Mary Ellen Schneider

The standard-setting group U.S. Pharmacopeia has established 146 unique therapeutic categories and pharmacologic classes to guide the establishment of formularies under the new Medicare Part D prescription drug benefit.

The model guidelines created by USP will serve as a voluntary framework for health plans and prescription drug plans as they create drug plan formularies for Medicare, as established by the Medicare Modernization Act of 2003.

“The model guidelines are not a formulary,” said Roger L. Williams, M.D., USP executive vice president and CEO and chair of the group's Model Guidelines Expert Committee, said in a press teleconference.

The group also created a separate listing of formulary key drug types to help the Centers for Medicare and Medicaid Services assess the comprehensiveness of proposed formularies.

Under proposed Medicare regulations, plans that follow the model guidelines would need to offer at least two drugs in each therapeutic category and pharmacologic class. USP has recommended that CMS require plans to offer at least one drug from the list of formulary key drug types or have a clinical or scientific rationale for excluding the drugs.

CMS officials will use the guidelines to help evaluate proposed formularies.

After USP issued draft guidelines for evaluating proposed formularies last August, physician groups and patient advocates complained that too many critical drugs were in a third category, where they would not be required to be covered.

The final guidelines include a new therapeutic category for inflammatory bowel disease agents and a new pharmacologic class for proton pump inhibitors. Other changes include additional antidementia drugs and expanded dermatologic agents.

Dr. Williams said he hopes all parties will see this as “workable compromise.”

The National Mental Health Association (NMHA) warned that the USP guidelines ignored recommendations from the mental health field not to group older medications with newer therapies. The association said that because these different medications are lumped together, health plans could choose to cover only the older, less expensive drugs. But NMHA president and CEO Michael M. Faenza said in a statement that his group is encouraged that CMS plans to consider widely accepted treatment guidelines for mental health when reviewing formularies.

But America's Health Insurance Plans (AHIP) praised the USP's final document.

“The final model continues to provide needed flexibility by not expanding the number of categories and classes previously proposed,” said Karen Ignagni, AHIP president and CEO. “The direction that CMS is clearly taking supports the building of effective private plan strategies to make the Part D benefit clinically appropriate and affordable for Medicare beneficiaries.”

Officials at the Pharmaceutical Research and Manufacturers of America, which has supported access to a broad array of treatments, were still reviewing the document at press time.

The standard-setting group U.S. Pharmacopeia has established 146 unique therapeutic categories and pharmacologic classes to guide the establishment of formularies under the new Medicare Part D prescription drug benefit.

The model guidelines created by USP will serve as a voluntary framework for health plans and prescription drug plans as they create drug plan formularies for Medicare, as established by the Medicare Modernization Act of 2003.

“The model guidelines are not a formulary,” said Roger L. Williams, M.D., USP executive vice president and CEO and chair of the group's Model Guidelines Expert Committee, said in a press teleconference.

The group also created a separate listing of formulary key drug types to help the Centers for Medicare and Medicaid Services assess the comprehensiveness of proposed formularies.

Under proposed Medicare regulations, plans that follow the model guidelines would need to offer at least two drugs in each therapeutic category and pharmacologic class. USP has recommended that CMS require plans to offer at least one drug from the list of formulary key drug types or have a clinical or scientific rationale for excluding the drugs.

CMS officials will use the guidelines to help evaluate proposed formularies.

After USP issued draft guidelines for evaluating proposed formularies last August, physician groups and patient advocates complained that too many critical drugs were in a third category, where they would not be required to be covered.

The final guidelines include a new therapeutic category for inflammatory bowel disease agents and a new pharmacologic class for proton pump inhibitors. Other changes include additional antidementia drugs and expanded dermatologic agents.

Dr. Williams said he hopes all parties will see this as “workable compromise.”

The National Mental Health Association (NMHA) warned that the USP guidelines ignored recommendations from the mental health field not to group older medications with newer therapies. The association said that because these different medications are lumped together, health plans could choose to cover only the older, less expensive drugs. But NMHA president and CEO Michael M. Faenza said in a statement that his group is encouraged that CMS plans to consider widely accepted treatment guidelines for mental health when reviewing formularies.

But America's Health Insurance Plans (AHIP) praised the USP's final document.

“The final model continues to provide needed flexibility by not expanding the number of categories and classes previously proposed,” said Karen Ignagni, AHIP president and CEO. “The direction that CMS is clearly taking supports the building of effective private plan strategies to make the Part D benefit clinically appropriate and affordable for Medicare beneficiaries.”

Officials at the Pharmaceutical Research and Manufacturers of America, which has supported access to a broad array of treatments, were still reviewing the document at press time.

The standard-setting group U.S. Pharmacopeia has established 146 unique therapeutic categories and pharmacologic classes to guide the establishment of formularies under the new Medicare Part D prescription drug benefit.

The model guidelines created by USP will serve as a voluntary framework for health plans and prescription drug plans as they create drug plan formularies for Medicare, as established by the Medicare Modernization Act of 2003.

“The model guidelines are not a formulary,” said Roger L. Williams, M.D., USP executive vice president and CEO and chair of the group's Model Guidelines Expert Committee, said in a press teleconference.

The group also created a separate listing of formulary key drug types to help the Centers for Medicare and Medicaid Services assess the comprehensiveness of proposed formularies.

Under proposed Medicare regulations, plans that follow the model guidelines would need to offer at least two drugs in each therapeutic category and pharmacologic class. USP has recommended that CMS require plans to offer at least one drug from the list of formulary key drug types or have a clinical or scientific rationale for excluding the drugs.

CMS officials will use the guidelines to help evaluate proposed formularies.

After USP issued draft guidelines for evaluating proposed formularies last August, physician groups and patient advocates complained that too many critical drugs were in a third category, where they would not be required to be covered.

The final guidelines include a new therapeutic category for inflammatory bowel disease agents and a new pharmacologic class for proton pump inhibitors. Other changes include additional antidementia drugs and expanded dermatologic agents.

Dr. Williams said he hopes all parties will see this as “workable compromise.”

The National Mental Health Association (NMHA) warned that the USP guidelines ignored recommendations from the mental health field not to group older medications with newer therapies. The association said that because these different medications are lumped together, health plans could choose to cover only the older, less expensive drugs. But NMHA president and CEO Michael M. Faenza said in a statement that his group is encouraged that CMS plans to consider widely accepted treatment guidelines for mental health when reviewing formularies.

But America's Health Insurance Plans (AHIP) praised the USP's final document.

“The final model continues to provide needed flexibility by not expanding the number of categories and classes previously proposed,” said Karen Ignagni, AHIP president and CEO. “The direction that CMS is clearly taking supports the building of effective private plan strategies to make the Part D benefit clinically appropriate and affordable for Medicare beneficiaries.”

Officials at the Pharmaceutical Research and Manufacturers of America, which has supported access to a broad array of treatments, were still reviewing the document at press time.

ALEXANDRIA, VA. — Traditional tort reform measures like damage caps won't address some of the fundamental problems with the medical liability system, experts said at a meeting on patient safety and medical liability sponsored by the Joint Commission on Accreditation of Healthcare Organizations.

To deal with the current malpractice situation, the medical community needs to address the reasons why people sue—injuries, unmet expenses, and anger, said Lucian L. Leape, M.D., of the department of health policy and management at the Harvard School of Public Health, Boston.

“The main reason most people sue is because they are angry at the physician,” Dr. Leape said.

But the current system and the most commonly proposed reforms, such as damage caps, don't address the need to increase disclosure of errors to patients or incentivize physicians to offer apologies, he said.

In the current tort system, filing a lawsuit is often the only way that patients feel they can get information about what happened to them or impose a penalty on the physician, said Michelle Mello, Ph.D., also of the department of health policy and management at the Harvard School of Public Health.

But this process often fails to secure an admission of responsibility or an apology, she said.

Traditional reforms such as caps would undercompensate seriously injured patients and increase administrative costs, Dr. Mello said. But they would not help deter medical malpractice, she said.

Damage caps also fail to address the poor correlation between medical injury and malpractice claims, she said. Instead of focusing on caps, the medical community needs to consider an administrative compensation system to replace torts.

The malpractice system is “blocking efforts at patient safety,” said Troyen A. Brennan, M.D., professor of medicine at Harvard Medical School, Boston, and professor of law and public health at the Harvard School of Public Health.

A new system should be established to separate compensation for injuries from deterrence, he said. In order to do that, liability for negligence has to be eliminated, and reporting has to be made based on patient injury.

“You have to enable open and honest reporting,” Dr. Brennan said.

And physicians have to realize that reporting patient injury is part of their professional responsibility, he said.

Currently, some physicians do not disclose errors or injuries. It's a rational economic response to their rising premiums and fear of being sued, he said, but it's not an ethical response.

ALEXANDRIA, VA. — Traditional tort reform measures like damage caps won't address some of the fundamental problems with the medical liability system, experts said at a meeting on patient safety and medical liability sponsored by the Joint Commission on Accreditation of Healthcare Organizations.

To deal with the current malpractice situation, the medical community needs to address the reasons why people sue—injuries, unmet expenses, and anger, said Lucian L. Leape, M.D., of the department of health policy and management at the Harvard School of Public Health, Boston.

“The main reason most people sue is because they are angry at the physician,” Dr. Leape said.

But the current system and the most commonly proposed reforms, such as damage caps, don't address the need to increase disclosure of errors to patients or incentivize physicians to offer apologies, he said.

In the current tort system, filing a lawsuit is often the only way that patients feel they can get information about what happened to them or impose a penalty on the physician, said Michelle Mello, Ph.D., also of the department of health policy and management at the Harvard School of Public Health.

But this process often fails to secure an admission of responsibility or an apology, she said.

Traditional reforms such as caps would undercompensate seriously injured patients and increase administrative costs, Dr. Mello said. But they would not help deter medical malpractice, she said.

Damage caps also fail to address the poor correlation between medical injury and malpractice claims, she said. Instead of focusing on caps, the medical community needs to consider an administrative compensation system to replace torts.

The malpractice system is “blocking efforts at patient safety,” said Troyen A. Brennan, M.D., professor of medicine at Harvard Medical School, Boston, and professor of law and public health at the Harvard School of Public Health.

A new system should be established to separate compensation for injuries from deterrence, he said. In order to do that, liability for negligence has to be eliminated, and reporting has to be made based on patient injury.

“You have to enable open and honest reporting,” Dr. Brennan said.

And physicians have to realize that reporting patient injury is part of their professional responsibility, he said.

Currently, some physicians do not disclose errors or injuries. It's a rational economic response to their rising premiums and fear of being sued, he said, but it's not an ethical response.

ALEXANDRIA, VA. — Traditional tort reform measures like damage caps won't address some of the fundamental problems with the medical liability system, experts said at a meeting on patient safety and medical liability sponsored by the Joint Commission on Accreditation of Healthcare Organizations.

To deal with the current malpractice situation, the medical community needs to address the reasons why people sue—injuries, unmet expenses, and anger, said Lucian L. Leape, M.D., of the department of health policy and management at the Harvard School of Public Health, Boston.

“The main reason most people sue is because they are angry at the physician,” Dr. Leape said.

But the current system and the most commonly proposed reforms, such as damage caps, don't address the need to increase disclosure of errors to patients or incentivize physicians to offer apologies, he said.

In the current tort system, filing a lawsuit is often the only way that patients feel they can get information about what happened to them or impose a penalty on the physician, said Michelle Mello, Ph.D., also of the department of health policy and management at the Harvard School of Public Health.

But this process often fails to secure an admission of responsibility or an apology, she said.

Traditional reforms such as caps would undercompensate seriously injured patients and increase administrative costs, Dr. Mello said. But they would not help deter medical malpractice, she said.

Damage caps also fail to address the poor correlation between medical injury and malpractice claims, she said. Instead of focusing on caps, the medical community needs to consider an administrative compensation system to replace torts.

The malpractice system is “blocking efforts at patient safety,” said Troyen A. Brennan, M.D., professor of medicine at Harvard Medical School, Boston, and professor of law and public health at the Harvard School of Public Health.

A new system should be established to separate compensation for injuries from deterrence, he said. In order to do that, liability for negligence has to be eliminated, and reporting has to be made based on patient injury.

“You have to enable open and honest reporting,” Dr. Brennan said.

And physicians have to realize that reporting patient injury is part of their professional responsibility, he said.

Currently, some physicians do not disclose errors or injuries. It's a rational economic response to their rising premiums and fear of being sued, he said, but it's not an ethical response.

Leaders in medicine are trying to figure out how to make primary care attractive to students and residents once again.

“We've got to change the way students see primary care,” said Michael Whitcomb, M.D., senior vice president of the division of medical education at the Association of American Medical Colleges.

Over the last few years, students have been choosing internal medicine subspecialties over primary care, causing groups like the AAMC, the American College of Physicians, and the American Academy of Family Medicine to reevaluate how to sell primary care to students.

Part of the problem is how students and residents are trained, said Holly Humphrey, M.D., dean for medical education at the University of Chicago. For example, students don't usually get a chance to see the multidisciplinary team approach that works best in primary care, Dr. Humphrey said.

Students training in the hospital see chronic disease management as “overwhelming” and don't see the infrastructure that could make it workable, she said.

But showing the proper management of chronic care patients could be a way to attract more medical students into primary care, said Dr. Whitcomb of the AAMC.

AAMC has formed a group to consider broad issues around improving chronic care, including how a change in emphasis could be one way to attract more students into primary care. This group started its work last fall and is expected to produce a proposal sometime this year, Dr. Whitcomb said.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP. He said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients.

One way that the AAFP is looking to increase student interest is by providing students access to competent role models in family medicine. One of the academy's efforts in this area includes piloting an online mentoring system. The concept began in Ohio where the Ohio Academy of Family Physicians and students from Ohio State University in Columbus have been using the Internet to connect medical students with practicing physicians in the community.

This year, AAFP is testing out the concept of an online mentoring program through similar projects in three states, said Jay Fetter, AAFP's student interest manager.

These organizations are also working on revitalizing primary care at the practice level.

Repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice, are all important steps, Dr. Weinberger said.

In fact, improving practice issues may be more important to attracting students than making educational changes, said Tod Ibrahim, executive vice president for the Alliance for Academic Internal Medicine. “I think the generational issues are bigger than anyone realizes,” he said.

The federal government could help by offering economic incentives, such as repayment of medical school loans, said Richard Lang, M.D., chairman of the department of general internal medicine at the Cleveland Clinic. Everyone is medicine is working hard, he said, but the salaries for primary care are much lower than other areas of medicine.

The key is to bring back job satisfaction for practicing primary care physicians, said Lawrence Smith, M.D., dean of medical education at the Mount Sinai School of Medicine, New York.

Dr. Smith predicts that electronic health records could make practice easier in the future. New practice models that revolve around a team of caregivers in a single office, could also help. In addition, physicians need to be reimbursed for how they spend their time, including phone calls and e-mail consultations with patients.

If the problem of attracting new practitioners isn't addressed, the United States could end up with a system without primary care physicians, Dr. Smith said.

Leaders in medicine are trying to figure out how to make primary care attractive to students and residents once again.

“We've got to change the way students see primary care,” said Michael Whitcomb, M.D., senior vice president of the division of medical education at the Association of American Medical Colleges.

Over the last few years, students have been choosing internal medicine subspecialties over primary care, causing groups like the AAMC, the American College of Physicians, and the American Academy of Family Medicine to reevaluate how to sell primary care to students.

Part of the problem is how students and residents are trained, said Holly Humphrey, M.D., dean for medical education at the University of Chicago. For example, students don't usually get a chance to see the multidisciplinary team approach that works best in primary care, Dr. Humphrey said.

Students training in the hospital see chronic disease management as “overwhelming” and don't see the infrastructure that could make it workable, she said.

But showing the proper management of chronic care patients could be a way to attract more medical students into primary care, said Dr. Whitcomb of the AAMC.

AAMC has formed a group to consider broad issues around improving chronic care, including how a change in emphasis could be one way to attract more students into primary care. This group started its work last fall and is expected to produce a proposal sometime this year, Dr. Whitcomb said.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP. He said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients.

One way that the AAFP is looking to increase student interest is by providing students access to competent role models in family medicine. One of the academy's efforts in this area includes piloting an online mentoring system. The concept began in Ohio where the Ohio Academy of Family Physicians and students from Ohio State University in Columbus have been using the Internet to connect medical students with practicing physicians in the community.

This year, AAFP is testing out the concept of an online mentoring program through similar projects in three states, said Jay Fetter, AAFP's student interest manager.

These organizations are also working on revitalizing primary care at the practice level.

Repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice, are all important steps, Dr. Weinberger said.

In fact, improving practice issues may be more important to attracting students than making educational changes, said Tod Ibrahim, executive vice president for the Alliance for Academic Internal Medicine. “I think the generational issues are bigger than anyone realizes,” he said.

The federal government could help by offering economic incentives, such as repayment of medical school loans, said Richard Lang, M.D., chairman of the department of general internal medicine at the Cleveland Clinic. Everyone is medicine is working hard, he said, but the salaries for primary care are much lower than other areas of medicine.

The key is to bring back job satisfaction for practicing primary care physicians, said Lawrence Smith, M.D., dean of medical education at the Mount Sinai School of Medicine, New York.

Dr. Smith predicts that electronic health records could make practice easier in the future. New practice models that revolve around a team of caregivers in a single office, could also help. In addition, physicians need to be reimbursed for how they spend their time, including phone calls and e-mail consultations with patients.

If the problem of attracting new practitioners isn't addressed, the United States could end up with a system without primary care physicians, Dr. Smith said.

Leaders in medicine are trying to figure out how to make primary care attractive to students and residents once again.

“We've got to change the way students see primary care,” said Michael Whitcomb, M.D., senior vice president of the division of medical education at the Association of American Medical Colleges.

Over the last few years, students have been choosing internal medicine subspecialties over primary care, causing groups like the AAMC, the American College of Physicians, and the American Academy of Family Medicine to reevaluate how to sell primary care to students.

Part of the problem is how students and residents are trained, said Holly Humphrey, M.D., dean for medical education at the University of Chicago. For example, students don't usually get a chance to see the multidisciplinary team approach that works best in primary care, Dr. Humphrey said.

Students training in the hospital see chronic disease management as “overwhelming” and don't see the infrastructure that could make it workable, she said.

But showing the proper management of chronic care patients could be a way to attract more medical students into primary care, said Dr. Whitcomb of the AAMC.

AAMC has formed a group to consider broad issues around improving chronic care, including how a change in emphasis could be one way to attract more students into primary care. This group started its work last fall and is expected to produce a proposal sometime this year, Dr. Whitcomb said.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP. He said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients.

One way that the AAFP is looking to increase student interest is by providing students access to competent role models in family medicine. One of the academy's efforts in this area includes piloting an online mentoring system. The concept began in Ohio where the Ohio Academy of Family Physicians and students from Ohio State University in Columbus have been using the Internet to connect medical students with practicing physicians in the community.

This year, AAFP is testing out the concept of an online mentoring program through similar projects in three states, said Jay Fetter, AAFP's student interest manager.

These organizations are also working on revitalizing primary care at the practice level.

Repairing the payment system, reducing administrative hassles, articulating the value of internal medicine, and redesigning training to better meet the scope of practice, are all important steps, Dr. Weinberger said.

In fact, improving practice issues may be more important to attracting students than making educational changes, said Tod Ibrahim, executive vice president for the Alliance for Academic Internal Medicine. “I think the generational issues are bigger than anyone realizes,” he said.

The federal government could help by offering economic incentives, such as repayment of medical school loans, said Richard Lang, M.D., chairman of the department of general internal medicine at the Cleveland Clinic. Everyone is medicine is working hard, he said, but the salaries for primary care are much lower than other areas of medicine.

The key is to bring back job satisfaction for practicing primary care physicians, said Lawrence Smith, M.D., dean of medical education at the Mount Sinai School of Medicine, New York.

Dr. Smith predicts that electronic health records could make practice easier in the future. New practice models that revolve around a team of caregivers in a single office, could also help. In addition, physicians need to be reimbursed for how they spend their time, including phone calls and e-mail consultations with patients.

If the problem of attracting new practitioners isn't addressed, the United States could end up with a system without primary care physicians, Dr. Smith said.

As physicians push for professional liability reform at the national level, the Maryland legislature signed off on a bill aimed at halting rising malpractice premiums.

The centerpiece of the legislation is a rate stabilization fund for medical professional liability insurance that will be funded through a tax on HMOs.

The Maryland State Medical Society (MedChi) and the Maryland Hospital Association estimate that the fund would cover about 95% of the increase in premiums for 2005. Obstetricians in Maryland are paying about $120,000–$160,000 for insurance coverage this year.

Maryland physicians have been pushing hard for reform—especially since last fall, when the state's largest malpractice carrier, Medical Mutual of Maryland, said it would raise its premium rates in 2005 an average 33%. The move follows a 28% increase a year ago.

Maryland is considered a medical liability insurance crisis state by the American College of Obstetricians and Gynecologists. And physicians of all specialties in the state are choosing to lay off staff, close practices, or move, in order to deal with the malpractice problem, according to MedChi.

The new legislation was passed in dramatic fashion during an end-of-the-year special session called by Gov. Robert Ehrlich. But he objected to the HMO tax and said the bill didn't contain meaningful tort reform. He then vetoed the measure in January, but legislators returned to work to override the veto.

The saga is expected to continue as Mr. Ehrlich prepares to introduce other legislation with more comprehensive reforms.

The state's physician and hospital groups are applauding the new legislation as an important first step. “While we agree with the governor and others that Maryland needs more comprehensive reform, it does offer important positive elements,” MedChi and the Maryland Hospital Association said in a joint statement.

The groups pointed out that the measure contains a reduction in the cap on noneconomic damages in death cases, reform of how past medical expenses are calculated, and new requirements for expert witnesses. However, the legislation fails to include needed reforms such as mandatory structured settlements of awards, an expansion of the Good Samaritan Act to include emergency department professionals, and parameters on the calculation of future economic damages, the groups said.

Although there is still more work to be done, the attention brought to medical liability reform through the special session is good news for physicians, said Willarda V. Edwards, M.D., an internist in South Baltimore and MedChi president.

The increased awareness and the better understanding of the issues that resulted from the special session will help as physicians seek increased reform this year, she said. MedChi plans to pursue limits on lawyers' fees, structured settlements that can be paid over time, reforming the calculation of economic damage payments, and enactment of a Good Samaritan law.

“This is just a little taste of what we think should be done,” Dr. Edwards said.

But physicians in Maryland are still waiting to see what the current legislation will mean in terms of premiums. “It's too early to say how this is going work,” said Miriam Yudkoff, M.D., an ob.gyn. in Annapolis.

And Dr. Yudkoff said she has some concerns about what the insurance reform provisions in the legislation will mean for liability carriers. If Maryland becomes an unprofitable place for insurers, it could have a significant impact on physicians' ability to obtain coverage. “We need a bill that will make Maryland a favorable state for carriers,” she said.

Carol Ritter, M.D., a solo gynecologist in Towson, who gave up obstetrics last year, said the legislation was a first step in reform, though not enough for her to practice obstetrics again.

The rate stabilization fund is likely to limit the 2005 average premium increase, Dr. Ritter said, but it will still be more than 2004 rates, which were already more than she could afford. However, she's hopeful it will allow some of her colleagues to stay in practice in the short term.

The legislation also won't help David Zisow, M.D., a gynecologist in Bel Air, to start practicing obstetrics again. Like Dr. Ritter, Dr. Zisow gave up obstetrics at the beginning of 2004 when the rates became too high. But even though the new legislation contains significant reforms, Dr. Zisow said he wouldn't be able to afford to buy the tail coverage that would be necessary to start practicing obstetrics again. His insurer, Medical Mutual, allowed him to forego paying tail coverage for obstetrics because of his many years with the company. However, he would have to pay a significant amount if he were to go back into obstetrics, he said.

As it is, Dr. Zisow has already seen a major increase in his premiums for gynecology alone in 2005, and he said he isn't optimistic that the legislation will result in too much change in premiums.

“It's business as usual,” he said.

This is a wake-up call to physicians to get politically active, said Mark Seigel, M.D., an ob.gyn. in Gaithersburg and the former president of MedChi. Passing meaningful changes to the system takes time, he said, and ultimately it may mean voting officials out of office who fail to take on medical liability reform.

As physicians push for professional liability reform at the national level, the Maryland legislature signed off on a bill aimed at halting rising malpractice premiums.

The centerpiece of the legislation is a rate stabilization fund for medical professional liability insurance that will be funded through a tax on HMOs.

The Maryland State Medical Society (MedChi) and the Maryland Hospital Association estimate that the fund would cover about 95% of the increase in premiums for 2005. Obstetricians in Maryland are paying about $120,000–$160,000 for insurance coverage this year.

Maryland physicians have been pushing hard for reform—especially since last fall, when the state's largest malpractice carrier, Medical Mutual of Maryland, said it would raise its premium rates in 2005 an average 33%. The move follows a 28% increase a year ago.

Maryland is considered a medical liability insurance crisis state by the American College of Obstetricians and Gynecologists. And physicians of all specialties in the state are choosing to lay off staff, close practices, or move, in order to deal with the malpractice problem, according to MedChi.

The new legislation was passed in dramatic fashion during an end-of-the-year special session called by Gov. Robert Ehrlich. But he objected to the HMO tax and said the bill didn't contain meaningful tort reform. He then vetoed the measure in January, but legislators returned to work to override the veto.

The saga is expected to continue as Mr. Ehrlich prepares to introduce other legislation with more comprehensive reforms.

The state's physician and hospital groups are applauding the new legislation as an important first step. “While we agree with the governor and others that Maryland needs more comprehensive reform, it does offer important positive elements,” MedChi and the Maryland Hospital Association said in a joint statement.

The groups pointed out that the measure contains a reduction in the cap on noneconomic damages in death cases, reform of how past medical expenses are calculated, and new requirements for expert witnesses. However, the legislation fails to include needed reforms such as mandatory structured settlements of awards, an expansion of the Good Samaritan Act to include emergency department professionals, and parameters on the calculation of future economic damages, the groups said.

Although there is still more work to be done, the attention brought to medical liability reform through the special session is good news for physicians, said Willarda V. Edwards, M.D., an internist in South Baltimore and MedChi president.

The increased awareness and the better understanding of the issues that resulted from the special session will help as physicians seek increased reform this year, she said. MedChi plans to pursue limits on lawyers' fees, structured settlements that can be paid over time, reforming the calculation of economic damage payments, and enactment of a Good Samaritan law.

“This is just a little taste of what we think should be done,” Dr. Edwards said.

But physicians in Maryland are still waiting to see what the current legislation will mean in terms of premiums. “It's too early to say how this is going work,” said Miriam Yudkoff, M.D., an ob.gyn. in Annapolis.

And Dr. Yudkoff said she has some concerns about what the insurance reform provisions in the legislation will mean for liability carriers. If Maryland becomes an unprofitable place for insurers, it could have a significant impact on physicians' ability to obtain coverage. “We need a bill that will make Maryland a favorable state for carriers,” she said.

Carol Ritter, M.D., a solo gynecologist in Towson, who gave up obstetrics last year, said the legislation was a first step in reform, though not enough for her to practice obstetrics again.

The rate stabilization fund is likely to limit the 2005 average premium increase, Dr. Ritter said, but it will still be more than 2004 rates, which were already more than she could afford. However, she's hopeful it will allow some of her colleagues to stay in practice in the short term.

The legislation also won't help David Zisow, M.D., a gynecologist in Bel Air, to start practicing obstetrics again. Like Dr. Ritter, Dr. Zisow gave up obstetrics at the beginning of 2004 when the rates became too high. But even though the new legislation contains significant reforms, Dr. Zisow said he wouldn't be able to afford to buy the tail coverage that would be necessary to start practicing obstetrics again. His insurer, Medical Mutual, allowed him to forego paying tail coverage for obstetrics because of his many years with the company. However, he would have to pay a significant amount if he were to go back into obstetrics, he said.

As it is, Dr. Zisow has already seen a major increase in his premiums for gynecology alone in 2005, and he said he isn't optimistic that the legislation will result in too much change in premiums.

“It's business as usual,” he said.

This is a wake-up call to physicians to get politically active, said Mark Seigel, M.D., an ob.gyn. in Gaithersburg and the former president of MedChi. Passing meaningful changes to the system takes time, he said, and ultimately it may mean voting officials out of office who fail to take on medical liability reform.

As physicians push for professional liability reform at the national level, the Maryland legislature signed off on a bill aimed at halting rising malpractice premiums.

The centerpiece of the legislation is a rate stabilization fund for medical professional liability insurance that will be funded through a tax on HMOs.

The Maryland State Medical Society (MedChi) and the Maryland Hospital Association estimate that the fund would cover about 95% of the increase in premiums for 2005. Obstetricians in Maryland are paying about $120,000–$160,000 for insurance coverage this year.

Maryland physicians have been pushing hard for reform—especially since last fall, when the state's largest malpractice carrier, Medical Mutual of Maryland, said it would raise its premium rates in 2005 an average 33%. The move follows a 28% increase a year ago.

Maryland is considered a medical liability insurance crisis state by the American College of Obstetricians and Gynecologists. And physicians of all specialties in the state are choosing to lay off staff, close practices, or move, in order to deal with the malpractice problem, according to MedChi.

The new legislation was passed in dramatic fashion during an end-of-the-year special session called by Gov. Robert Ehrlich. But he objected to the HMO tax and said the bill didn't contain meaningful tort reform. He then vetoed the measure in January, but legislators returned to work to override the veto.

The saga is expected to continue as Mr. Ehrlich prepares to introduce other legislation with more comprehensive reforms.

The state's physician and hospital groups are applauding the new legislation as an important first step. “While we agree with the governor and others that Maryland needs more comprehensive reform, it does offer important positive elements,” MedChi and the Maryland Hospital Association said in a joint statement.

The groups pointed out that the measure contains a reduction in the cap on noneconomic damages in death cases, reform of how past medical expenses are calculated, and new requirements for expert witnesses. However, the legislation fails to include needed reforms such as mandatory structured settlements of awards, an expansion of the Good Samaritan Act to include emergency department professionals, and parameters on the calculation of future economic damages, the groups said.

Although there is still more work to be done, the attention brought to medical liability reform through the special session is good news for physicians, said Willarda V. Edwards, M.D., an internist in South Baltimore and MedChi president.

The increased awareness and the better understanding of the issues that resulted from the special session will help as physicians seek increased reform this year, she said. MedChi plans to pursue limits on lawyers' fees, structured settlements that can be paid over time, reforming the calculation of economic damage payments, and enactment of a Good Samaritan law.

“This is just a little taste of what we think should be done,” Dr. Edwards said.

But physicians in Maryland are still waiting to see what the current legislation will mean in terms of premiums. “It's too early to say how this is going work,” said Miriam Yudkoff, M.D., an ob.gyn. in Annapolis.

And Dr. Yudkoff said she has some concerns about what the insurance reform provisions in the legislation will mean for liability carriers. If Maryland becomes an unprofitable place for insurers, it could have a significant impact on physicians' ability to obtain coverage. “We need a bill that will make Maryland a favorable state for carriers,” she said.

Carol Ritter, M.D., a solo gynecologist in Towson, who gave up obstetrics last year, said the legislation was a first step in reform, though not enough for her to practice obstetrics again.

The rate stabilization fund is likely to limit the 2005 average premium increase, Dr. Ritter said, but it will still be more than 2004 rates, which were already more than she could afford. However, she's hopeful it will allow some of her colleagues to stay in practice in the short term.

The legislation also won't help David Zisow, M.D., a gynecologist in Bel Air, to start practicing obstetrics again. Like Dr. Ritter, Dr. Zisow gave up obstetrics at the beginning of 2004 when the rates became too high. But even though the new legislation contains significant reforms, Dr. Zisow said he wouldn't be able to afford to buy the tail coverage that would be necessary to start practicing obstetrics again. His insurer, Medical Mutual, allowed him to forego paying tail coverage for obstetrics because of his many years with the company. However, he would have to pay a significant amount if he were to go back into obstetrics, he said.

As it is, Dr. Zisow has already seen a major increase in his premiums for gynecology alone in 2005, and he said he isn't optimistic that the legislation will result in too much change in premiums.

“It's business as usual,” he said.

This is a wake-up call to physicians to get politically active, said Mark Seigel, M.D., an ob.gyn. in Gaithersburg and the former president of MedChi. Passing meaningful changes to the system takes time, he said, and ultimately it may mean voting officials out of office who fail to take on medical liability reform.

Plan B Decision Delay Spawns Lawsuit

An advocacy group is suing the Food and Drug Administration for delaying its decision on over-the-counter status for the emergency contraceptive Plan B (levonorgestrel). “Half of the 3 million pregnancies in the U.S. are unintended each year. By denying women over-the-counter access to a safe and effective drug that would significantly reduce those numbers—including pregnancies that end in abortion—the FDA is acting unlawfully,” said Nancy Northrup, president of the Center for Reproductive Rights, which filed its suit in a New York district court. The FDA had been scheduled to issue a decision in late January on a second application for OTC status for Plan B by its manufacturer, Barr Pharmaceuticals. Steven Galson, M.D., acting director of the FDA's Center for Drug Evaluation and Research, had rejected Barr's initial request for over-the-counter marketing status last spring, citing a lack of sufficient evidence regarding the effects of OTC availability of emergency contraception in younger women. The FDA should be completing its review in the near future, Barr indicated in a statement. “The company remains optimistic that the agency will approve Plan B for OTC sale.”

Emergency Contraception Omitted

A coalition of abortion rights advocates and health care professionals is urging the U.S. Department of Justice to add information about emergency contraception to its “National Protocol for Sexual Assault Medical Forensic Examination.” The group is asking the Justice Department to revise its protocol to include the routine offering of emergency contraception to rape victims at risk of pregnancy. “The failure to include a specific discussion of emergency contraception in the first national protocol for sexual assault treatment is a glaring omission in an otherwise thorough document,” the coalition said in a letter to the Justice Department. The protocol, which provides medical treatment guidelines for sexual assault patients, was released late last year. The coalition includes the American College of Obstetricians and Gynecologists.

Misleading Ads

The Food and Drug Administration recently warned Barr Research that one of its advertisements for the oral contraceptive Seasonale (levonorgestrel/ethinyl estradiol) was misleading consumers. “By omitting and minimizing the risks associated with Seasonale, the TV ad misleadingly suggests that Seasonale is safer than has been demonstrated by substantial evidence or substantial clinical experience,” the FDA said in a letter. The ad fails to mention that patients using Seasonale may experience breakthrough bleeding or spotting for up to a year, according to the letter. In addition, the ad minimizes risk information through fast-paced scene changes, background music, and compelling visuals, according to the FDA. Barr intends to work with FDA to make the necessary change to the ad, according to company spokesman Carol A. Cox. “Seasonale is safe and effective oral contraception when used as directed, and we intend to continue to educate all consumers and health care providers about the product, its indications, risks, and side effects,” she said.

HIV Prevention

Although current law allows for the delivery and financing of HIV-prevention programs through Medicaid and the Ryan White Comprehensive AIDS Resources Emergency Act grants, neither program delivers a significant level of services, according to an analysis by the Kaiser Family Foundation. Financial pressures contribute to the situation, according to the study, but organizational barriers also keep prevention from being integrated into clinical care. The study said prevention could be enhanced through the development of models of integration in primary care and increased training of health care providers on incorporating HIV prevention practices into routine practice activities.

The Malpractice Debate

President Bush hit the road in January to drum up support for his medical liability reform legislation. The president traveled to Illinois to draw attention to the problem of frivolous lawsuits and called on Congress to enact a $250,000 cap on noneconomic damages in medical malpractice cases. He also called on Congress to pass joint and several liability reform and to work on reform for class action lawsuits. “It's important for the United States senators from this state and other states to recognize the significance of the problem and get a meaningful, real medical liability bill to my desk,” President Bush said during his speech in Illinois. But Sen. Byron Dorgan (D-N.D.) said the proposal would shelter drug manufacturers from lawsuits. “In its zeal to support the big drug companies, the Bush administration is seriously overreaching with this proposal,” he said in a statement.

Plan B Decision Delay Spawns Lawsuit

An advocacy group is suing the Food and Drug Administration for delaying its decision on over-the-counter status for the emergency contraceptive Plan B (levonorgestrel). “Half of the 3 million pregnancies in the U.S. are unintended each year. By denying women over-the-counter access to a safe and effective drug that would significantly reduce those numbers—including pregnancies that end in abortion—the FDA is acting unlawfully,” said Nancy Northrup, president of the Center for Reproductive Rights, which filed its suit in a New York district court. The FDA had been scheduled to issue a decision in late January on a second application for OTC status for Plan B by its manufacturer, Barr Pharmaceuticals. Steven Galson, M.D., acting director of the FDA's Center for Drug Evaluation and Research, had rejected Barr's initial request for over-the-counter marketing status last spring, citing a lack of sufficient evidence regarding the effects of OTC availability of emergency contraception in younger women. The FDA should be completing its review in the near future, Barr indicated in a statement. “The company remains optimistic that the agency will approve Plan B for OTC sale.”

Emergency Contraception Omitted

A coalition of abortion rights advocates and health care professionals is urging the U.S. Department of Justice to add information about emergency contraception to its “National Protocol for Sexual Assault Medical Forensic Examination.” The group is asking the Justice Department to revise its protocol to include the routine offering of emergency contraception to rape victims at risk of pregnancy. “The failure to include a specific discussion of emergency contraception in the first national protocol for sexual assault treatment is a glaring omission in an otherwise thorough document,” the coalition said in a letter to the Justice Department. The protocol, which provides medical treatment guidelines for sexual assault patients, was released late last year. The coalition includes the American College of Obstetricians and Gynecologists.

Misleading Ads

The Food and Drug Administration recently warned Barr Research that one of its advertisements for the oral contraceptive Seasonale (levonorgestrel/ethinyl estradiol) was misleading consumers. “By omitting and minimizing the risks associated with Seasonale, the TV ad misleadingly suggests that Seasonale is safer than has been demonstrated by substantial evidence or substantial clinical experience,” the FDA said in a letter. The ad fails to mention that patients using Seasonale may experience breakthrough bleeding or spotting for up to a year, according to the letter. In addition, the ad minimizes risk information through fast-paced scene changes, background music, and compelling visuals, according to the FDA. Barr intends to work with FDA to make the necessary change to the ad, according to company spokesman Carol A. Cox. “Seasonale is safe and effective oral contraception when used as directed, and we intend to continue to educate all consumers and health care providers about the product, its indications, risks, and side effects,” she said.

HIV Prevention

Although current law allows for the delivery and financing of HIV-prevention programs through Medicaid and the Ryan White Comprehensive AIDS Resources Emergency Act grants, neither program delivers a significant level of services, according to an analysis by the Kaiser Family Foundation. Financial pressures contribute to the situation, according to the study, but organizational barriers also keep prevention from being integrated into clinical care. The study said prevention could be enhanced through the development of models of integration in primary care and increased training of health care providers on incorporating HIV prevention practices into routine practice activities.

The Malpractice Debate

President Bush hit the road in January to drum up support for his medical liability reform legislation. The president traveled to Illinois to draw attention to the problem of frivolous lawsuits and called on Congress to enact a $250,000 cap on noneconomic damages in medical malpractice cases. He also called on Congress to pass joint and several liability reform and to work on reform for class action lawsuits. “It's important for the United States senators from this state and other states to recognize the significance of the problem and get a meaningful, real medical liability bill to my desk,” President Bush said during his speech in Illinois. But Sen. Byron Dorgan (D-N.D.) said the proposal would shelter drug manufacturers from lawsuits. “In its zeal to support the big drug companies, the Bush administration is seriously overreaching with this proposal,” he said in a statement.

Plan B Decision Delay Spawns Lawsuit

An advocacy group is suing the Food and Drug Administration for delaying its decision on over-the-counter status for the emergency contraceptive Plan B (levonorgestrel). “Half of the 3 million pregnancies in the U.S. are unintended each year. By denying women over-the-counter access to a safe and effective drug that would significantly reduce those numbers—including pregnancies that end in abortion—the FDA is acting unlawfully,” said Nancy Northrup, president of the Center for Reproductive Rights, which filed its suit in a New York district court. The FDA had been scheduled to issue a decision in late January on a second application for OTC status for Plan B by its manufacturer, Barr Pharmaceuticals. Steven Galson, M.D., acting director of the FDA's Center for Drug Evaluation and Research, had rejected Barr's initial request for over-the-counter marketing status last spring, citing a lack of sufficient evidence regarding the effects of OTC availability of emergency contraception in younger women. The FDA should be completing its review in the near future, Barr indicated in a statement. “The company remains optimistic that the agency will approve Plan B for OTC sale.”

Emergency Contraception Omitted

A coalition of abortion rights advocates and health care professionals is urging the U.S. Department of Justice to add information about emergency contraception to its “National Protocol for Sexual Assault Medical Forensic Examination.” The group is asking the Justice Department to revise its protocol to include the routine offering of emergency contraception to rape victims at risk of pregnancy. “The failure to include a specific discussion of emergency contraception in the first national protocol for sexual assault treatment is a glaring omission in an otherwise thorough document,” the coalition said in a letter to the Justice Department. The protocol, which provides medical treatment guidelines for sexual assault patients, was released late last year. The coalition includes the American College of Obstetricians and Gynecologists.

Misleading Ads

The Food and Drug Administration recently warned Barr Research that one of its advertisements for the oral contraceptive Seasonale (levonorgestrel/ethinyl estradiol) was misleading consumers. “By omitting and minimizing the risks associated with Seasonale, the TV ad misleadingly suggests that Seasonale is safer than has been demonstrated by substantial evidence or substantial clinical experience,” the FDA said in a letter. The ad fails to mention that patients using Seasonale may experience breakthrough bleeding or spotting for up to a year, according to the letter. In addition, the ad minimizes risk information through fast-paced scene changes, background music, and compelling visuals, according to the FDA. Barr intends to work with FDA to make the necessary change to the ad, according to company spokesman Carol A. Cox. “Seasonale is safe and effective oral contraception when used as directed, and we intend to continue to educate all consumers and health care providers about the product, its indications, risks, and side effects,” she said.

HIV Prevention

Although current law allows for the delivery and financing of HIV-prevention programs through Medicaid and the Ryan White Comprehensive AIDS Resources Emergency Act grants, neither program delivers a significant level of services, according to an analysis by the Kaiser Family Foundation. Financial pressures contribute to the situation, according to the study, but organizational barriers also keep prevention from being integrated into clinical care. The study said prevention could be enhanced through the development of models of integration in primary care and increased training of health care providers on incorporating HIV prevention practices into routine practice activities.

The Malpractice Debate

President Bush hit the road in January to drum up support for his medical liability reform legislation. The president traveled to Illinois to draw attention to the problem of frivolous lawsuits and called on Congress to enact a $250,000 cap on noneconomic damages in medical malpractice cases. He also called on Congress to pass joint and several liability reform and to work on reform for class action lawsuits. “It's important for the United States senators from this state and other states to recognize the significance of the problem and get a meaningful, real medical liability bill to my desk,” President Bush said during his speech in Illinois. But Sen. Byron Dorgan (D-N.D.) said the proposal would shelter drug manufacturers from lawsuits. “In its zeal to support the big drug companies, the Bush administration is seriously overreaching with this proposal,” he said in a statement.

More than 4 years ago, Raymond M. Pomm, M.D., started to see a pattern of disruptive behavior occurring in physicians across Florida, where he is the medical director for the state's Impaired Professionals Program.

Hospitals were reporting a range of inappropriate and disruptive behaviors, from yelling to berating nurses in front of other staffers to physical violence. But the behavior did not fit any patterns typically associated with psychiatric disorders such as bipolar disorder or substance abuse, he said, so he searched the country for a person or a program that could help to change the behavior.

“It became a real dilemma,” Dr. Pomm said.

Then in 2002, Eva Ritvo, M.D., a psychiatrist, and Larry Harmon, Ph.D., a psychologist, stepped forward with a unique approach. The two health care professionals started the Physicians Development Program, which provides a complete psychiatric, psychological, and workplace evaluation of potentially disruptive physicians. The program also offers referrals to local treatment, and monitors behavior to chart physician improvement.

“We really try to tailor the program to the individual doctor,” said Dr. Ritvo of the department of psychiatry and behavioral sciences at the University of Miami and chair of the department of psychiatry at Mount Sinai Medical Center in Miami Beach.

They also use the Physicians' Universal Leadership Skills Survey Enhancement (PULSE) tool to evaluate and monitor physician behavior. The survey was developed by asking a variety of health care professionals what their colleagues do at work that motivates them to perform at their best, and what disrupts or discourages them.

When a physician agrees to go through the program, Dr. Harmon sends the survey to nurses, physician colleagues, and hospital leadership to find out how the individual physician behaves.

This feedback process gives the physician some insight into how he or she is viewed by colleagues. This is a “magic moment” in the program, according to Dr. Harmon, who is the chair of the ethics advisory board of the Florida Psychological Association.

The physicians, along with hospital administrators, choose the people who will complete the survey. “This is not mental health treatment, this is physician development,” Dr. Harmon said.

Seeing this report usually turns around the behavior, Dr. Harmon said.

Once the behavior is pointed out in a structured, objective way by a neutral third party, the findings are seen as credible and they have an impact on the doctor.

The feedback report allows Dr. Harmon to constructively confront the doctor's lack of insight, he said. Physicians do not notice their disruptive impact on others until they see the collective voice of their team members reflected in the report.

It's also the best way to find out if a physician isn't being disruptive, but may be a political target at the hospital.

After the survey is shown to the physician, Dr. Harmon conducts a follow-up survey to chart the physician's progress.

So far, all of the physicians who have been through the program have improved their behavior, he said.

About 42 physicians have completed the program since its inception in 2002. The program participants come from around the country and from various specialties, Dr. Ritvo said.

“Typically, our physicians are not what you'd expect,” she said in an interview with this newspaper.

These physicians usually don't see their behavior as inappropriate and will say that they are just trying to get the best care for their patients. And they are usually excellent doctors but they are operating under a lot of stress and generally have some type of personality disorder involving obsessive behavior and control issues.

“We see a lot of perfectionism,” Dr. Ritvo said.

In the future, Dr. Ritvo said she hopes to focus more on prevention and to be able to offer physicians an opportunity to assess their behavior before they are reported for inappropriate behavior.

The Physicians Development Program isn't just for disruptive physicians, Dr. Harmon said. It can also be used by groups of physicians who want to provide confidential feedback about how they are impacting their staff and colleagues.

“It gives physicians a chance to see themselves as others see them, and maybe for the first time,” Dr. Harmon noted.

Prevention is key, Dr. Pomm said. Hospitals should conduct ongoing assessments of personnel and work environments and offer help to employees, he recommended.

State medical boards are also in a position to help physicians get help before a disciplinary action is necessary, said James N. Thompson, M.D., who is the president and CEO of the Federation of State Medical Boards.

Developing a nonpunitive way to identify those physicians who are heading toward trouble would serve the public, reduce disciplinary actions against doctors, and help keep physicians in practice longer, according to Dr. Thompson.

Avoid Becoming a Disruptive Physician

So how do you avoid becoming a disruptive physician? Dr. Ritvo and Dr. Harmon have put together some tips on how to ensure that your behavior is appropriate:

▸ Periodically ask staff, supervisors, and colleagues how you are doing with “teamwork.”

▸ Let your staff know when they are doing a good job.

▸ Praise in public; reprimand in private.

▸ Reprimand the mistake, not the person.

▸ Foster positive and open communication with staff.

▸ Beware of sarcasm, tone of voice, and body language.

▸ Set clear and realistic goals for yourself and your staff and make sure the goals are communicated effectively.

▸ Develop stress reducing techniques.

▸ Humor can be an effective way to cope, but remember what is funny to one person may be offensive to another.

▸ Avoid all sexual comments at the office.

▸ Avoid excessive work hours.

▸ Add balance to your life.

▸ Seek help when needed.

More than 4 years ago, Raymond M. Pomm, M.D., started to see a pattern of disruptive behavior occurring in physicians across Florida, where he is the medical director for the state's Impaired Professionals Program.

Hospitals were reporting a range of inappropriate and disruptive behaviors, from yelling to berating nurses in front of other staffers to physical violence. But the behavior did not fit any patterns typically associated with psychiatric disorders such as bipolar disorder or substance abuse, he said, so he searched the country for a person or a program that could help to change the behavior.

“It became a real dilemma,” Dr. Pomm said.

Then in 2002, Eva Ritvo, M.D., a psychiatrist, and Larry Harmon, Ph.D., a psychologist, stepped forward with a unique approach. The two health care professionals started the Physicians Development Program, which provides a complete psychiatric, psychological, and workplace evaluation of potentially disruptive physicians. The program also offers referrals to local treatment, and monitors behavior to chart physician improvement.

“We really try to tailor the program to the individual doctor,” said Dr. Ritvo of the department of psychiatry and behavioral sciences at the University of Miami and chair of the department of psychiatry at Mount Sinai Medical Center in Miami Beach.

They also use the Physicians' Universal Leadership Skills Survey Enhancement (PULSE) tool to evaluate and monitor physician behavior. The survey was developed by asking a variety of health care professionals what their colleagues do at work that motivates them to perform at their best, and what disrupts or discourages them.

When a physician agrees to go through the program, Dr. Harmon sends the survey to nurses, physician colleagues, and hospital leadership to find out how the individual physician behaves.

This feedback process gives the physician some insight into how he or she is viewed by colleagues. This is a “magic moment” in the program, according to Dr. Harmon, who is the chair of the ethics advisory board of the Florida Psychological Association.

The physicians, along with hospital administrators, choose the people who will complete the survey. “This is not mental health treatment, this is physician development,” Dr. Harmon said.

Seeing this report usually turns around the behavior, Dr. Harmon said.

Once the behavior is pointed out in a structured, objective way by a neutral third party, the findings are seen as credible and they have an impact on the doctor.

The feedback report allows Dr. Harmon to constructively confront the doctor's lack of insight, he said. Physicians do not notice their disruptive impact on others until they see the collective voice of their team members reflected in the report.

It's also the best way to find out if a physician isn't being disruptive, but may be a political target at the hospital.

After the survey is shown to the physician, Dr. Harmon conducts a follow-up survey to chart the physician's progress.

So far, all of the physicians who have been through the program have improved their behavior, he said.

About 42 physicians have completed the program since its inception in 2002. The program participants come from around the country and from various specialties, Dr. Ritvo said.

“Typically, our physicians are not what you'd expect,” she said in an interview with this newspaper.

These physicians usually don't see their behavior as inappropriate and will say that they are just trying to get the best care for their patients. And they are usually excellent doctors but they are operating under a lot of stress and generally have some type of personality disorder involving obsessive behavior and control issues.

“We see a lot of perfectionism,” Dr. Ritvo said.

In the future, Dr. Ritvo said she hopes to focus more on prevention and to be able to offer physicians an opportunity to assess their behavior before they are reported for inappropriate behavior.

The Physicians Development Program isn't just for disruptive physicians, Dr. Harmon said. It can also be used by groups of physicians who want to provide confidential feedback about how they are impacting their staff and colleagues.

“It gives physicians a chance to see themselves as others see them, and maybe for the first time,” Dr. Harmon noted.

Prevention is key, Dr. Pomm said. Hospitals should conduct ongoing assessments of personnel and work environments and offer help to employees, he recommended.

State medical boards are also in a position to help physicians get help before a disciplinary action is necessary, said James N. Thompson, M.D., who is the president and CEO of the Federation of State Medical Boards.

Developing a nonpunitive way to identify those physicians who are heading toward trouble would serve the public, reduce disciplinary actions against doctors, and help keep physicians in practice longer, according to Dr. Thompson.

Avoid Becoming a Disruptive Physician

So how do you avoid becoming a disruptive physician? Dr. Ritvo and Dr. Harmon have put together some tips on how to ensure that your behavior is appropriate:

▸ Periodically ask staff, supervisors, and colleagues how you are doing with “teamwork.”

▸ Let your staff know when they are doing a good job.

▸ Praise in public; reprimand in private.

▸ Reprimand the mistake, not the person.

▸ Foster positive and open communication with staff.

▸ Beware of sarcasm, tone of voice, and body language.

▸ Set clear and realistic goals for yourself and your staff and make sure the goals are communicated effectively.

▸ Develop stress reducing techniques.

▸ Humor can be an effective way to cope, but remember what is funny to one person may be offensive to another.

▸ Avoid all sexual comments at the office.

▸ Avoid excessive work hours.

▸ Add balance to your life.

▸ Seek help when needed.

More than 4 years ago, Raymond M. Pomm, M.D., started to see a pattern of disruptive behavior occurring in physicians across Florida, where he is the medical director for the state's Impaired Professionals Program.

Hospitals were reporting a range of inappropriate and disruptive behaviors, from yelling to berating nurses in front of other staffers to physical violence. But the behavior did not fit any patterns typically associated with psychiatric disorders such as bipolar disorder or substance abuse, he said, so he searched the country for a person or a program that could help to change the behavior.

“It became a real dilemma,” Dr. Pomm said.

Then in 2002, Eva Ritvo, M.D., a psychiatrist, and Larry Harmon, Ph.D., a psychologist, stepped forward with a unique approach. The two health care professionals started the Physicians Development Program, which provides a complete psychiatric, psychological, and workplace evaluation of potentially disruptive physicians. The program also offers referrals to local treatment, and monitors behavior to chart physician improvement.

“We really try to tailor the program to the individual doctor,” said Dr. Ritvo of the department of psychiatry and behavioral sciences at the University of Miami and chair of the department of psychiatry at Mount Sinai Medical Center in Miami Beach.

They also use the Physicians' Universal Leadership Skills Survey Enhancement (PULSE) tool to evaluate and monitor physician behavior. The survey was developed by asking a variety of health care professionals what their colleagues do at work that motivates them to perform at their best, and what disrupts or discourages them.

When a physician agrees to go through the program, Dr. Harmon sends the survey to nurses, physician colleagues, and hospital leadership to find out how the individual physician behaves.

This feedback process gives the physician some insight into how he or she is viewed by colleagues. This is a “magic moment” in the program, according to Dr. Harmon, who is the chair of the ethics advisory board of the Florida Psychological Association.

The physicians, along with hospital administrators, choose the people who will complete the survey. “This is not mental health treatment, this is physician development,” Dr. Harmon said.

Seeing this report usually turns around the behavior, Dr. Harmon said.

Once the behavior is pointed out in a structured, objective way by a neutral third party, the findings are seen as credible and they have an impact on the doctor.

The feedback report allows Dr. Harmon to constructively confront the doctor's lack of insight, he said. Physicians do not notice their disruptive impact on others until they see the collective voice of their team members reflected in the report.

It's also the best way to find out if a physician isn't being disruptive, but may be a political target at the hospital.

After the survey is shown to the physician, Dr. Harmon conducts a follow-up survey to chart the physician's progress.

So far, all of the physicians who have been through the program have improved their behavior, he said.

About 42 physicians have completed the program since its inception in 2002. The program participants come from around the country and from various specialties, Dr. Ritvo said.

“Typically, our physicians are not what you'd expect,” she said in an interview with this newspaper.

These physicians usually don't see their behavior as inappropriate and will say that they are just trying to get the best care for their patients. And they are usually excellent doctors but they are operating under a lot of stress and generally have some type of personality disorder involving obsessive behavior and control issues.

“We see a lot of perfectionism,” Dr. Ritvo said.

In the future, Dr. Ritvo said she hopes to focus more on prevention and to be able to offer physicians an opportunity to assess their behavior before they are reported for inappropriate behavior.

The Physicians Development Program isn't just for disruptive physicians, Dr. Harmon said. It can also be used by groups of physicians who want to provide confidential feedback about how they are impacting their staff and colleagues.

“It gives physicians a chance to see themselves as others see them, and maybe for the first time,” Dr. Harmon noted.

Prevention is key, Dr. Pomm said. Hospitals should conduct ongoing assessments of personnel and work environments and offer help to employees, he recommended.

State medical boards are also in a position to help physicians get help before a disciplinary action is necessary, said James N. Thompson, M.D., who is the president and CEO of the Federation of State Medical Boards.

Developing a nonpunitive way to identify those physicians who are heading toward trouble would serve the public, reduce disciplinary actions against doctors, and help keep physicians in practice longer, according to Dr. Thompson.

Avoid Becoming a Disruptive Physician

So how do you avoid becoming a disruptive physician? Dr. Ritvo and Dr. Harmon have put together some tips on how to ensure that your behavior is appropriate:

▸ Periodically ask staff, supervisors, and colleagues how you are doing with “teamwork.”

▸ Let your staff know when they are doing a good job.

▸ Praise in public; reprimand in private.

▸ Reprimand the mistake, not the person.

▸ Foster positive and open communication with staff.

▸ Beware of sarcasm, tone of voice, and body language.

▸ Set clear and realistic goals for yourself and your staff and make sure the goals are communicated effectively.

▸ Develop stress reducing techniques.

▸ Humor can be an effective way to cope, but remember what is funny to one person may be offensive to another.

▸ Avoid all sexual comments at the office.

▸ Avoid excessive work hours.

▸ Add balance to your life.

▸ Seek help when needed.

A new organization is moving forward with plans to provide accreditation and certification services for neurology subspecialties.

The United Council for Neurologic Subspecialties (UCNS) is currently working on accreditation and certification standards in the area of behavioral neurology and neuropsychiatry. Accreditation standards for behavioral neurology and neuropsychiatry are expected to be available early this year and certification standards are expected to be available in 2006, CLINICAL NEUROLOGY NEWS has learned in interviews with neurologists involved in the process.

In addition, the group is reviewing applications from five other neurology subspecialties that are seeking to pursue accreditation and certification through UCNS. Officials at UCNS are keeping the names of the subspecialties that have applied for membership confidential until the process is complete.

A number of neurology groups launched UCNS in 2003 to provide accreditation and certification of neurology subspecialties that are at an early stage in their development process. UCNS was established by the American Academy of Neurology, the American Neurological Association, the Association of University Professors of Neurology, the Child Neurology Society, and the Professors of Child Neurology.

The new body provides an alternative pathway for subspecialties that are established enough for accreditation and certification but are not large enough to go through the traditional routes—accreditation through the Accreditation Council for Graduate Medical Education (ACGME) and certification through the American Board of Medical Specialties (ABMS).

For example, the vascular neurology subspecialty recently succeeded in getting a certification exam for its subspecialists through ABMS; however, the subspecialty of behavioral neurology and neuropsychiatry is much smaller and requires more developmental support to navigate the process.

The ACGME and ABMS criteria have been used as models for the UCNS requirements.

“We felt we needed to offer this,” said Stephen Sergay, M.D., chair of UCNS and a clinical neurologist in Tampa, Fla.

For over 10 years, subspecialties have been a major part of neurology, but there hasn't been recognition of the extra time and training that neurologists have invested in their subspecialty area, Dr. Sergay said.

Accreditation and certification for these subspecialties will help to ensure high-quality patient care, he said.

The activities of UCNS will increase the cohesiveness of the approach to training for various subspecialties, Dr. Sergay said. Currently, there may be five training programs in a given subspecialty, and they will all be slightly different. Now, the sponsoring organizations for a new subspecialty will have to come to a consensus on a core curriculum and training requirements before they apply for membership in UCNS.

That made the subspecialty of behavioral neurology and neuropsychiatry a good fit for UCNS since so much work had already been done on establishing a core curriculum in the field, said David L. Bachman, M.D., president of the Society for Behavioral and Cognitive Neurology, one of the groups that sponsored the subspecialty for membership with UCNS. Dr. Bachman chairs the behavioral neurology section for the American Academy of Neurology and is director of the division of adult neurology at the Medical University of South Carolina in Charleston.

UCNS recently finished a draft of the application form that will be used to accredit training programs in behavioral neurology and neuropsychiatry. The application form was developed according to the training requirements provided by the subspecialty. Currently, nine training programs have agreed to pilot the form. These programs will review the form and provide comments to UCNS.

“We want the programs to feel comfortable that these are reasonable criteria that people can live with,” said Dr. Bachman, who now sits on the UCNS board of directors as a representative of his specialty.

It's likely that the training programs will be able to begin applying early this year and UCNS plans to begin accrediting programs in the fall, said Mari Mellick, UCNS manager, in St. Paul.

Certification for physicians will run on a parallel track to accreditation, Dr. Bachman said.

There are a number of people who have already been trained in behavioral neurology and neuropsychiatry. As a result, leaders from the subspecialty and officials at UCNS are also working to develop grandfathering criteria for those physicians who have already been training in this field.

UCNS has also formed an examination committee for behavioral neurology and neuropsychiatry with experts from the subspecialty who will develop the certification exam.

The committee's first meeting is scheduled for early this year with the goal of offering the certification exam in 2006, Ms. Mellick said.

A new organization is moving forward with plans to provide accreditation and certification services for neurology subspecialties.

The United Council for Neurologic Subspecialties (UCNS) is currently working on accreditation and certification standards in the area of behavioral neurology and neuropsychiatry. Accreditation standards for behavioral neurology and neuropsychiatry are expected to be available early this year and certification standards are expected to be available in 2006, CLINICAL NEUROLOGY NEWS has learned in interviews with neurologists involved in the process.

In addition, the group is reviewing applications from five other neurology subspecialties that are seeking to pursue accreditation and certification through UCNS. Officials at UCNS are keeping the names of the subspecialties that have applied for membership confidential until the process is complete.

A number of neurology groups launched UCNS in 2003 to provide accreditation and certification of neurology subspecialties that are at an early stage in their development process. UCNS was established by the American Academy of Neurology, the American Neurological Association, the Association of University Professors of Neurology, the Child Neurology Society, and the Professors of Child Neurology.

The new body provides an alternative pathway for subspecialties that are established enough for accreditation and certification but are not large enough to go through the traditional routes—accreditation through the Accreditation Council for Graduate Medical Education (ACGME) and certification through the American Board of Medical Specialties (ABMS).

For example, the vascular neurology subspecialty recently succeeded in getting a certification exam for its subspecialists through ABMS; however, the subspecialty of behavioral neurology and neuropsychiatry is much smaller and requires more developmental support to navigate the process.

The ACGME and ABMS criteria have been used as models for the UCNS requirements.

“We felt we needed to offer this,” said Stephen Sergay, M.D., chair of UCNS and a clinical neurologist in Tampa, Fla.

For over 10 years, subspecialties have been a major part of neurology, but there hasn't been recognition of the extra time and training that neurologists have invested in their subspecialty area, Dr. Sergay said.

Accreditation and certification for these subspecialties will help to ensure high-quality patient care, he said.

The activities of UCNS will increase the cohesiveness of the approach to training for various subspecialties, Dr. Sergay said. Currently, there may be five training programs in a given subspecialty, and they will all be slightly different. Now, the sponsoring organizations for a new subspecialty will have to come to a consensus on a core curriculum and training requirements before they apply for membership in UCNS.

That made the subspecialty of behavioral neurology and neuropsychiatry a good fit for UCNS since so much work had already been done on establishing a core curriculum in the field, said David L. Bachman, M.D., president of the Society for Behavioral and Cognitive Neurology, one of the groups that sponsored the subspecialty for membership with UCNS. Dr. Bachman chairs the behavioral neurology section for the American Academy of Neurology and is director of the division of adult neurology at the Medical University of South Carolina in Charleston.

UCNS recently finished a draft of the application form that will be used to accredit training programs in behavioral neurology and neuropsychiatry. The application form was developed according to the training requirements provided by the subspecialty. Currently, nine training programs have agreed to pilot the form. These programs will review the form and provide comments to UCNS.

“We want the programs to feel comfortable that these are reasonable criteria that people can live with,” said Dr. Bachman, who now sits on the UCNS board of directors as a representative of his specialty.

It's likely that the training programs will be able to begin applying early this year and UCNS plans to begin accrediting programs in the fall, said Mari Mellick, UCNS manager, in St. Paul.

Certification for physicians will run on a parallel track to accreditation, Dr. Bachman said.

There are a number of people who have already been trained in behavioral neurology and neuropsychiatry. As a result, leaders from the subspecialty and officials at UCNS are also working to develop grandfathering criteria for those physicians who have already been training in this field.

UCNS has also formed an examination committee for behavioral neurology and neuropsychiatry with experts from the subspecialty who will develop the certification exam.

The committee's first meeting is scheduled for early this year with the goal of offering the certification exam in 2006, Ms. Mellick said.

A new organization is moving forward with plans to provide accreditation and certification services for neurology subspecialties.

The United Council for Neurologic Subspecialties (UCNS) is currently working on accreditation and certification standards in the area of behavioral neurology and neuropsychiatry. Accreditation standards for behavioral neurology and neuropsychiatry are expected to be available early this year and certification standards are expected to be available in 2006, CLINICAL NEUROLOGY NEWS has learned in interviews with neurologists involved in the process.

In addition, the group is reviewing applications from five other neurology subspecialties that are seeking to pursue accreditation and certification through UCNS. Officials at UCNS are keeping the names of the subspecialties that have applied for membership confidential until the process is complete.

A number of neurology groups launched UCNS in 2003 to provide accreditation and certification of neurology subspecialties that are at an early stage in their development process. UCNS was established by the American Academy of Neurology, the American Neurological Association, the Association of University Professors of Neurology, the Child Neurology Society, and the Professors of Child Neurology.

The new body provides an alternative pathway for subspecialties that are established enough for accreditation and certification but are not large enough to go through the traditional routes—accreditation through the Accreditation Council for Graduate Medical Education (ACGME) and certification through the American Board of Medical Specialties (ABMS).

For example, the vascular neurology subspecialty recently succeeded in getting a certification exam for its subspecialists through ABMS; however, the subspecialty of behavioral neurology and neuropsychiatry is much smaller and requires more developmental support to navigate the process.

The ACGME and ABMS criteria have been used as models for the UCNS requirements.

“We felt we needed to offer this,” said Stephen Sergay, M.D., chair of UCNS and a clinical neurologist in Tampa, Fla.

For over 10 years, subspecialties have been a major part of neurology, but there hasn't been recognition of the extra time and training that neurologists have invested in their subspecialty area, Dr. Sergay said.

Accreditation and certification for these subspecialties will help to ensure high-quality patient care, he said.

The activities of UCNS will increase the cohesiveness of the approach to training for various subspecialties, Dr. Sergay said. Currently, there may be five training programs in a given subspecialty, and they will all be slightly different. Now, the sponsoring organizations for a new subspecialty will have to come to a consensus on a core curriculum and training requirements before they apply for membership in UCNS.

That made the subspecialty of behavioral neurology and neuropsychiatry a good fit for UCNS since so much work had already been done on establishing a core curriculum in the field, said David L. Bachman, M.D., president of the Society for Behavioral and Cognitive Neurology, one of the groups that sponsored the subspecialty for membership with UCNS. Dr. Bachman chairs the behavioral neurology section for the American Academy of Neurology and is director of the division of adult neurology at the Medical University of South Carolina in Charleston.

UCNS recently finished a draft of the application form that will be used to accredit training programs in behavioral neurology and neuropsychiatry. The application form was developed according to the training requirements provided by the subspecialty. Currently, nine training programs have agreed to pilot the form. These programs will review the form and provide comments to UCNS.

“We want the programs to feel comfortable that these are reasonable criteria that people can live with,” said Dr. Bachman, who now sits on the UCNS board of directors as a representative of his specialty.

It's likely that the training programs will be able to begin applying early this year and UCNS plans to begin accrediting programs in the fall, said Mari Mellick, UCNS manager, in St. Paul.

Certification for physicians will run on a parallel track to accreditation, Dr. Bachman said.

There are a number of people who have already been trained in behavioral neurology and neuropsychiatry. As a result, leaders from the subspecialty and officials at UCNS are also working to develop grandfathering criteria for those physicians who have already been training in this field.

UCNS has also formed an examination committee for behavioral neurology and neuropsychiatry with experts from the subspecialty who will develop the certification exam.

The committee's first meeting is scheduled for early this year with the goal of offering the certification exam in 2006, Ms. Mellick said.

WASHINGTON — Physicians should continue to control access to outpatient physical therapy for Medicare beneficiaries, according to the Medicare Payment Advisory Commission.

In a report to Congress, MedPAC recommended that Medicare keep in place its current policy of using physicians as gatekeepers to accessing physical therapy.

Under current law, Medicare beneficiaries must be referred by a physician to receive physical therapy services; the physician must review a written plan of care every 30 days.

The Medicare Modernization Act required MedPAC to examine the idea of allowing Medicare beneficiaries to have direct access to these services.

But MedPAC commissioners were reluctant to recommend removing the restrictions because so many Medicare beneficiaries have multiple and chronic health conditions.

“Without these physician requirements, the medical appropriateness of starting or continuing physical therapy services would be more uncertain,” the MedPAC commissioners said in their report.

“Under Medicare, physical therapists are not allowed to order the diagnostic services that may be critical to identifying the patient's underlying medical conditions.”

And current requirements do not appear to impair access for most beneficiaries. In 2003, 85% of beneficiaries reported no problem in getting physical therapy services, commission consultant Carol Carter said at a MedPAC meeting last November.

These restrictions are also the only way that Medicare can curb unnecessary utilization, she added.

But MedPAC recommended that additional steps should be taken to make the current restrictions more effective.

For example, MedPAC advised that there should be increased provider education about Medicare coverage rules both for physicians making the referrals and for physical therapists.

The Office of Inspector General has repeatedly recommended that Medicare claims contractors, the facilities where physical therapists practice, and the professional associations step up their efforts in increasing provider knowledge about Medicare's coverage rules, Ms. Carter said.

In addition, the MedPAC report pointed out that that better, more reliable data are needed in order to understand more about the efficacy of physical therapy for older patients.

This evidence could then be used to establish practice guidelines to educate physical therapists and physicians about what physical therapy service provisions are likely to be effective for Medicare beneficiaries.

WASHINGTON — Physicians should continue to control access to outpatient physical therapy for Medicare beneficiaries, according to the Medicare Payment Advisory Commission.

In a report to Congress, MedPAC recommended that Medicare keep in place its current policy of using physicians as gatekeepers to accessing physical therapy.

Under current law, Medicare beneficiaries must be referred by a physician to receive physical therapy services; the physician must review a written plan of care every 30 days.

The Medicare Modernization Act required MedPAC to examine the idea of allowing Medicare beneficiaries to have direct access to these services.

But MedPAC commissioners were reluctant to recommend removing the restrictions because so many Medicare beneficiaries have multiple and chronic health conditions.

“Without these physician requirements, the medical appropriateness of starting or continuing physical therapy services would be more uncertain,” the MedPAC commissioners said in their report.

“Under Medicare, physical therapists are not allowed to order the diagnostic services that may be critical to identifying the patient's underlying medical conditions.”

And current requirements do not appear to impair access for most beneficiaries. In 2003, 85% of beneficiaries reported no problem in getting physical therapy services, commission consultant Carol Carter said at a MedPAC meeting last November.

These restrictions are also the only way that Medicare can curb unnecessary utilization, she added.

But MedPAC recommended that additional steps should be taken to make the current restrictions more effective.

For example, MedPAC advised that there should be increased provider education about Medicare coverage rules both for physicians making the referrals and for physical therapists.

The Office of Inspector General has repeatedly recommended that Medicare claims contractors, the facilities where physical therapists practice, and the professional associations step up their efforts in increasing provider knowledge about Medicare's coverage rules, Ms. Carter said.

In addition, the MedPAC report pointed out that that better, more reliable data are needed in order to understand more about the efficacy of physical therapy for older patients.

This evidence could then be used to establish practice guidelines to educate physical therapists and physicians about what physical therapy service provisions are likely to be effective for Medicare beneficiaries.

WASHINGTON — Physicians should continue to control access to outpatient physical therapy for Medicare beneficiaries, according to the Medicare Payment Advisory Commission.

In a report to Congress, MedPAC recommended that Medicare keep in place its current policy of using physicians as gatekeepers to accessing physical therapy.

Under current law, Medicare beneficiaries must be referred by a physician to receive physical therapy services; the physician must review a written plan of care every 30 days.

The Medicare Modernization Act required MedPAC to examine the idea of allowing Medicare beneficiaries to have direct access to these services.

But MedPAC commissioners were reluctant to recommend removing the restrictions because so many Medicare beneficiaries have multiple and chronic health conditions.

“Without these physician requirements, the medical appropriateness of starting or continuing physical therapy services would be more uncertain,” the MedPAC commissioners said in their report.

“Under Medicare, physical therapists are not allowed to order the diagnostic services that may be critical to identifying the patient's underlying medical conditions.”

And current requirements do not appear to impair access for most beneficiaries. In 2003, 85% of beneficiaries reported no problem in getting physical therapy services, commission consultant Carol Carter said at a MedPAC meeting last November.

These restrictions are also the only way that Medicare can curb unnecessary utilization, she added.

But MedPAC recommended that additional steps should be taken to make the current restrictions more effective.

For example, MedPAC advised that there should be increased provider education about Medicare coverage rules both for physicians making the referrals and for physical therapists.

The Office of Inspector General has repeatedly recommended that Medicare claims contractors, the facilities where physical therapists practice, and the professional associations step up their efforts in increasing provider knowledge about Medicare's coverage rules, Ms. Carter said.

In addition, the MedPAC report pointed out that that better, more reliable data are needed in order to understand more about the efficacy of physical therapy for older patients.

This evidence could then be used to establish practice guidelines to educate physical therapists and physicians about what physical therapy service provisions are likely to be effective for Medicare beneficiaries.

WASHINGTON — Medicare currently is not equipped to handle care for chronic illnesses, so officials at the Centers for Medicare and Medicaid Services are testing out some new approaches.

“What we're really after is to change Medicare's role from a passive payer of services … to a more aggressive purchaser of better health care for our beneficiaries,” said Stuart Guterman, director of the Office of Research, Development, and Information at CMS.

In fee-for-service Medicare, there is no incentive to coordinate care. The emphasis is on the provision of services by individual physicians, and care is centered on single encounters, Mr. Guterman said at a meeting on Medicare and Medicaid sponsored by America's Health Insurance Plans.

Instead, CMS officials are planning a number of demonstration projects to look at the impact of capitated payment systems for patients with high-cost illnesses, “gainsharing” arrangements with physicians, and financial incentives for the adoption of health information technology.

Currently, Medicare is running the Coordinated Care Demonstration project with fee-for-service beneficiaries in 15 sites around the country.

The project tests whether paying for coordinated care for beneficiaries with chronic illnesses can produce better outcomes without increasing costs. The project focuses on heart failure; heart, liver, and lung diseases; Alzheimer's and other dementias; cancer; and HIV/AIDS.

The initial results from the demonstration project show that beneficiary recruitment can be a challenge but that most of the successful plans have been those with close ties to physicians, Mr. Guterman said.

The agency has several more demonstration projects planned. CMS recently received approval to move forward with the Physicians Group Practice demonstration, which will offer bonus payments to large, multispecialty physician groups that achieve savings through improvements in the management of patient care and services.

In addition to the bonus payments, physicians will be paid on a fee-for-service basis.

The agency is seeking approval for its End-Stage Renal Disease Management demonstration, which will provide fully risk-adjusted capitated payment for treatment of ESRD beneficiaries.

“[This is] a portion of the population that is very much in need of better coordination of care,” Mr. Guterman said.

Currently ESRD beneficiaries have broad coverage for services besides dialysis, but that care is generally not coordinated across all of their conditions, he said.

This demonstration is aimed at providing an incentive for physicians to coordinate care across the entire spectrum of care.

CMS is also developing the Medicare Care Management Performance demonstration, a project that was mandated under the Medicare Modernization Act.

It would provide financial incentives to encourage physicians to adopt health information technology and to use the technology to better manage chronic care patients.

“We believe information technology is an important tool, and it's a tool to accomplish better quality of care for our beneficiaries,” Mr. Guterman said.

“Just buying doctors computers isn't what we're after. We want them to be able to use better information systems to be able to run their practices better,” he added.

Also in the pipeline is a demonstration aimed at managing care for high-cost beneficiaries with serious illnesses. The project, which is scheduled to run for 3 years, will emphasize provider-oriented models, Mr. Guterman said.

“One of the things we've heard in our disease management initiatives is that they're third-party oriented, that is, physicians have been commenting that we're paying a third-party management organization to do what physicians should be getting paid to do,” he said.

WASHINGTON — Medicare currently is not equipped to handle care for chronic illnesses, so officials at the Centers for Medicare and Medicaid Services are testing out some new approaches.

“What we're really after is to change Medicare's role from a passive payer of services … to a more aggressive purchaser of better health care for our beneficiaries,” said Stuart Guterman, director of the Office of Research, Development, and Information at CMS.

In fee-for-service Medicare, there is no incentive to coordinate care. The emphasis is on the provision of services by individual physicians, and care is centered on single encounters, Mr. Guterman said at a meeting on Medicare and Medicaid sponsored by America's Health Insurance Plans.

Instead, CMS officials are planning a number of demonstration projects to look at the impact of capitated payment systems for patients with high-cost illnesses, “gainsharing” arrangements with physicians, and financial incentives for the adoption of health information technology.

Currently, Medicare is running the Coordinated Care Demonstration project with fee-for-service beneficiaries in 15 sites around the country.

The project tests whether paying for coordinated care for beneficiaries with chronic illnesses can produce better outcomes without increasing costs. The project focuses on heart failure; heart, liver, and lung diseases; Alzheimer's and other dementias; cancer; and HIV/AIDS.

The initial results from the demonstration project show that beneficiary recruitment can be a challenge but that most of the successful plans have been those with close ties to physicians, Mr. Guterman said.

The agency has several more demonstration projects planned. CMS recently received approval to move forward with the Physicians Group Practice demonstration, which will offer bonus payments to large, multispecialty physician groups that achieve savings through improvements in the management of patient care and services.

In addition to the bonus payments, physicians will be paid on a fee-for-service basis.

The agency is seeking approval for its End-Stage Renal Disease Management demonstration, which will provide fully risk-adjusted capitated payment for treatment of ESRD beneficiaries.

“[This is] a portion of the population that is very much in need of better coordination of care,” Mr. Guterman said.

Currently ESRD beneficiaries have broad coverage for services besides dialysis, but that care is generally not coordinated across all of their conditions, he said.

This demonstration is aimed at providing an incentive for physicians to coordinate care across the entire spectrum of care.

CMS is also developing the Medicare Care Management Performance demonstration, a project that was mandated under the Medicare Modernization Act.

It would provide financial incentives to encourage physicians to adopt health information technology and to use the technology to better manage chronic care patients.

“We believe information technology is an important tool, and it's a tool to accomplish better quality of care for our beneficiaries,” Mr. Guterman said.

“Just buying doctors computers isn't what we're after. We want them to be able to use better information systems to be able to run their practices better,” he added.

Also in the pipeline is a demonstration aimed at managing care for high-cost beneficiaries with serious illnesses. The project, which is scheduled to run for 3 years, will emphasize provider-oriented models, Mr. Guterman said.

“One of the things we've heard in our disease management initiatives is that they're third-party oriented, that is, physicians have been commenting that we're paying a third-party management organization to do what physicians should be getting paid to do,” he said.

WASHINGTON — Medicare currently is not equipped to handle care for chronic illnesses, so officials at the Centers for Medicare and Medicaid Services are testing out some new approaches.

“What we're really after is to change Medicare's role from a passive payer of services … to a more aggressive purchaser of better health care for our beneficiaries,” said Stuart Guterman, director of the Office of Research, Development, and Information at CMS.

In fee-for-service Medicare, there is no incentive to coordinate care. The emphasis is on the provision of services by individual physicians, and care is centered on single encounters, Mr. Guterman said at a meeting on Medicare and Medicaid sponsored by America's Health Insurance Plans.

Instead, CMS officials are planning a number of demonstration projects to look at the impact of capitated payment systems for patients with high-cost illnesses, “gainsharing” arrangements with physicians, and financial incentives for the adoption of health information technology.

Currently, Medicare is running the Coordinated Care Demonstration project with fee-for-service beneficiaries in 15 sites around the country.

The project tests whether paying for coordinated care for beneficiaries with chronic illnesses can produce better outcomes without increasing costs. The project focuses on heart failure; heart, liver, and lung diseases; Alzheimer's and other dementias; cancer; and HIV/AIDS.

The initial results from the demonstration project show that beneficiary recruitment can be a challenge but that most of the successful plans have been those with close ties to physicians, Mr. Guterman said.

The agency has several more demonstration projects planned. CMS recently received approval to move forward with the Physicians Group Practice demonstration, which will offer bonus payments to large, multispecialty physician groups that achieve savings through improvements in the management of patient care and services.

In addition to the bonus payments, physicians will be paid on a fee-for-service basis.

The agency is seeking approval for its End-Stage Renal Disease Management demonstration, which will provide fully risk-adjusted capitated payment for treatment of ESRD beneficiaries.

“[This is] a portion of the population that is very much in need of better coordination of care,” Mr. Guterman said.

Currently ESRD beneficiaries have broad coverage for services besides dialysis, but that care is generally not coordinated across all of their conditions, he said.

This demonstration is aimed at providing an incentive for physicians to coordinate care across the entire spectrum of care.

CMS is also developing the Medicare Care Management Performance demonstration, a project that was mandated under the Medicare Modernization Act.

It would provide financial incentives to encourage physicians to adopt health information technology and to use the technology to better manage chronic care patients.

“We believe information technology is an important tool, and it's a tool to accomplish better quality of care for our beneficiaries,” Mr. Guterman said.

“Just buying doctors computers isn't what we're after. We want them to be able to use better information systems to be able to run their practices better,” he added.

Also in the pipeline is a demonstration aimed at managing care for high-cost beneficiaries with serious illnesses. The project, which is scheduled to run for 3 years, will emphasize provider-oriented models, Mr. Guterman said.

“One of the things we've heard in our disease management initiatives is that they're third-party oriented, that is, physicians have been commenting that we're paying a third-party management organization to do what physicians should be getting paid to do,” he said.

Fed to Evaluate Arthritis Treatments

The Agency for Healthcare Research and Quality plans to spend $15 million this year to evaluate interventions and prescription drugs used by Medicare beneficiaries. AHRQ will consider interventions aimed at treating patients with ischemic heart disease, cancer, chronic obstructive pulmonary disease and asthma, stroke, hypertension, arthritis and nontraumatic joint disorders, diabetes, dementia, peptic ulcer, and depression and mood disorders. “The additional medical evidence provided by this initiative will help doctors and patients make more informed decisions,” said Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services. AHRQ research will focus on the evidence of outcomes and comparative clinical effectiveness and appropriateness. The results of these studies will be made available to the Medicare, Medicaid, and state children's health insurance programs (SCHIPs), as well as to private health plans, prescription drug plans, health care providers, and the public.

New Leadership

Former Rep. James Greenwood (R.-Pa.) is now the new president of the Biotechnology Industry Organization (BIO) and is predicting continued growth in biotech drug products in 2005. Last year, the Food and Drug Administration approved 32 new therapeutic products that were either discovered, developed, or marketed by biotechnology and related companies, according to a BIO analysis. “More than 800 million patients have benefited from biotech medicines and vaccines already, and millions more will benefit in the future,” Mr. Greenwood said in a statement. “Literally hundreds of products are in the development queue.”

Spending for Power Wheelchairs

Federal safeguards did not go far enough to curb out-of-control spending growth for power wheelchairs under the Medicare program, the Government Accountability Office found. Medicare spending for the wheelchairs rose more than fourfold from 1999 through 2003, raising concerns that some of the payments may have been improper. Following the indictment of several power wheelchair suppliers in Texas who fraudulently billed Medicare, GAO was asked to examine earlier steps taken by the Centers for Medicare and Medicaid Services to respond to improper payments. CMS' contractors started informing the agency in 1997 about escalating spending for wheelchairs, and some started taking steps to respond to improper payments—yet the agency didn't assume an active role until 2003. Since then, CMS has worked to prevent fraudulent suppliers from entering the Medicare program, although it has not implemented a revised form to collect better information for power wheelchair claims reviews, according to teh GAO report.

Portable Health Plans

Patients can take their health insurance coverage with them when they change or lose a job, under the final regulations that implement the last piece of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to a statement by the Health and Human Services Department, it is important that American workers, who often change jobs several times in the course of their lives, be able to respond to the modern workplace without having to fear for their health insurance. The regulations allow greater portability and availability of group health coverage during a time of job transition, setting limits on preexisting condition exclusions that could be imposed, and requiring group health plans and insurance issuers to offer “special enrollment” to certain patients who lose eligibility for other group health coverage or health insurance, or to otherwise eligible new dependents. The regulation goes into effect for plan years starting on or after July 1.

Computer Entries Lead to Errors

Automation isn't necessarily a foolproof way to improve patient safety and reduce medical errors, a report from the United States Pharmacopeia (USP) found. Computer entry errors were the fourth leading cause of medication errors according to MEDMARX, USP's national medication error reporting system. These errors have steadily increased and represent about 12% of all MEDMARX records from 1999 through 2003. Performance deficits—where an otherwise qualified physician makes a mistake—were the most frequently reported cause of errors. Distractions were the leading contributing factor, accounting for almost 57% of errors associated with computer entry. The report provided an analysis of 235,159 medication errors voluntarily reported by 570 hospitals and health care facilities nationwide.

Reduced Benefits for Retirees

Businesses are asking retirees to pay more for their health coverage as they struggle to control rising costs, the Kaiser Family Foundation reported. In the last year, 79% of firms increased their retirees' contributions for premiums, and 85% expect to do so in the coming year. In addition, 8% of employers surveyed eliminated subsidized health benefits for future retirees in 2004. For 2005, 11% said they are likely to terminate coverage for future retirees. However, 58% of responding firms said they were likely to continue offering prescription drug benefits and accept the tax-free subsidy created by the new Medicare law. The survey included responses from 333 large private-sector firms that offer retiree health benefits.

Fed to Evaluate Arthritis Treatments

The Agency for Healthcare Research and Quality plans to spend $15 million this year to evaluate interventions and prescription drugs used by Medicare beneficiaries. AHRQ will consider interventions aimed at treating patients with ischemic heart disease, cancer, chronic obstructive pulmonary disease and asthma, stroke, hypertension, arthritis and nontraumatic joint disorders, diabetes, dementia, peptic ulcer, and depression and mood disorders. “The additional medical evidence provided by this initiative will help doctors and patients make more informed decisions,” said Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services. AHRQ research will focus on the evidence of outcomes and comparative clinical effectiveness and appropriateness. The results of these studies will be made available to the Medicare, Medicaid, and state children's health insurance programs (SCHIPs), as well as to private health plans, prescription drug plans, health care providers, and the public.

New Leadership

Former Rep. James Greenwood (R.-Pa.) is now the new president of the Biotechnology Industry Organization (BIO) and is predicting continued growth in biotech drug products in 2005. Last year, the Food and Drug Administration approved 32 new therapeutic products that were either discovered, developed, or marketed by biotechnology and related companies, according to a BIO analysis. “More than 800 million patients have benefited from biotech medicines and vaccines already, and millions more will benefit in the future,” Mr. Greenwood said in a statement. “Literally hundreds of products are in the development queue.”

Spending for Power Wheelchairs

Federal safeguards did not go far enough to curb out-of-control spending growth for power wheelchairs under the Medicare program, the Government Accountability Office found. Medicare spending for the wheelchairs rose more than fourfold from 1999 through 2003, raising concerns that some of the payments may have been improper. Following the indictment of several power wheelchair suppliers in Texas who fraudulently billed Medicare, GAO was asked to examine earlier steps taken by the Centers for Medicare and Medicaid Services to respond to improper payments. CMS' contractors started informing the agency in 1997 about escalating spending for wheelchairs, and some started taking steps to respond to improper payments—yet the agency didn't assume an active role until 2003. Since then, CMS has worked to prevent fraudulent suppliers from entering the Medicare program, although it has not implemented a revised form to collect better information for power wheelchair claims reviews, according to teh GAO report.

Portable Health Plans

Patients can take their health insurance coverage with them when they change or lose a job, under the final regulations that implement the last piece of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to a statement by the Health and Human Services Department, it is important that American workers, who often change jobs several times in the course of their lives, be able to respond to the modern workplace without having to fear for their health insurance. The regulations allow greater portability and availability of group health coverage during a time of job transition, setting limits on preexisting condition exclusions that could be imposed, and requiring group health plans and insurance issuers to offer “special enrollment” to certain patients who lose eligibility for other group health coverage or health insurance, or to otherwise eligible new dependents. The regulation goes into effect for plan years starting on or after July 1.

Computer Entries Lead to Errors

Automation isn't necessarily a foolproof way to improve patient safety and reduce medical errors, a report from the United States Pharmacopeia (USP) found. Computer entry errors were the fourth leading cause of medication errors according to MEDMARX, USP's national medication error reporting system. These errors have steadily increased and represent about 12% of all MEDMARX records from 1999 through 2003. Performance deficits—where an otherwise qualified physician makes a mistake—were the most frequently reported cause of errors. Distractions were the leading contributing factor, accounting for almost 57% of errors associated with computer entry. The report provided an analysis of 235,159 medication errors voluntarily reported by 570 hospitals and health care facilities nationwide.

Reduced Benefits for Retirees

Businesses are asking retirees to pay more for their health coverage as they struggle to control rising costs, the Kaiser Family Foundation reported. In the last year, 79% of firms increased their retirees' contributions for premiums, and 85% expect to do so in the coming year. In addition, 8% of employers surveyed eliminated subsidized health benefits for future retirees in 2004. For 2005, 11% said they are likely to terminate coverage for future retirees. However, 58% of responding firms said they were likely to continue offering prescription drug benefits and accept the tax-free subsidy created by the new Medicare law. The survey included responses from 333 large private-sector firms that offer retiree health benefits.

Fed to Evaluate Arthritis Treatments

The Agency for Healthcare Research and Quality plans to spend $15 million this year to evaluate interventions and prescription drugs used by Medicare beneficiaries. AHRQ will consider interventions aimed at treating patients with ischemic heart disease, cancer, chronic obstructive pulmonary disease and asthma, stroke, hypertension, arthritis and nontraumatic joint disorders, diabetes, dementia, peptic ulcer, and depression and mood disorders. “The additional medical evidence provided by this initiative will help doctors and patients make more informed decisions,” said Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services. AHRQ research will focus on the evidence of outcomes and comparative clinical effectiveness and appropriateness. The results of these studies will be made available to the Medicare, Medicaid, and state children's health insurance programs (SCHIPs), as well as to private health plans, prescription drug plans, health care providers, and the public.

New Leadership

Former Rep. James Greenwood (R.-Pa.) is now the new president of the Biotechnology Industry Organization (BIO) and is predicting continued growth in biotech drug products in 2005. Last year, the Food and Drug Administration approved 32 new therapeutic products that were either discovered, developed, or marketed by biotechnology and related companies, according to a BIO analysis. “More than 800 million patients have benefited from biotech medicines and vaccines already, and millions more will benefit in the future,” Mr. Greenwood said in a statement. “Literally hundreds of products are in the development queue.”

Spending for Power Wheelchairs

Federal safeguards did not go far enough to curb out-of-control spending growth for power wheelchairs under the Medicare program, the Government Accountability Office found. Medicare spending for the wheelchairs rose more than fourfold from 1999 through 2003, raising concerns that some of the payments may have been improper. Following the indictment of several power wheelchair suppliers in Texas who fraudulently billed Medicare, GAO was asked to examine earlier steps taken by the Centers for Medicare and Medicaid Services to respond to improper payments. CMS' contractors started informing the agency in 1997 about escalating spending for wheelchairs, and some started taking steps to respond to improper payments—yet the agency didn't assume an active role until 2003. Since then, CMS has worked to prevent fraudulent suppliers from entering the Medicare program, although it has not implemented a revised form to collect better information for power wheelchair claims reviews, according to teh GAO report.

Portable Health Plans

Patients can take their health insurance coverage with them when they change or lose a job, under the final regulations that implement the last piece of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). According to a statement by the Health and Human Services Department, it is important that American workers, who often change jobs several times in the course of their lives, be able to respond to the modern workplace without having to fear for their health insurance. The regulations allow greater portability and availability of group health coverage during a time of job transition, setting limits on preexisting condition exclusions that could be imposed, and requiring group health plans and insurance issuers to offer “special enrollment” to certain patients who lose eligibility for other group health coverage or health insurance, or to otherwise eligible new dependents. The regulation goes into effect for plan years starting on or after July 1.

Computer Entries Lead to Errors

Automation isn't necessarily a foolproof way to improve patient safety and reduce medical errors, a report from the United States Pharmacopeia (USP) found. Computer entry errors were the fourth leading cause of medication errors according to MEDMARX, USP's national medication error reporting system. These errors have steadily increased and represent about 12% of all MEDMARX records from 1999 through 2003. Performance deficits—where an otherwise qualified physician makes a mistake—were the most frequently reported cause of errors. Distractions were the leading contributing factor, accounting for almost 57% of errors associated with computer entry. The report provided an analysis of 235,159 medication errors voluntarily reported by 570 hospitals and health care facilities nationwide.

Reduced Benefits for Retirees

Businesses are asking retirees to pay more for their health coverage as they struggle to control rising costs, the Kaiser Family Foundation reported. In the last year, 79% of firms increased their retirees' contributions for premiums, and 85% expect to do so in the coming year. In addition, 8% of employers surveyed eliminated subsidized health benefits for future retirees in 2004. For 2005, 11% said they are likely to terminate coverage for future retirees. However, 58% of responding firms said they were likely to continue offering prescription drug benefits and accept the tax-free subsidy created by the new Medicare law. The survey included responses from 333 large private-sector firms that offer retiree health benefits.