tanning facility in California, she would need parental consent to get a tan. But in Wisconsin, that same teen would be turned away at the door.

Twenty-one states and some counties restrict minors' access to indoor tanning facilities in some way, according to a recent analysis (Arch. Dermatol. 2005;141:524–5).

But restrictions vary widely, with some areas requiring written parental consent that can be signed outside of the presence of an operator, others requiring parental accompaniment, and still others prohibiting access for individuals under age 14 years.

Six states—Texas, Illinois, Wisconsin, California, North Carolina, and New Hampshire—have minimum age limits for indoor UV tanning. And over the past few years, there has been a growing interest in this area from state-level policy makers.

“The effectiveness of even the most stringent regulations is measurable only as far as enforcement is enacted on a local level,” said Jessica Krant, M.D., of the dermatology department at the State University of New York Downstate Medical Center in Brooklyn, N.Y.

Where written parental consent is required, teens may forge their parent's signature, Dr. Krant said. And a new study shows that compliance with age limits and requirements for parental accompaniment vary. For example, in Wisconsin and Illinois, where restrictions have been in place for a number of years, compliance with age limits is about 89% and 74%, respectively. But in Texas, where age restrictions are newer, compliance is about 23% (Arch. Dermatol. 2005;141:959–62).

Uniform federal legislation could be helpful, said Jack Resneck Jr., M.D., president-elect of the California Society of Dermatology and Dermatologic Surgery. Without an overall federal policy, state dermatological societies have to fight this “one state house at a time,” he said.

The American Medical Association recently approved a policy that calls for federal legislation to prohibit the use of indoor tanning equipment by individuals under age 18 years. The policy also supports the creation of a U.S. surgeon general's warning on all indoor tanning equipment about the correlation between UV radiation, the use of indoor tanning equipment, and the incidence of skin cancer.

“Children and teens are still growing and undergoing rapid development, so it's particularly critical that we take the necessary steps to help ensure their long-term health and well-being,” AMA Trustee Ronald M. Davis, M.D., said in a statement.

Currently, there is no pending federal legislation or regulation that would prohibit access to tanning facilities by minors.

The growing public awareness and physician involvement in this area will eventually lead to proposed legislation at the federal level, Dr. Krant said, but it will be a tough political battle. Any effort would meet resistance from a strong corporate lobby of tanning bed makers and UV bulb producers, she said.

“Time will tell in terms of what we are able to accomplish on the national stage, but with so many national and world medical organizations behind our efforts, I am optimistic,” said Dr. Krant.

But action is most likely to continue on the state level, unless members of Congress take an interest in this issue, said James Spencer, M.D., professor of clinical dermatology at the Mount Sinai School of Medicine, New York. “The momentum is there at the state level.”

But John Overstreet, executive director of the Indoor Tanning Association, said the problem of teen tanning is overblown. Industry estimates are that less than 5% of indoor tanning customers are under age 18. And it's truly a nonissue for children under age 14, Mr. Overstreet said.

He predicted that the federal government would not act to further restrict the industry since the Food and Drug Administration already requires a warning statement on each device.

In addition to working with policy makers, doctors need to reach out to teens, Dr. Spencer said. The reality is that tanning is very popular among young people; they may know that it's not a good idea but they value looking good for the prom over the risk of skin cancer years down the road, he said.

“I think we have gotten the word out, but they just don't care,” said Dr. Spencer, who is a former cochair of the National Council for Skin Cancer Prevention.

One way to make the message stronger is to limit the use of indoor tanning facilities by minors, Dr. Spencer said.

A mix of regulation and education is appropriate, said Daniel Krowchuk, M.D., professor of pediatrics and dermatology at Wake Forest University in Winston-Salem, N.C. Physicians have been trying to educate the public about sun exposure for many years and have been only modestly successful, he said. So Dr. Krowchuk thinks it makes sense to regulate an unhealthy behavior like tanning similar to the way many states have mandated the use of seatbelts.

If a 14-year-old girl walks into an indoor tanning facility in California, she would need parental consent to get a tan. But in Wisconsin, that same teen would be turned away at the door.

Twenty-one states and some counties restrict minors' access to indoor tanning facilities in some way, according to a recent analysis (Arch. Dermatol. 2005;141:524–5).

But restrictions vary widely, with some areas requiring written parental consent that can be signed outside of the presence of an operator, others requiring parental accompaniment, and still others prohibiting access for individuals under age 14 years.

Six states—Texas, Illinois, Wisconsin, California, North Carolina, and New Hampshire—have minimum age limits for indoor UV tanning. And over the past few years, there has been a growing interest in this area from state-level policy makers.

“The effectiveness of even the most stringent regulations is measurable only as far as enforcement is enacted on a local level,” said Jessica Krant, M.D., of the dermatology department at the State University of New York Downstate Medical Center in Brooklyn, N.Y.

Where written parental consent is required, teens may forge their parent's signature, Dr. Krant said. And a new study shows that compliance with age limits and requirements for parental accompaniment vary. For example, in Wisconsin and Illinois, where restrictions have been in place for a number of years, compliance with age limits is about 89% and 74%, respectively. But in Texas, where age restrictions are newer, compliance is about 23% (Arch. Dermatol. 2005;141:959–62).

Uniform federal legislation could be helpful, said Jack Resneck Jr., M.D., president-elect of the California Society of Dermatology and Dermatologic Surgery. Without an overall federal policy, state dermatological societies have to fight this “one state house at a time,” he said.

The American Medical Association recently approved a policy that calls for federal legislation to prohibit the use of indoor tanning equipment by individuals under age 18 years. The policy also supports the creation of a U.S. surgeon general's warning on all indoor tanning equipment about the correlation between UV radiation, the use of indoor tanning equipment, and the incidence of skin cancer.

“Children and teens are still growing and undergoing rapid development, so it's particularly critical that we take the necessary steps to help ensure their long-term health and well-being,” AMA Trustee Ronald M. Davis, M.D., said in a statement.

Currently, there is no pending federal legislation or regulation that would prohibit access to tanning facilities by minors.

The growing public awareness and physician involvement in this area will eventually lead to proposed legislation at the federal level, Dr. Krant said, but it will be a tough political battle. Any effort would meet resistance from a strong corporate lobby of tanning bed makers and UV bulb producers, she said.

“Time will tell in terms of what we are able to accomplish on the national stage, but with so many national and world medical organizations behind our efforts, I am optimistic,” said Dr. Krant.

But action is most likely to continue on the state level, unless members of Congress take an interest in this issue, said James Spencer, M.D., professor of clinical dermatology at the Mount Sinai School of Medicine, New York. “The momentum is there at the state level.”

But John Overstreet, executive director of the Indoor Tanning Association, said the problem of teen tanning is overblown. Industry estimates are that less than 5% of indoor tanning customers are under age 18. And it's truly a nonissue for children under age 14, Mr. Overstreet said.

He predicted that the federal government would not act to further restrict the industry since the Food and Drug Administration already requires a warning statement on each device.

In addition to working with policy makers, doctors need to reach out to teens, Dr. Spencer said. The reality is that tanning is very popular among young people; they may know that it's not a good idea but they value looking good for the prom over the risk of skin cancer years down the road, he said.

“I think we have gotten the word out, but they just don't care,” said Dr. Spencer, who is a former cochair of the National Council for Skin Cancer Prevention.

One way to make the message stronger is to limit the use of indoor tanning facilities by minors, Dr. Spencer said.

A mix of regulation and education is appropriate, said Daniel Krowchuk, M.D., professor of pediatrics and dermatology at Wake Forest University in Winston-Salem, N.C. Physicians have been trying to educate the public about sun exposure for many years and have been only modestly successful, he said. So Dr. Krowchuk thinks it makes sense to regulate an unhealthy behavior like tanning similar to the way many states have mandated the use of seatbelts.

Officials at the Department of Health and Human Services have loosened restrictions on ownership of pharmaceutical and biotech company stocks for employees of the National Institutes of Health under a final rule on conflict of interest.

But the final regulation announced at a teleconference on NIH conflict of interest regulations continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership.

“We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” Dr. Zerhouni said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families will be required to divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case by case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed a number of potential conflicts of interest by NIH scientists. Under the policy outlined earlier this year, about 6,000 top NIH employees would have been required to sell off all of their stock holdings in companies impacted by NIH decisions. And the remainder of NIH employees would have been subject to the $15,000 limit.

The changes are designed to target the requirements at employees who are making decisions on grants and studies, Dr. Zerhouni said, and to ease restrictions on employees who are unlikely to have conflicts. “It's impossible to have a one-size-fits-all approach,” he said.

The final regulation will also allow NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews. These activities were prohibited under the earlier policy.

The final rule continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees can also practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology or medical device manufacturers, health care providers or insurers, and NIH grantee institutions.

Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said.

While some outside consulting activities hold value for NIH and the public, he said the agency currently has no way to distinguish between those positive interactions and others such as product marketing.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. But the changes reflect the correct balance.

Ms. Woolley said the final regulation will serve as a benchmark for the rest of the research community.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to get control of the problem of conflict of interest. Allowing NIH employees to participate in paid outside academic work, which frequently includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni said it's important to have a broad dialogue about conflict of interest with the entire scientific community.

“I think this is a debate that is way beyond that of NIH,” he said.

For more information on NIH ethics rules, visit www.nih.gov/about/ethics_COI.htm

Officials at the Department of Health and Human Services have loosened restrictions on ownership of pharmaceutical and biotech company stocks for employees of the National Institutes of Health under a final rule on conflict of interest.

But the final regulation announced at a teleconference on NIH conflict of interest regulations continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership.

“We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” Dr. Zerhouni said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families will be required to divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case by case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed a number of potential conflicts of interest by NIH scientists. Under the policy outlined earlier this year, about 6,000 top NIH employees would have been required to sell off all of their stock holdings in companies impacted by NIH decisions. And the remainder of NIH employees would have been subject to the $15,000 limit.

The changes are designed to target the requirements at employees who are making decisions on grants and studies, Dr. Zerhouni said, and to ease restrictions on employees who are unlikely to have conflicts. “It's impossible to have a one-size-fits-all approach,” he said.

The final regulation will also allow NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews. These activities were prohibited under the earlier policy.

The final rule continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees can also practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology or medical device manufacturers, health care providers or insurers, and NIH grantee institutions.

Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said.

While some outside consulting activities hold value for NIH and the public, he said the agency currently has no way to distinguish between those positive interactions and others such as product marketing.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. But the changes reflect the correct balance.

Ms. Woolley said the final regulation will serve as a benchmark for the rest of the research community.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to get control of the problem of conflict of interest. Allowing NIH employees to participate in paid outside academic work, which frequently includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni said it's important to have a broad dialogue about conflict of interest with the entire scientific community.

“I think this is a debate that is way beyond that of NIH,” he said.

For more information on NIH ethics rules, visit www.nih.gov/about/ethics_COI.htm

Officials at the Department of Health and Human Services have loosened restrictions on ownership of pharmaceutical and biotech company stocks for employees of the National Institutes of Health under a final rule on conflict of interest.

But the final regulation announced at a teleconference on NIH conflict of interest regulations continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership.

“We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” Dr. Zerhouni said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families will be required to divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case by case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed a number of potential conflicts of interest by NIH scientists. Under the policy outlined earlier this year, about 6,000 top NIH employees would have been required to sell off all of their stock holdings in companies impacted by NIH decisions. And the remainder of NIH employees would have been subject to the $15,000 limit.

The changes are designed to target the requirements at employees who are making decisions on grants and studies, Dr. Zerhouni said, and to ease restrictions on employees who are unlikely to have conflicts. “It's impossible to have a one-size-fits-all approach,” he said.

The final regulation will also allow NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews. These activities were prohibited under the earlier policy.

The final rule continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees can also practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology or medical device manufacturers, health care providers or insurers, and NIH grantee institutions.

Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said.

While some outside consulting activities hold value for NIH and the public, he said the agency currently has no way to distinguish between those positive interactions and others such as product marketing.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. But the changes reflect the correct balance.

Ms. Woolley said the final regulation will serve as a benchmark for the rest of the research community.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to get control of the problem of conflict of interest. Allowing NIH employees to participate in paid outside academic work, which frequently includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni said it's important to have a broad dialogue about conflict of interest with the entire scientific community.

“I think this is a debate that is way beyond that of NIH,” he said.

For more information on NIH ethics rules, visit www.nih.gov/about/ethics_COI.htm

Most hospital officials are having trouble getting specialists to take emergency department call, according to a national survey of physician executives.

About 64% of physician executives surveyed reported having a problem getting specialists to take call at their hospitals. Many of them—about 47%—report that their hospitals are coping with this problem by paying specialists to take call. Of those whose hospitals were not offering payments, 46% said the idea has been considered.

The survey, conducted by the American College of Physician Executives, was sent to 3,000 physician executives in hospitals and group practices around the country. The poll had 814 responses, or a 27% response rate.

The results of the survey are consistent with previous studies over the last several years, said Alex Valadka, M.D., chairman of the Joint Section of Neurotrauma and Critical Care for the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons.

Dr. Valadka said he sees taking emergency call as part of his responsibility as a physician, but said many of his colleagues just can't afford to do it anymore.

With the high cost of professional liability insurance, some neurosurgeons are stopping or cutting back on emergency call because certain insurance carriers offer discounts to physicians who do so, he said.

In the past, physicians may have had enough of a profit margin to cover the cost of taking emergency call, he said, but declining reimbursements have mostly eliminated that margin.

“Nothing is for free,” said Dr. Valadka, who also is a professor of neurosurgery at Baylor College of Medicine in Houston.

But even with stipends for taking call, some neurosurgeons still won't do it, he said. “I think the money will help, but it's not going to solve all the problems.”

These financial incentives need to be coupled with federal medical liability reform to ease the strain of the high cost of premiums, Dr. Valadka said.

Paying specialists to take call helps to offset their costs, but it's only a stopgap solution, said James Bean, M.D., AANS treasurer and a neurosurgeon in private practice in Lexington, Ky.

In the short term, hospitals should create more incentives for physicians to take call. “You've got to create a carrot, not a stick,” Dr. Bean said.

Over the long term, physicians and hospitals should consider the idea of a regional trauma system with a large staff of rotating specialists to handle cases.

“Clearly the community needs physicians to take call,” said Andrew Pollak, M.D., associate professor of orthopedics at the University of Maryland in Baltimore and a member of the board of directors of the American Academy of Orthopaedic Surgeons.

Hospitals and physicians need to work together to provide reasonable ways to manage call, he said. For example, hospitals should provide stipends to help offset physician costs. In addition, hospitals need to provide physicians with the right resources to work in the emergency department, such as having an adequate level of ancillary staff to assist physicians, Dr. Pollak said.

Emergency physicians have a different take on the issue, however. It's often the hospitals with the highest number of uninsured patients that face shortages in specialist care in the emergency department, said Wesley Fields, M.D., immediate past president of the California chapter of the American College of Emergency Physicians and an emergency physician in Laguna Hills, Calif. But those are also the hospitals that are least able to provide stipends to physicians.

“This really just reflects the weakness of the hospital safety net,” Dr. Fields said.

And money diverted to pay for physician stipends often means that less money is available to cover emergency department costs, he said. This worsens the burden on emergency medical groups, Dr. Fields said.

Paying stipends to physicians to take emergency department call is taking away from other services and the funding for uncompensated care, said Jeff Micklos, general counsel for the Federation of American Hospitals.

The federation is concerned that more hospitals will need to offer stipends for taking call, Mr. Micklos added. Otherwise, they will be creating an incentive for physicians to invest in local specialty hospitals.

Most hospital officials are having trouble getting specialists to take emergency department call, according to a national survey of physician executives.

About 64% of physician executives surveyed reported having a problem getting specialists to take call at their hospitals. Many of them—about 47%—report that their hospitals are coping with this problem by paying specialists to take call. Of those whose hospitals were not offering payments, 46% said the idea has been considered.

The survey, conducted by the American College of Physician Executives, was sent to 3,000 physician executives in hospitals and group practices around the country. The poll had 814 responses, or a 27% response rate.

The results of the survey are consistent with previous studies over the last several years, said Alex Valadka, M.D., chairman of the Joint Section of Neurotrauma and Critical Care for the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons.

Dr. Valadka said he sees taking emergency call as part of his responsibility as a physician, but said many of his colleagues just can't afford to do it anymore.

With the high cost of professional liability insurance, some neurosurgeons are stopping or cutting back on emergency call because certain insurance carriers offer discounts to physicians who do so, he said.

In the past, physicians may have had enough of a profit margin to cover the cost of taking emergency call, he said, but declining reimbursements have mostly eliminated that margin.

“Nothing is for free,” said Dr. Valadka, who also is a professor of neurosurgery at Baylor College of Medicine in Houston.

But even with stipends for taking call, some neurosurgeons still won't do it, he said. “I think the money will help, but it's not going to solve all the problems.”

These financial incentives need to be coupled with federal medical liability reform to ease the strain of the high cost of premiums, Dr. Valadka said.

Paying specialists to take call helps to offset their costs, but it's only a stopgap solution, said James Bean, M.D., AANS treasurer and a neurosurgeon in private practice in Lexington, Ky.

In the short term, hospitals should create more incentives for physicians to take call. “You've got to create a carrot, not a stick,” Dr. Bean said.

Over the long term, physicians and hospitals should consider the idea of a regional trauma system with a large staff of rotating specialists to handle cases.

“Clearly the community needs physicians to take call,” said Andrew Pollak, M.D., associate professor of orthopedics at the University of Maryland in Baltimore and a member of the board of directors of the American Academy of Orthopaedic Surgeons.

Hospitals and physicians need to work together to provide reasonable ways to manage call, he said. For example, hospitals should provide stipends to help offset physician costs. In addition, hospitals need to provide physicians with the right resources to work in the emergency department, such as having an adequate level of ancillary staff to assist physicians, Dr. Pollak said.

Emergency physicians have a different take on the issue, however. It's often the hospitals with the highest number of uninsured patients that face shortages in specialist care in the emergency department, said Wesley Fields, M.D., immediate past president of the California chapter of the American College of Emergency Physicians and an emergency physician in Laguna Hills, Calif. But those are also the hospitals that are least able to provide stipends to physicians.

“This really just reflects the weakness of the hospital safety net,” Dr. Fields said.

And money diverted to pay for physician stipends often means that less money is available to cover emergency department costs, he said. This worsens the burden on emergency medical groups, Dr. Fields said.

Paying stipends to physicians to take emergency department call is taking away from other services and the funding for uncompensated care, said Jeff Micklos, general counsel for the Federation of American Hospitals.

The federation is concerned that more hospitals will need to offer stipends for taking call, Mr. Micklos added. Otherwise, they will be creating an incentive for physicians to invest in local specialty hospitals.

Most hospital officials are having trouble getting specialists to take emergency department call, according to a national survey of physician executives.

About 64% of physician executives surveyed reported having a problem getting specialists to take call at their hospitals. Many of them—about 47%—report that their hospitals are coping with this problem by paying specialists to take call. Of those whose hospitals were not offering payments, 46% said the idea has been considered.

The survey, conducted by the American College of Physician Executives, was sent to 3,000 physician executives in hospitals and group practices around the country. The poll had 814 responses, or a 27% response rate.

The results of the survey are consistent with previous studies over the last several years, said Alex Valadka, M.D., chairman of the Joint Section of Neurotrauma and Critical Care for the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons.

Dr. Valadka said he sees taking emergency call as part of his responsibility as a physician, but said many of his colleagues just can't afford to do it anymore.

With the high cost of professional liability insurance, some neurosurgeons are stopping or cutting back on emergency call because certain insurance carriers offer discounts to physicians who do so, he said.

In the past, physicians may have had enough of a profit margin to cover the cost of taking emergency call, he said, but declining reimbursements have mostly eliminated that margin.

“Nothing is for free,” said Dr. Valadka, who also is a professor of neurosurgery at Baylor College of Medicine in Houston.

But even with stipends for taking call, some neurosurgeons still won't do it, he said. “I think the money will help, but it's not going to solve all the problems.”

These financial incentives need to be coupled with federal medical liability reform to ease the strain of the high cost of premiums, Dr. Valadka said.

Paying specialists to take call helps to offset their costs, but it's only a stopgap solution, said James Bean, M.D., AANS treasurer and a neurosurgeon in private practice in Lexington, Ky.

In the short term, hospitals should create more incentives for physicians to take call. “You've got to create a carrot, not a stick,” Dr. Bean said.

Over the long term, physicians and hospitals should consider the idea of a regional trauma system with a large staff of rotating specialists to handle cases.

“Clearly the community needs physicians to take call,” said Andrew Pollak, M.D., associate professor of orthopedics at the University of Maryland in Baltimore and a member of the board of directors of the American Academy of Orthopaedic Surgeons.

Hospitals and physicians need to work together to provide reasonable ways to manage call, he said. For example, hospitals should provide stipends to help offset physician costs. In addition, hospitals need to provide physicians with the right resources to work in the emergency department, such as having an adequate level of ancillary staff to assist physicians, Dr. Pollak said.

Emergency physicians have a different take on the issue, however. It's often the hospitals with the highest number of uninsured patients that face shortages in specialist care in the emergency department, said Wesley Fields, M.D., immediate past president of the California chapter of the American College of Emergency Physicians and an emergency physician in Laguna Hills, Calif. But those are also the hospitals that are least able to provide stipends to physicians.

“This really just reflects the weakness of the hospital safety net,” Dr. Fields said.

And money diverted to pay for physician stipends often means that less money is available to cover emergency department costs, he said. This worsens the burden on emergency medical groups, Dr. Fields said.

Paying stipends to physicians to take emergency department call is taking away from other services and the funding for uncompensated care, said Jeff Micklos, general counsel for the Federation of American Hospitals.

The federation is concerned that more hospitals will need to offer stipends for taking call, Mr. Micklos added. Otherwise, they will be creating an incentive for physicians to invest in local specialty hospitals.

NASHVILLE, TENN. — States have shown renewed interest in building on employer-sponsored insurance to expand access, Sharon Silow-Carroll, senior vice president of the Economic and Social Research Institute in Teaneck, N.J., said at the annual conference of the National Academy for State Health Policy.

Factors driving the trend include declining employer-sponsored insurance and rising health care costs.

States have applied various approaches:

▸ Limited benefit plans. Some states are allowing the sale of lower-cost, limited benefit plans and other options such as health savings accounts coupled with high-deductible plans.

▸ Premium assistance. Other states are offering premium assistance through Medicaid, the State Children's Health Insurance Program, and other public programs.

▸ Reinsurance. There has also been a lot of interest in reinsurance through indirect subsidies to employers and workers. New York pays 90% of claims between $5,000 and $75,000 for eligible individuals.

▸ State-negotiated health plans. States also are using their purchasing power with or without additional subsidies to provide more affordable health insurance options.

▸ Employer mandates. State policy makers can try to increase employer-sponsored coverage by requiring employers to cover workers or pay a fee to the state to arrange coverage. Strategies that build on employer-sponsored insurance offer a way to expand access without the state bearing the full cost. But employer participation in voluntary strategies has been fairly low so far.

NASHVILLE, TENN. — States have shown renewed interest in building on employer-sponsored insurance to expand access, Sharon Silow-Carroll, senior vice president of the Economic and Social Research Institute in Teaneck, N.J., said at the annual conference of the National Academy for State Health Policy.

Factors driving the trend include declining employer-sponsored insurance and rising health care costs.

States have applied various approaches:

▸ Limited benefit plans. Some states are allowing the sale of lower-cost, limited benefit plans and other options such as health savings accounts coupled with high-deductible plans.

▸ Premium assistance. Other states are offering premium assistance through Medicaid, the State Children's Health Insurance Program, and other public programs.

▸ Reinsurance. There has also been a lot of interest in reinsurance through indirect subsidies to employers and workers. New York pays 90% of claims between $5,000 and $75,000 for eligible individuals.

▸ State-negotiated health plans. States also are using their purchasing power with or without additional subsidies to provide more affordable health insurance options.

▸ Employer mandates. State policy makers can try to increase employer-sponsored coverage by requiring employers to cover workers or pay a fee to the state to arrange coverage. Strategies that build on employer-sponsored insurance offer a way to expand access without the state bearing the full cost. But employer participation in voluntary strategies has been fairly low so far.

NASHVILLE, TENN. — States have shown renewed interest in building on employer-sponsored insurance to expand access, Sharon Silow-Carroll, senior vice president of the Economic and Social Research Institute in Teaneck, N.J., said at the annual conference of the National Academy for State Health Policy.

Factors driving the trend include declining employer-sponsored insurance and rising health care costs.

States have applied various approaches:

▸ Limited benefit plans. Some states are allowing the sale of lower-cost, limited benefit plans and other options such as health savings accounts coupled with high-deductible plans.

▸ Premium assistance. Other states are offering premium assistance through Medicaid, the State Children's Health Insurance Program, and other public programs.

▸ Reinsurance. There has also been a lot of interest in reinsurance through indirect subsidies to employers and workers. New York pays 90% of claims between $5,000 and $75,000 for eligible individuals.

▸ State-negotiated health plans. States also are using their purchasing power with or without additional subsidies to provide more affordable health insurance options.

▸ Employer mandates. State policy makers can try to increase employer-sponsored coverage by requiring employers to cover workers or pay a fee to the state to arrange coverage. Strategies that build on employer-sponsored insurance offer a way to expand access without the state bearing the full cost. But employer participation in voluntary strategies has been fairly low so far.

Officials at the Centers for Medicare and Medicaid Services are seeking physicians to test electronic health record software originally developed by the Department of Veterans Affairs and adapted for use in physicians' offices.

CMS is releasing a test version of the software—called VistA-Office—in an effort to assess its effectiveness, usability, and potential for interoperability in small physician practices, the agency announced late last month.

“The release of an evaluation version of VistA-Office will provide a testing laboratory for interoperability and will supplement efforts by the American Health Information Community to establish a certification criteria and process,” CMS Administrator Mark B. McClellan, M.D., Ph.D., said in a statement.

The goal is to refine the software based on the results of the test period and develop a version of the VistA-Office electronic health record (EHR) that could be certified under a process recognized by the Department of Health and Human Services.

The VistA-Office EHR was adapted from the hospital information system of the Department of Veterans Affairs (VA). The VA system is used in 1,300 sites and has been in use for more than 20 years.

The test version of the software includes core functions such as clinical order entry, standard progress note templates, and results reporting. It also includes features designed specifically for physician offices including interfaces to existing practice management and billing systems, quality measure reporting capabilities, clinical reminders for disease management, and templates for ob.gyn. and pediatric care.

The VistA-Office test software will not be free. The first-year costs (cost of software, licensing fees, and support) are estimated to be about $2,740 for a group of one to seven users, according to a CMS spokesman, who added that practices are likely to incur added office staff costs associated with implementing the EHR.

Health information technology experts welcomed the testing of a new office-based EHR product, but cautioned that not all physician practices are suited to becoming a beta-test site.

“It's good for physicians to have more choices,” said Mark Leavitt, M.D., Ph.D., chair of the Certification Commission for Healthcare Information Technology, a voluntary, private-sector initiative to certify health information technology products.

But Dr. Leavitt warned that participating in a beta test isn't for everyone. Generally in such a test, practices are not supposed to rely on the new software, so physicians would have to run the test software parallel with their paper systems. That extra step can cost the practice in terms of time and money, he said.

“A beta test definitely stresses the office,” he said.

The best candidates for a beta test are physicians who are technically savvy and who have the extra time and interest to devote to the project, Dr. Leavitt said.

Physicians should carefully review the VistA-Office product before volunteering to test it and not just choose it because it is less expensive than some other options on the market, said Joe Heyman, M.D., secretary of the board of trustees of the American Medical Association and a gynecologist in solo practice in Amesbury, Mass.

As with any other EHR, it's important for physicians to survey their own office and work flow, Dr. Heyman said.

Family physicians are looking forward to evaluating and providing feedback on the ease of use and associated costs of the product, said David C. Kibbe, M.D., director of the Center for Health Information Technology at the American Academy of Family Physicians.

While the costs cited by CMS were below market costs for most EHR systems, Dr. Kibbe cautioned that charging at all for a beta test could diminish physicians' participation. “Uncertainty is a cost as well,” according to Dr. Kibbe.

The test software provides a reasonable cost option for physicians, said Arthur McDowell III, M.D., a cardiologist in Middletown, Conn., who has already implemented an EHR in his practice.

But what will really spur adoption of EHRs will be government-sponsored pay-for-performance programs, he said.

The fear among physicians on pay for performance is that the government will choose to pay physicians less. Instead, the government needs to take the step of providing reasonably priced software and then offering payments for making the change, Dr. McDowell said.

The current discussion about incentives from the federal government is very promising, said Dr. Leavitt. Physicians want to see incentives that offer extra payment or lower the cost or administrative hassle, he said.

The Certification Commission can help spur incentives, he said, because then government payers and health plans will know that they are paying for something robust. “All the signs are pointing the right way,” Dr. Leavitt said.

Physicians who are interested in being part of a beta test should contact an approved vendor who will actually run the test of the software. A list of approved vendors is available at www.vista-office.org

Officials at the Centers for Medicare and Medicaid Services are seeking physicians to test electronic health record software originally developed by the Department of Veterans Affairs and adapted for use in physicians' offices.

CMS is releasing a test version of the software—called VistA-Office—in an effort to assess its effectiveness, usability, and potential for interoperability in small physician practices, the agency announced late last month.

“The release of an evaluation version of VistA-Office will provide a testing laboratory for interoperability and will supplement efforts by the American Health Information Community to establish a certification criteria and process,” CMS Administrator Mark B. McClellan, M.D., Ph.D., said in a statement.

The goal is to refine the software based on the results of the test period and develop a version of the VistA-Office electronic health record (EHR) that could be certified under a process recognized by the Department of Health and Human Services.

The VistA-Office EHR was adapted from the hospital information system of the Department of Veterans Affairs (VA). The VA system is used in 1,300 sites and has been in use for more than 20 years.

The test version of the software includes core functions such as clinical order entry, standard progress note templates, and results reporting. It also includes features designed specifically for physician offices including interfaces to existing practice management and billing systems, quality measure reporting capabilities, clinical reminders for disease management, and templates for ob.gyn. and pediatric care.

The VistA-Office test software will not be free. The first-year costs (cost of software, licensing fees, and support) are estimated to be about $2,740 for a group of one to seven users, according to a CMS spokesman, who added that practices are likely to incur added office staff costs associated with implementing the EHR.

Health information technology experts welcomed the testing of a new office-based EHR product, but cautioned that not all physician practices are suited to becoming a beta-test site.

“It's good for physicians to have more choices,” said Mark Leavitt, M.D., Ph.D., chair of the Certification Commission for Healthcare Information Technology, a voluntary, private-sector initiative to certify health information technology products.

But Dr. Leavitt warned that participating in a beta test isn't for everyone. Generally in such a test, practices are not supposed to rely on the new software, so physicians would have to run the test software parallel with their paper systems. That extra step can cost the practice in terms of time and money, he said.

“A beta test definitely stresses the office,” he said.

The best candidates for a beta test are physicians who are technically savvy and who have the extra time and interest to devote to the project, Dr. Leavitt said.

Physicians should carefully review the VistA-Office product before volunteering to test it and not just choose it because it is less expensive than some other options on the market, said Joe Heyman, M.D., secretary of the board of trustees of the American Medical Association and a gynecologist in solo practice in Amesbury, Mass.

As with any other EHR, it's important for physicians to survey their own office and work flow, Dr. Heyman said.

Family physicians are looking forward to evaluating and providing feedback on the ease of use and associated costs of the product, said David C. Kibbe, M.D., director of the Center for Health Information Technology at the American Academy of Family Physicians.

While the costs cited by CMS were below market costs for most EHR systems, Dr. Kibbe cautioned that charging at all for a beta test could diminish physicians' participation. “Uncertainty is a cost as well,” according to Dr. Kibbe.

The test software provides a reasonable cost option for physicians, said Arthur McDowell III, M.D., a cardiologist in Middletown, Conn., who has already implemented an EHR in his practice.

But what will really spur adoption of EHRs will be government-sponsored pay-for-performance programs, he said.

The fear among physicians on pay for performance is that the government will choose to pay physicians less. Instead, the government needs to take the step of providing reasonably priced software and then offering payments for making the change, Dr. McDowell said.

The current discussion about incentives from the federal government is very promising, said Dr. Leavitt. Physicians want to see incentives that offer extra payment or lower the cost or administrative hassle, he said.

The Certification Commission can help spur incentives, he said, because then government payers and health plans will know that they are paying for something robust. “All the signs are pointing the right way,” Dr. Leavitt said.

Physicians who are interested in being part of a beta test should contact an approved vendor who will actually run the test of the software. A list of approved vendors is available at www.vista-office.org

Officials at the Centers for Medicare and Medicaid Services are seeking physicians to test electronic health record software originally developed by the Department of Veterans Affairs and adapted for use in physicians' offices.

CMS is releasing a test version of the software—called VistA-Office—in an effort to assess its effectiveness, usability, and potential for interoperability in small physician practices, the agency announced late last month.

“The release of an evaluation version of VistA-Office will provide a testing laboratory for interoperability and will supplement efforts by the American Health Information Community to establish a certification criteria and process,” CMS Administrator Mark B. McClellan, M.D., Ph.D., said in a statement.

The goal is to refine the software based on the results of the test period and develop a version of the VistA-Office electronic health record (EHR) that could be certified under a process recognized by the Department of Health and Human Services.

The VistA-Office EHR was adapted from the hospital information system of the Department of Veterans Affairs (VA). The VA system is used in 1,300 sites and has been in use for more than 20 years.

The test version of the software includes core functions such as clinical order entry, standard progress note templates, and results reporting. It also includes features designed specifically for physician offices including interfaces to existing practice management and billing systems, quality measure reporting capabilities, clinical reminders for disease management, and templates for ob.gyn. and pediatric care.

The VistA-Office test software will not be free. The first-year costs (cost of software, licensing fees, and support) are estimated to be about $2,740 for a group of one to seven users, according to a CMS spokesman, who added that practices are likely to incur added office staff costs associated with implementing the EHR.

Health information technology experts welcomed the testing of a new office-based EHR product, but cautioned that not all physician practices are suited to becoming a beta-test site.

“It's good for physicians to have more choices,” said Mark Leavitt, M.D., Ph.D., chair of the Certification Commission for Healthcare Information Technology, a voluntary, private-sector initiative to certify health information technology products.

But Dr. Leavitt warned that participating in a beta test isn't for everyone. Generally in such a test, practices are not supposed to rely on the new software, so physicians would have to run the test software parallel with their paper systems. That extra step can cost the practice in terms of time and money, he said.

“A beta test definitely stresses the office,” he said.

The best candidates for a beta test are physicians who are technically savvy and who have the extra time and interest to devote to the project, Dr. Leavitt said.

Physicians should carefully review the VistA-Office product before volunteering to test it and not just choose it because it is less expensive than some other options on the market, said Joe Heyman, M.D., secretary of the board of trustees of the American Medical Association and a gynecologist in solo practice in Amesbury, Mass.

As with any other EHR, it's important for physicians to survey their own office and work flow, Dr. Heyman said.

Family physicians are looking forward to evaluating and providing feedback on the ease of use and associated costs of the product, said David C. Kibbe, M.D., director of the Center for Health Information Technology at the American Academy of Family Physicians.

While the costs cited by CMS were below market costs for most EHR systems, Dr. Kibbe cautioned that charging at all for a beta test could diminish physicians' participation. “Uncertainty is a cost as well,” according to Dr. Kibbe.

The test software provides a reasonable cost option for physicians, said Arthur McDowell III, M.D., a cardiologist in Middletown, Conn., who has already implemented an EHR in his practice.

But what will really spur adoption of EHRs will be government-sponsored pay-for-performance programs, he said.

The fear among physicians on pay for performance is that the government will choose to pay physicians less. Instead, the government needs to take the step of providing reasonably priced software and then offering payments for making the change, Dr. McDowell said.

The current discussion about incentives from the federal government is very promising, said Dr. Leavitt. Physicians want to see incentives that offer extra payment or lower the cost or administrative hassle, he said.

The Certification Commission can help spur incentives, he said, because then government payers and health plans will know that they are paying for something robust. “All the signs are pointing the right way,” Dr. Leavitt said.

Physicians who are interested in being part of a beta test should contact an approved vendor who will actually run the test of the software. A list of approved vendors is available at www.vista-office.org

Salary Affects Specialty Choice

When it comes to choosing a specialty, U.S. medical graduates are more concerned with their earning power than with medical liability costs, according to a study published in the September issue of Obstetrics and Gynecology. Procedure-based and hospital-based specialties, which generally are associated with higher incomes, are the most likely to have residency positions filled by U.S. medical graduates, the researchers found, even when the specialty had higher professional liability costs. For example, U.S. medical students filled more than 90% of the residency positions in neurosurgery and orthopedic surgery where medical liability insurance costs are high but so are average incomes. In contrast, U.S. students filled 70% of the available residency positions in obstetrics and gynecology, according to the American College of Obstetricians and Gynecologists. But the researchers noted that students also may be attracted to high-earning fields because of the technical challenges or the ability to have a more controllable lifestyle. The results are based on data from the 2004 National Resident Matching Program, the American Medical Association, the Medical Group Management Association, and a major Massachusetts liability insurer.

Greater Folic Acid Fortification

Officials at the March of Dimes are calling on the federal government to require higher levels of folic acid fortification in grain food. The request, which reflects a long-held policy of the March of Dimes, comes on the heels of new research showing that folic acid fortification in grain foods has resulted in a one-third drop in serious birth defects of the brain and spine. The Food and Drug Administration currently requires 140 mcg of folic acid per 100 g of grain. Since 1996, the March of Dimes has recommended that the FDA set the level in enriched grain foods at 350 mcg per 100 g of grain.

Pesticide Studies

A proposal from the Environmental Protection Agency would ban the inclusion of pregnant women and children in all new third-party intentional dosing research involving pesticides intended for submission to the agency. The proposal says that EPA officials will neither conduct nor support any intentional dosing studies that involve pregnant women or children. “We are pursuing a rigorous set of protections for human research participants,” Susan B. Hazen, principal deputy assistant administrator in the EPA's Office of Prevention, Pesticides, and Toxic Substances said in a statement. The agency has come under fire recently from congressional Democrats for relying on studies that involve intentionally dosing human subjects with pesticides. More information is available at

www.epa.gov/oppfead1/guidance/human-test.htm

Reporting Neonatal Herpes

A group of experts in obstetrics and gynecology and pediatrics is calling on the Centers for Disease Control and Prevention to request reporting of cases of neonatal herpes from all states and U.S. territories. The call to action, which was published in the September issue of the journal Sexually Transmitted Diseases, notes that a lack of reliable epidemiological data may be partly responsible for the continued development of neonatal herpes cases. While diseases such as congenital syphilis are reportable in 47 states, only 7 states—Connecticut, Florida, Massachusetts, Nebraska, Ohio, South Dakota, and Washington—require reporting of neonatal herpes. The CDC can request reports on various conditions, but the states have the regulatory authority to require reporting. The epidemiological data from reported cases of neonatal herpes would help to resolve debates over testing, treatment, and prevention strategies, the researchers wrote. The analysis was supported by GlaxoSmithKline Inc.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million.

Salary Affects Specialty Choice

When it comes to choosing a specialty, U.S. medical graduates are more concerned with their earning power than with medical liability costs, according to a study published in the September issue of Obstetrics and Gynecology. Procedure-based and hospital-based specialties, which generally are associated with higher incomes, are the most likely to have residency positions filled by U.S. medical graduates, the researchers found, even when the specialty had higher professional liability costs. For example, U.S. medical students filled more than 90% of the residency positions in neurosurgery and orthopedic surgery where medical liability insurance costs are high but so are average incomes. In contrast, U.S. students filled 70% of the available residency positions in obstetrics and gynecology, according to the American College of Obstetricians and Gynecologists. But the researchers noted that students also may be attracted to high-earning fields because of the technical challenges or the ability to have a more controllable lifestyle. The results are based on data from the 2004 National Resident Matching Program, the American Medical Association, the Medical Group Management Association, and a major Massachusetts liability insurer.

Greater Folic Acid Fortification

Officials at the March of Dimes are calling on the federal government to require higher levels of folic acid fortification in grain food. The request, which reflects a long-held policy of the March of Dimes, comes on the heels of new research showing that folic acid fortification in grain foods has resulted in a one-third drop in serious birth defects of the brain and spine. The Food and Drug Administration currently requires 140 mcg of folic acid per 100 g of grain. Since 1996, the March of Dimes has recommended that the FDA set the level in enriched grain foods at 350 mcg per 100 g of grain.

Pesticide Studies

A proposal from the Environmental Protection Agency would ban the inclusion of pregnant women and children in all new third-party intentional dosing research involving pesticides intended for submission to the agency. The proposal says that EPA officials will neither conduct nor support any intentional dosing studies that involve pregnant women or children. “We are pursuing a rigorous set of protections for human research participants,” Susan B. Hazen, principal deputy assistant administrator in the EPA's Office of Prevention, Pesticides, and Toxic Substances said in a statement. The agency has come under fire recently from congressional Democrats for relying on studies that involve intentionally dosing human subjects with pesticides. More information is available at

www.epa.gov/oppfead1/guidance/human-test.htm

Reporting Neonatal Herpes

A group of experts in obstetrics and gynecology and pediatrics is calling on the Centers for Disease Control and Prevention to request reporting of cases of neonatal herpes from all states and U.S. territories. The call to action, which was published in the September issue of the journal Sexually Transmitted Diseases, notes that a lack of reliable epidemiological data may be partly responsible for the continued development of neonatal herpes cases. While diseases such as congenital syphilis are reportable in 47 states, only 7 states—Connecticut, Florida, Massachusetts, Nebraska, Ohio, South Dakota, and Washington—require reporting of neonatal herpes. The CDC can request reports on various conditions, but the states have the regulatory authority to require reporting. The epidemiological data from reported cases of neonatal herpes would help to resolve debates over testing, treatment, and prevention strategies, the researchers wrote. The analysis was supported by GlaxoSmithKline Inc.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million.

Salary Affects Specialty Choice

When it comes to choosing a specialty, U.S. medical graduates are more concerned with their earning power than with medical liability costs, according to a study published in the September issue of Obstetrics and Gynecology. Procedure-based and hospital-based specialties, which generally are associated with higher incomes, are the most likely to have residency positions filled by U.S. medical graduates, the researchers found, even when the specialty had higher professional liability costs. For example, U.S. medical students filled more than 90% of the residency positions in neurosurgery and orthopedic surgery where medical liability insurance costs are high but so are average incomes. In contrast, U.S. students filled 70% of the available residency positions in obstetrics and gynecology, according to the American College of Obstetricians and Gynecologists. But the researchers noted that students also may be attracted to high-earning fields because of the technical challenges or the ability to have a more controllable lifestyle. The results are based on data from the 2004 National Resident Matching Program, the American Medical Association, the Medical Group Management Association, and a major Massachusetts liability insurer.

Greater Folic Acid Fortification

Officials at the March of Dimes are calling on the federal government to require higher levels of folic acid fortification in grain food. The request, which reflects a long-held policy of the March of Dimes, comes on the heels of new research showing that folic acid fortification in grain foods has resulted in a one-third drop in serious birth defects of the brain and spine. The Food and Drug Administration currently requires 140 mcg of folic acid per 100 g of grain. Since 1996, the March of Dimes has recommended that the FDA set the level in enriched grain foods at 350 mcg per 100 g of grain.

Pesticide Studies

A proposal from the Environmental Protection Agency would ban the inclusion of pregnant women and children in all new third-party intentional dosing research involving pesticides intended for submission to the agency. The proposal says that EPA officials will neither conduct nor support any intentional dosing studies that involve pregnant women or children. “We are pursuing a rigorous set of protections for human research participants,” Susan B. Hazen, principal deputy assistant administrator in the EPA's Office of Prevention, Pesticides, and Toxic Substances said in a statement. The agency has come under fire recently from congressional Democrats for relying on studies that involve intentionally dosing human subjects with pesticides. More information is available at

www.epa.gov/oppfead1/guidance/human-test.htm

Reporting Neonatal Herpes

A group of experts in obstetrics and gynecology and pediatrics is calling on the Centers for Disease Control and Prevention to request reporting of cases of neonatal herpes from all states and U.S. territories. The call to action, which was published in the September issue of the journal Sexually Transmitted Diseases, notes that a lack of reliable epidemiological data may be partly responsible for the continued development of neonatal herpes cases. While diseases such as congenital syphilis are reportable in 47 states, only 7 states—Connecticut, Florida, Massachusetts, Nebraska, Ohio, South Dakota, and Washington—require reporting of neonatal herpes. The CDC can request reports on various conditions, but the states have the regulatory authority to require reporting. The epidemiological data from reported cases of neonatal herpes would help to resolve debates over testing, treatment, and prevention strategies, the researchers wrote. The analysis was supported by GlaxoSmithKline Inc.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million.

A study of California women with ovarian cancer showed that the patients had distinguishable symptoms at least 6 months before diagnosis, according to Lloyd H. Smith, M.D., Ph.D., chair of the department of ob.gyn. at the University of California, Davis, and his colleagues.

The researchers found that women with ovarian cancer more frequently reported abdominal pain and received abdominal imaging in the 7–9 months before their diagnosis, compared with women who had no cancer and those with early-stage breast cancer (Cancer [online]2005;DOI:10.10002/cncr.21310).

And some patients may have their diagnosis delayed by 4 months or more because physicians order abdominal imaging or perform gastrointestinal procedures before ordering pelvic imaging or CA 125 screening, which are more likely to diagnose ovarian cancer, the researchers reported.

The population-based, retrospective case-control study compared case reports from 1,985 women, aged 68 years or older with a diagnosis of ovarian cancer, with two control groups: 10,941 women with early-stage breast cancer and 6,024 randomly selected age-matched women with no diagnosis of cancer. Researchers used information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and from Medicare Part B claims from women in California.

In the 1–3 months before diagnosis of ovarian cancer, 31% of women reported abdominal pain, 17% reported abdominal swelling, and 8% reported gastrointestinal symptoms.

Abdominal imaging and pelvic imaging/CA 125 screens were used frequently (70% and 54%, respectively) to investigate symptoms within 3 months prior to diagnosis of ovarian cancer. In the 4–36 months before their diagnosis, 61% of women with symptoms had abdominal imaging and 25% received pelvic imaging/CA 125 screening.

Although pelvic imaging and CA 125 screens are not recommended in asymptomatic patients, they could be “reasonable options for women who have target symptoms that are not explained by routine medical evaluation,” the researchers reported.

A study of California women with ovarian cancer showed that the patients had distinguishable symptoms at least 6 months before diagnosis, according to Lloyd H. Smith, M.D., Ph.D., chair of the department of ob.gyn. at the University of California, Davis, and his colleagues.

The researchers found that women with ovarian cancer more frequently reported abdominal pain and received abdominal imaging in the 7–9 months before their diagnosis, compared with women who had no cancer and those with early-stage breast cancer (Cancer [online]2005;DOI:10.10002/cncr.21310).

And some patients may have their diagnosis delayed by 4 months or more because physicians order abdominal imaging or perform gastrointestinal procedures before ordering pelvic imaging or CA 125 screening, which are more likely to diagnose ovarian cancer, the researchers reported.

The population-based, retrospective case-control study compared case reports from 1,985 women, aged 68 years or older with a diagnosis of ovarian cancer, with two control groups: 10,941 women with early-stage breast cancer and 6,024 randomly selected age-matched women with no diagnosis of cancer. Researchers used information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and from Medicare Part B claims from women in California.

In the 1–3 months before diagnosis of ovarian cancer, 31% of women reported abdominal pain, 17% reported abdominal swelling, and 8% reported gastrointestinal symptoms.

Abdominal imaging and pelvic imaging/CA 125 screens were used frequently (70% and 54%, respectively) to investigate symptoms within 3 months prior to diagnosis of ovarian cancer. In the 4–36 months before their diagnosis, 61% of women with symptoms had abdominal imaging and 25% received pelvic imaging/CA 125 screening.

Although pelvic imaging and CA 125 screens are not recommended in asymptomatic patients, they could be “reasonable options for women who have target symptoms that are not explained by routine medical evaluation,” the researchers reported.

A study of California women with ovarian cancer showed that the patients had distinguishable symptoms at least 6 months before diagnosis, according to Lloyd H. Smith, M.D., Ph.D., chair of the department of ob.gyn. at the University of California, Davis, and his colleagues.

The researchers found that women with ovarian cancer more frequently reported abdominal pain and received abdominal imaging in the 7–9 months before their diagnosis, compared with women who had no cancer and those with early-stage breast cancer (Cancer [online]2005;DOI:10.10002/cncr.21310).

And some patients may have their diagnosis delayed by 4 months or more because physicians order abdominal imaging or perform gastrointestinal procedures before ordering pelvic imaging or CA 125 screening, which are more likely to diagnose ovarian cancer, the researchers reported.

The population-based, retrospective case-control study compared case reports from 1,985 women, aged 68 years or older with a diagnosis of ovarian cancer, with two control groups: 10,941 women with early-stage breast cancer and 6,024 randomly selected age-matched women with no diagnosis of cancer. Researchers used information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and from Medicare Part B claims from women in California.

In the 1–3 months before diagnosis of ovarian cancer, 31% of women reported abdominal pain, 17% reported abdominal swelling, and 8% reported gastrointestinal symptoms.

Abdominal imaging and pelvic imaging/CA 125 screens were used frequently (70% and 54%, respectively) to investigate symptoms within 3 months prior to diagnosis of ovarian cancer. In the 4–36 months before their diagnosis, 61% of women with symptoms had abdominal imaging and 25% received pelvic imaging/CA 125 screening.

Although pelvic imaging and CA 125 screens are not recommended in asymptomatic patients, they could be “reasonable options for women who have target symptoms that are not explained by routine medical evaluation,” the researchers reported.

Officials at the Department of Health and Human Services have loosened restrictions on ownership of pharmaceutical and biotech company stocks for employees of the National Institutes of Health under a final rule on conflict of interest.

But the final regulation announced at a teleconference on NIH conflict of interest regulations continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership.

“We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” Dr. Zerhouni said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families will be required to divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case-by-case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed a number of potential conflicts of interest by NIH scientists. Under the policy outlined earlier, about 6,000 top NIH employees would have been required to sell off all of their stock holdings in companies impacted by NIH decisions. And the remainder of NIH employees would have been subject to the $15,000 limit.

The changes are designed to target the requirements at employees who are making decisions on grants and studies, Dr. Zerhouni said. The final regulation will also allow NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews. Under the earlier policy, these activities were prohibited, but they will now be allowed to go forward with prior approval and review by ethics officials.

The final rule continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees can also practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology or medical device manufacturers, health care providers or insurers, and NIH grantee institutions. Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said. While some outside consulting activities hold value for NIH and the public, he said the agency currently has no way to distinguish between those positive interactions and others such as product marketing.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. But the changes reflect the correct balance.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to get control of the problem of conflict of interest. Allowing NIH employees to participate in paid outside academic work, which often includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni said it's important to have a broad dialogue about conflict of interest with the entire scientific community.

For more information on NIH ethics rules visit www.nih.gov/about/ethics_COI.htm

Officials at the Department of Health and Human Services have loosened restrictions on ownership of pharmaceutical and biotech company stocks for employees of the National Institutes of Health under a final rule on conflict of interest.

But the final regulation announced at a teleconference on NIH conflict of interest regulations continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership.

“We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” Dr. Zerhouni said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families will be required to divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case-by-case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed a number of potential conflicts of interest by NIH scientists. Under the policy outlined earlier, about 6,000 top NIH employees would have been required to sell off all of their stock holdings in companies impacted by NIH decisions. And the remainder of NIH employees would have been subject to the $15,000 limit.

The changes are designed to target the requirements at employees who are making decisions on grants and studies, Dr. Zerhouni said. The final regulation will also allow NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews. Under the earlier policy, these activities were prohibited, but they will now be allowed to go forward with prior approval and review by ethics officials.

The final rule continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees can also practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology or medical device manufacturers, health care providers or insurers, and NIH grantee institutions. Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said. While some outside consulting activities hold value for NIH and the public, he said the agency currently has no way to distinguish between those positive interactions and others such as product marketing.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. But the changes reflect the correct balance.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to get control of the problem of conflict of interest. Allowing NIH employees to participate in paid outside academic work, which often includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni said it's important to have a broad dialogue about conflict of interest with the entire scientific community.

For more information on NIH ethics rules visit www.nih.gov/about/ethics_COI.htm

Officials at the Department of Health and Human Services have loosened restrictions on ownership of pharmaceutical and biotech company stocks for employees of the National Institutes of Health under a final rule on conflict of interest.

But the final regulation announced at a teleconference on NIH conflict of interest regulations continues to bar NIH employees from engaging in outside consulting relationships with industry.

NIH Director Elias A. Zerhouni, M.D., called the final regulation “stringent” despite the changes to stock ownership.

“We have worked hard with the Department of Health and Human Services and the Office of Government Ethics to try to come up with rules that first and foremost protect the integrity of NIH science and are balanced in terms of our ability to continue to attract and retain the best scientists and staff,” Dr. Zerhouni said.

Under the final rule, which became effective in August, about 200 NIH employees with senior decision-making authority and their families will be required to divest of all stock holdings in excess of $15,000 per company for organizations substantially affected by NIH decisions. The deadline for divestiture is Jan. 30, 2006.

About 6,000 individuals will be required to disclose more details about their financial holdings. The other approximately 12,000 employees won't be asked to specifically disclose stock holdings, according to Raynard S. Kington, M.D., NIH deputy director. Employees may be required to divest of stocks on a case-by-case basis if a potential conflict of interest is found.

This is a shift in the policy spelled out by NIH in February 2005 in the wake of a series of congressional hearings that exposed a number of potential conflicts of interest by NIH scientists. Under the policy outlined earlier, about 6,000 top NIH employees would have been required to sell off all of their stock holdings in companies impacted by NIH decisions. And the remainder of NIH employees would have been subject to the $15,000 limit.

The changes are designed to target the requirements at employees who are making decisions on grants and studies, Dr. Zerhouni said. The final regulation will also allow NIH employees more leeway to engage in outside activities with professional or scientific organizations, serve on data and safety monitoring boards, give grand rounds lectures, and perform scientific grant reviews. Under the earlier policy, these activities were prohibited, but they will now be allowed to go forward with prior approval and review by ethics officials.

The final rule continues to allow NIH scientists with prior approval to participate in compensated academic work such as teaching, writing textbooks, performing journal reviews or editing, and giving general lectures as part of continuing education programs. NIH employees can also practice medicine with prior approval.

But NIH held firm on its prohibition on relationships with pharmaceutical, biotechnology or medical device manufacturers, health care providers or insurers, and NIH grantee institutions. Keeping in place the ban on these activities is the best way to maintain the integrity of the agency at this point in time, Dr. Zerhouni said. While some outside consulting activities hold value for NIH and the public, he said the agency currently has no way to distinguish between those positive interactions and others such as product marketing.

The changes were praised as being “right on target” by Mary Woolley, president of Research!America. The stronger interim guidelines released in February were useful as a “cooling off period” and served as an opportunity to gather more information, she said. But the changes reflect the correct balance.

But Sidney M. Wolfe, M.D., director of Public Citizen's Health Research Group said the changes weakened the agency's earlier attempts to get control of the problem of conflict of interest. Allowing NIH employees to participate in paid outside academic work, which often includes money from industry, is riddled with loopholes, he said.

The final rule does not impose restrictions on extramural scientists, but Dr. Zerhouni said it's important to have a broad dialogue about conflict of interest with the entire scientific community.

For more information on NIH ethics rules visit www.nih.gov/about/ethics_COI.htm

Rituximab Reviewed for RA

Rituximab marketers Biogen Idec Inc. and Genentech Inc. are seeking Food and Drug Administration approval for a new indication for the drug in patients with active rheumatoid arthritis that inadequately responds to anti-TNF therapy. The submission of the supplemental Biologics License Application to the FDA is based in large part on the results of a 24-week phase III study known as Randomized Evaluation of Long-term Efficacy of Rituximab in RA (REFLEX). Patients who received a single course of two infusions of Rituximab with a stable dose of methotrexate had a statistically significant improvement in symptoms at 24 weeks, compared with patients who received placebo and methotrexate. The results of the REFLEX trial are slated to be presented at the American College of Rheumatology meeting in San Diego next month.

Pediatric Rheumatology Grant

Officials at the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) are trying to address the national shortage of pediatric rheumatologists through grants to training programs. One 5-year grant to train fellows in pediatric rheumatology was awarded to the Children's Hospital of Pittsburgh. The program will receive funding to train four fellows a year. There are currently 207 certified pediatric rheumatologists in the United States, according to the American Board of Pediatrics. “There is a tremendous need for this because pediatric rheumatology is one of the most underrepresented pediatric specialties, with only about 20 fellows a year in training nationwide,” Raphael Hirsch, M.D., division chief of pediatric rheumatology at Children's Hospital of Pittsburgh said in a statement. This is the second NIAMS grant awarded specifically for training pediatric rheumatologists. The first grant was awarded to the Children's Hospital Medical Center of Cincinnati.

Number of Uninsured Grows

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. In other statistics, the number of people with health insurance increased by 2 million, to 245.3 million, between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on Medicare's Rx Benefit

Patients' optimism about Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three (32%) seniors has a favorable impression of the benefit, and an equal portion (32%) have a negative one. This figure can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Adults of working age incur significantly higher rates of medical-bill and debt problems than adults 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt issue went without needed care because of cost.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the president agrees with the recommendations, he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and be completed within 6 years, according to the Base Realignment and Closure statute.

Rituximab Reviewed for RA

Rituximab marketers Biogen Idec Inc. and Genentech Inc. are seeking Food and Drug Administration approval for a new indication for the drug in patients with active rheumatoid arthritis that inadequately responds to anti-TNF therapy. The submission of the supplemental Biologics License Application to the FDA is based in large part on the results of a 24-week phase III study known as Randomized Evaluation of Long-term Efficacy of Rituximab in RA (REFLEX). Patients who received a single course of two infusions of Rituximab with a stable dose of methotrexate had a statistically significant improvement in symptoms at 24 weeks, compared with patients who received placebo and methotrexate. The results of the REFLEX trial are slated to be presented at the American College of Rheumatology meeting in San Diego next month.

Pediatric Rheumatology Grant

Officials at the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) are trying to address the national shortage of pediatric rheumatologists through grants to training programs. One 5-year grant to train fellows in pediatric rheumatology was awarded to the Children's Hospital of Pittsburgh. The program will receive funding to train four fellows a year. There are currently 207 certified pediatric rheumatologists in the United States, according to the American Board of Pediatrics. “There is a tremendous need for this because pediatric rheumatology is one of the most underrepresented pediatric specialties, with only about 20 fellows a year in training nationwide,” Raphael Hirsch, M.D., division chief of pediatric rheumatology at Children's Hospital of Pittsburgh said in a statement. This is the second NIAMS grant awarded specifically for training pediatric rheumatologists. The first grant was awarded to the Children's Hospital Medical Center of Cincinnati.

Number of Uninsured Grows

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. In other statistics, the number of people with health insurance increased by 2 million, to 245.3 million, between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on Medicare's Rx Benefit

Patients' optimism about Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three (32%) seniors has a favorable impression of the benefit, and an equal portion (32%) have a negative one. This figure can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Adults of working age incur significantly higher rates of medical-bill and debt problems than adults 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt issue went without needed care because of cost.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the president agrees with the recommendations, he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and be completed within 6 years, according to the Base Realignment and Closure statute.

Rituximab Reviewed for RA

Rituximab marketers Biogen Idec Inc. and Genentech Inc. are seeking Food and Drug Administration approval for a new indication for the drug in patients with active rheumatoid arthritis that inadequately responds to anti-TNF therapy. The submission of the supplemental Biologics License Application to the FDA is based in large part on the results of a 24-week phase III study known as Randomized Evaluation of Long-term Efficacy of Rituximab in RA (REFLEX). Patients who received a single course of two infusions of Rituximab with a stable dose of methotrexate had a statistically significant improvement in symptoms at 24 weeks, compared with patients who received placebo and methotrexate. The results of the REFLEX trial are slated to be presented at the American College of Rheumatology meeting in San Diego next month.

Pediatric Rheumatology Grant

Officials at the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) are trying to address the national shortage of pediatric rheumatologists through grants to training programs. One 5-year grant to train fellows in pediatric rheumatology was awarded to the Children's Hospital of Pittsburgh. The program will receive funding to train four fellows a year. There are currently 207 certified pediatric rheumatologists in the United States, according to the American Board of Pediatrics. “There is a tremendous need for this because pediatric rheumatology is one of the most underrepresented pediatric specialties, with only about 20 fellows a year in training nationwide,” Raphael Hirsch, M.D., division chief of pediatric rheumatology at Children's Hospital of Pittsburgh said in a statement. This is the second NIAMS grant awarded specifically for training pediatric rheumatologists. The first grant was awarded to the Children's Hospital Medical Center of Cincinnati.

Number of Uninsured Grows

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. In other statistics, the number of people with health insurance increased by 2 million, to 245.3 million, between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on Medicare's Rx Benefit

Patients' optimism about Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three (32%) seniors has a favorable impression of the benefit, and an equal portion (32%) have a negative one. This figure can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Adults of working age incur significantly higher rates of medical-bill and debt problems than adults 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt issue went without needed care because of cost.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the president agrees with the recommendations, he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and be completed within 6 years, according to the Base Realignment and Closure statute.

NASHVILLE, TENN. — The Medicaid program needs to undergo some fundamental changes, including asking patients to share some of the costs, Tennessee Gov. Phil Bredesen said at the annual conference of the National Academy for State Health Policy.

“We have got to get control of the economics of the program,” he said.

In Tennessee, Gov. Bredesen has come under fire for his attempts to make cuts and disenroll beneficiaries in the state's financially troubled Medicaid program, known as TennCare.

Just throwing money at the problem nationally won't work, Gov. Bredesen said. For starters, the United States already spends more than any other industrialized nation on health care and still has tens of millions of uninsured citizens. And politically, it's unlikely that an infusion of funds would be available for the program.

Instead, Gov. Bredesen suggested that policy makers need to figure out how to make the existing funding go further.

First, he proposed that everyone should pay a little something for everything. “Unless and until there is some economic tension in the program—unless the users make some of the choices for themselves about how scarce resources are going to be used—the system will continue to be inefficient,” Gov. Bredesen predicted.

The Medicaid Commission, which is charged with recommending ways to cuts costs in the program, has focused mainly on changes such as negotiating better prices with drug companies and cracking down on asset transfers made by Medicaid applicants.

However, the commission did tackle beneficiary cost sharing in its recommendation to give states the flexibility to increase copays for some beneficiaries on nonpreferred drugs.

The best way to do that is to let beneficiaries decide what they are willing to pay for and what they aren't, he said. “This is not about being hard-hearted.”

For example, Tennessee has a number of faith-based clinics that serve the uninsured; at these clinics, everyone pays something for their care. People tend to value things that they pay a little bit for and don't value things that are completely free, Gov. Bredesen said.

Second, government purchasers should pay for the most important things first, he said. Not everything that can be categorized as health care is on an equal footing, he said. For example, providing prenatal care is more important than covering antihistamines.

But in Tennessee, the state spends $280 million annually on two classes of drugs—antihistamines and gastric acid reducers.

These two classes of drugs account for 12% of the number of prescriptions written in the TennCare program. “We need to exercise some intelligent discretion here and prioritize what we do,” Gov. Bredesen said.

Third, he suggested that the Medicaid program should pay only for what works instead of paying for any new drug that comes on the market.

He noted that in 2002, the Food and Drug Administration approved 78 new drugs, of which only 7 contained any new active ingredients that were classified as improvements over medications that already existed.

“If we limit our oversight to a policy of buy everything but just argue about discounts, we've completely lost control,” he said.

NASHVILLE, TENN. — The Medicaid program needs to undergo some fundamental changes, including asking patients to share some of the costs, Tennessee Gov. Phil Bredesen said at the annual conference of the National Academy for State Health Policy.

“We have got to get control of the economics of the program,” he said.

In Tennessee, Gov. Bredesen has come under fire for his attempts to make cuts and disenroll beneficiaries in the state's financially troubled Medicaid program, known as TennCare.

Just throwing money at the problem nationally won't work, Gov. Bredesen said. For starters, the United States already spends more than any other industrialized nation on health care and still has tens of millions of uninsured citizens. And politically, it's unlikely that an infusion of funds would be available for the program.

Instead, Gov. Bredesen suggested that policy makers need to figure out how to make the existing funding go further.

First, he proposed that everyone should pay a little something for everything. “Unless and until there is some economic tension in the program—unless the users make some of the choices for themselves about how scarce resources are going to be used—the system will continue to be inefficient,” Gov. Bredesen predicted.

The Medicaid Commission, which is charged with recommending ways to cuts costs in the program, has focused mainly on changes such as negotiating better prices with drug companies and cracking down on asset transfers made by Medicaid applicants.

However, the commission did tackle beneficiary cost sharing in its recommendation to give states the flexibility to increase copays for some beneficiaries on nonpreferred drugs.

The best way to do that is to let beneficiaries decide what they are willing to pay for and what they aren't, he said. “This is not about being hard-hearted.”

For example, Tennessee has a number of faith-based clinics that serve the uninsured; at these clinics, everyone pays something for their care. People tend to value things that they pay a little bit for and don't value things that are completely free, Gov. Bredesen said.

Second, government purchasers should pay for the most important things first, he said. Not everything that can be categorized as health care is on an equal footing, he said. For example, providing prenatal care is more important than covering antihistamines.

But in Tennessee, the state spends $280 million annually on two classes of drugs—antihistamines and gastric acid reducers.

These two classes of drugs account for 12% of the number of prescriptions written in the TennCare program. “We need to exercise some intelligent discretion here and prioritize what we do,” Gov. Bredesen said.

Third, he suggested that the Medicaid program should pay only for what works instead of paying for any new drug that comes on the market.

He noted that in 2002, the Food and Drug Administration approved 78 new drugs, of which only 7 contained any new active ingredients that were classified as improvements over medications that already existed.

“If we limit our oversight to a policy of buy everything but just argue about discounts, we've completely lost control,” he said.

NASHVILLE, TENN. — The Medicaid program needs to undergo some fundamental changes, including asking patients to share some of the costs, Tennessee Gov. Phil Bredesen said at the annual conference of the National Academy for State Health Policy.

“We have got to get control of the economics of the program,” he said.

In Tennessee, Gov. Bredesen has come under fire for his attempts to make cuts and disenroll beneficiaries in the state's financially troubled Medicaid program, known as TennCare.

Just throwing money at the problem nationally won't work, Gov. Bredesen said. For starters, the United States already spends more than any other industrialized nation on health care and still has tens of millions of uninsured citizens. And politically, it's unlikely that an infusion of funds would be available for the program.

Instead, Gov. Bredesen suggested that policy makers need to figure out how to make the existing funding go further.

First, he proposed that everyone should pay a little something for everything. “Unless and until there is some economic tension in the program—unless the users make some of the choices for themselves about how scarce resources are going to be used—the system will continue to be inefficient,” Gov. Bredesen predicted.

The Medicaid Commission, which is charged with recommending ways to cuts costs in the program, has focused mainly on changes such as negotiating better prices with drug companies and cracking down on asset transfers made by Medicaid applicants.

However, the commission did tackle beneficiary cost sharing in its recommendation to give states the flexibility to increase copays for some beneficiaries on nonpreferred drugs.

The best way to do that is to let beneficiaries decide what they are willing to pay for and what they aren't, he said. “This is not about being hard-hearted.”

For example, Tennessee has a number of faith-based clinics that serve the uninsured; at these clinics, everyone pays something for their care. People tend to value things that they pay a little bit for and don't value things that are completely free, Gov. Bredesen said.

Second, government purchasers should pay for the most important things first, he said. Not everything that can be categorized as health care is on an equal footing, he said. For example, providing prenatal care is more important than covering antihistamines.

But in Tennessee, the state spends $280 million annually on two classes of drugs—antihistamines and gastric acid reducers.

These two classes of drugs account for 12% of the number of prescriptions written in the TennCare program. “We need to exercise some intelligent discretion here and prioritize what we do,” Gov. Bredesen said.

Third, he suggested that the Medicaid program should pay only for what works instead of paying for any new drug that comes on the market.

He noted that in 2002, the Food and Drug Administration approved 78 new drugs, of which only 7 contained any new active ingredients that were classified as improvements over medications that already existed.

“If we limit our oversight to a policy of buy everything but just argue about discounts, we've completely lost control,” he said.