In the News for the Week of 4-5-05
- Medicare premiums to rise, physician fees may fall in 2006
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
- New guidelines urge earlier colon cancer screening for blacks
- Government unveils site with hospital quality data
- Study: Fears of liability risk for chronic care coordination unfounded
- CareFirst to pay physicians for adopting EMRs
- Technology research firm issues its top-20 EMR product report
Access to care
- Court rules that health care benefits can't be cut at age 65
- Nominations sought for ACGME teaching awards
- College helps launch new commission to end health care disparities
- Fellows and Masters to receive special recognition at Annual Session
Citing an unexpected and sharp increase in spending last year, Medicare officials said last week that the agency will increase premiums by $11 a month in 2006. At the same time, Medicare physician fees may be cut by more than 4% next year—and for the next six years—unless Congress intervenes, CMS officials said.
Spending on physician services rose by 15% last year to $88.3 billion from $76.7 billion in 2003, according to the April 1 New York Times. Officials said the spending increase was due to longer office visits and a greater number of minor procedures, imaging tests and prescription drugs provided in physicians' offices.
CMS officials said that the physician cuts will occur because a Congressionally-mandated fee update formula triggers fee cuts whenever overall spending on such services exceeds growth in the economy as measured by per capita gross domestic product. Because the law also requires that beneficiaries pay a set percentage of total Part B expenditures, future premiums also will rise to keep pace with increased expenditures.
But physicians noted that beneficiaries could face access problems if the cuts take effect. The April 4 New York Times reported that if the fee cuts aren't averted, physician fees will be reduced by 26% by 2011.
To help avert fee cuts, ACP is urging lawmakers to enact legislation to change the fee update formula so that fees keep pace with the costs of providing care. ACP has also provided to Congress recommendations to reform Medicare payments to improve the care of patients with multiple chronic diseases, the category of patient that is the source of much of Medicare's increased spending.
The CMS estimated that premiums for beneficiaries in 2006 would rise to $89.20 a month, a 34% increase over 2004 premium rates, according to the April 1 New York Times. The cost of the prescription drug benefit that takes effect next year, which is expected to increase beneficiaries' premiums by an average of $35 a month, would be in addition to these premium increases.
An AMA official interviewed by the New York Times on April 1 noted that increased spending was due in part to physicians providing better patient care, including the use of new drugs and technology and more comprehensive screening. These services, encouraged by the CMS, he said, help keep patients out of hospitals.
The April 1 New York Times is online.
The April 4 New York Times is online.
The College's recommendations for improving the dysfunctional payment system are online.
Clinical news in the headlines
The following articles appear in the April 5 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
ACP releases new guidelines to treat obesity. In new guidelines for obesity management, the College recommends diet and exercise for overweight and obese patients, and drugs and surgery only for obese patients who cannot achieve weight-loss goals with diet and exercise alone.
According to the new guidelines, people with a body mass index (BMI) over 30 should consider drug therapy after an appropriate trial of diet and exercise has failed. For the first time, the College recommends surgery for those with a BMI over 40, who are considered morbidly obese and who also have obesity-related health problems such as high blood pressure, diabetes or sleep apnea.
In the guidelines, ACP identifies five drugs that, according to valid clinical studies, aid weight loss: sibutramine, orlistat, phentermine, diethylproprion and fluoxetine. The guidelines also discuss several types of bariatric surgical procedures and caution that none of the procedures is supported by evidence from randomized, controlled trials comparing surgical patients to non-surgical control groups.
The guidelines are online.
For more on the new ACP guidelines, see "New ACP guidelines target obesity management" from the April ACP Observer.
"Ethics Manual, Fifth Edition." ACP's newly revised "Ethics Manual" includes new or expanded sections on professionalism, end-of-life care, physician-assisted suicide, strikes and joint actions, third party evaluations, complementary and alternative medicine, confidentiality, boundaries and privacy, gifts from patients, the physician-patient relationship, and much more.
A case method for ethical decision-making tha toutlines steps physicians can take in making ethical decisions is included.
The newly revised "Ethics Manual" is online.
Platelet function normalizes within 24 hours after last dose of ibuprofen. In a study of 11 healthy adult volunteers given a one-week course of ibuprofen, their platelet functions returned to normal by 24 hours after stopping the drug. Patients are often asked to discontinue nonsteroidal anti-inflammatory drugs, such as ibuprofen, for at least one week before surgery. This study suggests that it may not be necessary to discontinue ibuprofen until 24 hours before surgery. However, the authors say that more studies involving patients with many common underlying medical conditions are needed.
The study is online.
African Americans should be screened for colorectal cancer earlier than other racial groups, according to new guidelines issued last week.
The American College of Gastroenterology based its new guidelines on recent findings that African Americans contract the disease at a younger age and have a higher incidence and mortality rate than whites, according to the March 29 Washington Post. Studies indicate that the higher mortality rate among blacks may be due partly to poor access to care and to screening services.
The guidelines recommend that African Americans undergo a colonoscopy every 10 years starting at age 45, compared with age 50 for the general population. The guidelines were published in the March American Journal of Gastroenterology.
The guideline authors speculated that the noted disparities may be due to the lower socioeconomic status of African Americans, making them less likely to have health insurance and hindering their access to diagnostic and screening services. The authors recommended a culturally sensitive approach that would include education programs aimed at primary care physicians to highlight care issues unique to black communities.
The authors also recommended using colonoscopy as a first-line screening procedure instead of sigmoidoscopy because of the higher incidence of cancerous lesions in blacks in the proximal part of the large bowel, as well as their higher overall rate of lesions.
The Washington Post noted that cancer of the colon or rectum is the third most common type of cancer in black men and the second most common type among black women. In addition, 10.6% of blacks with the disease are diagnosed before age 50, compared with 5.5% of whites.
The American Journal of Gastroenterology abstract is online.
The Washington Post is online.
The federal government last week launched a Web site with best practice data submitted by most of the nation's acute care hospitals. The new site—called Hospital Compare—presents hospital-reported data on 17 different quality indicators related to heart attack, heart failure and pneumonia care. Searchable by state, county, city or zip code, the site is designed to allow consumers to compare quality practices at their local hospitals.
About 65% of all acute care hospitals provided data on all 17 quality measures, although 98% submitted data on 10 measures, which include giving pneumococcal vaccine to pneumonia patients and prescribing aspirin to heart attack patients. Hospital data submission is voluntary, although the government intends to boost reimbursement to hospitals that supply data on quality measures.
According to the April 1 Seattle Times, one limitation of the site is that data are already a year old. Many hospitals, analysts say, may have substantially improved their compliance with best practices since data were collected. Others quoted in the article pointed out that data do not give mortality figures and that collecting data has been difficult for hospitals that don't have computerized records.
The new Hospital Compare site is online.
The Seattle Times is online. (Free registration is required.)
While physicians may fear that coordinating the care of chronically ill patients may increase their liability risk, a recent study found that those fears are unwarranted.
The study found that primary care physicians who coordinate the care of chronically ill patients do not face higher liability risk or malpractice premiums. In fact, researchers—two attorneys and one physician—concluded that successful care coordination could actually reduce liability risk. The researchers were from Wake Forest University Baptist Medical Center in Winston-Salem, N.C., while the study was published in the March/April issue of Annals of Family Medicine.
Study authors queried 1,230 practicing physicians nationwide and found that 49% of those responding listed legal liability as a major deterrent to coordinating care. Researchers found that many primary care physicians do not coordinate chronic care beyond advising patients to see specialists. The authors pointed out that chronically ill patients account for more than half of all medical spending.
Based on their legal research, study authors said chronically ill patients are not more likely to sue and that courts do not hold physicians who coordinate care liable for errors made by specialists.
The Annals of Family Medicine article is online.
A College position paper on physician-guided models of chronic care is online.
CareFirst BlueCross BlueShield—the largest health care insurer in the Mid-Atlantic region—announced last week that it would pay qualifying physicians up to $20,000 for installing electronic medical records (EMRs). The incentives are part of CareFirst's participation in the pay-for-performance program launched by Bridges to Excellence, a public-private partnership of employers, health plans and government agencies that seeks to create incentives for quality improvement.
CareFirst has committed to spending $800,000 on those incentives this year and $3.6 million over the next three years in a bonus plan that will target medical recordkeeping, according to the March 29 Baltimore Sun.
Under the Bridges to Excellence program, physicians already receive bonuses based on meeting or exceeding standards set by the National Committee for Quality Assurance for diabetes and cardiovascular care. According to the Baltimore Sun, CareFirst will pay qualifying physicians $50 for each patient they treat who is covered by the health plan, up to a maximum of $20,000.
The CareFirst program is intended to help physicians afford EMRs, according to the Baltimore Sun.
The Baltimore Sun is online.
More information on Bridges to Excellence is available online.
KLAS Enterprises LLC, a research and consulting firm specializing in health care information technology, recently issued its top 20 ambulatory electronic medical record (EMR) product list. That list—the Best in KLAS awards for late 2004—is based on physician survey responses on ambulatory EMR products.
The products that posted the eight best results in the survey were, in descending order: Eclinicalworks EMR, GE Centricity Physician Office EMR, NextGen EMR, Greenway PrimeSuite Chart, Misys EMR, MediNotes Charting Plus, JMJ Encounter PRO and A4 Healthmatics EMR.
According to this year's KLAS ambulatory survey, 54% of respondents claimed that reduced staffing and costs were important benefits of implementing EMRs, as well as increased efficiency.
Members attending Annual Session who visit the Practice Management Center at booth 1323 will receive a free copy, either at the booth or via e-mail, of the KLAS Top 20 reports by completing a short KLAS product evaluations survey form. ACP members who do so will also have free access to limited summary information technology evaluation reports and discounted prices on full reports. Annual Session will take place April 14-16 in San Francisco.
More information about KLAS can be found online.
KLAS survey forms can be found online.
Access to care
A federal court in Philadelphia ruled last week that employers cannot cut health insurance benefits for retirees when they turn 65 and become eligible for Medicare.
The ruling stemmed from a suit involving the AARP and the Equal Employment Opportunity Commission (EEOC), in which the AARP said that the federal agency could not legally exempt employers from providing retiree benefits when they become Medicare beneficiaries, according to the March 31 Washington Post. The EEOC plans to appeal last week's decision.
The lawsuit, filed a few years ago, occurred when the county of Erie in Pennsylvania cut their retired employees benefits when they turned 65, according to the Washington Post. Employees filing suit said Medicare benefits were inferior and in 2000, a federal court of appeals agreed.
At first, the EEOC agreed with the ruling, but eventually said the policy would encourage employers to eliminate all retiree benefits, the Washington Post reported. Two years ago, the agency tried to block that from happening by seeking to exempt employers' efforts coordinating retirees' benefits with Medicare eligibility from prohibitions included in federal laws governing age discrimination.
The AARP sued to stop that change. Last week's ruling agreed with the AARP that giving younger retirees better benefits than those aged 65 and older is illegal under age-discrimination statutes.
AARP officials said the EEOC rule would have allowed employers to reduce or stop benefits for about 10 million retirees, according to the Washington Post. However, employer groups said the ruling would only make the problem of uninsured retirees worse.
The Washington Post is online.
The College's monograph on preserving retiree drug benefits under Medicare reform is online.
Nominations are now being accepted for awards made each year to 10 different residency program directors by the Accreditation Council for Graduate Medical Education (ACGME). The deadline for nominations is June 15.
The ACGME invites program directors, administrators, faculty and residents to nominate those who have designed pioneering teaching programs and who have proven their dedication to graduate medical education. Of those nominated, 10 will receive a 2006 Parker J. Palmer Courage to Teach award, named for a noted educator.
More information about the nomination process is on the ACGME Web site.
ACP has joined with other national medical societies and 30 health care organizations to create a new commission to end health care disparities.
The commission, which was launched earlier this year, is designed to educate physicians and other health care professionals about racial and ethnic health care disparities and to develop strategies to close those gaps. Other society members include the AMA, the National Medical Association and the National Hispanic Medical Association.
The commission has established four committees to review the current health care system and recommend ways to improve patient care, according to an AMA press release. The commission is already surveying physicians about the causes of health care disparities and is working on a physician training program to increase doctors' cultural awareness.
In announcing the commission's formation, commission members cited a Jan. 14, 2005, Morbidity and Mortality Weekly Report that said that non-Hispanic blacks face substantial health care disparities that include earlier death, a decreased quality of life and fewer economic opportunities.
The AMA press release is online.
The MMWR report is online.
The College's position paper is online.
Both new and current ACP Fellows and Masters at Annual Session 2005 will have access to a special private lounge area and will receive distinctive badge ribbons highlighting their standing in the College.
New this year in the Moscone Center Exhibit Hall will be a private lounge area reserved for ACP Fellows and Masters. A comfortable place to meet with colleagues, the new lounge will feature complimentary refreshments and computers with Internet access. The lounge, supported by a grant from Schwarz Pharma, will be located in the right rear of the Exhibit Hall in booth #2243.
Newly elected and existing Fellows and Masters will also receive distinctive badge ribbons to acknowledge and celebrate their professional accomplishments. Look for colleagues with "new Fellow" ribbons (green on silver) and "new Master" ribbons (maroon on silver).
New Fellows (including Honorary Fellows), new Masters and other Fellows and Masters participating in the Convocation Ceremony will be able to pick up ribbons for their badges on Thursday before Convocation in the Hall D gowning areas.
Current Fellows and Masters attending Annual Session may pick up ribbons at the Advance Registration Counter (Tuesday and Wednesday), the Membership Booth (Wednesday evening, 5-7 p.m.; Thursday, Friday and Saturday, all day), or in the Fellows and Masters Lounge (Wednesday evening, 5-7 p.m.; Thursday, Friday and Saturday, all day).
An ACP proposal for advancement to Fellowship is online.
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Copyright 2005 by the American College of Physicians.
A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?
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