In the News for the Week of 2-8-05
Annual health care report
- ACP outlines needed reforms and incentives
Pay for performance
- New Medicare demo project will reward doctors for quality
- Safety, liability concerns drive hospitalist hiring spree
Clinical news in the headlines
- Women's heart disease still not treated as aggressively as men's
- Highlights of ACP Journal Club
- Naproxen coverage holds key lessons in medical reporting
Access to care
- College details problems with association health plan proposals
- ACP: Safeguards needed with consumer-directed plans
Public research access
- NIH announces public access for published findings
- ACP releases new edition that examines ethical choices
Annual health care report
The College last week issued its annual report on American health care, calling on government officials to pass needed reforms to improve the physician-patient relationship and create incentives for practice improvement.
In the address, delivered Feb. 2 at a Washington press conference, College representatives outlined a policy framework that Congress and the administration should use to initiate reform. Key among needed reforms was immediately stabilizing Medicare physician payments by replacing the sustainable growth rate (SGR) formula.
According to a Feb. 2 ACP news release, the current formula, if left in place, would trigger physician pay cuts through the end of this decade. Instead, ACP leaders said that Congress should replace the SGR with a formula that can keep pace with service costs.
The College recommended the following reforms and innovations:
Financial incentives to boost the use of electronic medical records and other information technology. College leaders pointed out that a bill that will be introduced this week in the House of Representatives, based directly on a proposal from the College, would provide loans, grants and tax credits to small practices to purchase health information technology. The bill would also direct the CMS to provide reimbursement incentives—such as an add-on to Medicare office visit payments—to physicians who use such technology to improve patient care.
Innovations to incorporate clinical decision support tools in daily practice.
New practice models to improve care coordination for patients with chronic diseases. ACP also called on Congress to authorize funds for a pilot program that would test a new chronic care improvement model centered on supporting the relationship between physicians and their patients. The model would provide participating physicians in small and mid-size practices with a care management fee for coordinating and managing the care of patients with chronic illness. In return, physicians would agree to incorporate practice improvements, including use of health information technology, to improve quality and achieve cost efficiencies.
The College also asked Congress to pass legislation to substantially reduce the number of uninsured Americans; shore up existing safety net programs; expand performance improvement programs under Medicare; and reform the current medical liability reform system.
The College's "State of the Nation's Health Care" report is online.
The ACP press release is online.
Pay for performance
The CMS last week announced the launch of Medicare's pay-for-performance demonstration program to reward physicians in large groups for improving care while holding down costs.
According to a Jan. 31 CMS news release, 10 large physician groups will participate in the physician group practice demonstration beginning April 1. The incentive-based system is designed to encourage physicians to focus on preventive and chronic care, in contrast to the existing reimbursement system, which rewards doctors according to the number and complexity of services they provide.
During the three-year program, the CMS will reward participating groups based on their success in coordinating patient care and achieving improved outcomes. The CMS will measure groups' performance on 32 different quality indicators that focus on congestive heart failure, coronary artery disease, diabetes mellitus and hypertension, as well as on preventive services such as influenza vaccination and cancer screening.
Participating physicians will still be paid on a fee-for-service basis but will be eligible for performance payments based on how well they improve quality of care and avoid costly complications and hospitalizations, the CMS release said. All 10 participants are multispecialty groups with at least 200 physicians and include group practices, integrated delivery systems, faculty group practices and independent practitioner associations.
Medicare has already implemented several other quality incentive programs, including one for hospitals, another for chronic care and one for physicians in small practices, according to the news release. The agency is also looking into launching quality improvement programs focused on nursing home care and home health and dialysis providers.
A link to the CMS news release, which includes a list of quality measures being used, is online.
A new study has found that the ranks of hospitalists have swelled from a few hundred to more than 8,000 over the past decade.
Findings indicate that, along with their growing numbers, hospitalists are also expanding their clinical roles. Besides providing inpatient care for the patients of community-based physicians, hospitalists are increasingly substituting for intensivists in intensive care units, caring for complicated patients, acting in skilled nursing facilities as primary attending physicians and caring for nursing home patients who are admitted to hospitals at night. The study appeared in the February Journal of General Internal Medicine (JGIM).
A number of factors are driving those growth trends, including financial pressures on hospitals, patient safety concerns and rising medical liability costs, according a Feb. 1 news release from the Center for Studying Health System Change (HSC), which conducted the study. Findings were based on site visits in 2002-03 to 12 U.S. communities, all of which had hospitalists in at least one major hospital system.
Hospitalist use varied across those communities, ranging from 5% of non-ICU patient care in one Miami hospital to 100% of non-ICU patient care at a facility in Phoenix, the study found. According to the study authors, the growth trend is likely to affect medical education—as schools and training programs will perhaps move to offer a hospitalist track for internists—and how hospitals are run.
The JGIM abstract is online.
The HSC news release is online.
Clinical news in the headlines
Two new studies published this month found that physicians routinely underestimate women's risk of heart disease and often do not treat women as intensively as male patients for heart disease, by prescribing aspirin and drugs to lower blood pressure and high cholesterol, and recommending other preventive measures.
One study found that physicians were "40% less likely" to identify women as high risk as they were male patients, even when women had the same risk factors, according to the Feb. 2 Washington Post.
Another study used a database of more than 1 million patients to identify women at high risk and followed them for three years to gauge their cholesterol treatment. Researchers found that only one-third of those women were prescribed cholesterol-lowering drugs.
Both studies were published in the Feb. 1 Circulation, the journal of the American Heart Association. According to the Washington Post, both studies received funding from a pharmaceutical company that manufactures drugs to treat cholesterol.
The Washington Post is online.
A recent review study found that sedative-hypnotic drugs were more effective than neuroleptic drugs in treating patients with alcohol withdrawal delirium.
Researchers looked at five controlled trials that compared sedative-hypnotic agents with neuroleptic drugs and found that patients taking neuroleptic drugs had a greater than 6-fold increase in risk for death in the two trials in which deaths occurred. The review also concluded that sedative-hypnotic drugs were more effective than neuroleptics in reducing the duration of delirium. The study is abstracted in the January-February ACP Journal Club.
Alcohol withdrawal delirium is a serious illness that often goes unrecognized, thus delaying effective treatment, the Journal Club reviewer noted. Patients with delirium often need intravenous medication because they are unable to swallow.
The review indicated that doses of sedative-hypnotic agents should be repeated and reassessed every few minutes in a well-monitored setting, the reviewer said. Physicians should also consider other diagnoses and examine for concurrent illnesses.
The review found little evidence to support using ancillary medications such as magnesium and thiamine to treat withdrawal. In addition, there was a lack of evidence supporting intravenous multivitamin supplements to treat nutritional deficiency, especially considering their relatively high cost.
ACP Journal Club is online.
Three Dartmouth Medical School faculty members have published an analysis of how government announcements and media coverage exaggerated the risks associated with a recent trial of naproxen. The trial, which was sponsored by the NIH and designed to test naproxen's efficacy against Alzheimer's disease, was halted in December due to safety concerns about cardiovascular and cerebrovascular events.
According to the analysis, the information released by the NIH was too vague, leading to prominent headlines that overstated the evidence against naproxen. For example, the NIH didn't give details about the kinds of cardiovascular and cerebrovascular events that occurred in the trial or about how much more serious those events were among naproxen users than participants taking celecoxib or placebo. The analysis was published in the Feb. 1 Washington Post.
The NIH also did not release the number or the relative frequency of such events, although it was later reported that the risk of events among naproxen users was 50% higher than for those taking placebo. According to the authors, however, adverse events occurred in only 3.7% of patients taking naproxen, compared with 2.5% of patients on placebo-a much smaller risk than news reports suggested, especially given the fact that study participants were age 70 and older.
The authors also said the NIH failed to distinguish between study participants, who were taking naproxen in the hope of warding off Alzheimer's, and the general public who typically take the drug for pain. They concluded that naproxen's risk for events is modest and that, given a more accurate description of risks, many naproxen users may find that the drug's effectiveness against pain outweighs its relatively low risk.
The Washington Post is online.
Access to care
In a recent monograph, ACP outlined problems with an administration-backed proposal to extend health care coverage to more small business employees.
The administration's proposal would allow trade, industry and professional associations to create federal association health plans that could offer federally licensed health insurance to the small businesses they represent. The monograph pointed out that these plans would be exempt from existing state insurance regulations.
The College objects to such an exemption unless Congress can create a regulatory structure for plans that would protect patients' rights. Necessary safeguards include patients' rights to a grievance and appeals process, as well as a requirement that association plan coverage must include essential benefits, such as preventive and primary care services.
Instead of supporting the creation of federal association health plans, the College advocates for:
Allowing small employers to band together in state group purchasing arrangements. The College supports provisions in the Health Coverage, Affordability, Responsibility and Equity Act of 2003 that call for such purchasing pools.
Designing purchasing pools to encourage broad membership, minimal risk selection and maximum choice.
Allowing small businesses to buy into Medicaid or the State Children's Health Insurance Program.
The College monograph is online.
In a recently released monograph on consumer-directed health plans, the College acknowledged that such innovations can boost consumer involvement in health care decision-making. Such plans include health savings accounts linked to high-deductible health plans, an alternative established by Medicare reform legislation in 2003.
The College warned, however, that these accounts will not on their own lead to universal coverage nor significantly reduce health care costs. Instead, ACP said these accounts should be one among several different types of available coverage. The College also warned that relying on high-deductible coverage could leave big gaps in preventive benefits and make low-income patients more vulnerable to financial hardships.
The monograph endorsed a series of recommendations related to consumer-directed accounts, including:
Creating portable coverage, where benefits are not tied to a patient's place of employment. However, such insurance should not, ACP said, encourage businesses to terminate coverage that's already available.
Enacting safe harbor provisions to ensure that low-income patients are not forced to cut back on care or suffer severe financial hardships. The College also recommended expanding safety net programs, such as Medicaid.
Monitoring the coverage of vulnerable populations, such as low-income groups and the chronically ill. With consumer-directed accounts, ACP said that particular attention must be paid to issues like adverse selection, premium costs and the availability of preventive services.
Exempting prescription drug costs from health savings account deductibles.
The monograph is online.
The NIH last week announced a voluntary public access policy to give consumers and the medical community free access to federally funded research published in scientific journals. The new policy drew criticism from a few quarters.
The policy, set to take effect May 2, asks researchers who receive NIH grant money to submit their results to a public Web site within a year of publication, according to a Feb. 3 NIH news release. Researchers are called on to voluntarily submit an electronic version of their final manuscript, which should include, the NIH release said, "all modifications from the publishing peer review process."
The articles will be posted on the NIH's PubMed Central Web site, a permanent, searchable electronic archive.
According to the Feb. 4 Washington Post, the agency said the policy balances the concerns of patient advocacy groups—who claim that taxpayers should have access to federally funded research—with those of journal publishers, who worry that free access could lead to fewer journal subscribers.
NIH director Elias A. Zerhouni, MD, noted that having the data on one Web site will make it easier for consumers and physicians to compare information among different trials, the Washington Post said.
ACP's Annals of Internal Medicine has its open access policy. Each issue of Annals, which is published twice a month, includes one free access article, which normally features guidelines. All articles become freely available to the public six months after publication.
The NIH release is online.
The Washington Post is online.
ACP's comments, which were submitted last fall on the draft NIH policy, are online.
The College has just released a second edition of its popular book, "Ethical Choices: Case Studies for Medical Practice."
The second edition includes new case studies on topics that have long been the subject of medical ethics debates: futility, organ donation and procurement, and physician treatment of relatives. This new edition addresses new issues such as complementary and alternative medicine, direct-to-consumer prescription drug advertising, and technological advances such as genetic testing. The new edition features an annotated bibliography for each case study, designed to bring each case up to date and guide readers to the latest sources of information.
The collection's case studies were developed from 1990-2003 under the auspices of the College's Ethics and Human Rights Committee. Commentaries accompanying each case study expand on principles contained in the ACP "Ethics Manual."
"Ethical Choices: Case Studies for Medical Practice" makes ethical principles more relevant to daily medical practice by exploring their application to common clinical situations. At the same time, it motivates readers to consider important but seemingly mundane issues of everyday medical encounters and demonstrates medical ethics in action by considering the real motivations behind physician and patient behavior.
The 188-page softcover book is available to members for $30. You can order online or call ACP Customer Service at 800-523-1546, ext. 2600, and refer to product code #330300540.
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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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