In the News for the Week of 3-16-04
The business of medicine
- Physicians look for new ways to boost income
- New College service helps in-office labs meet federal standards
Clinical news in the headlines
- New study confirms benefits of much lower cholesterol levels
- Obesity overtaking smoking as leading cause of death
- Highlights of the March 16 Annals of Internal Medicine
- FDA approves new drug for kidney dialysis patients
- Report airs physician-patient complaints
- Cover the Uninsured Week slated for May 10-16
The Senate last week rejected an administration proposal to cut $11 billion in Medicaid funds from the 2005 budget.
ACP strongly opposed the proposed cuts in a March 9 letter that the College and 17 other medical associations sent to Senate members. The letter noted that states will already face reduced Medicaid support when $10 billion in temporary state fiscal relief expires later this year. Cuts in funding, the letter stated, would severely restrict physicians' ability to care for the country's most vulnerable patients.
The March 11 Modern Healthcare reported that the House budget proposal, still being developed, is expected to include up to $2.2 billion in cuts to Medicaid over five years.
Modern Healthcare is online at http://www.modernhealthcare.com/news.cms?newsId=2168&potId=FS.
The letter from the College and other medical organizations is online at http://www.acponline.org/hpp/hp_oppose05.htm.
In other Senate news, the budget resolution passed by the Senate Budget Committee last week included a sense of the Senate resolution on amending the use of the sustainable growth rate formula in deciding physician fee updates. While the sense of the Senate resolution is not binding, it will help College efforts to change the formula by putting Congress on record that there are serious problems with the current methods of determining physician payments.
ACP had urged support for the amendment in a letter to committee members. The letter is online at http://www.acponline.org/hpp/nickles.htm.
The College also sent a letter last week to the House Budget Committee. Among other recommendations, the letter called on the committee to reject reductions in Medicaid program funding. The letter also expressed support for health program funding, including for Title VII programs and the Agency for Healthcare Research and Quality. Capping spending for those programs, the letter said, would be "inadvisable."
The letter is online at http://www.acponline.org/hpp/budget_res05.htm.
After changing his anti-drug importation stance, internist and FDA commissioner Mark B. McClellan, MD, PhD, last week won Senate approval to become the new administrator of CMS.
Dr. McClellan, who has been head of the FDA since November 2002, has led the administration's campaign against importing prescription drugs from Canada, the March 12 New York Times reported. After several senators vowed to hold up his confirmation over the issue, Dr. McClellan said he would work with Congress on bipartisan legislation to ensure the safety of imported drugs.
Last month, College President Munsey S. Wheby, FACP, sent a letter to Senate members, asking that Dr. McClellan be confirmed. He cited Dr. McClellan's efforts to reduce prescription drug costs and halt the spread of counterfeit drugs as factors in the College's support.
The New York Times is online at http://www.nytimes.com/2004/03/12/politics/12CND-HEAL.html?hp.
The business of medicine
In response to declining reimbursements, physicians are looking for ways to incorporate new service lines and cut back on less lucrative services, according to a study released last week.
The study found that more physicians are offering uncovered services such as concierge care, cosmetic surgery and botox treatments. They are also expanding the ancillary services they offer, and they are cutting back on unpaid services or ones that increase their risk of liability, such as providing on-call services in emergency departments. The study, which was conducted by the nonprofit Center for Studying Health System Change (HSC), appeared in the March/April Health Affairs.
While the entrepreneurial trend among physicians is not new, the study found that it has intensified over the past 10 years because of higher managed care penetration, payment cuts from public programs, and higher liability insurance and labor costs. According to a March 9 press release from Health Affairs, these factors caused physicians' income to fall by 5% from 1995-1999.
The study pointed out that policymakers may need to revise physician anti-kickback and self-referral laws to make sure the new trend doesn't restrict access to care.
An abstract of the study is online at http://content.healthaffairs.org/cgi/content/abstract/23/2/70.
The Health Affairs press release is online at http://www.healthaffairs.org/press/marapr0403.htm.
In another study published in the March/April Health Affairs, researchers found that physicians are increasingly opting to join single-specialty groups over multispecialty practices. The study, which was also conducted by HSC, found that physicians are choosing single-specialty groups to share the cost of equipment and facilities, increase their negotiating leverage with health plans, and benefit from professional management services.
A study abstract is online at http://content.healthaffairs.org/cgi/content/abstract/23/2/82.
Physicians with in-office laboratories now have access to a comprehensive service package that combines laboratory accreditation, e-learning courses and educational products with proficiency testing. The new service is a result of a cooperative alliance between ACP's Medical Laboratory Evaluation (MLE) proficiency testing service and COLA, a national healthcare accreditation organization.
Internists who take advantage of the package will get a turnkey solution to quality laboratory care that meets Clinical Laboratory Improvement Amendments (CLIA) requirements. Passed in 1988, CLIA established federal standards for all lab testing to ensure the accuracy, reliability and timeliness of test results.
For internists who operate laboratories, the integrated product and service package provides an efficient way to meet accreditation requirements while enhancing professional knowledge. Qualifying COLA and ACP members receive a discount on initial enrollment in the MLE proficiency testing program.
Clinical news in the headlines
A study released last week found that bringing cholesterol levels well below those currently recommended dramatically reduces patients' risk of heart attacks and death. The findings suggest that patients at high risk should receive more intensive statin therapy, while many patients with elevated LDL levels who are not now being treated could benefit from cholesterol-lowering drugs.
The results, which will be published in the April 8 New England Journal of Medicine, were released early. The study compared the benefits of giving patients who had already been hospitalized with ruptured plaque either an 80 mg dose of atorvastatin (Lipitor, manufactured by Pfizer) or a 40 mg dose of pravastatin (Pravachol, manufactured by Bristol-Myers Squibb). The study was sponsored by Bristol-Myers Squibb.
Researchers found that patients taking atorvastatin had LDL levels of 62 milligrams per deciliter versus 95 among the patients taking pravastatin. (Current guidelines recommend getting LDL levels in high risk patients below 100 milligrams per deciliter, according to the March 9 New York Times.) Participants taking atorvastatin also had a 16% lower rate of heart attack, death, angioplasty and bypass surgery than those taking pravastatin.
The study confirmed findings of a study presented last November and published in the March 3 Journal of the American Medical Association (JAMA). That study, sponsored by Pfizer, found that an 80 mg dose of atorvastatin halted plaque growth in patients, while a 40 mg dose of pravastatin slowed plaque growth but did not stop it. According to the New York Times, cardiologists said at the time that the earlier study was not definitive because halting plaque growth was not the same as reducing the incidence of heart attacks and death.
Among patients in the NEJM study who took atorvastatin, 3.3% of them had elevated liver enzymes versus 1.1% of patients taking pravastatin.
An NEJM abstract is online at http://content.nejm.org/cgi/content/abstract/NEJMoa040583, with an accompanying editorial at http://content.nejm.org/cgi/reprint/NEJMe048061v1.pdf.
The New York Times is online at http://www.nytimes.com/2004/03/09/health/09STAT.html.
An abstract of the JAMA study is online at http://jama.ama-assn.org/cgi/content/abstract/291/9/1071.
A study released last week found that obesity ranked as the second-leading cause of death behind smoking and could become the No. 1 health threat to Americans if current trends continue.
Together, poor diet, physical inactivity and smoking accounted for the greatest percentage of deaths in 2000, according to the report. The report was compiled by the CDC and published in the March 10 Journal of the American Medical Association (JAMA). The study defined actual causes of death as lifestyle and behavioral factors that contribute to serious diseases such as heart disease, cancer and stroke.
The study found that smoking accounted for 18.1% of the actual deaths in 2000, while obesity accounted for 16.6% of the total number of actual deaths. Next was alcohol consumption at 3.5%, followed by, in descending order, microbial agents such as influenza and pneumonia, exposure to pollutants and other toxic agents, motor vehicle accidents, use of firearms, sexual behavior and illicit drug use.
The number of lives claimed by poor diet and physical inactivity rose during the 1990s, according to the March 9 Los Angeles Times. While tobacco remains the leading killer, the percentage of deaths from obesity increased between 1990 and 2000 to 16.6% from 14%, whereas deaths from smoking among men decreased slightly over the same period.
The study coincided with the launch of new programs to fight obesity by HHS, including a nationwide public education campaign and 25 new obesity research centers sponsored by the National Institutes of Health. The NIH wants to increase its budget for obesity research by 10% to more than $440 million in 2005, the Los Angeles Times reported.
The JAMA abstract is online at http://jama.ama-assn.org/cgi/content/abstract/291/10/1238.
A CDC press release is online at http://www.cdc.gov/od/oc/media/pressrel/fs040309.htm.
The Los Angeles Times is online at http://www.latimes.com/news/nationworld/nation/la-030904
The following articles appear in today's Annals of Internal Medicine. The full text of the issue is available to College members and subscribers online at http://www.annals.org?wkly.
Task Force recommends against routine hepatitis C screening. The U.S. Preventive Services Task Force has recommended against routine hepatitis C screening for patients not at high risk. The Task Force also concluded that there isn't enough evidence to recommend screening for high risk patients, including those who are current or former intravenous drug users or those who received blood transfusions before 1990. http://www.annals.org/cgi/content/full/140/6/462
Lack of definitive evidence on best nicotine replacement therapy. Researchers found that patients who used a nicotine nasal spray to help them quit smoking were able to quit at about the same rate as those using a skin patch. However, smokers who were highly dependent on nicotine, obese and nonwhite had better success with the spray, while those with low to moderate dependence who were white and not obese had higher cessation rates with the patch. Findings suggest that ethnicity, weight and level of dependence are factors in determining which replacement therapy to use. http://www.annals.org/cgi/content/full/140/6/426
Full disclosure of medical errors may not affect patients' likelihood of seeking legal advice. A study found that while full disclosure of medical errors increased patients' trust of and satisfaction with their physicians, it did not necessarily change the likelihood that they will get legal advice. http://www.annals.org/cgi/content/full/140/6/409
The FDA last week approved a drug to treat bone loss and other complications of kidney disease, as well as complications of a rare form of cancer.
The drug, called cinacalcet (Sensipar), is the first in a class of drug compounds known as calcimimetics to receive FDA approval, according to a March 8 FDA press release. It treats secondary hyperparathyroidism in patients with chronic kidney disease on dialysis, as well as hypercalcemia in patients with parathyroid cancer.
Currently, physicians try to reduce excessive parathyroid hormone levels by giving patients intravenous vitamin D, the March 9 Los Angeles Times reported. However, too much vitamin D can increase blood levels of calcium and phosphorus and lead to calcification of blood vessels. Cinacalcet regulates the hormone without increasing levels of calcium and phosphorus.
According to the FDA, however, treating chronic kidney disease patients with cinacalcet was associated with low serum calcium levels in some patients. The drug's labeling includes recommendations to frequently monitor patients' calcium levels on the drug.
The FDA press release is online at http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01282.html.
The Los Angeles Times is online at http://www.latimes.com/business/la-fi-amgen9mar09,1,2184538.story.
In related news, an NIH survey found that many black Americans have at least one major risk factor for kidney disease, such as diabetes or high blood pressure, but few were aware of their risk.
The survey of more than 2,000 blacks age 30 or older found that 44% of respondents had at least one major risk factor for kidney disease, but only 15% felt that their personal risk was higher than average, according to a March 8 NIH press release. Only a small percentage of respondents knew that hypertension and diabetes are leading causes of kidney failure.
The NIH is preparing to launch its National Kidney Disease Education Program. NIH statistics show that blacks have four times the risk of kidney failure as whites and that black men between the ages of 25 and 44 are 20 times more likely to develop the disease than white men of the same age.
The NIH press release is online at http://www.nih.gov/news/pr/mar2004/niddk-08.htm.
A new report being distributed to physician networks and health plans on physician-patient relationships outlines concerns that both physicians and patients have with each other. Authors of the report hope it will spur change on both sides of the physician-patient equation to improve care.
The "Defining the Patient-Physician Relationship for the 21st Century" report grew out of a summit held last fall by Johns Hopkins University and a chronic disease management firm. At the summit, 100 physician-patient teams vented their complaints about each other, according to the March 9 Washington Post.
The authors cited seven areas where improvements are needed, including communications, education, decision-making, the office experience, the hospital experience, integration and outcomes.
Top complaints from physicians included patients who arrive late for appointments, forget to bring updated information on their conditions such as lab results or reports from other physicians, or fail to take responsibility for their own health by making recommended lifestyle changes.
Patients complained about long waits for appointments. They also called on physicians to be more open to discussing alternative therapies and to spending more time going over treatment plans.
The report is online at http://www.patient-physician.com.
The Washington Post is online at http://www.washingtonpost.com/wp-dyn/articles/A41692-2004Mar8.html.
Cover the Uninsured Week slated for May 10-16
The College has joined other national health care organizations in supporting Cover the Uninsured Week, which will take place May 10-16. The Robert Wood Johnson Foundation initiative draws attention to the problem of the uninsured by holding public education and community events across the country.
Last year's event brought together more than 800 national and local groups (including close to a dozen ACP Chapters), which together sponsored nearly 900 public events. In addition to holding community health fairs, educational forums and workshops, Cover the Uninsured Week organizers this year will feature health care providers who donate time to caring for patients without coverage. Some events will also offer medical screening for the uninsured patients and opportunities for families to enroll in Medicaid and the State Children's Health Insurance Program.
According to the most recent Census Bureau statistics, an estimated 15.2% of the population—43.6 million people—had no health care coverage in 2002. While Medicaid covered 14 million people that year, an additional 10.5 million impoverished patients were not enrolled.
The College last week joined close to 60 other professional societies and medical organizations in urging Senators to pass a bill to help boost patient safety.
The Patient Safety and Quality Improvement Act of 2003 (S. 720) would create a confidential, voluntary reporting system that physicians and hospitals would use to report error information. That information, which would be reported to patient safety organizations, would then be analyzed to provide feedback on ways to improve patient safety.
According to the letter, the bill would not preempt state requirements on error reporting.
The letter is online at http://www.acponline.org/hpp/pass_s720.htm
In a letter sent last week to the acting CMS administrator, the College commented on 2004 changes in Medicare payments for physician services related to outpatient drugs and in physician fee schedule payments.
The College urged CMS to assign work relative value units to codes governing immunization and vaccine administration. Even though nurses often administer vaccines, the letter said, physicians spend time in counseling patients about immunization.
The letter also made several recommendations related to changes in CMS' reimbursements for Part B drugs and their administration. The letter stated that Medicare payments for drugs should cover physicians' acquisition costs; that any reduction in payments for drugs "must be accompanied" by increases in administrative reimbursement; and that increased administrative payments should not be restricted to only certain specialties.
The letter also recommended that Medicare look into using other data sources when revising the drug administration payments now in effect.
The letter is online at http://www.acponline.org/hpp/cms_final.pdf.
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Copyright 2004 by the American College of Physicians.
A 57-year-old man is evaluated in follow-up for a right-sided pleural effusion. He initially presented with increasing dyspnea and a constant dull ache on his right side. He also has lost 9.1 kg (20.0 lb) over the last 6 months. Medical history is otherwise unremarkable. Following chest radiographs and repeat thoracentesis, what is the most appropriate diagnostic test to perform next?
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