In the News for the Week of 9-13-05
- Federal, state regulations waived to speed medical relief
- Volunteer opportunities for physicians
- CDC calls for emergency immunizations
Flu vaccine update
- FDA approves new flu vaccine
Clinical news in the headlines
Mental health screening
- Physicians can access free mental health screening kit
To meet overwhelming health care needs in the wake of Hurricane Katrina, federal and state agencies last week waived or suspended many normal health care requirements and regulations. Here is a partial list of waived requirements, according to the American Health Lawyers Association (AHLA):
The HHS is waiving certain Medicare and Medicaid requirements to allow providers to be paid despite noncompliance with those requirements. The waiver applies not only to states affected by the hurricane but to those where large numbers of displaced Americans have relocated. States where the waiver applies include Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, Oklahoma, Tennessee, Texas, Utah and West Virginia.
The federal government is waiving Social Security Act requirements that physicians and other providers hold a license in the state in which they are supplying services. In addition, Louisiana, Mississippi and Tennessee are suspending in-state license requirements or in-state licensing applications for physicians who hold a current unrestricted license from another jurisdiction. The suspensions will clear the way for out-of-state professionals to deliver medical care in affected states.
The federal government is waiving certain certification requirements for specific types of providers, to allow psychiatric or rehabilitation facilities, for instance, to be used for acute care. Normal preauthorization and out-of-network regulations have also been waived for Medicare, Medicaid and SCHIP managed care beneficiaries.
In addition, states are creating arrangements so that care provided to health plan members when they are out of state will be reimbursed by plans in patients' home state. Physicians providing emergency care to displaced persons will eventually be reimbursed by the Federal Emergency Management Agency, but should keep careful records of services, devices, supplies and drugs furnished to submit later for reimbursement.
Links to emergency declarations and waivers are online.
Many relief organizations are looking for volunteer medical personnel to help with rescue and relief efforts. The following are some resources for physicians looking to volunteer.
Project HOPE, a nonprofit group that conducts land-based medical training, is looking for medical volunteers to join its team aboard the U.S. Navy hospital ship COMFORT. The ship is now arriving in the Gulf states with ACP Regent and past Chair of the Board of Governors Jeffrey P. Harris, FACP, on board as a volunteer.
Physician volunteers are needed for a second two-week rotation scheduled to start Sept. 26. The group is in particular need of specialists in anesthesia, orthopedics, cardiology, pathology, urology and pediatrics.
Project HOPE volunteers will work with Navy personnel to provide aid to hurricane survivors and with land-based organizations to facilitate the delivery of medicines and other first-aid supplies. Information on volunteering is on the group’s employment and volunteer page.
The HHS has set up a Web site to identify potential health care volunteers for assignments lasting 14 days or longer. Physicians and physician assistants are among those cited on the HHS’ list of top volunteer needs.
Volunteers must be healthy enough to withstand such conditions as 12-hour shifts, austere conditions (living in tents, no showers) and long periods of standing. The government will cover volunteers’ travel and daily living costs and will provide liability coverage under the Federal Tort Claims Act. Volunteers are required to have Hepatitis B and tetanus/diphtheria immunizations.
Those wishing to volunteer should follow the "Donate and Volunteer" link on the HHS’ Web site to fill out an application. For more information, call the Hurricane Katrina volunteer call center at 866-KATMEDI.
The State of Louisiana has posted an urgent request for volunteers to help with relief efforts. Those wishing to do so are asked to fill out an online form with details of contact information, availability and areas of expertise. Volunteers will be contacted as needs arise.
Annals.org has posted a Hurricane Katrina resource page with updated information for physicians who want to help with hurricane relief efforts.
The CDC has issued interim immunization recommendations to protect against disease outbreaks in the aftermath of Hurricane Katrina.
Adults in affected areas should be vaccinated according to recommended schedules, the CDC said in a Sept. 5 health advisory. If records are not available, the following immunizations are recommended:
Adult formulation tetanus and diphtheria toxoids in people who received tetanus toxoid-containing vaccine more than 10 years ago.
Pneumococcal polysaccharide vaccine for adults age 65 or older with a high risk condition.
Influenza vaccine for those in priority groups, such as seniors with comorbid conditions.
In addition, those displaced by the storm and living in crowded conditions should be given vaccines for influenza, varicella, MMR and Hepatitis A. The CDC noted that immunocompromised people, such as those infected with HIV and those taking systemic steroids, should not receive varicella and MMR live viral vaccines.
People should not receive typhoid and cholera vaccines, the CDC said, because the diseases are extremely rare in the Gulf states and because the United States has no licensed vaccine against cholera. Rabies vaccine should be used only for post-exposure prophylaxis, such as after an animal bite or bat exposure.
The CDC advisory is online.
A recent New England Journal of Medicine (NEJM) article has detailed the major Capitol Hill struggle shaping up over how the government should reimburse physicians. The payment reform debate is intensifying as the medical community, government and other interest groups try to find a balance between fair reimbursement and making the most efficient use of limited federal resources.
This fall, Congress will consider legislation to eliminate the scheduled 4.3% reduction in Medicare payments to physicians, with the likely tradeoff of linking higher payments to quality improvements, wrote John K. Iglehart, an NEJM correspondent, in the Sept. 1 issue. He noted that three committees with jurisdiction over Medicare—the House Ways and Means, House Energy and Commerce, and Senate Finance committees—favor linking between 1.5% and 3% of physician payments to clinically valid quality measures, such as appropriate care for asthma or congestive heart failure.
Accepting an incentive-based payment system may be the only way to get rid of the flawed sustainable growth rate (SGR) reimbursement formula, which effectively ties growth in Medicare physician payments to growth in the national economy, the article noted. Pay-for-performance initiatives are already happening in the private sector, with large insurers linking physician payments to quality measures as well as to the use of disease registries and information technology.
A bipartisan consensus has emerged that any change to the current formula must be combined with quality improvement incentives, said Mr. Iglehart. In the article, he noted that CMS administrator Mark McClellan, FACP, has singled out ACP as a leader in proposing concrete solutions.
Medicare is engaged in demonstration projects designed to test pay-for-performance approaches in ambulatory care settings, Mr. Iglehart said. The agency also plans to make claims data available to physicians to educate them about how they compare with their peers on effective use of resources.
According to the article, the administration recognizes that instituting pay-for-performance measures will not fix the reimbursement problem unless the SGR formula is eliminated. However, it also does not want to jeopardize the new prescription drug benefit slated to start in January.
The New England Journal of Medicine excerpt is online.
ACP members who want to contact elected officials about payment reform can access background information and sample letters at the ACP Legislative Action Center Web site.
They can also join the College's Key Contact Program. For enrollment assistance, contact Tracy Novak, Grassroots Associate, by phone at 800-338-2746, ext. 4532, or e-mail.
The College has launched a new quality improvement Web site that focuses on pay for performance, performance measures and practice redesign, and includes a number of informational resources for internists.
The site features a seven-minute video summarizing the evolving national environment related to health care quality improvement and explains ACP's efforts to influence the pay-for-performance debate. A slide show details the College's legislative framework and policy guiding those activities, as well as a comprehensive set of frequently asked questions.
The new site also contains links to related articles from ACP Observer, Annals of Internal Medicine and New England Journal of Medicine. The new quality improvement Web site is online at http://www.acponline.org/quality/?ow.
Flu vaccine update
The FDA recently approved a new adult flu vaccine in an effort to ensure adequate vaccine supply for the upcoming flu season.
Fluvarix, which protects against virus types A and B, was the first vaccine to undergo an FDA accelerated approval process, according to an Aug. 31 FDA news release. Prior to its approval, Fluvarix's manufacturer, GlaxoSmithKline, conducted four clinical studies that included about 1,200 adults. Findings showed the vaccine produced protective blood antibodies likely to be effective in flu prevention, the release said. The company is conducting additional studies to verify the vaccine’s clinical benefits.
Last year’s flu vaccine shortage revealed the need for speedy approval of additional vaccines, according to the FDA release. The agency estimated that more than 200,000 people per year are hospitalized in the United States due to flu complications and that the virus causes about 36,000 deaths in this country each year.
The manufacturer noted that Fluvarix is distributed in 79 countries and has been in use outside the United States since 1992, according to an Aug. 31 GlaxoSmithKline news release. The vaccine's composition is adjusted annually to match federal recommendations on which strains are expected to be most prevalent.
The FDA news release is online.
A GlaxoSmithKline news release is online.
Clinical news in the headlines
The following articles appear in the Sept. 6 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
U.S. group does not recommend routine screening for breast cancer gene. In newly issued recommendations, the U.S. Preventive Services Task Force does not recommend routine screening for mutations in the breast cancer genes BRCA1 and BRCA2, which are associated with an increased risk for breast and ovarian cancer.
The Task Force did say, however, that genetic counseling is appropriate for women with specific family histories associated with an increased risk of mutations in the BRCA1 or BRCA2 genes. Such histories include women with two first-degree relatives (parent, sibling or child) with breast cancer, one of whom received the diagnosis at age 50 or younger, as well as women of Ashkenazi Jewish descent.
An editorial points out that the recommendations show the importance of knowing one’s family medical history and that they will help eligible women consider getting tested, as well as “the tradeoffs and uncertainties" of different preventive strategies if they are found to have a BRCA mutation.
Inhaled drug reduces COPD flare-ups, hospitalizations better than placebo. In a six-month study of more than 1,800 patients with moderate to severe chronic obstructive pulmonary disease (COPD), a daily dose of the inhaled bronchodilator tiotropium reduced the percentage of patients experiencing one or more flare-ups from 32% to 28%, compared to placebo.
Patients taking tiotropium also had fewer hospitalizations. According to an editorial, tiotropium should be considered a first-line medication in COPD therapy.
A recent study found that many medical residents are not adequately trained to treat a culturally diverse patient population.
Researchers surveyed more than 2,000 residents in their final year of training and found that one-quarter of respondents believed they were not prepared to care for new immigrants or patients with health beliefs different from those in Western medicine. In addition, 20% of respondents said they were not prepared to care for patients whose religious beliefs affected treatment and 24% said they lacked skills to identify cultural customs that affect care. The study appears in the Sept. 7 Journal of the American Medical Association (JAMA).
The authors concluded that training in cross-cultural care lags far behind residents’ training in clinical and technical areas. Most respondents said they received little or no instruction in specific areas of cross-cultural care during their residencies.
Another study in the same issue looked at trends in primary care. The study found that more medical school graduates are pursuing subspecialty training than in the past while more women, international medical school graduates (IMGs) and osteopathic graduates (DOs) are pursuing careers in primary care.
The study, which surveyed more than 100,000 physician trainees over nine years ending with the 2004-05 academic year, found that the number of residents in primary care specialties leveled off after peaking in the 1990s. Meanwhile, the number of U.S. IMGs going into primary care specialties nearly doubled between 1995-96 and 2004-05. while the number of U.S. IMGs training in internal medicine or pediatrics increased by almost 46% during the same period.
The survey also found that more than half of primary care residents were women and that the proportion of women residents increased in all primary care specialties and subspecialties, with the greatest gains made in obstetrics/gynecology. The authors noted that positions once filled by U.S. allopathic medical school graduates are now being filled by DOs and IMGs, especially in family medicine.
ACP's "Cross-Cultural Medicine," printed in 2003, provides important information on many racial and cultural groups, their health care problems and religious issues. The 300-page softcover is $38.
More information is online.
Mental health screening
ACP is once again partnering with many other national professional organizations to sponsor National Depression Screening Day, being held this year on Oct. 6.
Physicians can access a free screening kit to use in their offices. The kit includes materials to test for four different disorders: depression, bipolar disorder, generalized anxiety disorder and post-traumatic stress disorder. Physicians can also get information about holding National Depression Screening Day events.
The nonprofit organization Screening for Mental Health has sponsored the national screening day for the past 15 years. (ACP has been a co-sponsor since 1998.) According to the organization's Web site, nearly 550,000 screenings were completed at 10,000 facilities using programs provided by Screening for Mental Health throughout 2004.
The screening kits are being distributed as part of the the organization's primary care outreach program. They include a 10-point depression screening form that can be completed by patients in the waiting room and placed in their files for review. The kits also include clinical guidance for physicians.
ACP members can download materials online.
The materials are also accessible on the Screening for Mental Health Web site.
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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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