American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News for the Week of 4-6-04

Access fees

  • Physicians warned about charging extra fees to Medicare patients

The business of medicine

  • CMS releases long-awaited Stark II final rule

MKSAP news

  • Earn a free College product by answering MKSAP 13 questions

Clinical news in the headlines

FDA news

Vaccine update

Primary care

Patient safety

Access to care

Alcohol screening

ACP news

  • College voices opposition to Medicaid cuts
  • New ACP book offers stories of ordinary people and extraordinary heroism

Access fees

Physicians warned about charging extra fees to Medicare patients

The HHS' Office of Inspector General (OIG) last week issued an alert to physicians reminding them of their "potential liability" in charging patients extra fees for services already covered by Medicare.

Physicians can certainly charge Medicare beneficiaries deductibles and coinsurance amounts, as well as for services and items that are not covered by Medicare, the alert said. However, when they charge patients additional fees for services that are considered covered by Medicare, the alert continued, they could face penalties or exclusion from federal programs.

The alert did not refer specifically to concierge medicine, a business model where physicians charge annual fees for services such as 24-hour access. However, the OIG expressed concern that some Medicare patients might be paying twice for covered services.

The OIG alert is at:

Also see "Access fees have physicians moving cautiously" in the April 2004 ACP Observer at:


The business of medicine

CMS releases long-awaited Stark II final rule with new exceptions

The CMS late last month issued the second phase of its final Stark II rule, which addresses physician referrals for services at entities with which physicians have a financial relationship. Physicians are prohibited from referring Medicare and Medicaid patients for services to those entities, unless the Stark II statute provides an exception.

According to a CMS press release, the recently-released final rule creates several new exceptions. They include:

  • investment and ownership exceptions, including one for hospital ownership;
  • compensation exceptions, including ones for office space and equipment rental, personal service and employment relationships, and physician recruitment; and
  • new exceptions, including one on providing information technology items and services to community physicians, and an exception for free or discounted health care services offered by hospitals to medical staff members.

In drafting the final rule, the CMS adopted many of the College's recommendations to clarify the exceptions and make the regulation more flexible.

The CMS press release is online at:

An analysis from the College is online at:


MKSAP news

Earn a free College product by answering MKSAP 13 questions

ACP is looking for 300 physicians to help complete the development of norm tables for MKSAP 13. Selected participants will be asked to complete a free, advance copy of one of the self-assessment tests from the new MKSAP 13 program.

Norm tables are an important component of MKSAP. Instead of reflecting the knowledge of open-book test takers, the tables will provide a baseline reflection of the knowledge of selected physicians before the answers are published. The results of the prepublication tests will be kept strictly confidential and will be used for statistical purposes only.

Physicians who complete and return the test by May 14, 2004, may select their choice of a free MKSAP 13 Update CD-ROM (including multiple-choice questions and CME credits), a MKSAP Prep for Boards CD-ROM, a subscription to Clinical Problem-Solving Cases (including up to 48 CME credit hours online), or a copy of ACP's 2004 Multiple Small Feedings of the Mind book. To participate, simply register at:

Part A of MKSAP 13 is currently available, with Part B due to be released May 14, 2004. Order your copy before April 30, and receive a free MKSAP 13 Update CD-ROM (a $109 value). Order online at:


Clinical news in the headlines

Study questions value of CRP in predicting heart disease

A new study on C-reactive protein (CRP) testing found that measuring inflammation in the bloodstream helped only "marginally" in predicting heart disease. That finding is at odds with earlier studies.

The study, published in the April 1 New England Journal of Medicine (NEJM), found that measuring inflammation had little predictive value over measuring other risk factors for atherosclerosis, such as smoking, high cholesterol or high body mass index.

In the study, researchers found that patients with higher CRP levels had a 45% higher risk of heart disease compared with patients with the lowest levels; the percentage rose to 50% when researchers took 22 other studies into account. By comparison, studies done on CRP before 2000 suggested that high CRP doubled the risk, according to the April 1 Philadelphia Inquirer.

Based on those earlier studies, the CDC and the American Heart Association last year recommended that physicians test CRP levels in patients already considered to have at least a 10% to 20% risk of heart disease. Researchers involved in the new study suggested that those recommendations may need to be reviewed.

Another U.S. researcher quoted in the Philadelphia Inquirer, however, cautioned that halting CRP testing may do more harm than good. He claimed that the inexpensive test is a way for physicians to spot heart disease risk in patients when other factors aren't present.

The Philadelphia Inquirer is online at:

The NEJM abstract is online at: (Full text is available only to subscribers.)


Medicare patients over 50 skipping mammograms

Many older women are forgoing mammograms, despite recommendations that all women over 40 should have the screening annually for breast cancer.

The CMS, which began paying for once-a-year mammograms in 1998, reported that only 51.8% of women over 50 had the screening procedure in 2001 or 2002, according to the March 31 Las Vegas Sun. That low figure may reflect a misperception among older women that breast cancer affects mainly younger women, when postmenopausal women are in fact at much higher risk than premenopausal women.

The Las Vegas Sun reported that the New Mexico Medical Review Association over the last three years has been able to boost screening rates among older women--from 55.7% to 60%--with telephone reminder calls to patients and an aggressive public service campaign targeting both physicians and patients.

About 30 million mammograms are performed in the United States each year, detecting about 75% of cancers, according to the American Cancer Society. The disease affects about 200,000 women a year and results in 40,000 deaths.

The Las Vegas Sun is online at:

More information about CMS' mammography campaign is online at:


Highlights of the April 6 Annals of Internal Medicine

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.

Diagnosis of Alzheimer's disease associated with reduced life expectancy. A new study of 521 people with newly diagnosed Alzheimer's disease found that the median survival period was 4.2 years for men and 5.7 years for women. The severity of cognitive impairment was strongly associated with decreased survival, as were walking disturbances, falling, congestive heart failure and diabetes. An editorial notes that the diagnosis of dementia and Alzheimer's disease is a sentinel event akin to finding metastatic cancer. Realistic estimates of life expectancies can help patients and physicians plan for end-of-life care.

Task force: Screen adults for alcohol misuse in primary care settings. The U.S. Preventive Services Task Force (USPSTF) recommends screening and counseling for alcohol misuse in adults, but not adolescents. The task force found good evidence that screening for misuse of alcohol, and behavioral counseling to reduce alcohol misuse, is effective in adults, including pregnant women. The USPSTF did not evaluate the effectiveness of interventions to reduce alcohol dependence because the benefits of those interventions are well established.

Task force does not recommend routine ECG, treadmill test or EBCT screening to detect severe coronary artery stenosis or predict CHD in low risk patients. The U.S. Preventive Services Task Force recommends against routinely screening adults at low risk for coronary heart disease to detect the presence of severe coronary artery stenosis or predict coronary heart disease. The recommendation applies to screening with resting electrocardiography, exercise treadmill test or electron-beam computerized tomography scanning for coronary calcium.


FDA news

Antibiotic approved to treat drug-resistant pneumonia

The first in a new class of antibiotics called ketolides received FDA approval last week to treat drug-resistant pneumonia, sinusitis and bronchitis.

The drug, telithromycin (Ketek), offers a potentially important alternative to erythromycin and other antibiotics to which the bacteria have built up resistance, the April 1 Houston Chronicle reported. About 20% of streptococcus pneumoniae are resistant to different antibiotics and have proven immune even to newer drugs, like fluoroquinolones, that were developed specifically to target drug-resistant strains.

An expert quoted by the Houston Chronicle noted that ketolides might prove more effective than other antibiotics because they can target bacteria in the respiratory tract and may be less likely to lead to resistant bacterial strains. Ketolides, which are taken in pill form for five to 10 days, are also effective in treating acute bacterial sinusitis and chronic bronchitis.

The Houston Chronicle is online at:


Vaccine update

CMS: Order flu vaccine now

The CMS is recommending that physicians begin ordering supplies of influenza vaccine now for the 2004-05 flu season to ensure ample supply.

The recommendation is designed to help physicians avoid the supply problems that occurred last year when large numbers of flu cases appeared early in the season. Physicians should begin to prepare now to handle an anticipated high demand from older patients and others at high risk for complications from influenza.

Despite recent changes to Medicare's drug reimbursement policy contained in last year's Medicare reform legislation, the CMS said it will continue to reimburse physicians for lfu vaccine at 95% of the average wholesale price.

Physicians should address reimbursement questions to:
or use the feedback page at:


Primary care

Report recommends steps to reinvigorate family practice

A report commissioned by the American Academy of Family Physicians (AAFP) recommends relying on e-mail consultations, the use of advanced information systems and electronic guidelines, and universal health care coverage to help "reinvent" family medicine.

The report, recently published in the Annals of Family Medicine, calls for family physicians to become "the medical home" for patients, coordinating patient care delivered by nutritionists and other providers and using electronic health records (EHRs) and continuously updated evidence-based guidelines. The report is based on surveys of about 2,000 physicians and patients, as well as on findings of physician-led task forces.

The recommendations are in part a response to concerns about declining interest by medical students in pursuing family practice as a career. According to the March 30 Modern Physician, there has been a nearly 50% drop since 1997 in the number of U.S. seniors matching to family medicine residencies.

The surveys commissioned for the report also found some encouraging news, however: a majority of patients surveyed rated their family physicians as very good or excellent. The AAFP hopes to build on those positive relationships by promoting quality improvements, through national EHR standards and standardized evidence-based medical guidelines, and instituting career-long physician self-assessment and educational requirements.

To help speed adoption of the new practice model, the report called on family practice residency programs to be using EHRs by 2006. EHRs are now used in only 20% of those programs, Modern Physician reported. Later this year, another task force will report on potential funding sources for information technology through special reimbursement arrangements with government and private payers.

The College is also involved in intensive revitalization efforts for internal medicine, with several work groups developing recommendations.

"The Future of Family Medicine" report is online at:

Modern Physician is online at:


Patient safety

Clinician intimidation linked to medical errors

Intimidation by physicians can lead to medication errors by making nurses and pharmacists less willing or likely to question orders. That is according to a new report by the Institute for Safe Medical Practices, a nonprofit group in Huntingdon Valley, Pa., that researches way to improve patient safety.

About 40% of the more than 2,000 nurses, pharmacists and other providers surveyed said they had concerns about medication orders at some time over the past year, but did not raise questions because they were reluctant to interact with an intimidating physician.

Nearly half of respondents said past confrontations with physicians influence the way they handle concerns about medications, according to the March 31 Modern Physician. Cited examples of intimidation included condescending language, impatience with questions, verbal abuse and threatening body language.

Of those that did question orders, the report found that 49% of respondents dispensed a medication anyway because they felt pressured by the physician. Seven percent of respondents said they were involved in a medication error over the past year where intimidation was a factor.

The ISMP recommended that health care organizations create a code of conduct to improve the work environment and protect patients.

Modern Physician is online at:

A summary of the ISMP report is online at:


Access to care

More Americans going without health insurance, accumulating health care debt

More than one-quarter of American adults were without health insurance for part or all of last year, according to a new survey by the nonprofit Commonwealth Fund.

The survey found that, among those with household incomes of between $20,000 and $34,999, 35% had no coverage in 2003, up from 28% in 2001. Among black Americans, 38% were uninsured for at least part of 2003, compared with 27% in 2001.

The survey also found that 49% of those who had insurance were being asked to pay a higher share of their health care costs or had reduced benefits. These higher out-of-pocket costs resulted in more people--up to 37% from 29% in 2001--reporting that they had not filled prescriptions or sought necessary care.

Just over 40% of survey respondents reported having medical debt, including those with and without coverage. Sixty-two percent of those in debt said they had insurance at the time the bills were incurred.

The Commonwealth Fund survey results are online at:


Alcohol screening

National Alcohol Screening Day set for April 8

The College is encouraging internists to participate in National Alcohol Screening Day on April 8 by screening all patients for alcohol use and misuse. Screening materials available through event coordinators can be used at any time to screen patients.

Screening materials include a one-page screening form that addresses the full range of alcohol disorders, from at-risk drinking to dependence. The form can be completed by the patient in the waiting room, scored by staff and then placed in the patient's file for physician review.

Screening kits also include patient educational materials, including brochures and a video, and "Helping Patients with Alcohol Problems: A Health Practitioner's Guide" from the NIH and the National Institute on Alcohol Abuse and Alcoholism.

For more information and screening materials, visit: or call 800-253-7658.


ACP news

College voices opposition to Medicaid cuts

The College joined with 19 other medical groups in opposing Medicaid funding cuts and urging lawmakers to reject such cuts in the 2005 budget resolution.

A March 29 letter sent to all members of both the House and the Senate expressed strong opposition to achieving budgetary savings by reducing Medicaid funding. The letter noted that states may look to provider payment cuts and benefit reductions as a way to offset reduced Medicaid funding, which will ultimately increase the number of uninsured Americans.

The College also urged lawmakers to consider extending Medicaid's federal matching assistance program beyond June 30, when $10 billion in temporary state relief will expire.

Both the Senate and the House passed their respective versions of the budget resolution. A conference committee made up of members of both the House and the Senate is working to agree on a final package.

The letter can be accessed online at:


New ACP book offers stories of ordinary people and extraordinary heroism

In "Healers & Heroes: Ordinary People in Extraordinary Times," Clif Cleaveland, MACP--the author of "Sacred Space," also from ACP--has collected true stories about ordinary men and women who, through courage and fortitude, exemplify heroism and bravery.

Featuring 12 different accounts of individuals, "Healers & Heroes" shows ordinary people rising to the rank of hero.

Dr. Cleaveland will be signing copies and reading from his new book at Annual Session in New Orleans on Wednesday, April 21, at 6:00 p.m. in the Exhibit Hall. Additional book signing sessions will be held on Thursday and Friday in the Exhibit Hall as well.

The 250-page hardcover book is available to members for $22 ($25 for non-members). You can get more information and order the book online at

You can also order by phone at 800-523-1546, ext. 2600 (refer to product #330300730).


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Copyright 2004 by the American College of Physicians.

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