In the News for the Week of 3-8-05
- MedPAC recommends pay-for-performance incentives
Clinical news in the headlines
- Study: Physician empathy is essential to healing
- ACP Journal Club: Nonsteroidal anti-inflammatory drugs provide better pain relief than opioids for acute renal colic
- FDA issues advisory on popular statin
The business of medicine
- MGMA "better performers" see higher revenues, efficiencies
- Project HOPE seeks ACP members to volunteer overseas
- Free new ACP brochures help educate patients on heart failure and HIV/AIDS
- ACP issues recommendations on retiree drug benefits
- College, others, ask for increased QIO funding
In its semi-annual report to Congress issued last week, the Medicare Payment Advisory Commission (MedPAC) recommended that Medicare move toward pay-for-performance incentives for hospitals and physicians.
The report said Medicare should adopt incentive payments for hospitals, home health agencies and physicians who meet higher performance standards, according to a March 1 MedPAC news release. In addition, the commission said quality measures should reflect the use of information technology in physicians' offices and that the CMS should require reporting of lab values and prescription claims data.
The recommendations, which Congress can accept or reject, also advise applying quality standards to providers who perform and interpret imaging studies. MedPAC also recommended that the CMS measure physicians' use of resources and relay that data back to physicians in confidential reports.
The MedPAC news release is online.
A link to the full report is online.
In other Medicare news, the CMS recently proposed a new policy for physicians who administer drugs in their offices, allowing physicians to obtain those drugs directly from vendors without billing Medicare, starting in 2006.
The proposed rule would allow approved vendors, instead of physicians, to bill Medicare for the cost of office-administered drugs, according to a Feb. 26 CMS news release. Physicians could choose to get drugs from a Medicare-approved vendor—-saving them time and paperwork—or could continue to buy drugs on the open market and bill Medicare themselves.
The CMS would select participating vendors based on price and their ability to meet certain quality and service standards, the release said. Participating physicians would bill Medicare only for drug-administration services while vendors would collect any deductibles and copays from beneficiaries.
Under the program, physicians would choose a sole-source vendor but would have the option of switching vendors annually or dropping out of the program, according to the release. The proposed rule was published in the March 4 Federal Register, with public comments accepted until April 26.
The CMS news release is online.
Clinical news in the headlines
A new commentary published last week explores empathy as a key component of both effective healing and physician job satisfaction.
The authors of the study outlined a model for applying acting techniques to patient-doctor interactions. The study, published in the March 2 Journal of the American Medical Association (JAMA), was co-authored by Eric B. Larson, FACP, Chair of ACP's Board of Regents.
When interacting with patients, doctors should use a combination of "deep acting," which relies on memories and imagination, and "surface acting," when physicians feign empathetic emotions they do not feel, according to a March 1 news release from Seattle's Group Health Cooperative, a partner in the study.
While deep acting is preferred, doctors may have to use surface acting in situations where they cannot identify with a patient's values or beliefs, the release reported. The authors said physicians should recognize that "emotional labor" is essential to effective healing, especially as medical practice becomes more fragmented and technologically driven.
Medical schools and residencies should actively design training programs and create cultures that value empathy in treatment, the authors wrote. Future research should test the empathy model by, for instance, investigating whether physicians who are good at communicating and empathizing with patients experience more job satisfaction and less burnout.
The JAMA abstract is online.
The Group Health Cooperative news release is online.
A recent study found that nonsteroidal anti-inflammatory drugs (NSAIDs) were more effective than opioids in relieving pain and reducing vomiting in patients with acute renal colic.
The meta-analysis looked at 20 randomized controlled trials that compared NSAIDs with opioids in adults diagnosed with acute renal colic. Patients who took NSAIDs were less likely to require rescue analgesia and to report vomiting than those receiving opioids. The study is abstracted in the March-April ACP Journal Club.
NSAIDs are a logical treatment option for renal colic because they decrease intrarenal pressure and prevent ureteral spasm, noted the Journal Club reviewer, and this study provides further evidence for their use.
Because of the lack of evidence on NSAIDs' potential adverse effects, however, physicians should think about other possible diagnoses when patients present with undifferentiated abdominal pain. They should also consider combining NSAIDs with narcotics for patients in severe pain.
While NSAIDs appeared to be slightly more effective in relieving pain than narcotics, the difference is probably not clinically important, the reviewer noted. In addition, the study did not explore the effectiveness of adding an antiemetic to a narcotic to prevent vomiting.
ACP Journal Club is online.
The FDA last week issued a formal advisory, saying the cholesterol-lowering drug rosuvastatin calcium (Astra Zeneca's Crestor) may increase the risk for potentially fatal muscle damage, especially among Asian Americans.
The advisory contained new guidance for physicians, according to a March 2 FDA news release. The new package insert urges physicians to consider prescribing lower starting doses of the drug. The March 3 Washington Post clarified that the advisory calls for starting patients on 20 mg of rosuvastatin calcium, not 40 mg.
The FDA advisory also said that lower doses were "particularly important" when prescribing the drug for Asian Americans, because trial data suggest these patients tend to maintain higher drug levels that put them at greater risk of muscle injury. Other patients at elevated risk include those taking cyclosporine and those with severe renal insufficiency.
A small risk of muscle damage was identified when the drug was approved in 2003 but more recent studies have heightened those concerns, the Washington Post reported. The FDA said the drug label should now state that rosuvastatin calcium may, in rare cases, cause rhabdomyolysis, which can lead to kidney failure.
The advisory noted that kidney failure cannot be positively linked to taking rosuvastatin calcium or other statins, because patients taking statins often have increased risk due to other conditions such as diabetes, hypertension or atherosclerosis. Overall, the agency said, the benefits of taking rosuvastatin calcium outweigh the risks.
The advisory signals a shift in how the FDA handles new drug safety information, the Washington Post noted. That is due in part, the article said, to criticism that the agency moved too slowly in releasing information on potential cardiovascular risks of COX-2 inhibitors. The FDA release said the agency now plans to provide consumers with earlier access to emerging safety information.
The FDA advisory is online.
The Washington Post is online.
The business of medicine
Sending medical history forms to patients before appointments and other innovations helped top-performing medical groups substantially boost revenues in 2003, according to a recent Medical Group Management Association (MGMA) survey report.
Total medical revenue increased more than 6% in 2003--from $280,717 to $298,255 per FTE—at multispecialty groups recognized as MGMA "better performers," according to MGMA's "Performance and Practices of Successful Medical Groups: 2004 Report Based on 2003 Data." Overall, the more than 1,240 survey respondents—including groups considered to be "better performers" and those who were not—reported a 2.5% increase in revenue in 2003.
According to a March 2 MGMA news release, "better performers" were more likely than other practices to:
- Look at appointment availability in patient satisfaction surveys.
- Verify new patient insurance before the time of service.
- Partner new physicians with physician mentors.
- Base 100% of physician compensation formulas on productivity.
The MGMA news release is online.
The full report can be purchased through MGMA's online store.
ACP members are invited to apply for different overseas volunteer opportunities being offered by Project HOPE, a nonprofit organization that provides land-based health care and health care education programs on five continents, including North America.
One opportunity is as a professor/trainer in Hubei Province, China, an assignment lasting between two and eight weeks. The trainer would provide faculty lectures, case discussions and direct observation of patient care. Applicants should be trained in HIV care and prevention.
The other opportunity is for an evaluation consultant to assess health care management programs in the Czech Republic, Lithuania and Hungary, a two- to three-week assignment.
At the request of ACP's Board of Regents, the College is working with Project HOPE to identify opportunities of mutual interest.
More information and a candidate submission form are online.
More information about Project HOPE is also online.
College members can now order the two latest titles in ACP's popular "Special Report" series of free patient education brochures. The brochures are designed to be easily understood by patients with low literacy levels.
"Understanding and Living with Heart Failure," developed in cooperation with the American Heart Association, educates patients about the signs and causes of heart failure. The brochure also explains appropriate diagnostic tests and discusses treating heart failure with medications and lifestyle changes.
"HIV/AIDS: Preventing, Testing, Treating" helps patients understand what HIV is and how it attacks the human body. The brochure offers prevention tips and explains testing and diagnosis. Readers also learn about treatment options and receive a list of resources for more information.
Each brochure also clearly explains the role of the internist and includes the URL to the ACP Doctors for Adults Web site.
All nine ACP Special Reports are available for free download online.
ACP members can also order printed copies of the brochures in packs of 100 at no charge.
Saying that retirees should not lose through employer-based drug benefits, the College recently released a monograph with recommendations on retiree drug benefits as they relate to new Medicare reform legislation passed in 2003. The law creates a Medicare prescription benefit that takes effect in 2006.
According to the monograph, employers have been reducing prescription coverage for retirees for several years. The percentage of retirees covered by employer-based prescription benefits has dropped from 66% to 38% between 1988 and 2003.
The College monograph included the following recommendations for the federal government:
Monitor the employer subsidy included in the new benefit that would support employer-sponsored benefits. That monitoring should be used to determine whether employers are reducing or dropping coverage.
Create a safety net for retirees and employees who lose employer-based coverage.
Ensure that employers who receive subsidies for retirees under the new law do not use those funds to pay for coverage for existing employees.
The College monograph is online.
The leaders of 10 national medical associations and health care organizations, including ACP, have asked the federal Office of Management and Budget to fund Medicare quality improvement organizations (QIOs) at the level requested by the HHS.
In a letter sent Feb. 25, signatories said they supported Medicare's current plans to increase QIO efforts. They also said they concurred with the initial request made by HHS for an estimated $2 billion to fund QIO efforts between mid-2005 and mid-2008. The letter noted, however, that the $2 billion request has since been scaled back in fiscal budget negotiations.
The $2 billion funding level, the signatories said, would represent a significant down payment on the country's health care quality infrastructure. However, the letter pointed out that the scaled-back amount, which has not been made public, was not enough to adequately fund needed QIO efforts.
The letter was signed by John Tooker, FACP, the College's Executive Vice President, as well as by leaders of the American Academy of Family Physicians, the American Health Quality Association and the National Rural Health Association, among others.
The letter is online.
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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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