In the News for the Week of 2-15-05
- College urges Congress to change Medicare payment system
- ACP Expert Guides series now features new rheumatology book
- New College resource helps with ABIM exam prep
- Blacks, whites respond differently to asthma drugs
- Cost estimates soar for Medicare drug benefit
Clinical news in the headlines
- JCAHO outlines steps to medical liability reform
- FDA issues alert on drug mix-up
- ACP members get registration discounts at e-health summit
In recent comments to a Congressional subcommittee, the College called on Congress to enact laws that would repair the dysfunctional payment system and enhance the patient-physician relationship.
In a statement made to the House Ways and Means Health Subcommittee, ACP noted that the dysfunctional Medicare reimbursement system and excessive paperwork requirements prevent physicians from establishing the kind of patient relationship they need to improve quality of care. The statement was based on the College's recently released State of the Nation's Health Care address.
In its Feb. 10 statement, the College outlined a policy framework that would reestablish the physician-patient relationship. Recommendations included:
Permanently fixing the reimbursement system by replacing the sustainable growth rate formula with one that connects future payment increases to the increased costs of physician services. If the current system isn't replaced, ACP pointed out, physicians will face cuts of 5% every year until the end of this decade.
Enacting a national health information incentive act to provide upfront funding mechanisms, including grants, refundable tax credits and revolving loans, to help physicians purchase health information technology. ACP's porposal was introduced as a bill on Feb. 10 in the House of Representatives by Reps. John McHugh (R-N.Y.) and Charles Gonzalez (D-Texas). The legislation also provides for sustained reimbursement incentives—including an add-on to Medicare office visits—when health information technology is used by physicians to support their participation in quality improvement projects.
Passing legislation that would create a federal pilot program designed to test the efficacy of a physician-guided chronic care management program in small practices. Pilot programs, the College said, should include a care management fee to support physicians' roles in guiding and coordinating the care of patients with chronic diseases and allow internists to share in bonus payments linked to measurable quality improvements.
ACP made other recommendations, including reforming the medical liability system. The College also urged Congress to enact legislation that would reduce the number of Americans who lack health insurance.
The statement is online.
The College's State of the Nation's Health Care is online.
"Rheumatology," the newest addition to ACP's Expert Guides series, provides an accessible reference to state-of-the-art rheumatology practice for internists and subspecialists. The book highlights clinical aspects of rheumatology and gives special emphasis to current concepts of etiology and pathogenesis pertinent to practical patient management.
The book provides a discussion of the general clinical approach to inflammation as well as a description of major disorders in several groupings: erosive inflammatory arthropathies, collagen vascular disease, vasculitides, infections and degenerative disease. Two final sections consider common symptoms and comorbidities and summarize the latest findings in the pharmacological treatment of inflammatory rheumatic disease.
The book emphasizes practical approaches to diagnosis and management, with many tables and figures illustrating the text. Internists will also find case studies of examples commonly seen in the office setting.
The 494-page softcover book is available to members for $45. You can order it online or call ACP Customer Service at 800-523-1546, ext. 2600, and refer to product #330300440.
Internists now have an updated resource designed to help them with ABIM certification or recertification preparation.
ACP's "Prep for Boards 2" supplements the College's MKSAP 13 program by focusing solely on the core content that is tested on the ABIM certification and recertification exams. The resource can help you assess your current knowledge of internal medicine and improve your test-taking ability.
"Prep for Boards 2" contains more than 500 Board-like multiple-choice questions with answers, references and evidence-based critiques that explain why each option is either right or wrong. "Prep for Boards 2" also contains more than 50 questions presented in an image-based format, which are modeled after questions on the ABIM exam. The CD-ROM "Prep for Boards 2" version includes a PDA companion application.
"Prep for Boards 2" is available in print, on CD-ROM or as a combination package. MKSAP 13 subscribers get $80 off the regular purchase price of either the print or CD-ROM version—and $100 off the package price.
More details and pricing information are online.
A recently released study on asthma suggests that blacks may be less responsive than whites to medications commonly used to control the disease.
Researchers did in vitro testing of blood samples from 395 patients with asthma (27% of whom were African Americans) and 202 patients without asthma (52% of whom were African Americans), according to the Feb. 7 WebMD Medical News. Results showed that African Americans required a higher concentration of glucocorticoid medication than whites to suppress lymphocyte production. The study appears in the February issue of Chest.
Researchers said the results may mean that blacks have an inherent predisposition affecting their ability to respond to certain medications and may benefit from higher doses or additional medications, WebMD reported. In addition, the findings may help explain why blacks are four times more likely than whites to be hospitalized or die as a result of asthma.
The Chest abstract is online.
WebMD Medical News is online.
Government officials last week pegged 10-year spending on the new Medicare drug benefit at $720 billion, significantly higher than previous estimates. The benefit is slated to take effect next year.
The benefit's original projected cost of $400 billion, made when legislation was passed in late 2003, covered estimated spending between 2004-2013, according to the Feb. 9 New York Times. Officials noted that the new estimate is higher because it covers the costs of drug coverage for Medicare beneficiaries starting in 2006 and extending to 2015. Medicare enrollment and drug prices are expected to be higher in 2014 and 2015—years that weren't included in the first estimate, the New York Times reported.
The higher estimate may spur lawmakers to revisit the approved benefit, the New York Times said. The original bill—based on the first cost estimates—passed by a narrow margin of 220-215.
The New York Times is online.
In other news, a report released last week found that health care spending now accounts for one quarter of U.S. economic growth, three times as much as defense spending and twice as much as the education budget, according to the Feb. 9 Los Angeles Times. Researchers from the Health Reform Program at Boston University School of Public Health projected that health care spending will reach $1.9 trillion this year, or 15.5% of the economy, up from 13.2% in 2000.
The report noted that per-capita spending on health care in the United States was more than two times the average spent in Canada, France, Germany, Italy, Japan and the United Kingdom, according to a Feb. 9 Health Reform Program news release. The figures suggest that a disproportionate amount is being spent on unnecessary services, administrative costs and other expenses.
The Health Reform Program press release is online.
The Los Angeles Times is online.
Clinical news in the headlines
The following articles appear in the Feb. 15 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Fourteen-year clinical trial finds that quitting smoking adds years to life. In a new study of 5,887 middle-aged smokers with mild lung disease, those who were randomly assigned to a smoking cessation program had a lower death rate than those assigned to usual care, even though only 21.7% of them actually quit smoking.
The annual death rates were 8.8 per 1,000 patients in the quit-smoking program and 10.4 per 1,000 in the usual care group. The annual death rate for those who gave up cigarettes was 6 per 1,000 patients, compared to 11 per 1,000 in those who did not quit. The article is online.
Older doctors are not better healers, study finds. Researchers examined 59 medical research articles that measured quality of care or medical knowledge. The majority of the studies found that older or more experienced physicians had worse performance on health care quality or medical knowledge measures than younger physicians. Only one study found that older physicians performed better on quality measures than younger colleagues. The negative association was consistent across medical specialties and measures of performance.
An accompanying editorial said the findings indicate that medical practice "must be accompanied by ongoing active effort to maintain competence and quality of care." The writers point to new methods of ongoing performance measurement built into physician maintenance of certification. The article is online.
Studies released last week found that routine HIV screening is cost effective and may lead to earlier diagnoses and treatment for infected patients.
Two studies in the Feb. 10 New England Journal of Medicine (NEJM) concluded that widespread routine screening would offer significant benefits at a reasonable cost.
One study found that screening is cost effective even when the prevalence of HIV infection in an area is lower than 1%, a general guideline for routine screening now used by the CDC. The other study estimated that routine one-time screening would reduce the annual rate of transmission by 20%. The studies also estimate that screening would prolong survival for the average HIV-infected patient by 1.5 years.
The cost of one-time screening would be less than the commonly cited threshold for cost effective care, especially among high-risk populations, according to an accompanying editorial. In addition, screening could have secondary benefits, such as increasing the allocation of regional resources to prevent and treat HIV infection.
Widespread screening could have negative effects as well, the editorial pointed out, such as those related to the complexity and cost of setting up and operating programs. In addition, the editorial noted that some patients' fear of screening could lead them to avoid other types of necessary care. These potential problems suggest that screening should not be mandatory and highlight the need for patient privacy protections and additional program resources.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) last week weighed in with tort reform recommendations, calling for specific steps to solve the nation's current liability crisis.
A new paper entitled "Healthcare at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury," developed by JCAHO and a panel of 29 experts, said the current system does not deter negligence or fairly compensate victims, according to a Feb. 10 JCAHO news release. JCAHO officials noted that too little progress has been made to improve safety since the Institute of Medicine's influential report on medical errors was released in 1999.
Among its 19 recommendations to improve safety, the JCAHO recommended the following:
- instituting pay-for-performance programs with incentives for improving quality;
- enacting laws that protect the disclosure of medical errors and physician apologies from being used in court;
- conducting demonstration projects on alternatives to the current medical liability system; and
- using court-appointed, independent expert witnesses.
The commission also recommended redesigning or replacing the National Practitioner Data Bank, which it said has not proven to be a meaningful source of information on physician performance.
The commission also noted that its own national voluntary reporting database for adverse events, as well as JCAHO standards requiring practitioners to inform patients or families of adverse outcomes due to errors, have been undermined by flaws in the current system. Instead, the news release said the current system is designed to discourage the identification and reporting of errors, which prevents hospitals and clinicians from learning from their mistakes.
The JCAHO news release with a link to the white paper is online.
The FDA last week issued an alert about cases in which physicians and pharmacists have confused olanzapine (Eli Lilly's Zyprexa) with cetirizine HCI (Pfizer's Zyrtec), two drugs used to treat very different conditions.
Olanzapine is used to treat schizophrenia and acute mixed or manic episodes associated with bipolar disorder, according to the Feb. 8 FDA alert, while cetirizine HCI treats allergic rhinitis or chronic urticaria. Cases where the two drugs have been confused have led to unnecessary adverse events, as well as potential relapses in patients being treated for schizophrenia or bipolar disorder.
In a Jan. 26 letter, Eli Lilly said mistakes in prescribing or dispensing resulted from several factors. First, the brand names of both drugs begin with the same letter, while both are also available in the same dose strengths (5 mg and 10 mg tablets) and both drugs are usually placed close together on pharmacy shelves.
The FDA alert is online under the Zyprexa link.
Eli Lilly's letter is online.
ACP members can now receive a discounted registration fee for the eHealth Initiative Foundation summit being held March 6-8 in San Francisco.
The summit will feature reports from national experts on how health care markets and policy-makers are responding to emerging health information technology trends. The summit will also feature case studies highlighting the principles, strategies and financing of existing technologies, as well as emerging state, regional and community-based information technology initiatives.
The eHealth Initiative and its Foundation are independent nonprofit organizations working to bring diverse health care stakeholders together to define and implement interoperable information technology. ACP is a member of the eHealth Initiative.
More information about the summit and a registration form are online. To get the discount rate of $200 off the regular registration fee, enter "ACP" in the "optional registration code" box on the online form.
More information about the eHealth Initiative is also 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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