College takes stand on MSAs, OKs guidelines
Medical savings accounts (MSAs), themselves, will not achieve the College's "goal of universal access to health care services," according to a new College position statement approved by the ACP Board of Regents this summer.
Consequently, the Board concluded, ACP can only support MSAs (also called medical IRAs) as a "supplemental mechanism for financing health care services that may improve access to health care services for some people." According to the new position statement, the College would only favor legislation calling for "experimentation and examination of MSAs through research and demonstration projects."
ACP leadership acknowledged that MSAs have some attractive features--among them, empowering patients in health care decision-making, enhancing cost-consciousness on the part of patients and potentially reducing administrative costs and paperwork. However, the Board said that MSAs have the potential to actually hurt access to health insurance for some Americans. Allowing employers to contribute to tax-free personal savings accounts for their employees could segment the insurance market, thereby raising premiums for people who want traditional health insurance, the College stated.
MSAs are a cornerstone of the AMA's health reform proposal and a favorite of many leading Congressional Republicans.
Limited use of MSAs, the College concluded, "is not likely to have a dramatic impact on either costs or access."
At its July meeting, the Board of Regents also OK'd two revised screening guidelines produced by the Clinical Efficacy Assessment Project (CEAP) Subcommittee, approved position papers on various aspects of incremental heath reform and authorized several new College programs that could help practicing internists.
The two new screening guidelines--for colorectal and breast cancers--will update chapters on those topics in the ACP-published book, "Common Screening Tests," which is currently being revised.
The new colorectal cancer screening guideline paper, written by David M. Eddy, MD, Chris Ferioti, MD, and Daniel S. Anderson, MD, concludes that although the "case for screening for colorectal cancer is stronger now than ever before," choosing a screening strategy is very difficult. The paper, therefore, recommends that patient preferences and the costs of the tests be figured into individual physicians' decision making.
According to the new recommendations, all patients should be offered 10-year flexible sigmoidoscopies at ages 50, 60 and 70. For patients who want "maximum protection" and in settings where it is logistically feasible and the cost is reasonable, colonoscopy should be offered every 10 years. In some practices, air-contrast barium enemas might be logistically preferable to colonoscopies and preferred by patients, and consequently should be offered every 10 years. Patients who decline these options should be offered annual fecal occult blood tests starting at age 50. People who have any first-degree relatives with colorectal cancer should be offered colonoscopy at age 40 and at least every 10 years thereafter, the guideline states.
The new screening guideline for breast cancer, which was written by Dr. Eddy, Margaret A. Gordon, MD, and Allen Bredt, FACP, discourages use of mammography in women younger than age 50 because of the "lack of evidence of benefit, the probability of harm, the high probability of a false-positive result, the costs, and the low degree of benefit and cost-effectiveness even if optimistic assumptions are used."
The guideline recommends screening for women age 50 to 74 every 2 years. Baseline mammograms and mammography screening in women older than 75 should be discouraged, says the guideline. It also recommends that high-risk women receive the same advice as average-risk women, "unless a woman expresses great anxiety about breast cancer and insists on more intensive screening."
The following are some other actions taken by the Board of Regents:
- The College took positions on several proposals for incremental health reform that could surface in Congress this year.
First, ACP would support federal and state initiatives that stimulate the creation of voluntary health insurance purchasing pools in every state. According to the new position paper, these purchasing cooperatives could serve as an incremental mechanism for expanding access to health insurance for small businesses and individuals, could help save administrative dollars and could help promote high quality medical care "in a marketplace increasingly dominated by corporate managed care." Moreover, the College stated, these pools have the potential to strengthen the ability of patients to choose their health plan.
Secondly, the Board approved a paper laying out a series of key insurance reforms that, given the absence of universal coverage, could help make health insurance more accessible and affordable. These include requiring guaranteed issue and renewability, restricting pre-existing condition exclusions, setting requirements for standardized benefit plans, limiting the amount of variation allowed in premiums and setting a federal minimum standard for both market and rating reforms.
- Free membership in the College for medical students will continue next year as part of the year-old Medical Student Membership Pilot Program. To date, about 3,000 medical students have joined ACP.
- ACP this fall will kick off a new program to help internists measure patient satisfaction with their care. The new Office Practice Assessment Program grows out of a research project that had been funded by the Commonwealth Fund to measure the quality of ambulatory care as perceived by patients.
- To help encourage practicing internists to serve as community-based preceptors of internal medicine residents, ACP will be issuing certificates to practitioners who volunteer their time to participate as office-based educators.
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