In the News for the Week of 11-8-05
- College lashes out against looming pay cuts
- ACP will launch a new practice innovation center
Avian flu update
- Government reveals strategy for fighting global pandemic
The business of medicine
- Aetna will reimburse for depression screening
Clinical news in the headlines
- One-stop testing may boost cervical cancer treatment for low-income women
- ACP Journal Club: Blacks and whites have similar responses to different hypertension drugs
- Survey: Medical error rate highest in U.S. among six nations
- College-supported organization offers opportunities overseas
Medicare last week released final rules on Medicare payment cuts, implementing the expected 4.4% cut for physicians and a 3.7% increase for hospitals.
The cuts will take effect Jan. 1 unless legislation is passed to reverse them. Last Thursday, the Senate reconciliation bill—which passed 52-47—included a 1% payment update for 2006 to replace the 4.4% cut.
The Senate reconciliation bill also included pay-for-reporting provisions to start in 2007, with a 2% reduction in the conversion factor for physicians who do not report. The House reconciliation bill, which does not contain any Medicare provisions, was approved last Friday by the House budget committee.
If and when the House passes its version, the differences between the House and Senate provisions would then have to be worked out by a conference committee later this month. Any agreement among the conferees would then have to pass the full House and Senate before it would become law.
It is the College’s view that persuading Congress to halt the 4.4% cut will require a constant and sustained communications campaign to explain how the cuts will adversely affect patient care.
To this end, College representatives continue to send blast faxes to senators and representatives, protesting the cuts and advocating for payment reform. Some arguments ACP is making in favor of reform include:
Payment cuts would push many older doctors into retirement and discourage younger physicians from going into internal medicine, while those left in practice would be forced to limit their number of new Medicare patients.
Cuts would slow the adoption of electronic health records because lower payments fall hardest on physicians in small practices who can least afford that investment.
Payment cuts would slow the move toward quality measurement and reporting because small practices would be unable to make the necessary time and financial investments.
In addition, representatives of the College, the American Academy of Family Physicians and the American Osteopathic Association will be meeting with key lawmakers on Nov. 10 to hand-deliver first-hand accounts from primary care physicians on how the payment cuts will adversely affect them, their patients and their community.
Copies of College faxes on reform are online.
The latest ACP update on payment reform is online.
The College has received a two-year grant worth nearly $1 million to create a center for practice innovation to help small and midsize internal medicine practices attain enhanced quality performance while addressing the economic challenges of medical practice.
Slated to open Jan. 1, the Center for Practice Innovation (CPI) will support a patient-centered, physician-guided model of care targeting practice support. Staff will be based in the ACP Washington office.
The CPI plan calls for selecting between 25 and 50 representative medical offices across the country in different settings to test the CPI’s resources and recommended practice innovations, said Michael S. Barr, FACP, the College's Vice President for Practice Advocacy and Improvement.
These offices will receive tools, educational workshops and ongoing consultation from experts in small-practice economics, health information technology and quality improvement. The program will allow ACP to learn how best to support small and midsize internal medicine practices in making the transition to new models of care delivery that will result in improved physician and patient satisfaction, quality, value and reimbursement.
Program results will then be made available to internists nationwide at no cost. The CPI, which Dr. Barr will direct, will be staffed with ACP employees and at least one outside consultant. The application and selection processes for CPI participants are still being determined.
The $996,000 grant to ACP was part of $16 million awarded by the Physicians’ Foundation for Health Systems Excellence (PFHSE), a Florida-based nonprofit dedicated to promoting high quality health care. According to a Nov. 7 press release, PFHSE funds were being distributed to 26 different organizations nationwide. ACP is also contributing $250,000 through in-kind contributions towards the project.
The press release is online.
Avian flu update
The federal government last week requested $7.1 billion from Congress to pay for vaccine development, drug stockpiling and other preparations for a possible global influenza pandemic.
About $2.8 billion of the requested funding would subsidize the development of influenza vaccines, said the Nov. 2 Washington Post. Between $1.2 billion and $1.5 billion would be earmarked for building a 20 million-dose stockpile of experimental vaccine targeting avian flu, while the remainder would go to develop antiviral drugs, new treatments and local government assistance.
There have been 122 human cases of avian flu since December 2003, 62 of them fatal, said the Washington Post. The H5N1 virus is not easily transmitted between people but experts have warned that it could undergo genetic alterations as it spreads. Of the three pandemics in the past 100 years, the worst was in 1918 when 50 million infected people died.
The government last week also released an almost 400-page document detailing its plan for dealing with a pandemic, said the Nov. 3 Washington Post. The plan includes suggestions for physicians on what to do if they suspect a patient has a novel form of influenza. It also favors voluntary quarantines, where “snow days” would be declared to keep people at home during a flu incubation period.
The plan claims that a pandemic would typically infiltrate a community for about two months, often returning a second time, said the Washington Post. Health care workers were urged to prepare for possible shortages of hospital beds, mechanical ventilators and antibiotics.
According to the plan, priority groups to receive vaccines should be workers in vaccine manufacturing plants; medical providers and public health workers; people older than age 65 with chronic illness; and people at high risk of complications, said the Washington Post. States would be expected to pay part of the cost of treating people infected with the flu.
The business of medicine
One of the nation’s biggest health insurers said it would begin covering depression management programs, including reimbursing primary care physicians for screening.
The new program by Hartford, Conn.-based Aetna calls for paying primary care physicians extra fees to screen for depression and provide follow-up visits, according to the Nov. 2 New York Times. Aetna is starting the program in six states and plans eventually to expand it nationwide.
The program was prompted in part by depression’s heavy toll on the workplace, where it is blamed for absenteeism and low productivity, the New York Times said. Untreated depression can lead to even higher medical costs in the long term, the article said, because depressed patients who develop chronic diseases often stop taking their medications or fail to make lifestyle changes.
According to a Nov. 2 Aetna press release, the new program will give doctors access to a network of on-call psychiatrists who can answer questions about specialist referrals as well as to Aetna case managers who will track and follow up with patients. Aetna will also provide Web-based training materials for physicians and staff as well as patient education materials.
Aetna said it would provide additional reimbursement for doctors who take its depression care management training program. And doctors who use Aetna’s screening questionnaire during routine visits with patients will be eligible for a fee increase of between 30% and 40%, or about $15 more per visit, the New York Times reported.
The new program debuts as Aetna ends its outsourcing relationship with Magellan Health Services for its behavioral health business, according to the company release. The pilot phase starting in Jan. 1, 2006, will be launched in the District of Columbia, Maryland, New Jersey, Oklahoma, Pennsylvania, Texas and Virginia.
The New York Times is online.
The Aetna news release is online.
Clinical news in the headlines
A recent study suggests that providing single-visit screening and treatment for cervical cancer is an effective way to ensure that low-income women with abnormal test results receive timely treatment.
The study involved more than 3,500 women located in predominantly underserved Latino areas in Orange County, Calif. After receiving a Pap smear, women were either sent home as usual or kept in the clinic to await results. Women with high-grade lesions were significantly more likely to attend a one-year follow-up visit than women with similar lesions in the usual care group (63% vs. 21%). The results appear in the Nov. 2 Journal of the American Medical Association (JAMA).
Cervical cancer is most prevalent in poor countries where testing is rare and in low-income U.S. neighborhoods, where women are less likely to get Pap tests or return for follow-up care, said the Nov. 1 Washington Post. In the United States, the death rate from cervical cancer is highest among black and Hispanic women.
The single-visit program, which took an average of 2.8 hours, could prevent most cervical cancer if used on women with severely abnormal test results, said the study’s authors. To ensure a quick turnaround, specimens were sent by courier to a lab, an easy adjustment for most labs. The authors also noted that women in the study readily accepted the longer wait.
Providing test results on the day of the visit did not improve overall compliance, with only 36% of the women returning for screening at one year, said the study. However, the program helped ensure that severe lesions were treated quickly.
The JAMA abstract is online.
The Washington Post is online.
Race did not affect patient responses to three different classes of hypertensive agents in a large trial that included black and non-black adults.
The trial involved more than 33,000 adults age 55 or older in centers in the United States, Canada, Puerto Rico and the U.S. Virgin Islands. Patients were divided into three groups who daily received either 12.5-25 mg of chlorthalidone, 2.5-10 mg of amlodipine or 10-40 mg of lisinopril. The drugs were equally effective in reducing cardiovascular disease in all subjects, although chlorthalidone was associated with a lower risk of heart failure than the other two drugs.
The trial, a substudy of the ALLHAT (Antihypertensive and Lipid-lowering Treatment to Prevent Heart Attack) trial, is abstracted in the November-December ACP Journal Club.
The study is consistent with ALLHAT’s overall results, showing that initial treatment with either amlodipine or lisinopril is not superior to chlorthalidone in either racial group, said reviewers Meera Jain, MD, and Mark Rosenberg, MD, of Providence Portland Medical Center in Portland, Ore. However, lisinopril, an ACE inhibitor, was less effective in lowering blood pressure in blacks.
Blacks in the lisinopril group had increased rates of stroke and coronary heart disease, the reviewers said. But it is unclear whether the outcomes were the result of poor blood pressure control or an ACE inhibitor-related effect.
From a clinical perspective, it is noteworthy that fewer patients of either race developed heart failure while taking chlorthalidone, the reviewers said. This result is in line with the Joint National Committee 7 recommendation that thiazide diuretics should be the first-line treatment for hypertension, regardless of race.
Peer ratings for this review: general internal medicine/family practice/general practice/cardiology: 6/7 stars.
ACP Journal Club is online.
The United States had the highest rate of medical errors among six countries included in a recent survey on health care access, safety and care coordination.
The report by the Commonwealth Fund found that one-third of U.S. patients experienced medical, medication or test errors, according to a Nov. 3 Commonwealth Fund news release. Other countries included in the survey were Australia, Canada, Germany, New Zealand and the United Kingdom.
The errors fell into four categories: medical treatment mistakes; wrong medication or dose; incorrect test results; and delays in notification of abnormal test results, according to a Nov. 3 Commonwealth Fund news release. Canada had the next highest percentage of reported errors, with 30% of respondents reporting at least one type of error, followed by Australia (27%), New Zealand (25%), Germany (23%) and the United Kingdom (22%).
The number of errors was especially high among U.S. patients who saw four or more doctors in the past two years, the release said, indicating poor communication among physicians. In every country surveyed, at least 60% of patients said medical errors occurred outside of a hospital.
The United States also stood out on cost comparisons, with 51% of adults reporting that they had forgone care due to financial concerns over the past year, said the release, compared with 13% in the United Kingdom. In addition, 34% of U.S. patients said their annual out-of-pocket expenses exceeded $1,000.
Patients in New Zealand and Germany reported having the fastest access to physicians, while Canadian and American patients were least likely to get same-day appointments, according to the release. Patients in Germany, New Zealand and the U.K. were also more likely than patients in the United States, Australia or Canada to have frequent access to after-hours care.
The Commonwealth Fund news release is online.
U.S. medical schools had their largest enrollment ever this year, according to a new report, with the number of applicants growing by almost 5% over last year's figures.
The 2005-06 enrollment of more than 17,000 first-time students in the country’s 125 medical schools is the largest on record, according to an Oct. 25 Association of American Medical Colleges (AAMC) news release.
Seven schools increased their enrollment by more than 10%, while enrollment at 15 schools grew by more than 5%, noted the release. The numbers are encouraging, the AAMC said, in light of the looming physician shortage expected over the next decade.
The 2005-06 applicant pool increased by 4.6% to 37,364, driven by more Hispanic and Asian applicants, said the release. Applications from Hispanic students rose by 6.4%, while applications from Asians increased by 8.1% over 2004. The number of black applicants remained steady at just over 2,800 while black enrollment declined slightly.
The schools with the largest percentages increases in enrollment for 2005-06 are:
- Florida State University College of Medicine, Tallahassee, Fla. (38%)
- Brown Medical School, Providence, R.I. (20%)
- Joan C. Edwards School of Medicine at Marshall University, Huntington, W. Va. (15%)
- University of Miami School of Medicine, Miami (14%)
- Northeastern Ohio Universities College of Medicine, Rootstown, Ohio (13%)
- University of Missouri-Kansas City School of Medicine, Kansas City, Mo. (12%)
- Jefferson Medical College of Thomas Jefferson University, Philadelphia (11%)
The AAMC release is online.
The National Foundation for Infectious Diseases (NFID) has launched an online in-practice resource program with free materials to help physicians and practices implement new meningococcal vaccine recommendations.
The program now offers a toolkit that ACP helped develop, which contains information on the disease, as well as new recommendations and tips for vaccine delivery, proper billing, and reimbursement. The toolkit also contains sample patient education materials.
Called S.T.O.P Meningitis!, the toolkit material targets adolescents and college-bound students who make up nearly 30% of the close to 3,000 meningitis cases diagnosed in the United States each year, according to the National Meningitis Association (NMA). Up to 80% of these cases, the NMA claims, could be prevented with vaccine.
Medical organizations as well as the CDC now recommend that 11- and 12-year-olds receive new conjugate vaccine. For those not previously immunized, guidelines recommend vaccination when students enter high school or college.
Toolkit materials can be downloaded from the NFID Web site.
More information about meningitis is online.
Physicians who want to volunteer overseas should consider Health Volunteers Overseas (HVO), an ACP-supported organization committed to improving global health. For the past twenty years, HVO has implemented clinical education and training programs in developing countries around the world.
By mentoring health care providers in less developed nations, HVO works to improve global health. ACP sponsors HVO's internal medicine overseas section, which supports training programs for internal medicine generalists and subspecialists in Cambodia, India, Peru, Tanzania and Uganda.
HVO currently supports over 60 projects in more than 25 countries. Each project is different depending on the country's educational needs and technological capacity. HVO volunteers train local health care providers, giving them the knowledge and skills to make a difference in their own communities. Volunteers lecture, conduct ward rounds and demonstrate various techniques in classrooms, clinics and operating rooms.
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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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