In the News for the Week of 10-18-05
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
- Study finds 12% error rate in cancer diagnoses
- Pertussis vaccine proves highly effective in teens and adults
- FDA approves Chiron’s vaccine for shipment
Pay for performance
- Study: Rewarding quality alone yields mixed results
- Health policy research fellowships now available
- HMO survey: Quality is up, enrollment down
- Call for spring 2006 Board of Governors resolutions
Congress has only a few weeks left to stop Medicare from cutting your payments effective Jan. 1. The Senate Finance Committee will be making initial decisions on the proposed Medicare physician payment cuts as early as Wednesday, Oct.19. It is critical that Congress hear from you! It is especially important for ACP members with senators on the Finance Committee and in leadership positions to contact them immediately.
Use ACP’s Legislative Action Center (LAC)—and log on using your e-mail address and ACP as the password—to send an e-mail to your senators and representatives. Click here to learn if they serve in a leadership position or on key health committees.
If you have already sent an e-mail to your legislators, please contact them again to reinforce the urgency of this issue. (The LAC site has sample follow-up messages you can use). If you prefer to reach legislators by phone, use the AMA’s toll-free Grassroots Hotline at 800-833-6354 and enter your zip code.
Click here for talking points for your phone call. Members of the Senate Finance Committee include:
Chair Charles Grassley (R-Iowa)
Max Baucus (D-Mont.), ranking member
Jeff Bingaman (D-N.M.)
Jim Bunning (R-Ky.)
Kent Conrad (D-N.D.)
Mike Crapo (R-Ind.)
Bill Frist (R-Tenn.)
Orrin Hatch (R-Utah)
James Jeffords (I-Vt.)
John Kerry (D-Mass.)
Jon Kyl (R-Ariz.)
Blanche Lincoln (D-Ark.)
Trent Lott (R-Miss.)
John Rockefeller (D-W.V.)
Rick Santorum (R-Pa.)
Charles Schumer (D-N.Y.)
Gordon Smith (R-Ore.)
Olympia Snowe (R-Maine)
Craig Thomas (R-Wyo.), and
Ron Wyden (D-Ore.)
ACP has joined more than 120 other medical organizations in urging Congress to avert the looming 4.4% Medicare payment cut for physicians that is set to take effect Jan. 1, 2006.
In an Oct. 3 letter sent to all senators and representatives, the organizations pointed out that if the January payment cut occurs, the physician payment rate in 2006 will be less than it was in 2001, even though practice expenses have risen sharply during that time.
The letter further cited results from an AMA physician survey, which found that 38% of responding physicians plan to reduce the number of new Medicare patients they accept if the pay cut goes into effect. More than half—54%—of responding physicians plan to put off buying information technology, while 34% of respondents who serve rural populations will discontinue rural outreach services.
The letter also called on Congress to make necessary changes to the sustainable growth rate formula (SGR). The SGR produces negative physician payment updates, the letter explained, because the formula is tied to the gross domestic product, not to the actual cost of providing care. The letter noted that other health care providers—such as home health providers, hospitals, and nursing homes—receive positive updates that reflect practice cost increases, while only physicians are subject to the SGR.
According to the letter, a 2005 Medicare trustees' report projected physician practice cost inflation for 2006 to be 2.7%. After a severe pay cut in 2002 followed by three consecutive years of updates that didn't cover practice cost increases, the letter said, physicians cannot absorb more payment cuts.
The letter is online.
Clinical news in the headlines
The following articles appear in the Oct. 18 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online. All subscribers may receive their issue copy a day or two later than usual, due to printing problems.
Two new diabetes treatments may provide options, but diet and exercise are still first defenses. Studies in this issue describe two new diabetes treatments: exenatide, an injected drug, and inhaled insulin. Both treatments have pluses and minuses, and both were tested on patients with type 2 diabetes who were already taking two oral blood-sugar-lowering drugs but whose levels were not under control.
A 26-week trial comparing benefits and risks of exenatide and insulin glargine injections in 551 patients with type 2 diabetes found that both drugs improved overall sugar control. However, researchers found that patients in the exenatide group lost about five pounds while patients in the insulin glargine group gained about four.
Neither drug helped patients achieve recommended fasting sugar levels, with only 21.6% of the exenatide group and 8.6% of the insulin group achieving target blood sugar levels. Patients in the exenatide group had more side effects, such as nausea, vomiting and diarrhea, and more patients taking exenatide dropped out of the study than in the insulin glargine group.
A 12-week trial comparing effects of inhaled fast-acting insulin with oral drug therapy in 309 patients assigned patients to one of three treatments: inhaled insulin alone, inhaled insulin added to two blood-sugar-lowering oral drugs or oral drug therapy alone.
Researchers found that both groups receiving insulin therapy had improved blood sugar levels. Patients receiving inhaled insulin gained more weight and had more episodes of hypoglycemia and coughing than the oral therapy alone group. The study didn’t compare inhaled insulin with injected insulin and it lasted only 12 weeks, so the drug’s long-term effects on the lungs and on diabetes control are not clear.
An editorial pointed out that the two new treatments provide much-needed options for treating patients in later stages of diabetes. However, until precise molecular targets for type 2 diabetes are developed, increasing exercise and losing weight will be the keys to managing this increasingly common disease.
Drug company assistance programs may still be needed with new Medicare drug programs. An internal medicine practice group calculated drug expenses for 137 low-income Medicare patients without prescription drug coverage who had been helped by pharmaceutical company assistance programs.
Authors put patients into one of four hypothetical groups: no financial assistance; aid from pharmaceutical programs; Medicare drug discount cards, which provided transitional assistance; and the new Medicare prescription benefit, which takes effect Jan. 1, 2006. They then determined out-of-pocket expenses for patients’ prescribed drugs.
They found that the pharmaceutical assistance programs offered the most savings for low-income patients. All plans provided cheaper drugs than having no coverage, while month-to-month expenses for the two Medicare programs varied, depending on patient deductibles.
Researchers say that before enrolling in a new drug benefit program, individuals should consider their eligibility for low-income subsidies as well as their prescription needs and projected costs. For some seniors, alternatives such as pharmaceutical company assistance programs may provide more cost savings.
Errors in diagnosing cancer occurred in almost 12% of cases included in a recent study, triggering repeat testing and some treatment delays.
The majority of errors occurred in the lab as a result of improper tissue and blood sampling and inaccurate reading of results, said the Oct. 10 Forbes.com’s HealthDay News. In the yearlong study, researchers analyzed one year of errors recorded at four medical centers. The study appears in the Oct. 10 online edition of the journal Cancer.
Misdiagnoses occurred in a wide range of cancers, both gynecologic and non-gynecologic, said Forbes.com. The study authors noted that efforts to reduce errors were confounded by the lack of uniform standards across hospitals on how to monitor and review errors.
Error frequency varied widely by institution, ranging from 1.79% to 11.8%, authors said. Even though all four hospitals used the same process to review conflicting diagnoses, physicians at the different institutions often disagreed about what caused an error and what harm resulted to patients.
Errors for gynecological cancers—interpreting Pap smears or cervical biopsies, for example—occurred between 2% and 9% of the time, said Forbes.com, while non-gynecological cancer diagnoses were in error in between 5% and 11.8% of cases studied. Researchers said the actual percentages of errors are likely higher because the medical centers were still in the early stages of creating a uniform assessment system.
The authors urged the medical community to adopt standard error identification and monitoring guidelines to facilitate comparisons across institutions.
The Cancer abstract is online.
Forbes.com is online.
Two new pertussis vaccines tested in a recent study were very effective in preventing infection in adolescents and adults, triggering a call for routine booster shots in adolescence.
In the trial, 2,800 people between ages 15 and 65 received either tricomponent acellular pertussis vaccine or a hepatitis A vaccine, and were monitored for 2.5 years for signs of illness with persistent cough.
Investigators found that the vaccine was 92% effective, with only one person in the vaccine group developing pertussis vs. nine in the non-vaccine group. The study appears in the Oct. 13 New England Journal of Medicine (NEJM).
Pertussis has declined in frequency over the last 50 years because most children get immunized by age 6, said the Oct. 13 Philadelphia Inquirer. However, outbreaks among adults and teens spiked in the 1990s as immunity wore off. Those two groups now account for about 60% of all pertussis cases.
Two new booster vaccines were approved by the FDA last spring, said the Philadelphia Inquirer. Boostrix, made by GlaxoSmithKline PLC, is geared to adolescents, while Sanofi-Aventis SA’s Adacel is recommended for teens and adults. The new vaccines, which also protect against diphtheria and tetanus (dTaP), cause fewer side effects than older tetanus-diphtheria toxoids (Td).
Pertussis is one of the least well controlled yet preventable illnesses, the study’s authors said. While the disease is not as serious in adults as in children, adults often pass it on to children in whom it can be fatal.
An accompanying editorial noted that there is enough evidence to recommend the dTaP vaccine for all adolescents. However, more research is needed to develop better diagnostic tools and to test the safety of the vaccine in the elderly, pregnant women and newborns.
The NEJM abstract is online.
The Philadelphia Inquirer is online.
The FDA last week approved Chiron Corp.’s first batch of 1.5 million doses of influenza vaccine, easing fears about tight supplies going into the flu season.
California-based Chiron Corp.—which destroyed 50 million doses last year following fears of contamination, a move that led to a U.S. vaccine shortage—expects to produce between 18 million and 26 million doses this year, according to the Oct. 13 New York Times. Three other manufacturers, Sanofi-Aventis, GlaxoSmithKline and MedImmune, are slated to bring the combined total of available vaccine doses to about 90 million.
The FDA approval relieves fears that distributors may have to ration supplies to ensure that high-risk patients receive shots, the New York Times said. Sanofi-Aventis, the largest producer with an expected shipment of 60 million doses, has been making partial shipments to make sure all customers receive some vaccine in case of another shortage.
Chiron said it expects to continue vaccine deliveries through early December, the New York Times reported. London-based GlaxoSmithKline is expected to ship about 8 million doses of vaccine while Gaithersburg, Md.-based MedImmune said it has increased production of its nasal vaccine FluMist beyond the 1.7 million doses it delivered last year.
The New York Times is online.
Most physician offices should receive their ordered vaccine supplies by mid- to late- October. If you have not received all your vaccine, here are resources you can recommend to high-risk patients to get vaccinated:
The American Lung Association's Flu Locator Web site allows you to enter your zip code to find flu shot clinics near you.
211 is a new by-phone flu vaccine finder call service for people without Internet access. Operators are on hand to help callers find the nearest clinic and connect them to other community resources. The service is operating in all or parts of 32 states and the District of Columbia.
Pay for performance
A recent study on the effects of pay-for-performance programs in a large health plan concluded that tying bonuses to fixed quality standards largely rewards high performers while neglecting those who make the biggest improvements in patient care.
The study compared California doctors participating in PacifiCare Health Systems’ pay-for-performance program with similar data on physicians in Oregon and Washington who were not involved in incentive programs. The California group showed greater improvement than the other groups in cervical cancer screening (5.3% improvement vs. 1.7%), but improvements were about the same for all groups in the two other measures studied: mammography and HA1c testing.
The study, which included 300 large physician groups who received quality reports between 2001 and 2004, appears in the Oct. 12 Journal of the American Medical Association (JAMA).
PacifiCare’s initial payout was $3.4 million, the authors said, with 75% of that going to groups who had already achieved quality targets before the program began and showed the smallest percentage improvement. Lower performing groups achieved the greatest improvement but had a small share of the bonuses.
The findings suggest that incentive plans should be designed to reward both performance and improvement, the authors said, so rewards help low performers improve as well as award high-achieving providers who consistently exceed quality thresholds. The findings also suggest that the financial rewards in the study—$27 per patient—were too small to motivate better performers to reach beyond the status quo. In the study, PacifiCare accounts made up only about 15% of the average practice’s revenue.
The authors noted that the PacifiCare program may not have been operating long enough to realize substantial quality improvements. Participating groups may be using bonus payments from several quarters to make infrastructure improvements that would help them increase their scores.
Researchers also pointed out that PacifiCare’s improvement program should be viewed as a first step toward aligning incentives with quality goals. The chief lesson to be gleaned from this study, they added, is that incentive plan design is a key factor in improving patient care.
The JAMA abstract is online.
In related news, the National Quality Forum (NQF) earlier this month endorsed another 35 ambulatory care measures, six of them designed for public reporting. The new endorsements bring the number of ambulatory care measures that have now been endorsed by the NQF to 51. The new public reporting measures include standards for treating asthma and coronary artery disease, childhood immunization and cancer screening, according to the Oct. 12 Modern Physician. The other 29 measures are geared toward internal quality improvement in diabetes care, Modern Physician reported.
Modern Physician is online.
The CDC's National Center for Health Statistics (NCHS) is seeking applicants for its 2006 health policy fellowship program. The program brings visiting scholars in health services-related research to NCHS' headquarters in Hyattsville, Md., to use NCHS data system and collaborate on health services research.
Up to two individuals will be selected for the full-time fellowship, which lasts between 13 and 24 months and begins September 2006. Applicants must demonstrate training or experience in health services research and be at least at the doctoral student level. Doctoral students must have completed course work and be at the dissertation phase of their program.
The fellowship program, which is now in its fourth year, gives researchers access to new data resources and strengthens their opportunities to understand health policy.
More information is online.
A recent survey of major HMOs found that quality has improved but enrollment has slid as patients switch to preferred provider organizations.
The survey of 289 mostly HMOs found that performance in 2004 improved on 18 of 22 clinical measures, said an Oct. 11 Commonwealth Fund news release. However, the number of people enrolled in the HMOs declined by 4.5 million over the previous year, to 64.5 million. The survey was conducted by the National Committee for Quality Assurance.
The most significant quality improvements at surveyed HMOs were related to controlling high blood pressure across all patients and controlling cholesterol levels in diabetics, the release said.
The Commonwealth Fund is online.
The deadline for submitting new resolutions to be heard at the April 2006 Board of Governors meeting is Monday, Dec. 5, 2005. To initiate a resolution, ACP members must submit that resolution to their Governor and/or chapter council. A resolution may address any issue or topic. It becomes a resolution of the chapter once it is approved by the chapter council.
In accordance with the ACP Board of Governors resolutions process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy …”), or a directive, which requests action or study on an issue (“Resolved that the Board of Regents …”). If more than one action is proposed, each should have its own resolved clause.
For more information on the resolution format, please contact your Governor.
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A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?
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