In the News for the Week of 3-9-04
The business of medicine
- Changes in drug reimbursement could affect cancer care
Clinical news in the headlines
- Antibiotic-resistant staph infections on the rise
- Primary care intervention may help prevent suicide in older patients
- Estrogen-only study halted over concern about stroke risk
- Highlights of ACP Journal Club
Prescription drug abuse
- Government plans to step up fight against prescription drug abuse
- New PDA tool helps physicians gauge pneumonia severity
- CMS moves to standardize carriers' educational material
- AAMC seeking award nominees
- College gives physician fee schedule recommendations
- ACP supports Senate action to change fee update formula
- New College newsgroup helps small practices
- ACP urging more flu vaccinations for health care workers
The business of medicine
Oncologists and cancer patients are concerned that changes in the way CMS reimburses for cancer treatment may deny patients effective therapies or force them to get chemotherapy in hospitals instead of physician offices.
CMS officials are considering no longer paying for off-label uses of drugs approved for other types of cancer. Patient advocates say that move would prevent cancer patients from receiving effective treatments, according to the March 4 Washington Post.
Oncologists are also worried about the financial impact of changes in the way Medicare pays for the cost and administration of cancer drugs used in physician offices. Those changes were mandated by the new Medicare reform legislation passed late last year.
Beginning this year, CMS reduced its reimbursement to physicians for the cost of cancer drugs, from 95% of the drugs' average wholesale price to 85%. That cut was offset by an increase in what Medicare pays physicians to administer the drugs.
Next year, however, that increase will be substantially reduced, which oncologists say could lead many practices to stop office-based drug treatments. That would result in more patients being inconvenienced by having to seek treatment in hospitals.
According to the Washington Post, the American Society of Clinical Oncology is asking Congress to freeze payments for drug reimbursement and administration at their 2004 levels until studies on the new pricing system can be completed.
The Post article is online at: http://www.washingtonpost.com/wp-dyn/articles/A29059-2004Mar4.html.
Clinical news in the headlines
Communities across the country are reporting a sharp rise in the number of antibiotic-resistant staph infections being found in the outpatient setting. Once confined to hospitals, the infections are now spreading to healthy patients via new and more aggressive strains.
The resistant strains can be successfully treated with antibiotics, but not the penicillin-like drugs physicians typically prescribe for staph infections. Delays in starting the right treatment can turn a minor infection into a life-threatening condition.
According to the March 2 New York Times, the new staph bacteria are resistant to cephalexin and ceftriaxone, but can be treated with trimethoprim/sulfamethoxazole, doxycycline and clindamycin.
Over the last several years, clusters of newly-resistant infections have been reported across the country among populations who share living quarters or are in close bodily contact. They include babies and young children, athletic team members, military recruits and prison inmates.
Because staph infections are so common, physicians typically do not report them to public health departments, an omission that makes tracking resistant strains more difficult. Infectious disease specialists urge doctors to become more vigilant about treating staph by draining pus in skin infections, taking cultures and possibly changing the type of antibiotic they typically prescribe.
The New York Times is online at http://www.nytimes.com/2004/03/02/health/policy/02INFE.html.
A new study suggests that a comprehensive treatment plan at the primary care level, which combine the use of SSRIs and therapy, can reduce the risk of suicide in older, depressed patients.
The study followed two groups of older, depressed patients for one year at 20 primary care practices in several different cities. Patients in the intervention group were assigned depression care managers—social workers, nurses and psychologists—who advised the primary care physicians on recognizing symptoms of depression and monitoring clinical status. They also made recommendations for treatment and follow-up. The study was published in the March 3 Journal of the American Medical Association (JAMA).
Researchers found that thoughts of suicide declined by almost 13% among patients in the intervention group, compared with 3% in the group receiving usual primary care treatment. The intervention was more effective with patients who had major depression than minor depression.
Study authors concluded that treatment guidelines for structured primary care treatment, as well as management by a master's-level clinician, significantly reduced thoughts of suicide in older patients with depression.
The JAMA abstract is online at http://jama.ama-assn.org/cgi/content/abstract/291/9/1081.
For more information, see "SSRIs: Too much—or too little—of a good thing?" in the March 2004 ACP Observer at http://www.acponline.org/journals/news/march04/ssri.htm.
The NIH last week announced that it had halted its study of estrogen-only therapy in postmenopausal women a year early because the hormone appears to increase the risk of stroke.
The increased stroke risk—about eight more strokes per year for every 10,000 women—was small, according to the March 3 New York Times. However, it was considered unacceptable for healthy women participating in a research study. A related study indicated that estrogen might increase the risk of dementia, the New York Times reported.
NIH researchers also found that estrogen-only therapy, used by women who have had hysterectomies, did not increase subjects' risk of breast cancer or heart disease. A study of the effects of combined estrogen and progestin HRT therapy was halted in 2002 because subjects were found to have an increased risk of breast cancer.
NIH officials said women taking estrogen alone should not necessarily stop treatment because the risk of stroke is small and because the hormone has proven effective in treating menopausal symptoms. A March 2 NIH press release advised women to discuss the potential risks and benefits of estrogen-only therapy with their physicians before starting or stopping treatment.
The NIH press release is online at http://www.nih.gov/news/pr/mar2004/nhlbi-02.htm.
The New York Times is online at http://www.nytimes.com/2004/03/03/science/03HORM.html.
Adding the ACE-inhibitor perindopril to the regimen of patients with stable coronary artery disease reduced cardiac events.
According to a study abstracted in the March/April issue of ACP Journal Club, patients taking perindopril had fewer fatal and nonfatal heart attacks, as well as fewer hospital admissions and resuscitated cardiac arrests. All of the participants had coronary artery disease but no evidence of heart failure.
The study's authors pointed out, however, that the study did not address how effective perindopril was compared to other ACE-inhibitors.
More information is online at http://www.acpjc.org/Content/140/2/issue/ACPJC-2004-140-2-031.htm.
Prescription drug abuse
The administration last week announced a plan to expand efforts to police prescription drug abuse, a problem it says affects more than 6 million Americans every year.
The proposed plan would target patients who "doctor shop," finding multiple physicians to write prescriptions, as well as illegal Internet sites that sell prescription drugs. According to the March 2 Washington Post, a recent study identified more than 450 Web sites selling controlled prescription drugs. Many of those sites advertised opioid-based medications, such as oxycodone.
The plan would increase the number of state programs that monitor prescription drug sales and would help educate physicians on how to identify patients abusing prescription drugs.
The DEA and the Justice Department have become more vigilant policing abuse in recent years, prosecuting several physicians and pharmacists for improper prescriptions and drug distribution. The Washington Post reported that some physicians and patient advocates are concerned that the expanded crackdown may inhibit doctors from prescribing appropriate pain medication.
ACP, along with the AMA and others, participated in a recent meeting convened by the DEA to explore continuing education for physicians in opioid use. Physician groups and licensing board organizations questioned the effectiveness of mandatory continuing education to address the problem of overuse of opioids.
The Washington Post is online at http://www.washingtonpost.com/wp-dyn/articles/A20863-2004Mar1.html.
The Agency for Healthcare Research and Quality (AHRQ) last week released a computerized decision-support tool designed to help physicians decide whether pneumonia patients can be treated at home or need to be hospitalized.
The Pneumonia Severity Index Calculator is an interactive application for PDAs available in Palm OS, Pocket PC and HTML formats. The tool is based on a clinical pneumonia algorithm produced by an AHRQ-funded research team in 1997. According to AHRQ, the tool can help avoid unnecessary hospitalization of patients with low-risk pneumonia.
Every year, community acquired pneumonia in the United States affects close to 4 million people and costs about $10 billion to treat, according to a March 1 AHRQ press release. Most of those costs result from patient hospitalizations.
This is the first PDA decision-support tool released by the AHRQ, which is developing other PDA applications.
The free program can be downloaded from AHRQ's website at http://pda.ahrq.gov.
The AHRQ press release is online at http://www.ahrq.gov/news/press/pr2004/psipdapr.htm.
Effective this week, CMS is standardizing the educational material that Medicare carriers make available to physicians to explain coverage and reimbursement policies. Carriers have until July 1 to begin using the standardized material.
All material for CMS' coverage and reimbursement rules will now be written by clinicians and medical coding or billing specialists. Carriers will have to use that standardized text in their provider educational materials, on their Web sites and in their call centers. In the past, physicians have complained that much of the information they receive from carriers is irrelevant or confusing, problems that CMS hopes to correct by issuing standardized text.
CMS invites both carriers and physicians to provide feedback on the newly standardized material at http://www.cms.hhs.gov/medlearn/suggestform.asp.
College members are also invited to submit comments on the new standardization program to Carol McKenzie in the Washington office at firstname.lastname@example.org.
The Association of American Medical Colleges (AAMC) is seeking nominees for 11 different awards that will honor individuals and programs that contribute to medical education, research and community service. Award amounts range from $5,000 to $10,000.
Each of the awards has a different deadline for nominations, with the earliest AAMC deadline for nominees being March 29. Names of nominees can also be submitted until March 15 to Patrick Alguire, FACP, the College's Director of Education and Career Development, at email@example.com.
More information about the awards is online at http://www.aamc.org/about/awards/start.htm.
The College has provided the Practicing Physicians Advisory Council (PPAC)—which advises HHS about the Medicare program—a comprehensive statement of testimony on the Medicare 2005 physician fee schedule.
Among other recommendations, the College called for separate reimbursement for physician review of electronically transmitted data, a service that is now bundled. ACP also urged the council to recommend separate payment for anticoagulation monitoring. The lack of a separate payment, the statement said, may contribute to underutilization of anticoagulant drugs.
The College also made several recommendations to reduce physicians' documentation burden and improve the medical review process. Those recommendations included eliminating the use of detailed documentation guidelines and assessing the effectiveness of the current medical review process by conducting a cost-benefit analysis.
The College's statement to PPAC can be accessed from http://www.acponline.org/hpp/menu/physicianpmt.htm.
ACP last week sent a letter to members of the Senate Budget Committee, supporting an amendment to the fiscal year 2005 budget that expresses support for changing the formula used to update physician fees. The Committee approved the amendment to the budget resolution, which is now being debated on the Senate floor.
The letter pointed out that the current update, which is based on the sustainable growth rate formula, is deeply flawed. A new formula needs to be crafted that takes into account increased service costs and utilization. Without update reform, the letter said, physicians will face a continuing erosion of economic conditions.
The College also sent a letter to the House Budget Committee in support of funding for health programs such as Medicaid, Agency for Healthcare Research and Quality, Veterans' health and others.
ACP's letter to the Senate Budget Committee is online at http://www.acponline.org/hpp/nickles.htm.
A new online discussion group gives internists in small groups a place to discuss solutions to practice management problems.
The Small Practice Management Discussion Group is targeted to members in practices with between one and five physicians. Participants can exchange information about what works and what doesn't work in small practices, and get help with particular management problems.
Each month a featured guest will stimulate discussion by presenting a particular topic and responding to comments and questions. This month's topic is "Expense and Revenue Management—What Makes a Difference to the Bottom Line?" It is being moderated by Steven D. Atwood, FACP, who will present a seminar on practice management at Annual Session 2004.
Future topics will include outsourcing billing and collections, hiring staff, and office-based procedures.
The discussion group is free to ACP members (registration on ACP Online is required), and may be accessed at http://www.acponline.org/pmc/spm/?ow.
The College has joined more than 20 other national health care organizations in supporting a call from the National Foundation for Infectious Diseases (NFID) for more comprehensive influenza vaccination among health care professionals.
The NFID found that only 36% of all health care professionals get vaccinated against the flu every year, even though the lack of vaccination among health care workers makes it more likely that they will spread influenza in health care settings. More comprehensive vaccination would also cut down on the costs hospitals and practices incur every year related to workers sick with the flu.
To improve vaccination rates, the NFID is calling for more convenient vaccination clinic times, among other recommendations.
More information is online at http://www.acponline.org/aii/immuno_news.htm.
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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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