In the News for the Week of 8-2-05
- Congress passes long-awaited patient safety bill
- ACP President comments on proposed value purchasing bill
- College urges payment reform to protect patient access
Clinical news in the headlines
- Practices serving low-income patients score lowest on preventive care
- New Web service can assist low-income Medicare patients
- Workshops, toolkit provide Medicare drug benefit information
- Project HOPE seeks summer medical volunteers
The president signed a bill into law last week that will create a national system for voluntary, confidential reporting of medical errors—a measure the College, other medical organizations and consumer groups have spent years lobbying for on Capitol Hill. ACP participated in the president's signing ceremony for the new legislation at the White House's invitation.
The Patient Safety and Quality Improvement Act of 2005, which received bipartisan support in both the House and Senate, will allow health care officials to report errors to newly created patient safety organizations, according to the July 29 Washington Post. Those organizations will analyze error information and make recommendations on safety improvements. All error reports would be kept confidential and could not be used in malpractice suits.
Legislation was first proposed in the wake of a 1999 report by the Institute of Medicine (IOM). That report estimated the number of deaths that occurred in U.S. hospitals as a result of medical errors and called for a nationwide mandatory reporting system, the Washington Post said. The new law is in response to that IOM report—but makes hospital error reporting voluntary.
Twenty-three states already have systems in place for reporting mistakes, almost all of them mandatory, the Washington Post reported. Hospitals and physicians lobbied for a voluntary system, contending that mandatory reporting discourages people from participating.
Under the new plan, physicians and other providers would make confidential reports about medical errors to hospitals, which would then submit them to patient safety organizations, said the Washington Post. The new safety organizations could contract with hospitals to analyze the mistakes and come up with strategies to prevent future errors. The program will be coordinated by the federal government, which will develop the computer network used to analyze the data.
Supporters of the legislation applauded the creation of a national framework for studying errors and sharing potential solutions, according to the Washington Post.
However, some consumer groups and researchers expressed concern that the system could duplicate state efforts and create confusion. While the new reporting system will be confidential, for example, some states already publish errors along with the names of hospitals where those errors occur. It is unclear whether state reporting agencies would share information with the new patient safety organizations.
The Washington Post is online.
A College letter supporting the legislation is online.
College President C. Anderson Hedberg, FACP, told members of the press last week that a new Medicare reimbursement bill would provide a practical plan for phasing in evidence-based performance measures, while halting payment cuts that would make it impossible for physicians to participate in such quality improvement activities.
The Medicare Value-Based Purchasing for Physicians' Services Act of 2005 (H.R. 3617) is sponsored by Rep. Nancy L. Johnson (R-Conn.), who chairs the House Subcommittee on Health. The bill calls for several College-endorsed provisions, including using performance measures that are evidence-based, reliable and valid. It was introduced into the House on July 29.
With Rep. Johnson at his side, Dr. Hedberg said the bill "recognizes that quality improvement cannot take place in an environment where physicians' fees are being cut." Among other key points, Dr. Hedberg said, the bill would:
Sunset the sustainable growth rate (SGR) formula, recognizing that the formula is incompatible with quality improvement. (The SGR would cut Medicare payments to physicians by 4.3% in 2006 and 2007, and by 26% over the next five years.)
Provide positive updates to all physicians and additional payments for those who participate in performance reporting and improvement.
Gradually phase in such reporting, with voluntary reporting to begin in 2007 and 2008 and pay for performance to be launched in 2009.
A press release on Dr. Hedberg's appearance is online.
Last month, Dr. Hedberg testified on pay for performance before the House Ways and Means' Subcommittee on Health. His testimony is online.
Earlier this month, the College sent members of the Senate Finance Committee a letter detailing ACP's comments on a related bill, the Medicare Value Purchasing Act of 2005 (S. 1356). The letter noted the College's concern that if that bill was passed, physicians participating in quality improvement programs would not be compensated until the year following their participation.
The letter also expressed concerns about provisions that would authorize the CMS to pay physicians in part based on "efficiency" measures derived from Medicare claims data, instead of evidence-based clinical measures that consider both quality and cost.
The letter, signed by Dr. Hedberg, noted another major concern: The Senate bill calls for a 2% reduction in the 2006 update for physicians who do not submit quality data. Dr. Hedberg wrote that the College's support for the bill depends on assurances that the 2006 and 2007 physician fee updates will be set at a level that provides positive updates.
The letter is online.
The bill is online.
The College has joined more than 100 other health care organizations and medical societies in asking Congress to pass legislation that would create a physician payment system that accurately reflects the costs of medical practice and safeguards patient access to care.
In letters dated July 15 and sent to House and Senate leaders, the College urged them to pass the Preserving Patient Access to Physicians Act of 2005 (H.R. 2356/S. 1081), which would provide a two-year fix to the sustainable growth rate formula.
The bill would provide an update of not less than 2.7% in 2006, in accordance with Medicare Payment Advisory Commission (MedPAC) recommendations, the letter said. The 2007 update would be based on MedPAC's proposal that updates should reflect a practice's inflation costs. The letter was signed by 122 different groups, including the American College of Surgeons, the American Medical Association, and medical societies and associations from all 50 states and the District of Columbia.
Without Congressional action, the signatories said, physicians will be forced to limit the services they provide to seniors. The letter cited a recent AMA survey, which found that scheduled Medicare payment cuts would result in 38% of physicians reducing the number of new Medicare patients they accept, while 34% of physicians in rural areas would discontinue outreach services and 54% of physicians nationwide would defer buying information technologies.
The letter also noted that only physicians are subject to arbitrary cuts beyond their control and that other health care providers—including hospitals--receive positive updates based on the cost of doing business.
A copy of the letter is online.
The bill is online.
Clinical news in the headlines
The following articles appear in the August 2 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
New study: GERD linked to obesity. A new meta-analysis of nine existing studies of GERD finds that the risk for GERD symptoms, erosive esophagitis and esophageal cancer increases 1.5-to-2.0 fold with overweight or obesity, compared with normal weight. Researchers say that the link with obesity implies that losing excess weight may be important to prevent and treat GERD and associated complications.
Study assesses risk for death associated with two kinds of kidney dialysis. A study of 1,041 patients with end-stage renal disease receiving peritoneal dialysis or hemodialysis found that although risk of death did not differ between the groups during the first year of dialysis, risk was higher in the second year among those undergoing peritoneal dialysis. An editorial notes that for many reasons, the study cannot help the individual patient choose between the two forms of dialysis. The editorial also discusses newer dialysis technologies.
A national health information infrastructure will cost billions. Researchers have estimated that achieving a workable national health information infrastructure within the next five years would cost at least $156 billion in capital investment and $48 billion in annual operating costs.
At current rates of spending, U.S. hospitals, physician practices and nursing homes will invest only $24 billion in capital costs and $7 billion in annual operating costs in functionalities alone, said the researchers, whose work was partially funded by the Commonwealth Fund.
The interoperability system by which various providers enter data into a record and communicate with each other would require an additional $53 billion in capital investment and $21 billion in ongoing annual operating costs. The bulk of this money will be needed by physician office practices.
A recent study found that giving beta-blockers before noncardiac surgery does not help—and may harm—patients at low risk for postsurgical complications.
While guidelines recommend that beta-blockers be given to intermediate and high-risk patients preoperatively, many hospitals prescribe them routinely to those at low-risk, according to the July 28 Newsday.com. The retrospective study of about 664,000 patients found a 43% increase in the risk of death among the lowest-risk patients given beta-blockers before surgery vs. the highest-risk patients. The study appears in the July 28 New England Journal of Medicine.
In contrast, patients with the highest risk scores had between a 10% and a 43% reduction in the risk of death, the study reported. Patients were assigned a risk category based on their history of one or more of the following: ischemic heart disease, congestive heart failure, cerebrovascular disease, preoperative treatment with insulin and a preoperative serum creatinine level greater than 2.0 mg/dL.
The results, combined with earlier trials showing benefits in high-risk surgical patients, supports the continued use of beta-blockers in high-risk patients, an accompanying editorial pointed out. The study noted that one in 10 patients experience complications within 30 days following major surgery.
Two large ongoing randomized trials may provide more answers on the effects of beta-blockers on low-risk patients, the editorial continued. One trial is evaluating the ability of metroprolol to prevent death in 10,000 patients undergoing noncardiac surgery.
The second trial is focusing on the efficacy of combining fluvastatin and bisoprolol in 6,000 patients scheduled for noncardiac, non-vascular surgery.
Pending the results of these trials, physicians are advised to continue beta-blocker therapy in low-risk patients currently receiving it. However, there is not enough evidence to support routine perioperative beta-blocker therapy for patients at low risk of complications.
The NEJM is online.
Newsday.com is online.
A recent study of Medicare beneficiaries found that many are not receiving adequate preventive services from primary care.
The study of more than 24,500 beneficiaries looked at whether eligible patients were receiving preventive services such as hemoglobin A1C measurement for diabetics or screening for colon or breast cancer.
Researchers found that the quality of care was lowest at practices that received more than 15% of their revenue from Medicaid and that patients were more likely to receive preventive care in group vs. solo practices. The study appears in the July 27 Journal of the American Medical Association.
Practices that derive a higher proportion of their revenue from Medicaid may suffer from lower levels of reimbursement—creating the need to see more patients—and from other challenges of caring for disadvantaged patients, the authors said. These “spillover” effects raise concerns, they added, about whether pay-for-performance programs will have a negative impact on these practices.
The difference in care between group (three or more physicians) vs. solo or two-physician practices may be due to group practices having better access to data collection systems and financial systems, as well as more support staff, the study said.
Researchers also found that board-certified physicians were more likely to provide preventive services, although certification is not required by Medicare or other large insurers. Authors noted that the 15% of physicians in the survey who were not board certified disproportionately cared for black patients.
Previous studies have found that the delivery of preventive services is below national goals, the authors said. This study shows that in addition to patients’ race and income, practice setting is a significant factor in the level of care provided.
The JAMA abstract is online.
A new Web-based service can help low-income Medicare beneficiaries access extra financial resources available to them through the Medicare prescription drug reform act of 2003.
The new service—a special version of the CMS' BenefitsCheckUpRx program—can help low-income beneficiaries enroll in other health care and prescription drug assistance programs.
The service also helps screen patients to find out if they are eligible for the Medicare low-income subsidy, which covers an average of 95% of drug costs for Medicare enrollees of limited means. (The service also supplies a link for eligible patients to apply for the subsidy online.) The Web-based tool is confidential, so patients do not have to enter personal information—including their name and Social Security number—until they enroll.
According to the CMS, about one in three Medicare beneficiaries should be eligible for the additional assistance. The Web service has been designed by the CMS, the Administration on Aging and the National Council on Aging.
The new service is available online.
Medicare has also posted information on different states' eligibility criteria for Medicare beneficiaries to receive extra assistance if they receive Medicaid benefits or are enrolled in a Medicare savings program. The information is online.
The CMS is hosting a series of free workshops around the country and has released a new Web-based toolkit for physicians and other health care professionals--all to provide information about the new Medicare prescription drug benefit that will take effect at the beginning of next year.
Free day-long workshops on the Medicare prescription drug benefit are being held for physicians, agencies and organizations that assist Medicare beneficiaries. The following workshops are being held:
- August 9, San Diego
- August 12, Chicago
- September 7, Westminster (Denver), Colo.
At the same time, the CMS' "Toolkit for Healthcare Professionals: Medicare Prescription Drug Coverage" kit includes free, downloadable educational materials designed specifically for physicians, other health care professionals and staff to learn the basics about Medicare prescription drug coverage. The kit also includes materials that can be given to patients.
The toolkit contains a fact sheet in English and Spanish about the new benefit, as well as brochures, articles and a list of resources. Physicians and groups are encouraged to add their logo and business information to the free materials and copy them for distribution.
Registration for a free workshop is online or call 800-886-1696.
Project HOPE is looking for ACP members who are interested in volunteering this summer in Egypt as an evidence-based medicine expert (EBM) volunteer or as an expert nutritionist (MD and/or PhD).
Known to many as the S.S. HOPE, the world's first peacetime hospital ship, Project HOPE now conducts land-based medical training and health care education programs on five continents, including North America.
ACP leadership has met with Project HOPE executives and determined that the mission and goals of the two organizations are very similar. At the request of the College's Board of Regents, ACP is working with Project HOPE to identify opportunities of mutual interest to both groups.
Efforts are being made to match ACP members' volunteer interests with Project HOPE's needs.
More information about volunteering for the Project HOPE opportunities in Egypt is available on ACP Online.
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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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