In the News for the Week of 10-12-04
- CDC urges rationing of scarce flu vaccine supplies
Clinical news in the headlines
The business of medicine
- States continue to cut or freeze Medicaid provider payments
- MGMA estimates price tag of administrative waste
- Medicare clarifies new language on treating obesity
- Nurses offer free blood pressure screening and patient education
- College calls on Senate to support full Title VII funding
- ACP releases news feature on chlamydia
- College to CMS: Rethink proposed changes to physician fee schedule
Responding to last week's surprise announcement that the United States will receive only half its ordered flu vaccine this season, the CDC has distributed priority guidelines for flu vaccination programs.
According to an Oct. 5 CDC news release, the agency has identified eight priority groups who are considered to be of equal importance. They include:
- all children aged 6-23 months;
- adults aged 65 or older;
- patients aged 2-64 who have underlying chronic medical conditions;
- all women pregnant during flu season;
- residents of nursing homes and long-term care facilities;
- children aged 6 months-18 years on chronic aspirin therapy;
- health care workers involved in direct patient care; and
- out-of-home caregivers and household contacts of children under six months.
Patients not included in those groups should defer or forgo vaccination, the CDC said.
The recommendations come as Chiron Corporation, a British manufacturer that was supposed to supply as many as 48 million doses to the U.S. market this year, had its manufacturing license suspended in England because of contamination concerns, the Oct. 6 New York Times reported.
Instead of the 100 million doses anticipated, American health care professionals will have only 54 million injectable vaccine doses and between 1 million and 2 million intranasal flu vaccine doses to distribute.
The CDC guidelines are online.
The New York Times is online.
Clinical news in the headlines
A U.S. cardiologist has called for a full Congressional review of the process that led to approval of the arthritis drug rofecoxib (Vioxx) despite warning signs that the drug increased the risk of cardiovascular complications.
Cleveland Clinic's Eric J. Topol, FACP, accused Merck, which manufactured the drug, and the FDA of failing to protect the public by allowing rofecoxib to be sold. While many studies had demonstrated increased risk of myocardial infarction and serious cardiovascular events associated with rofecoxib since the drug was approved in 1999, neither Merck nor the FDA acted on the information, Dr. Topol wrote. His New England Journal of Medicine (NEJM) editorial was posted online last week.
Merck pulled rofecoxib from the worldwide market late last month after halting a clinical trial in which some patients taking the drug were found to have twice the risk of heart attacks or strokes.
Instead of spending money on a trial to determine the drug's cardiovascular risk, the company chose instead to fund an aggressive consumer advertising campaign, Dr. Topol stated. The FDA's failure to order a trial is equally unacceptable, he wrote, given the fact that many alternative arthritis medications are on the market.
An accompanying editorial by Garret A. FitzGerald, MD, from the University of Pennsylvania Health System, noted that the rofecoxib case raises questions about the safety of other drugs in the cox-2 inhibitor class. Dr. FitzGerald suggested that physicians not prescribe these drugs to patients with or at risk for cardiovascular disease until studies determine whether there is a class effect.
Links to the two editorials, which will appear in the Oct. 21 print issue of NEJM, are online.
A new prognostic tool using office spirometry was found to be effective in identifying patients with chronic obstructive pulmonary disease (COPD) who were at increased risk of death, paving the way for physicians to prescribe the latest treatments to combat the disease.
Findings were from two studies of more than 830 patients in stable condition being treated for COPD. Researchers developed an index—dubbed "BODE"—that included body mass index, airflow obstruction (FEV1), dyspnea score and exercise capacity (6-minute walk test).
Researchers found that patients with the highest BODE scores had a greater risk of death. The study was abstracted in the Sept.-Oct. ACP Journal Club.
The reviewer noted that the BODE index is a more comprehensive tool for assessing COPD risk than forced expiratory volume alone, because volume readings do not accurately predict dyspnea symptoms, exercise tolerance and mortality. Because the BODE index uses easily implemented office tools, such as body mass index and the six-minute walk, the reviewer said the findings should encourage non-pulmonologists to invest in office spirometry to help identify patients in need of interventions.
The ACP Journal Club abstract and commentary are online.
The business of medicine
The majority of states are maintaining a freeze on or reducing Medicaid payments to physicians and other health care professionals, according to a report released last week. The payment cuts come as Medicaid enrollment continues to grow.
The report by the Kaiser Commission on Medicaid and the Uninsured found that all 50 states cut provider payments in fiscal 2004, while almost all are planning continued cuts or freezes in fiscal 2005. In addition to reducing or freezing provider payments, most states are cutting drug spending, with some states also limiting program eligibility or benefits.
Enrollment in Medicaid has grown by close to one-third since 2001 and is expected to grow by almost 5% in 2005, spurred on by the economic downturn, rising drug costs and overall health care cost increases, an Oct. 4 Kaiser Family Foundation news release reported. Despite cost containment measures, state spending outpaced state tax revenue growth in 2004 by 9.5% to 3.4%.
The federal government increased its share of Medicaid funding in 2004 to help states maintain coverage, but that funding expired June 30, 2004, leaving states to make up the shortfall, the report noted.
The Kaiser Foundation news release is online.
A study released last week quantified the value of time and money medical practices spend on administrative tasks that add no value to the practice or to patient care.
The study of almost 300 group practices by the Medical Group Management Association (MGMA) found that a medical practice of 10 physicians typically wastes each year more than $247,000 in costs and in physician and staff time on duplicative administrative duties, according to an Oct. 4 MGMA press release. That figure included:
More than $38,000 a year verifying patient coverage, copays and deductibles.
More than $33,000 each year negotiating insurance contracts with an average of 15 different health plans each year.
Almost $20,000 a year on phone calls with pharmacies to resolve formulary issues.
More than $9,000 each year resubmitting denied claims, 73% of which are eventually paid.
Almost $8,000 a year submitting credentialing applications for each physician.
MGMA has proposed a simplified system in which multiple payers would offer a limited set of standardized insurance plans, with universal standards adopted for credentialing, clinical guidelines, billing and other office processes.
The MGMA plan is online.
The MGMA news release is online.
In related news, another MGMA group practice survey found that many practices are cutting back on operating costs to offset declining revenue.
The MGMA's 2004 Cost Survey released last week found that primary care practices in 2003 had reductions in total operating costs of 2.4% while medical revenue declined by 4.3%. Staffing was a key area for cutbacks, according to an Oct. 4 MGMA news release.
Multispecialty groups cut costs—with primarily housekeeping, maintenance and security expense reductions—by almost 14% and lowered spending on registered nurses by almost 4%. At the same time, practices spent more on management fees, suggesting that some functions are being outsourced. Despite these cutbacks, multispecialty groups reported that their operating cost increases outpaced revenue growth by 3.18% to 2.96%.
The MGMA news release is online.
The CMS this month issued further clarification of its decision, which was announced earlier this year, to cover some obesity treatment.
Medicare is removing language from its regulations stating that obesity "cannot be considered an illness." That language is being revised to address obesity care and services.
However, the change in language will not directly affect current Medicare coverage of obesity treatments. Services in connection with obesity treatment are covered services only when they are an integral and necessary part of treating a medical condition. Treatment of obesity unrelated to such a medical condition remains uncovered.
Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension.
More information is online.
The American Nurses Association (ANA) last month launched a national bus tour designed to hold free blood pressure screening in 10 U.S. cities and to educate patients about the dangers of uncontrolled high blood pressure.
About 25 nurses will visit each city. Screening dates include:
- Oct. 15-16, Seattle
- Oct. 22-23, Los Angeles
- Oct. 29-30, Phoenix
- Nov. 5-6, Houston
- Nov. 12-13, Tampa
- Nov. 19-20, Atlanta
According to an ANA news release, nearly 65 million Americans have high blood pressure, but 70% of them do not have their condition under control.
More information, including screening sites in the different cities, is online.
The College has joined with other groups representing primary care physicians to urge Senate and House leaders to support full Title VII funding for 2005. Title VII funding is the only federal support given to help train the primary care workforce.
In an Oct. 4 letter, the College—along with 10 other medical organizations, including the American Academy of Pediatrics and the Society of General Internal Medicine—called on Congress to support the full $90.7 million for Title VII funding currently contained in a bill before the Senate. Any decrease in Title VII funding for 2005 would be devastating to general internal medicine and pediatrics training programs, the letter stated, particularly in the wake of a 12% Title VII funding decrease in 2004.
As many as 50% of those trained in Title VII programs go on to work in underserved areas, compared to only 10% of those in other training programs, the letter noted. Title VII programs also increase the diversity of the physician workforce and train up to five times as many minority and disadvantaged students than programs without such support.
The College's letter is online.
The College last week issued a 90-second video news release that focused on chlamydia, the nation's most widespread sexually transmitted disease. The video—which is entitled "Untreated 'Silent Disease Can Cause Infertility: Yearly Screening for Chlamydia Recommended"—was sent to television stations across the country.
Part of ACP's Internal Medicine Report series, the video release provides a patient-centered view of an article that appeared in the Oct. 5 Annals of Internal Medicine. That article found that yearly chlamydia screening for sexually active females up to the age of 29, followed by screening every six months for those with a history of infection, is the most effective and cost-effective strategy for dealing with the disease.
According to the video release, more than 3 million Americans are infected with chlamydia every year. Chlamydia infections in most females produce no symptoms, and the highest occurrence of infection is in sexually active females between 15 to 24 years old.
The video news release is available in streaming video format on the "Doctors for Adults" Web site.
The original Annals of Internal Medicine study and a patient summary are online.
The College is asking the CMS to reconsider suggested changes to its physician fee schedule, including changes to the sustainable growth rate formula (SGR) used to update physician fees.
In a letter dated Sept. 24, the College said that the SGR formula must take into account the direct cost of services related to new Medicare benefits. ACP is concerned, the letter said, that those costs will be "omitted or underestimated"--and will lead to financial penalties for physicians in the form of lower fees. The College also said that the CMS should not include the costs of Medicare-covered drugs in determining whether Medicare spending has exceeded the SGR target.
In other recommendations, the College asked the CMS to revise its proposal for how physicians report covered initial preventive physical exam and EKG codes. And ACP objected to the CMS' proposal to eliminate the discharge management clinical staff time from the 0-day global procedure codes, a proposal that would adversely affect gastrointestinal endoscopy codes.
The CMS is now considering public comments and will publish a final rule on or around Nov. 1.
The letter is online.
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Copyright 2004 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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