In the News for the Week of 10-25-05
- Senate proposal contains positive update for 2006, but prospects for halting Medicare pay cuts is an uphill battle
- Drug plan finder goes online
- Medical research dealt heavy blow by storm
Clinical news in the headlines
- Study findings raise risks of bariatric surgery
- Cancer drug cuts HER2 breast cancer recurrence in half
- ACP Journal Club: chemotherapy, hormonal therapy in early breast cancer
Access to care
- Hospitals change uninsured billing practices outside of court
- Survey: Uninsured lack means, not motivation to seek care
- Groups, hospitals needed to assess patient communication
At press time, the Senate Finance Committee was considering a budget reconciliation bill that would rescind the expected 4.4% reduction in physician reimbursement for 2006, and instead substitute a 1% increase. It is anticipated, but not certain, that the committee will approve the legislation. However, this does not guarantee that the positive update will occur.
The bill must then pass the full Senate, and the House of Representatives will also need to pass its own reconciliation bill. Further negotiations among the key leaders in the Senate and House then will follow in conference committee. Because the bill coming out of the House Ways and Means Committee is not expected to contain any Medicare provisions, ACP’s Washington office reports that it will take an unprecedented grassroots response from physicians and patients to persuade Congress to halt the cuts.
“The problem is that leaders of the House of Representatives are under intense pressure from fiscal conservatives to oppose any provisions that would increase Medicare spending—including relief from the Medicare SGR [sustainable growth rate] cuts," said Robert B. Doherty, ACP’s Senior Vice President for Governmental Affairs and Public Policy. “The only way for us to protect patients and members is to apply our own pressure, through an unprecedented grassroots membership effort, so that Congress becomes aware of the devastating impact the cuts will have on patient care.
"We have very little time left to get Congress to act," he continued, "since Congress hopes to adjourn for the year as early as November 18. We are asking every ACP member to contact their House member and Senators before it is too late.” Information on how to contact Congress regarding the Chairman's budget reconciliation mark can be found on ACP’s LAC.
The Senate bill, sponsored by Finance Committee Chairman Charles Grassley (R-Iowa), also includes pay-for-performance initiatives that are expected to save Medicare $4.5 billion over the life of the five-year bill. The proposed legislation sets in motion pay for performance, slated to begin in 2007. Physicians who do not participate in this quality improvement initiative would see 2% reductions in their Medicare reimbursements for 2007 and 2008, on top of any other possible reimbursement cuts.
While ACP recognizes that the 1% increase is a significant improvement over the projected 4.4% reduction, the College told Sen. Grassley in an Oct. 24 letter that unless the SGR system is permanently repaired, as opposed to just adjusted, then many physicians, especially those in small and rural practices, could not participate in any quality improvement programs. The expense involved in acquiring the necessary technologies, and most likely additional staff, would be cost-prohibitive.
College President C. Anderson Hedberg, who signed the letter, reminded Sen. Grassley that internists care for large numbers of Medicare patients, and reductions in physician pay could limit these patients' access.
The letter is online.
The CMS last week introduced a new tool to help Medicare beneficiaries select a plan under the new prescription drug coverage program that begins in January.
The Prescription Drug Plan Finder compares the costs, coverage and convenience of various plans based on beneficiaries' individual needs, said an Oct. 17 CMS news release. Beneficiaries without Internet access can get the same information by calling 800-MEDICARE.
The Plan Finder also checks to see if beneficiaries qualify for financial assistance, if they have coverage under an employer or union, and if they are already enrolled in a Medicare Advantage or other Medicare health or drug plan, the release said. Data may not be current until later in the year as drug plans are still updating their price and benefit information. Employers have until Oct. 31 to submit applications.
In addition to the Plan Finder, the CMS has also posted other online resources to assist with drug plan enrollment:
A “Getting Started” brochure.
The Medicare Prescription Drug Plan Cost Estimator.
The BenefitsCheckUpRx, an online service to help people assess drug coverage and explore their rights and options.
An online map showing plans that offer coverage in your area.
Enrollment in the prescription drug plan starts Nov. 15, 2005, and runs through May 15, 2006. Coverage begins on Jan. 1 or on the first day of the month following enrollment.
The CMS news release is online.
For more information, see "Getting yourself ready for Medicare Rx" in the October ACP Observer.
And, the College has launched a Web site dedicated to Part D information.
In the aftermath of Hurricane Katrina, scientists at New Orleans’ research universities have seen years of work destroyed.
At Tulane University, for example, 170-year-old labs were flooded with sewage-infested water while tissues and microbes decayed during power outages, according to the Oct. 21 Philadelphia Inquirer. The university’s 300 medical researchers have been trying to salvage what’s left of their projects, which represent hundreds of millions of dollars in federal funding.
Louisiana State University’s (LSU) medical research center also suffered catastrophic damage, the Philadelphia Inquirer said. LSU lost 8,000 lab animals while thousands more died at Tulane. The 7,000 primates in Tulane’s primate research center, situated on 500 acres in nearby Covington, La., survived.
Tulane also lost many blood and urine samples linked to its ongoing four-decade Bogalusa heart study, the article said. The project, which studied heart disease risk in children living in Bogalusa, Miss., followed 8,000 children, measuring blood pressures and cholesterol at routine intervals to search for disease indicators.
Tulane’s collection of stem cells used in research on Alzheimer’s, cystic fibrosis and other diseases was also jeopardized. Industrial freezers usually set at 80 degrees below zero rose to 80 degrees above zero following the storm.
Many of the city’s researchers have moved to Houston or are taking visiting professorships at out-of-state universities, said the Philadelphia Inquirer. Tulane University officials said they hoped to reopen labs by January.
The Philadelphia Inquirer is online.
Clinical news in the headlines
A recent study of Medicare patients found that the risks of dying after bariatric surgery are higher than previously thought, especially for elderly patients and for those who undergo procedures in low-volume surgical centers.
Among the more than 16,000 Medicare beneficiaries in the study who underwent bariatric surgery between 1997 and 2002, the risk of dying increased with age and was highest among men. The overall mortality rate was 2% at 30 days, 2.8% at 90 days and 4.6% at one year. The study appears in the Oct. 19 Journal of the American Medical Association (JAMA).
Previous estimates of death rates among surgical patients between ages 30 and 50 have been under 1%, noted the Oct. 19 Philadelphia Inquirer, compared with more than 5% of men and almost 3% of women between ages 35 and 44 in the current study. The study also reported that patients older than age 65 had an 11.1% risk of dying one year after surgery and that the odds of dying within 90 days increased another fivefold for patients older than age 75.
Patients in the study died of a variety of complications following bariatric surgery including malnutrition, infection, and bowel and gallbladder problems, the Philadelphia Inquirer said. The study included all types of obesity surgery, with gastric bypass being the most common.
The study also reported that the death rate increased among patients treated by less experienced surgeons or at low-volume surgical centers. For patients older than age 65, the death rate was 21% at centers that performed the fewest procedures compared with 3.6% at the highest volume centers.
An accompanying editorial noted that approximately 90% of the Medicare beneficiaries in the study were younger than age 65 and medically disabled. This group’s greater disease burden may have contributed to the mortality rate.
The editorial also suggested that while bariatric surgery may be riskier than previously thought, it also can save lives—if done correctly. Surgical volume and experience help mitigate the costs and risks associated with performing these procedures on vulnerable patients.
The JAMA abstract is online.
The Philadelphia Inquirer is online.
A recent study found that a drug commonly used to treat advanced breast cancer can significantly improve survival among women in the early stage of the disease.
Trastuzumab taken for one year after primary therapy reduced the rate of recurrence by 50% in women with HER2-positive breast cancer. The trial, which included more than 5,000 women, also showed that trastuzumab was effective regardless of the type of chemotherapy regimen received before treatment and of the extent of nodal involvement. The results appear in the Oct. 20 New England Journal of Medicine (NEJM).
The authors noted that the results were the most promising news in breast cancer treatment since tamoxifen was tested in hormone-receptor-positive disease. HER2-positive breast cancers account for between 15% and 25% of breast cancers.
The drug, marketed by Genentech Corp. as Herceptin, is currently approved for advanced breast cancer. Genentech has applied to have early stage treatment added to the drug’s label, according to the Oct. 20 Washington Post. Many physicians began recommending the drug for early stage treatment when study results were first announced last spring.
Of the approximately 200,000 women diagnosed with breast cancer each year in the United Sates, about 30,000 are expected to take trastuzumab, preventing potentially 7,000 relapses, the Washington Post said. However, experts cautioned that more research is needed since the women in the study were followed for a maximum of only three years.
In addition, said the article, the study did not make clear whether trastuzumab should be taken with or without chemotherapy drugs. However, the study’s authors concluded that the results are powerful enough to consider one year of adjuvant trastuzumab as a standard treatment option for women with HER2-positive breast cancer after primary therapy.
A New England Journal of Medicine abstract is online.
The Washington Post is online.
A recent review demonstrated that the benefits of adjuvant therapy for women with breast cancer persist far beyond the end of treatment.
The reviewers looked at 194 randomized clinical trials begun before 1995 that tested adjuvant chemotherapy, tamoxifen, and ovarian ablation or suppression in women with early breast cancer. After 15 years, there was a 10% absolute improvement in breast cancer mortality in women who underwent polychemotherapy between four and six months and a 9.2% absolute improvement in women given tamoxifen for five years.
The review is abstracted in the November-December ACP Journal Club and has been released early.
With more effective and less toxic treatments becoming available in the intervening years since the trials, the benefits of adjuvant therapy may be even greater than indicated, said Journal Club reviewer Thomas J. Smith, FACP, and James Khatcheressian, MD, of Virginia Commonwealth University in Richmond, Va. Recent trials indicate that adding paclitaxel to four cycles of doxorubicin-cyclophosphamide further increases women’s chances of survival.
Reviewers noted that new therapies that may improve overall survival are emerging at a rapid rate. Examples include giving chemotherapy every two weeks instead of every three; adding trastuzumab to those cancers overexpress human epidermal growth factor receptor-2; switching to a low-fat diet; and using aromatase inhibitors in addition to tamoxifen.
Adjuvant!, an online evidence-based program, is a good resource for physicians to keep up with new developments, the reviewers said. The Web site has a simple prediction tool to estimate the absolute benefits for women considering various additional therapies.
Peer ratings for this article: 7/7 stars by oncologists, general internists, general practitioners and family practitioners.
ACP Journal Club is online.
Access to care
Increased scrutiny of nonprofit hospital billing practices in the wake of lawsuits alleging overcharging of uninsured patients has led to positive changes by hospitals included in a national study.
Many hospitals have modified their billing and collection procedures for low-income uninsured patients, according to the Center for Studying Health System Change (HSC), which collected data in 2005 in 12 U.S. communities. Many hospitals have shifted bad debt to charity care write-offs, said an October 2005 HSC issue brief, with little impact on their bottom line.
Most hospitals are making changes without being directed by the courts or regulators, the HSC report said. While most federal lawsuits against nonprofit hospitals have been unsuccessful, suits in state courts and the threat of Congressional investigations have kept pressure on hospitals to act on their own.
Hospitals in more than 50 health systems nationwide have been named as defendants in class-action lawsuits alleging that the hospitals charged uninsured patients full billed charges despite Medicare and other insurers receiving large discounts, the HSC report said. In response, according to the report, many hospitals have altered their pricing, billing or collection policies; improved communication with patients; and increased the income threshold for charity care.
While changes are positive, the report urged policymakers to remember that many hospitals are dealing with continuing increases in uncompensated care as a result of the overall increase in the uninsured population and poor access to specialty care. Fixing billing and collection practices, researchers said, is not a substitute for addressing fundamental problems in the health care system.
The Center's Issue Brief is online.
The Center for Studying Health System Change’s 2003 Household survey argues against the notion that uninsured people are uninsured by choice.
The nationally representative survey asked adults whether they had recently experienced one of 15 serious symptoms, such as shortness of breath or chest pain, and whether they perceived the need to seek medical care, according to an October 2005 HSC Issue Brief. Uninsured respondents were just as likely to see the need for care but were much less likely to seek it out. Among insured respondents with one of those symptoms, 82% saw or talked with a provider compared with 37% of the uninsured.
The survey found that the perceived need for care also was not affected by race, economic status or education. After accounting for these differences, the uninsured were still less than one-third as likely to seek care for potentially life-threatening or serious symptoms.
Findings indicate that lack of health insurance is the main reason for differences in access to care between the uninsured and the insured, the HSC said. The findings are also consistent with research showing that the uninsured have poorer health outcomes than the insured.
The HSC Issue Brief is online.
A list of College advocacy letters and policy papers on behalf of the uninsured is online.
Physician practices and hospitals are being sought to field-test a self-assessment toolkit on patient-centered communication among diverse populations.
Eight hospitals and eight medical groups will be selected across the country to assess current communication practices and help develop the assessment tools. Selected facilities and groups will receive a one-day site visit, independent data entry and analysis, and a comprehensive report on results, as well as a $1,000 grant toward expenses. The toolkit is being developed by the Ethical Force Program, a collaboration of the AMA, the American Hospital Association and other groups.
The toolkit focuses on patients who risk poor health outcomes because they cannot communicate well with professionals in the health care system. These include patients with low health literacy and members of minority groups who do not share mainstream health care beliefs.
Initiative organizers are interested in collaborating with groups and facilities that have well-established communication programs, as well as those whose programs are in the planning or early development stages.
The deadline for applying is Nov. 4, with participants to be selected Nov. 12. More information is online.
ACP's "Cross-Cultural Medicine" provides important background information on various racial, ethnic and cultural groups, their general health problems and risks, and spiritual and religious issues. (Once at the URL, type "cultural competence" in the enter text box.)
The College's "Efficiency Through Effective Communication" video provides evidence-based material to help practicing physicians learn communication skills to make office visits more efficient and effective.
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Copyright 2005 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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