In the News for the Week of 5-17-05
- ACP Subcommittee works to address performance measures
- New editions of popular young physician guides now available
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
Access to care
- Federal government to help pay for care of illegal immigrants
- States propose restricting benefits for higher-income recipients
- Survey: quality improvement not yet part of physician 'culture'
- Medem launches patient e-records program
Kevin B. Weiss, FACP, is briefing Congressional staffers today on Capitol Hill about performance measures.
As chair of the multi-organizational Ambulatory Care Quality Alliance's (AQA) performance measures workgroup, Dr. Weiss has been called upon to provide in-depth background information about performance measures as Congress begins to consider integrating performance measures into national health care policy. The AQA is a broad alliance of national health care stakeholders, including ACP, other key national medical and quality organizations, health plans, purchasers, government agencies and accrediting organizations.
Dr. Weiss also serves as Chair of the ACP Performance Measures Subcommittee (PMSC), which supports College policy formulation, advocacy and educational efforts through the critical review, development and dissemination of physician clinical performance measures.
As reported earlier this month in ObserverWeekly, the AQA recently approved a uniform starter set of clinically relevant performance measures that could be incorporated into pay-for-performance programs throughout the country as early as 2006. Dr. Weiss' dual role as Chair of ACP's PMSC and chair of the AQA performance measures workgroup has allowed ACP to play a crucial role in AQA deliberations leading up to the starter set's final selection and announcement.
Since its formation in 2004, the College's PMSC has met regularly to develop and recommend guidance and strategies to ACP leadership in response to growing demands for physician performance measurement.
One of the PMSC's first tasks was to develop criteria for measures selection. When AQA deliberations began in earnest last fall, ACP was able to offer to the AQA performance measures workgroup the selection criteria the College had developed. The PMSC provided input throughout the AQA development process, reviewed the near-final list of measures and provided recommendations on those measures that subcommittee members felt should be retained in or dropped from the final set.
The PMSC will continue to meet during the coming months and will closely monitor the impact on College members as the AQA starter set measures are initially implemented. The PMSC is also continuing its research and investigations into measures of overuse and misuse, as well as into other ways to assess clinical efficiency.
The subcommittee is exploring the possibility of publishing a paper that would review the current state of measurement science, with suggestions on what further research needs to be done and to warn about potential negative and unintended consequences that may occur if clinical efficiency measures that are not evidence-based are implemented.
More information on ACP's Performance Measures Subcommittee is online.
Updated issues of two publications created by the ACP Young Physicians Subcommittee are now available free to ACP members.
The 34-page "Young Physician Practice Management Survival Handbook," developed with the College's Practice Management Center, provides helpful information on how to set up and manage a private practice. The handbook includes details on licensing, office technology, insurance, coding and billing, and other topics of interest.
The "Pocket Guide to Selected Preventive Services for Adults" lists recommended frequencies and target populations for common screening, immunization and counseling services. The guide also includes clinical guidelines for treating hypertension, high cholesterol and diabetes mellitus.
You can order either booklet online, via e-mail or by calling 800-523-1546, ext. 2714.
Clinical news in the headlines
The following articles appear in the May 17 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Guidelines now recommend against HT for women with hysterectomy. Updated recommendations from the U.S. Preventive Services Task Force (USPSTF) now recommend against routine use of estrogen alone to prevent chronic disease in postmenopausal women who have undergone hysterectomy. (The USPSTF's 2002 recommendations found insufficient evidence to recommend either for or against routine use of estrogen alone to prevent chronic conditions in these women.)The new guidelines for postmenopausal women also recommend against routine use of combined estrogen and progestin for the sole use of preventing chronic conditions.
Antibiotic successfully prevents travelers' diarrhea. A study of 210 adults traveling in Mexico, who were randomly assigned to take either the antibiotic drug rifaximin or placebo, found that those taking the drug had fewer cases of mild diarrhea (14.7%) than those who received the placebo (53.7%). Rifaximin has recently been approved in the United States for treatment of diarrhea.
An editorial gives four reasons why the drug should not be prescribed as diarrhea prevention for all 50 million U. S. travelers. The drug can be a good alternative for selected patients, the editorial said, but "rapid and judicious treatment of diarrhea, not antibiotic prophylaxis, is the best recommendation for most travelers. "
Access to care
The federal government said last week that it would earmark $1 billion to compensate physicians and hospitals that care for illegal immigrants.
The money, available through September 2008, was approved by Congress in 2003 as part of the same law that created the Medicare prescription drug program, according to the May 10 New York Times. Funding was sought by senators from border states, such as Arizona, which shoulder a disproportionate financial burden for providing emergency care for illegal immigrants.
The new program does not require physicians to ask directly if patients are undocumented aliens, said the New York Times. Instead, the CMS directed hospital personnel to determine a patient's status through indirect questioning, such as whether the person was born in another country or whether they have a foreign passport or driver's license. The agency assured civil rights groups that it would not give out patient information to law enforcement officials, except in rare criminal investigation cases.
This fiscal year, California will receive the largest allocation of $70.8 million, the New York Times reported, followed by Texas ($46 million), Arizona ($45 million), New York ($12.3 million), Illinois ($10.3 million), Florida ($8.7 million) and New Mexico ($5.1 million). Physicians must try to be reimbursed by other payers, such as Medicaid and private insurance, before applying for aid from the new program.
The New York Times is online.
In the wake of Congress's plan to cut projected Medicaid spending by $10 billion over the next five years, state governors and legislators have come up with a list of proposals to fix the ailing health care program.
The proposals by the National Governors Association and the National Conference of State Legislatures include allowing states to impose higher co-pays and deductibles on recipients with higher incomes, according to the May 9 New York Times. The groups also advocate for allowing states to offer different benefit packages to different populations.
Spending on Medicaid, which covers more than 50 million low-income patients, has grown by 10% a year on average over the last five years, to more than $300 billion annually, the New York Times reported. Much of that increase is due to higher enrollment, which grew by one-third from 2000-2004 as employers cut back on coverage, pushing many low-wage workers onto Medicaid rolls.
According to the New York Times, state governors are also recommending the following:
- Tax credits to help people and small businesses afford insurance.
- Greater discounts from drug companies to save on prescription costs.
- Multistate purchasing pools to buy drugs at lower prices.
- Federal funding of "block grant"-type funding to help states pay for long-term care.
- Broad discretion by states to set premiums, co-pays and deductibles or, alternatively, higher co-pays for families with higher incomes.
State governors and legislators are still finalizing the proposals, the New York Times said, and they expect to deliver them to Congress for action this year.
The New York Times is online.
ACP's 2005 position paper on "Redesigning Medicaid in a Time of Budget Deficits" in online.
Only 27% of physicians polled in a recent survey said they were using electronic medical records to track patient care, while almost three-quarters said they are missing important information during patient visits.
Results of a survey of 1,800 physicians, published in the May-June issue of Health Affairs, also found that physicians in large practices or health plans are more likely to use EMRs than physicians in small or solo practices, according to the May 10 Seattle Post-Intelligencer. The results indicate that quality improvement has yet to permeate the culture of professional medicine, said the authors of "Measure, Learn and Improve: Physicians' Involvement in Quality Improvement," based on a national survey by the Commonwealth Fund.
Only one-third of doctors surveyed said they were involved in redesign efforts aimed at quality improvement, according to a May 10 Commonwealth Fund news release. In addition, one-third said they had access to data on their clinical performance, while seven out of 10 respondents said the public should not have access to that data.
Small practices with less than nine physicians—which accounted for 68% of survey respondents—were more likely to direct resources to computerizing accounting systems than to electronic patient records, the Seattle Post-Intelligencer reported. Only 8% of respondents said their pay was tied to clinical care or patient satisfaction measures.
One-third of respondents said they sometimes had to repeat tests or procedures due to misplaced or poorly recorded results, while 85% said they found it difficult or impossible to extract lists of patients according to lab results or drugs prescribed, according to the Seattle Post-Intelligencer. Almost two-thirds of respondents said they could not access performance information on specialists when referring patients for care.
The Seattle Post-Intelligencer is online.
The Commonwealth Fund release is online.
Medem Inc. last week launched a new patient electronic health records program the company hopes will attract physicians who may lack the money to invest in electronic health records. Medem is a for-profit company that offers online physician e-mail services.
Called iHealthRecord, the new electronic patient record service will cost subscribing physicians $25 per month but will be free to patients, according to the May 10 Philadelphia Inquirer.
According to the iHealthRecord Web site, participating patients will create their own records and control who has access to them. They also can name someone to access those records in case of an emergency, the Philadelphia Inquirer reported. With access, physicians at different sites will be able to view the information contained in the e-records.
The service will also provide educational information to patients as well as safety warnings on FDA recalls or label changes. According to the company Web site, the records service will also make it easier for physicians to participate in pay-for-performance programs by helping them create patient registries from their patients' e-records and to automatically enroll patients in chronic care programs.
More information about iHealthRecord is online.
The Philadelphia Inquirer is online.
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Copyright 2005 by the American College of Physicians.
A 57-year-old man is evaluated in follow-up for a right-sided pleural effusion. He initially presented with increasing dyspnea and a constant dull ache on his right side. He also has lost 9.1 kg (20.0 lb) over the last 6 months. Medical history is otherwise unremarkable. Following chest radiographs and repeat thoracentesis, what is the most appropriate diagnostic test to perform next?
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