In the News for the Week of 12-20-05
Payment reform update
- House takes action, but the Senate debate continues
- Hospitals make slow progress with safety systems
- College releases comprehensive pay-for-performance guidelines
- ACP urges broader "safe harbors" for information technology
- College issues drug-importation recommendations
- CMS enacts new Medicare Rx safeguards for "dual eligibles"
- New HEALTH TiPS helps patients with Medicare Part D
Clinical news in the headlines
- Annals highlights: Yoga helps reduce back pain
- Birth control pill found to be safe for women with lupus
Pay for performance
- Most markets in study slow to embrace pay for performance
There will be no 12-27-05 or 1-3-06 ObserverWeekly editions.
Payment reform update
On December 19th, the House of Representatives by a vote of 212-206 passed a budget reconciliation bill that includes an extension of current Medicare physician payments through 2006.
The bill would avert the 4.4% cut scheduled to take effect Jan. 1, 2006, at a cost of approximately $7.3 billion over five years, and it does not include any pay-for-reporting of performance measures. The House has adjourned and is not expected to return for any further action.
The Senate is currently debating the budget reconciliation bill, but the bill is facing opposition due to unrelated spending cuts that would reduce Medicare and Medicaid spending by a combined $13 billion over the next five years. The final vote is expected during the next few days, and the vice president has been called into the Senate session in anticipation of a tie vote.
If the Senate passes the bill, the current Medicare physician payments will be extended in 2006 with minor changes to the fee schedule from other unrelated rules. We expect that the CMS will distribute and post a revised fee schedule on its Web site, or you could contact your carrier for more information. Physicians can find their carrier's Web site online by clicking "Contact Your Carrier/FI" link near the bottom on the right-hand column.
If the Senate defeats the bill, however, the 4.4% decrease in Medicare physician payments will take effect Jan. 1. More information will be posted on ACP Online as it becomes available.
Visit ACP’s Legislative Action Center for information on how to contact your legislators and for additional information on the College’s advocacy program.
New research has found that hospitals have made little progress in improving patient safety systems in the seven years since a seminal Institute of Medicine report on medical errors was published.
Hospital patient safety systems are “not close to meeting IOM recommendations,” concluded the authors of a study appearing in the Dec. 14 Journal of the American Medical Association (JAMA). The lack of progress is reason for concern, they said, and improvement efforts must be accelerated.
Researchers surveyed all acute care hospitals in Missouri and Utah in 2002 and 2004 to assess changes. They found that 74% of the hospitals had developed written safety plans but that almost 9% had no plans in place. While most hospitals had made substantial progress in surgical areas, that was not the case for medication safety, despite a long history of error prevention efforts. In the 2004 survey, only 34% of responding hospitals reported having a fully implemented computerized physician order entry (CPOE) system.
The survey asked about the following seven patient safety areas:
- CPOE, computerized test results and assessments of adverse events;
- specific patient safety policies;
- use of data in patient safety programs;
- drug storage, administration and safety procedures;
- manner of handling adverse event reporting; prevention policies; and
- root cause analysis.
While hospitals showed improvements in specific areas, there were setbacks in every area surveyed, the authors said. They recommended that hospitals conduct their own surveys to assess progress in each of the seven areas. In addition, more aggressive efforts are needed outside hospital systems, they said, such as heightened consumer awareness of quality and safety through performance reporting and mandatory public reporting of hospital errors.
The JAMA abstract is online.
ACP has issued sweeping recommendations that would support a fair and transparent pay-for-performance system within both the public and private sectors.
Released last week, the 34-page "Linking Physician Payments to Quality Care" position paper outlines detailed guidance for developing and implementing pay-for-performance programs. The recommendations include the following:
The current physician payment system should be replaced with new reimbursement methods that reward physicians using evidence-based standards of care. Financial incentives for physicians should be broad enough to encourage quality improvement efforts, the policy states. Incentives should be balanced between rewarding high performers and those who achieve substantial improvements over time.
Rewards should reflect physicians' quality improvement efforts, which will inevitably differ among physicians across and within medical specialties.
Pay-for-performance systems should rely on valid, reliable clinical measures, data collection and analysis, and reporting mechanisms.
Information technology capabilities, such as electronic health records (EHRs) and decision-support tools, should be recognized for their ability to allow internists to do well on quality measures and report their progress.
In a press release that accompanied the paper's release, College President C. Anderson Hedberg, FACP, noted that Congress would have to restructure Medicare payment policies to support quality improvement as a necessary first step before moving to a pay-for-performance system.
The paper, which was released last week, was sent to Congressional leaders and to key organizations, including the Institute of Medicine, the Robert Wood Johnson Foundation and the Commonwealth Fund.
The paper is online.
The ACP press release is online.
The College has asked the CMS to significantly expand a proposed safe harbor rule for electronic prescribing and electronic health records (EHRs). While the proposed rule would establish new safe harbors under federal anti-kickback statutes, ACP said the rule does not provide enough options to facilitate widespread technology adoption.
The CMS has proposed that physicians be allowed to accept information technology donations from specified donors, including large group practices and hospitals. In Dec. 12 letters to the CMS and the HHS' Office of Inspector General, ACP urged the CMS to adopt the following recommendations:
Modify the CMS requirement that hospitals can donate equipment only to physicians on their medical staff. Donors should be allowed to donate technology to all members of a group practice, ACP said, not just those with admitting privileges. Similarly, group practices should be able to donate technology to independent contractors who are not physicians.
Extend the proposed safe harbor to include other categories of donors and recipients, such as nursing homes and community health centers, as well as physician-hospital organizations and regional health information organizations.
Expand the types of technology that can be donated to include any equipment, license, software or training service used to develop or facilitate the adoption of information technology.
Remove provisions that limit the aggregate fair market value of all donated items and services. Setting any per-physician cap or limit, the College said, would stifle technology implementation.
The College also said that Congress should significantly increase financial incentives for physicians to offset the costs of implementing information technology. Those incentives could take the form of grants, loans, tax credits or Medicare payment add-ons for physicians using technology in their practice.
In a newly released monograph, the College has outlined its support for drug importation to relieve the high cost of prescription drugs in the United States—as long as the quality and safety of imported drugs can be maintained.
To safeguard drug quality and safety, the College recommends the following:
Congress should take several actions before legalizing importation, which include permitting state pilot programs to test the safe implementation of importation programs and creating an independent FDA oversight board to handle drug safety issues.
Importation systems should honor only prescriptions written by a U.S. licensed physician; include tight control and documentation requirements; and be restricted to countries with high assured safety standards.
Certain medications should not be imported, including controlled substances and drugs that have strict temperature requirements.
The monograph also states that drug importation should be only a temporary solution to counter high drug prices within the U.S. Other solutions, the College said, should include allowing Medicare to negotiate volume discounts with drug companies.
The policy monograph is online.
The CMS has recently taken steps to ensure that "dual eligibles"—patients who qualify for both Medicare and Medicaid—will suffer no lapse in drug coverage under the new Medicare drug benefit that takes effect Jan. 1.
The CMS is trying to identify and automatically enroll dual eligibles, whose drug coverage will switch from state plans to the Medicare prescription drug benefit, in a Medicare Part D plan. For dual eligibles not automatically enrolled by Jan. 1, according to a recent CMS news release, the agency has devised a point-of-sale solution so patients can avoid a coverage gap.
Those patients can take their prescription to any pharmacy nationwide. Pharmacists will be able to immediately verify patients' eligibility and sign them up for a Part D plan while filling their prescription. More than 6 million patients currently qualify as dual eligibles.
The CMS has enacted other safeguards for dual eligibles, the news release reported. Those include specific protections for dual eligibles living in long-term care facilities and making sure that plan formularies recognize patients with special needs. Those include patients with mental health issues, disabilities and HIV/AIDS, and those living in nursing homes.
The CMS will also have specially trained operators and case work coordinators to help dual eligibles with questions and concerns.
Information on CMS transition plans for dual eligibles is online.
The College has launched a Medicare Part D-dedicated Web site as part of ACP's Practice Management Center site with resources for physicians and patients.
The ACP Foundation has added a new Medicare Part D HEALTH TiPS to its patient education series, with important information physicians can give patients on the new Medicare prescription drug benefit.
The "Medicare Part D" tip sheet clarifies sign-up deadlines and provides follow-up telephone numbers and Web sites for more detailed information patients can use to understand the complex new Medicare drug program.
The ACP Foundation's "HEALTH TiPS" are user-friendly, often illustrated and written at a fifth grade reading level or lower. They are designed to provide just enough important information to orient patients and help them make decisions.
Other HEALTH TiPS materials cover pain management, hypertension and "Health Shelter Living" for people displaced by natural disasters. For more information, see the ACP Foundation Web site [LINK http://foundation.acponline.org/healthcom/ht_order.htm] on.
Clinical news in the headlines
The following articles appear in the Dec. 20 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
A new study has found that a yoga program was more effective in treating lower back pain than another exercise program or reading a book about low back pain.
In the study, more than 100 patients with lower back pain were assigned to one of three groups—yoga, another exercise program or education—and were followed for 26 weeks. Both the yoga group and the exercise group participated in 12 weekly 75-minute classes. All patients could use drugs for back pain as needed.
At 12 weeks, the yoga group had better back function than the other exercise group or the education group, although all reported the same levels of pain. At 26 weeks, the yoga group reported better back function and less pain. The study used viniyoga, a type of gentle yoga with fairly simple poses.
Common treatments for lower back pain—which include nonsteroidal anti-inflammatory drugs, pain medications and muscle relaxants, as well as exercise—are only modestly effective. The study's author pointed out that this is the first major study of yoga for back pain.
Two new studies have found that, despite conventional thinking, birth control pills appear to be safe for women with lupus.
The two studies involved hundreds of women with systemic lupus erythematosus in the United States and Mexico. In one study, 183 pre-menopausal women at 15 centers received either combined oral contraceptives or placebo and were asked to use an additional method of birth control. In the second study, 162 women were randomly assigned to receive combined oral contraceptives, a progestin-only pill or a copper intrauterine device (IUD).
In both studies, the percentage of women who experienced severe lupus flares, symptoms and side effects was about the same, indicating that oral contraceptives did not increase the risk of flare-ups. The studies appear in the Dec. 15 New England Journal of Medicine.
For 30 years, doctors have advised women with lupus not to take oral contraceptives because it was thought that estrogen triggered flare-ups, the Dec. 15 Philadelphia Inquirer reported. As a result, many women of childbearing age used less-reliable birth-control methods, said one study author, resulting in more unwanted and terminated pregnancies.
An accompanying editorial noted that the findings do not necessarily apply to women with severe active systemic lupus erythematosus. In addition, the editorial said, women in both trials who had titers of antiphospholipid antibodies experienced thrombotic events, suggesting that oral contraceptives should be avoided among women with these antibodies.
The editorial pointed out, however, that the studies support the use of oral contraceptives in women with inactive or moderately active, stable lupus.
The Philadelphia Inquirer is online.
Pay for performance
Despite the high profile of pay for performance as a way to improve health care quality, a new report found that incentive programs have been slow to take hold in most communities.
The study by the Center for Studying Health System Change (HSC) found that only two out of the 12 communities it surveyed—Orange County and Boston—had significant pay-for-performance programs in place, according to a Dec. 14 HSC news release. The nonprofit policy research organization based its findings on site visits to 12 nationally representative communities during 2005.
In the communities where no programs exist, physician attitudes toward pay-for-performance ranged from “skeptical to hostile,” the news release said. Programs in Orange County and Boston, meanwhile, are flourishing under the guidance of large medical groups, health systems or independent practice associations that have the resources to track physician performance.
Other report findings include:
In several communities, physicians are worried that the financial rewards would not justify the extra work of participating in an incentive program.
Health plans’ financial commitment to incentive programs have a big impact on physicians’ attitudes, as many physicians believe that health plans are simply redistributing existing funds instead of investing new money.
Physicians are more likely to accept pay for performance if all local health plans have the same program in place.
In markets without large physician organizations, payments per physician will be too small to be effective. That's because physicians in those markets are not able to track large groups of patients with the same health plans and the same illnesses.
The HSC news release is online.
The HSC issue brief is online.
John Tooker, FACP, the College’s Executive Vice President and CEO, has been named to the board of directors for the National Committee for Quality Assurance (NCQA).
The NCQA board oversees the work and programs of the NCQA, a nonprofit organization devoted to improving health care quality. Dr. Tooker is one of 16 health leaders from across the country appointed to the board, which also includes representatives from consumer groups, employers, academia and the public sector.
Dr. Tooker brings a wide range of experience to his new role, according to a Dec. 8 NCQA news release. In addition to his duties at ACP, he is a board-certified internist and pulmonologist as well as an adjunct professor at the University of Pennsylvania School of Medicine.
Dr. Tooker will replace Thomas Reardon, MD, past president of the AMA, on the NCQA board, the release said. NCQA accredits and certifies health care organizations and oversees the development of HEDIS measures used by more than 90% of health plans in the country.
The NCQA also offers both a diabetes and a heart/stroke physician recognition program, as well as a "Physician Practice Connections" program to recognize physicians who use information technology to improve patient care.
The NCQA news release is online.
New York City passed a regulation making it the first city in the country to track patients with diabetes in an effort to help control the disease.
The health code regulation adopted last week marks the first time that a city will collect information about patients with a disease that is non-contagious or not caused by an environmental toxin, said the Dec. 14 New York Times. Under the plan, most medical laboratories in New York will be required to electronically forward the results of blood-sugar tests to the city's health department.
Based on its analysis of those tests, the city will alert physicians about patients who are having trouble controlling their disease, the New York Times said. Doctors would then write or call the patients to urge them to take their medications, get a checkup or follow lifestyle recommendations.
While the move has the potential to help many diabetics, it also raises privacy concerns, the article said. The American Diabetes Association, for example, supports the idea of registries but says patients should be asked for their consent. City officials told the New York Times that they were working on a way for patients to opt out of the program.
New York first used a similar health registry during the late 19th century to combat a tuberculosis epidemic, said the New York Times. Since then, the city health department has tracked other contagious diseases, such as HIV, and environmentally triggered illnesses, including food poisoning.
The New York Times is online.
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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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