In the News for the Week of 8-9-05
Pay for performance
- College EVP testifies before IOM on pay for performance
- All Medicare claims must be HIPAA-compliant as of Oct. 1
- CMS to announce coverage of clot-busting stroke drug
Clinical news in the headlines
- Highlights of ACP Journal Club
- Drug companies adopt voluntary guidelines for DTC ads
- College, others, endorse new value-based purchasing bill
- ACP give Congress comments on information technology
- College backs bill to include benzodiazepines in drug benefit
- ACP applauds 'common sense solutions' in tort reform bill
Pay for performance
In testimony to an Institute of Medicine subcommittee on pay for performance, the College's Executive Vice President and Chief Executive Officer detailed ACP's efforts to improve the quality and delivery of American health care.
John Tooker, FACP, appeared before the subcommittee on July 25, telling members that ACP is involved in more than 40 projects to improve health care quality, from pay-for-performance initiatives to helping the frail elderly receive better care.
Regarding pay for performance, he told subcommittee members that the College continues to play a leading role in the Ambulatory Care Quality Alliance (AQA), the national consortium of stakeholders dedicated to defining clinical performance measures.
He also described College efforts to help federal legislators draft bills that include College recommendations on pay for performance, including phasing in value-based purchasing that is linked to physician performance. According to Dr. Tooker's statement, physicians are worried that pay-for-performance programs will require them to do more work, while paying them less and leaving them less time to spend with patients. To overcome these concerns, he said, Medicare must restructure its payment policies.
Dr. Tooker’s testimony is online.
The College also issued a statement on July 27 to the Senate’s Committee on Finance regarding pay for performance.
According to the statement, ACP supports the Medicare Payment Advisory Commission’s recommendation that physician performance profiling be kept confidential initially. Studies show that public reporting can create unintended incentives for physicians to avoid higher risk or noncompliant patients, the statement said, making risk adjustment essential.
The statement also pointed out that the College is urging Congress to allow a phased-in approach to pay for performance. The College recommends a three-part approach for any Medicare value-based purchasing program. Those include:
Medicare should start with pay for reporting, which would pay physicians for achieving basic structural measures, such as the use of information technology and electronic medical records.
Medicare should then implement a pay-for-participation payment system, paying physicians who participate in quality improvement programs that use evidence-based clinical measures.
Finally, Medicare should pay those physicians who achieve quality gains as defined by evidence-based measures, or pay for performance—but only after implementation issues, such as impact on high-risk patients, are addressed.
The statement to the Senate Finance Committee is online.
The CMS announced last week that it will no longer process non-HIPAA compliant electronic Medicare claims after Oct. 1, 2005.
As of that date, according to an Aug. 4 CMS press release, fee-for-service claims that do not meet HIPAA standards will be returned to physicians to be re-submitted as compliant claims.
As of June 2005, the CMS said, only 0.45% of claims from physicians continued to be non-compliant, along with 1.45% of hospital claims and 1.72% of claims from clinical laboratories.
The announcement affects only claims for fee-for-service Medicare services. The move will end a portion of the agency's HIPAA contingency plan announced in October 2003, which extended the deadline for submitting HIPAA-compliant claims. At the time, only 31% of Medicare claims were found to be compliant.
The contingency continues in effect for other electronic health care transactions, such as payment and remittance advice, eligibility, enrollment, claim status, and claims attachments. The remittance advice transaction is the next HIPAA transaction for which the CMS expects to end its contingency plan. Physicians still having difficulty may contact their carrier for assistance in submitting HIPAA-compliant claims.
The CMS news release is online.
The CMS is slated to begin covering a costly clot-busting drug approved for treatment of acute ischemic stroke.
According to the Aug. 4 Wall Street Journal, Medicare plans to start covering the use of tPA (formally tissue plasminogen activator) as early as October. The drug is designed to be administered by IV within three hours to patients who've suffered a stroke caused by a clot.
With Medicare now paying hospitals only $5,700 for stroke treatment, many hospitals don't administer the drug, which can cost as much as $2,000 or more per dose, according to the Wall Street Journal.
However, Medicare will begin paying about $6,000 more to hospitals for stroke care if the drug is used. According to the Wall Street Journal, actual reimbursements for tPA treatments to hospitals will vary by hospital and region.
The drug, which can cause hemorrhaging, is manufactured by Genentech. Out of 700,000 annual strokes in the United States every year, 80% are caused by clots.
The Wall Street Journal is online (subscription required).
Clinical news in the headlines
A recent trial concluded that prophylactic coronary artery revascularization did not reduce the risk of mortality in patients with stable coronary artery disease (CAD) undergoing elective surgery.
The randomized controlled trial (RCT) looked at just over 500 mostly male patients with stable CAD who were scheduled for elective major vascular surgery for an expanding abdominal aortic aneurysm or for severe symptoms of arterial occlusive disease involving the legs. There was no difference in long-term all-cause mortality between patients assigned to prophylactic preoperative coronary artery revascularization vs. those with no revascularization. The study is abstracted in the July-August ACP Journal Club.
The study is significant because it is the first to use an RCT design to evaluate whether preoperative revascularization improves major outcomes, said reviewers. While the results may surprise many physicians, the reviewers said these findings are in keeping with evidence suggesting that most perioperative cardiovascular events start in coronary arteries with nonhemodynamically significant stenoses.
The study shows that patients are at a substantial risk for death for almost three years, on average, following vascular surgery—highlighting the need for large RCTs to identify effective interventions, the reviewers noted. There is currently no strong evidence to support prophylactic intervention in patients undergoing noncardiac surgery.
Based on the trial findings, reviewers said physicians should avoid preoperative coronary revascularization in patients with stable CAD who will undergo vascular surgery.
The ACP Journal Club is online.
A pharmaceutical trade association announced last week that its members were adopting voluntary guidelines to regulate the industry's use of direct-to-consumer (DTC) ads.
The new 15-point plan calls for fully informing physicians about the benefits and risks of a new drug before that drug is advertised. The new principles also call for submitting DTC television ads to the FDA before ads are aired, according to the Aug. 3 Los Angeles Times.
An Aug. 2 press release from PhRMA, the trade association, pointed out that several of the new principles exceed FDA regulations. The guidelines are to take effect January 2006 and have already been endorsed by more than 20 individual drug companies.
Among other provisions, the principles call for TV ads to explicitly identify the health conditions being targeted by an advertised drug and to present a balanced representation in ads of a drug's risks and benefits.
Some consumer groups criticized the new principles as not being far-reaching enough, said the Los Angeles Times, which reported that the FDA may review its DTC policies. The FDA relaxed its rules in 1997, making it possible for drug companies to advertise their products on television. DTC ad spending currently tops $4 billion a year.
The Los Angeles Times is online.
The PhRMA principles are online.
The PhRMA press release is online.
ACP, along with two other national medical societies, has voiced strong support for a recently introduced House bill that would eliminate the sustainable growth rate (SGR) formula and ensure positive updates for physicians, while helping move to pay-for-performance initiatives in Medicare.
The College praised the bill—the Medicare Value-Based Purchasing for Physicians’ Services Act of 2005 (H.R. 3617)—in a July 28 release that was also signed by the American Academy of Family Physicians and the American Osteopathic Association. According to the release, the three organizations represent more than 245,000 primary care physicians nationwide.
The release noted that the bill, if passed, would replace "the volatile SGR" with a more predictable formula based on the Medicare Economic Index (MEI). The bill would also ensure a positive payment update for physicians for 2006, the release said.
College President C. Anderson Hedberg, FACP, also applauded introduction of the bill in a July 27 letter sent to the bill's sponsor, Rep. Nancy Johnson (R-Conn.). Dr. Hedberg noted that the College supports several provisions in the bill, including:
Giving physicians who participate in performance measurement and reporting programs a full update, while those who do not participate would receive the MEI minus 1%.
Gradually phasing in performance measures, starting with pay-for-reporting programs of structural and quality measures before Medicare starts paying physicians on actual performance.
Recognizing the critical role that medical specialty societies play in developing measures that are then validated by multiple, diverse stakeholders.
Dr. Hedberg also testified before the House Ways and Means Health Subcommittee last month and participated in a press conference with Rep. Johnson on Medicare payment and quality improvement.
The joint release is online.
Dr. Hedberg's letter is online.
ACP recently submitted a statement to a Congressional subcommittee that outlines ACP's recommendations for promoting the nationwide adoption of interoperable information technology.
In a statement dated July 27, ACP sent its recommendation to the House Ways and Means Committee's Subcommittee on Health. According to the statement, the HHS has estimated that the country could save between $140 billion and $170 billion a year from universal and interoperable information technology—close to 10% of total U.S. health care spending.
However, anticipated costs of adopting an interoperable electronic medical record range from between $16,000 and $36,000 per physician, according to ACP's statement—too much for small practices to bear alone.
The statement voiced support for several information technology bills, including the National Health Information Incentive Act (H.R. 747) and the Health Information Technology Act (S. 1227). The College also made the following recommendations:
Congress must begin immediately to fund initiatives to adopt uniform standards.
Congress must also fund pilot testing of information technology integration.
Medicare reimbursement must be reformed to reward physicians who incorporate health care information technology and value-based purchasing into their practice.
Physicians who adopt information technology must be allowed to share in savings attributable to the use of information technology and to quality improvements.
The statement is online.
ACP has voiced support for a recently introduced House bill that would remove the exclusion of benzodiazepines from coverage under the new Medicare prescription drug benefit.
In a July 29 letter, College President C. Anderson Hedberg, FACP, wrote that the coverage of benzodiazepines under the new Medicare Part D benefit would help keep patients from possible physical and mental harm. The letter was sent to Rep. Benjamin L. Cardin, (D-Md.), the sponsor of the bill, which is H.R. 3151.
Moreover, Dr. Hedberg said, many “dual eligible” beneficiaries who receive these drugs through a state Medicaid program are now slated to lose that coverage when their drug benefits are taken over by the new Medicare prescription drug program, which takes effect in January 2006.
The letter is online.
The College has sent a letter to the legislative sponsor of proposed tort reform, endorsing what the letter called "common sense solutions" contained in the bill.
In a letter dated July 25 and signed by College President C. Anderson Hedberg, FACP, ACP voiced its support for the Help Efficient, Accessible, Low Cost, Timely Health Care Act of 2004 (H.R. 5), which recently was passed in the House. The bill limits noneconomic damages in medical liability cases to $250,000.
The letter, which was sent to Rep. Phil Gingrey (R-Ga.), the bill's sponsor, noted that tort reform legislation would help safeguard patients' access to care while controlling the cost of medical liability insurance premiums. If malpractice premiums continue to rise, Dr. Hedberg wrote, patient access to care will continue to deteriorate.
The bill has passed the House, but has not been approved by the Senate.
The letter is online.
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Copyright 2005 by the American College of Physicians.
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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