In the News for the Week of 8-3-04
- New CMS rule boosts pay, covers physicals, cuts infusion drug payments
Clinical news in the headlines
- Report: Errors may claim more lives than previously estimated
- College applauds Senate passage of patient safety act
- ACP urges the CMS to cover tobacco cessation counseling
- Small practice newsgroup focuses on practice start-up
- College supports JCAHO symposium on nursing shortage
- Chapter meetings offer education, networking
In its proposed physician fee schedule rule released last week, the Centers for Medicare and Medicaid Services (CMS) delivered mixed news for some physicians. While the rule includes raising physician fees and expanding screening coverage for Medicare beneficiaries, it also contains reimbursement cuts for drugs administered in physician offices.
The proposed rule includes the 1.5% physician fee increase that was part of last year's Medicare reform legislation. The rule also includes a 5% pay increase for both primary care physicians and subspecialists in physician scarcity areas.
According to a July 27 CMS press release, the proposed rule expands coverage to include initial physical exams for new Medicare enrollees and screening tests for chronic diseases. The College has long advocated for more Medicare preventive benefits.
Under the proposed rule, the CMS will cover a physical exam for new enrollees and screening for heart disease, diabetes, osteoporosis and cancers of the colon, breast, cervix and prostate. As part of the initial physical, physicians can screen for depression and administer hearing and vision tests. Influenza, pneumonia and hepatitis B vaccinations would also be included.
However, the proposed rule also includes reimbursement cuts for drugs administered in physicians' offices. Beginning next year, the CMS will set the standard payment rate for most Part B drugs at 106% of the average sales price, which will be less than the average wholesale price rates the CMS has previously paid.
According to the July 27 New York Times, representatives of several subspecialties—including oncology, rheumatology, urology and pulmonology—say those cuts may jeopardize patients' access to office-administered drugs. The New York Times reported that reimbursement cuts, which will save $16 billion over 10 years, may curtail oncologists' Medicare revenue by 8% and urologists' by 13%, while reimbursements for two drugs used for patients with emphysema and chronic obstructive pulmonary disorder will be cut 89%.
Medicare will accept comments on the proposed rule until Sept. 24. The final rule will be published Nov. 1 and take effect Jan. 1, 2005.
The CMS press release is online.
The New York Times is online.
See also "Medicare's new office-drug payment policy has oncologists concerned about access" in the April ACP Observer.
Clinical news in the headlines
The following articles appeared in this week's Annals of Internal Medicine. Full text is available to College members and subscribers online.
Elderly benefit from early, aggressive CAD management. In a study of 2,220 patients admitted to hospitals with symptoms of acute coronary artery disease, researchers found that patients benefited from early invasive treatment to prevent heart attack or death. That benefit was greater in patients older than 65 than in younger patients.
Conservative treatment involved medication. Early, invasive treatment involved cardiac catheterization within four to 48 hours of presentation, with a subsequent revascularization procedure such as angioplasty, stent or surgery, when indicated. More...
Female physicians in academic medicine earn less than male counterparts. A survey of 1,814 full-time U.S. medical school faculty in 1995-1996 found that female faculty earned less than men, even after salaries were adjusted for hours worked, job responsibilities and productivity. According to editorial writers, census data show "no other profession in the United States exhibits greater salary disparities by sex". They suggest more transparency in promotion and compensation practices, as well as institutional commitment to remedy disparities. More...
Study examines practice of terminal sedation in the care of dying patients. A survey of more than 480 physicians in the Netherlands found that 52% had used terminal sedation with cessation of food and water in the care of terminally ill patients. In 211 of the most recent cases, hastening death was the physicians' explicit intent for 47% of the patients, while hastening death was partly the physicians' intent for 27% of the patients. Physicians reported that symptom relief was the main intent in many cases. More...
ACP cites principles to heal ethnic disparities in health care. A College position paper identifies eight principles to help eliminate ethnic disparities in U.S. health care. Commentaries point out potential difficulties in implementing those principles. More...
New research indicates that magnetic resonance imaging (MRI) scans can detect tumors better than mammograms in women at high-risk for breast cancer.
The study also found that MRIs lead to more frequent false positives. Findings suggest, however, that despite MRIs' higher costs and the greater incidence of false positives, MRI screening may be a better option for women with a familial or genetic predisposition to breast cancer.
Results were published in the July 29 New England Journal of Medicine (NEJM). Researchers studied 1,909 women, including more than 350 who had germ-line mutations. After an average of three years, researchers detected 45 tumors, 32 of which were identified by MRI. Of those, 22 were not detected by mammography.
MRI screening may also be a safer option for high-risk women who are considering surgery as a preventive measure, according to the July 28 Los Angeles Times. The study's authors noted that MRIs resulted in twice as many unneeded additional examinations as mammography (420 vs. 207) and three times as many unneeded biopsies (24 vs. 7).
The NEJM abstract is online.
The Los Angeles Times is online.
A report released last month concluded that as many as 195,000 Americans may die in hospitals every year due to preventable medical errors, almost double the controversial figure reported by the Institute of Medicine (IOM) in its 1999 "To Err is Human" report.
The new report was released by HealthGrades, a Colorado-based health care rating company. The report looked at data from 37 million hospitalizations of Medicare patients between 2000 and 2002 in all 50 states, according to a July 27 HealthGrades press release.
The IOM report estimated that as many as 98,000 patients every year die from medical errors. According to the July 27 Modern Physician, HealthGrades' higher estimate resulted from the addition of two categories of errors not included in the IOM report data: failure to diagnose, and unexpected deaths in low-risk hospitalizations.
The HealthGrades report estimated that costs associated with preventable errors during 2000-2002 were $6 billion a year. The report also found that the Central and Western regions of the United States had lower patient safety incident rates than in the Northeast and Sunbelt. Teaching hospitals and larger hospitals with more than 200 beds had "slightly higher" incident rates than non-teaching hospitals, the press release said.
The HealthGrades press release is online.
Modern Physician is online.
ACP voiced its approval of the Senate passage of a bill that would create a confidential, voluntary error reporting system.
Last month's Senate passage of the "Patient Safety and Quality Improvement Act of 2003" (S. 720/H.R. 663) paves the way for reconciling the Senate bill with a similar one passed in the House last year. The Senate bill calls for a reporting system that physicians and other providers could use to report error information to patient safety organizations. Those organizations would collect and analyze the data to develop safety improvement strategies.
The bill protects the confidentiality of patient safety data, although other sources of patient information--including medical and billing records--would not be privileged or confidential, according to a College press release. College President Charles K. Francis, FACP, said in the release that the bill "strikes the appropriate balance" between legal protections and accountability.
The College press release is online.
The College has joined more than 60 other national organizations in calling on the CMS to cover tobacco cessation counseling for Medicare beneficiaries.
In a letter sent last month to a CMS official, the College noted that tobacco cessation counseling has been proven effective in clinical trials. A July 2001 study cited in the letter found that tobacco cessation counseling ranked second for effectiveness among 30 different evaluated preventive services.
The letter pointed out that seniors who are motivated to quit smoking are 50% more likely to be able to quit than other age groups. The letter also said that beginning in 2006, Medicare will cover FDA-approved prescription cessation aids including nicotine patches and inhalers. With such devices covered under Medicare, the letter noted, cessation counseling by health care providers could be even more effective.
The letter is online.
This month, the ACP Small Practice Management Discussion Group will target starting a practice as well as those office procedures that can "fast-track" the start-up process.
This month's online discussion will be moderated by Bruce E. Taylor, ACP Member. Dr. Taylor started a solo practice in Selma, Ala., in September 2003 and now has 16 office visits a day. At the same time, Dr. Taylor reports that 30% of his office revenue now comes from in-office procedures, including EKGs, echos, Holters, dexascans, labs and X-rays.
Dr. Taylor will discuss building a practice from the ground up as well as how to negotiate for equipment and work aggressively with payers to maximize procedure coding and reimbursement.
The members-only online newsgroup is designed to promote networking among physicians in small practices, particularly those with between one and five providers.
The small practice newsgroup is online.
ACP has endorsed an upcoming conference being held by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on the national nursing shortage and its impact on patient safety. The College is one of the founders of JCAHO and a long-time member.
The symposium, which will be held Sept. 27-28 in Washington, will focus on critical links between nurse staffing and patient safety, as well as solutions to national and local nursing shortages. Conference leaders will present strategies that hospitals can use to increase their supply of qualified nurses. Physician leaders, health care and nursing executives, and public policy leaders are invited to attend.
More information about the Sept. 27-28 symposium is online.
A College report on the national nursing shortage is online.
This fall, close to 40 ACP chapters in the United States and Canada are holding chapter meetings, giving internists the opportunity to learn about the latest medical advances while developing valuable professional networks.
ACP chapter meetings allow members and guests to earn CME credit and enjoy the collegiality of their fellow chapter members. Regular attendance at ACP chapter meetings is also important for members interested in applying for Fellowship in the College.
Most chapter meetings are one to three days long, while many are held in interesting locations ideal for family vacations. Members are also encouraged to attend meetings of other chapters.
A complete calendar of chapter meetings and information on clinical content 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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