In the News for the Week of 1-10-06
Payment reform update
- Congress expected to restore 2005 payment rates
Medicare drug benefit
- New CMS site allows physicians to track Part D formularies
- States step in to ensure coverage for low-income patients
- Under benefit, seniors may pay more for some drugs
Clinical news in the headlines
- Annals: maintenance of certification survey results; walking and peripheral arterial disease
- Review finds no benefit in taking statins to prevent cancer
- Study signals promising advance in ovarian cancer treatment
- New series compares GERD treatment strategies
- CMS announces key changes to voluntary reporting program
- Annual correctional health care conference being held in April
- Wanted: proposals for Clinical Skills and Medical Informatics workshops for Annual Session 2007
- New HIV patient education video now free to members
- Save 25% on Update recordings from 2005 Annual Session
- Council of Associates issues call for nominations
- Council of Student Members calls for nominations
Payment reform update
Despite sustained efforts by ACP and other national medical organizations, Congress adjourned last month without halting the 4.4% cuts in Medicare physician fees. Those cuts took effect Jan. 1.
Before they adjourned, however, the House and Senate passed budget measures to extend physician payments at 2005 levels through 2006, thereby averting cuts at least through this year. While changes in the final Senate bill still need approval by the House of Representatives, that body is expected to do so when it reconvenes later this month.
In a Jan. 6 letter to key lawmakers, the CMS announced that once the new legislation is enacted, it is prepared to change its claims-processing software to eliminate the 4.4% reduction. The CMS also plans to automatically reprocess all of the 2006 claims submitted prior to the legislation enactment to pay physicians the amounts removed. Physicians will not have to resubmit these claims. Given the large number of claims that will require reprocessing, it may take several months for physicians to receive these additional payments.
The CMS also recognized that the updated, reprocessed claims would technically require additional copayments and deductibles. Moreover, a waiver of this additional cost-sharing by a physician, although small in monetary amount, could be viewed as violating the Medicare Anti-Kickback law. After discussing this issue with the HHS Office of the Inspector General, the CMS believes that the waiver of this additional amount would not violate the kickback law. ACP will let members know immediately if the Inspector General's office issues any guidance.
Physicians may hold claims until after Congress acts to improve payments. Physicians must decide whether this approach is worth the cash flow interruption.
The CMS said it also intends to offer an additional enrollment period for doctors to reconsider their Medicare participation decision in light of the anticipated better-pay situation. The original enrollment period ran from Nov. 15 to Dec. 31, 2005. The extended enrollment period will run an additional 45 days, and will start soon after the legislation is enacted.
"The fact that the House and Senate are on record as voting for identical provisions to stop the SGR [sustainable growth rate] cuts bodes well for getting the SGR cuts reversed early in 2006," ACP President C. Anderson Hedberg, FACP, wrote in a Dec. 23, 2005, e-mail sent to all College members.
However, Dr. Hedberg expressed dismay that "political gamesmanship" had delayed action on cuts that could dramatically affect patient care. Even temporary cuts are a hardship for practices already functioning within extremely tight financial constraints, Dr. Hedberg wrote.
ACP is asking all members to contact their representative and urge them to take immediate action, upon their return, to reverse the pay cuts retroactive to Jan. 1. You can contact your legislators through ACP's Legislative Action Center.
The Jan. 6 letter is online.
A copy of Dr. Hedberg's e-mail message to members is online.
Medicare drug benefit
A new CMS Web site lets physicians find out what specific drugs are covered by individual Medicare Part D health plans.
The CMS' new formulary finder allows physicians to research a drug's availability by state. The site also provides a list of all Part D plans in each state, with direct links to a plan's home page for a complete formulary.
In mid-January, the CMS formulary finder will be linked to individual plan formularies.
And, the CMS also has announced that Part D plan formularies are available through Epocrates software in either Web-based or hand-held PDA form. The free software is available online.
The CMS is also hosting a weekly question-and-answer conference call for physicians on the new Medicare drug benefit. During the call, prescribers are encouraged to ask questions and describe problems so the CMS can improve the Part D program.
The open 60-minute conference calls are being held Tuesdays at 2 p.m. EST. To participate, call 800-619-2457 and use the pass code "RBDML."
In the first week of the Medicare prescription drug benefit, several states responded to widespread problems by ensuring payments for prescriptions that low-income patients said they couldn't fill.
Those states last week moved to guarantee payments to pharmacies for patients covered by new Medicare Part D plans, according to the Jan. 8 New York Times. The move came in response to patients who could not fill prescriptions under the new benefit, even though they'd enrolled in a Part D plan, or were faced with inappropriately high deductibles and copays so they couldn't afford to fill their prescription.
Last week, Maine, New Hampshire, North Dakota and Vermont all announced they would guarantee payments for medications needed by low-income beneficiaries who had run into administrative problems with the new plans. Widespread problems being reported included Medicare drug plans not having proof of patient enrollment, and pharmacists not being able to verify patients' eligibility for drug coverage or for low-income subsidies. Pharmacists also reported very long wait times for calls placed to Medicare benefit managers.
CMS officials quoted in the article said they were working with health plans nationwide to get immediate improvement. More than 6 million beneficiaries are eligible for both Medicare and Medicaid benefits.
The New York Times is online.
While Medicare’s new drug benefit has made many common prescription drugs more affordable for seniors, patients with certain serious illnesses, such as cancer and rheumatoid arthritis, may be asked to pay more for those drugs than under previous drug coverage.
That’s because Medicare has a four-tiered pricing system that ties higher copays to top tier drugs, according to the Jan. 4 USA Today. Those drugs include treatments for rheumatoid arthritis, prostate cancer and multiple sclerosis.
Medicare patients would pay between 25% and 33% of the cost of drugs in the fourth tier, the article said. While some private-sector plans also have multiple tiers, the highest charges in those plans typically apply to drugs for non-life-threatening conditions, such as impotence or baldness.
If a patient paid 25% of the cost of the rheumatoid arthritis drug infliximab, for example, they would pay $143 a month, said USA Today. Medicare officials interviewed in the article noted that this would still be a savings for patients who did not have previous drug coverage before the drug benefit began.
Patient advocates interviewed in the article noted that some patients may not be able to afford to pay for drugs during the “doughnut hole,” the benefit coverage gap between $2,250 and $3,600, when catastrophic coverage kicks in. (Patients are expected to pay all drug costs during that gap.) Patient advocates also expressed concern that pharmaceutical companies would stop providing free or low-cost drugs to seniors with Medicare coverage.
USA Today is online.
Clinical news in the headlines
The following articles appear in the Jan. 3 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Survey looks at internal medicine recertification. A survey of 1,799 internists renewing their board certification found that the most common reasons physicians chose to recertify were to maintain their professional image and to update their knowledge. The survey also found that the most frequently cited reason given by those who don't recertify is that recertification takes too much time.
The self-reported survey—conducted by the American Board of Internal Medicine and ACP—was sent to physicians whose board certification was up for renewal in December 2002. According to survey results, 77% of internal medicine generalist physicians and 86% of internal medicine subspecialty physicians with time-limited certificates participate in maintenance of certification.
The survey found that 59% of the general internists and 60% of the subspecialists who updated their certification did so to maintain their professional image. (Fifty-one percent of general internists and 60% of subspecialists said they maintained certification to update their knowledge.) The survey also found that 69% of general internists and 72% of subspecialists felt that physicians working in direct patient care should maintain certification because patients and doctors perceive physicians with board certification to be more competent than non-certified physicians;
An accompanying editorial pointed out that the number of primary care physicians is probably declining faster than previously estimated. The editorial also recommended tracking career changes among practicing physicians, to determine the rate of physicians leaving medicine and of those migrating between different medical specialties.
Walking three times weekly slows decline of peripheral arterial disease. A study of patients with peripheral arterial disease found that those who walked at least three times a week had less decline in walking distance and speed than patients with peripheral arterial disease who walked less often.
A supervised walking program on a treadmill can improve walking performance and slow the progression of peripheral arterial disease, authors said. But many older people with the disease cannot participate in outpatient exercise programs because of cost or transportation problems. Walking sessions in the study were unsupervised. Authors concluded that simple unsupervised walking at home has many benefits for patients with this disease.
A recent meta-analysis of statin studies has ended hopes that the cholesterol-lowering drugs may help prevent cancer.
The review included 26 randomized controlled trials involving statins, with individual study enrollment ranging from between 150 and 20,500 patients. Researchers found that statins did not reduce the incidence of cancer or cancer deaths in any of the trials. The results appear in the Jan. 4 Journal of the American Medical Association (JAMA).
The findings suggest that statins should continue to be prescribed to lower cholesterol and prevent heart disease but that they should not be taken solely to prevent cancer, the Jan. 3 Chicago Sun-Times reported. This is especially true in light of statins’ rare potential side effects, which include liver damage and muscle pain.
Patients in the studies reviewed were treated primarily with simvastatin or pravastatin. The authors noted that while individual studies have noted a possible link between statin use and cancer prevention, three previous meta-analyses also found no difference in cancer incidence among those taking statins vs. those who did not.
The JAMA abstract is online.
The Chicago Sun-Times is online.
In the first significant advance in a decade in treating ovarian cancer, a recent study found that delivering chemotherapy drugs directly into the abdomen prolonged the survival of women with advanced tumors.
The findings were impressive enough for the National Cancer Institute (NCI) to recommend that physicians use the procedure, said the Jan. 5 Washington Post. It was the first endorsement of any cancer treatment by the NCI since 1999.
In the study, more than 400 women were randomly assigned to receive either standard intravenous therapy with paclitaxel and cisplatin or intravenous paclitaxel followed by intraperitoneal infusion of cisplatin and paclitaxel. Median survival was 49.7 months for the intravenous therapy group vs. 65.6 months for the intraperitoneal therapy group. The study appears in the Jan. 5 New England Journal of Medicine (NEJM).
While abdominal therapy prolonged survival, it was so arduous that 42% of the women in that group failed to complete treatment. The main reason for stopping the therapy was catheter-related complications. Side effects also included severe fatigue or pain, or hematologic, gastrointestinal, metabolic, or neurologic toxic effects.
Overall, women in the abdominal treatment group had a 25% reduction in the risk of death, the authors said. An editorial noted that the treatment should be considered first line therapy but that oncologists who offer it will require a skilled nursing staff to assist with scheduling catheter placement and multiple treatment visits, as well as with managing catheter-site infections.
The Washington Post is online.
Proton pump inhibitors (PPIs) can be as effective as surgery for patients with uncomplicated gastroesophageal reflux disease (GERD), according to the first in a new series of reports that compares different treatments for various health conditions.
The report by the Agency for Healthcare Research and Quality (AHRQ) compares treatments for chronic uncomplicated GERD that requires lifelong management but does not involve more serious esophageal disease, said a recent AHRQ news release. While some patients elect to have surgery with the goal of stopping medications, the release noted that between 10% and 65% of those surgery patients in studies reviewed for the report did not achieve that medication-free goal.
The GERD report reviewed over-the-counter medications, PPI drugs, fundoplication surgery and endoscopic procedures. Other findings included:
- Over-the-counter H2 receptor antagonist medications are not as effective as PPIs, but PPIs have more side effects.
- There was no significant difference in effectiveness among different brands of PPIs.
- PPIs and fundoplication surgery are similarly effective in relieving symptoms.
- Medications and surgery appear to have similar long-term effects for preventing Barrett’s esophagus or esophageal adenocarcinoma.
AHRQ officials stressed that while the findings are meant to help physicians select the best treatments, they are not recommendations per se. Also, the report did not take cost considerations into account.
The GERD report is the first in AHRQ’s "Effective Health Care Program," created to help patients and physicians select among different treatments, the release said. The agency has nine additional studies underway on other significant health conditions.
An AHRQ news release is online.
The CMS has announced revisions to the Medicare voluntary quality reporting program that begins this month. ACP leaders, who advocated strongly for those changes since the program was announced last fall, said the modifications will result in a smaller program with easier data submission for physicians who choose to participate.
The CMS identified 16 starter-set measures to be used in its "Physician Voluntary Reporting Program." Seven of them are relevant to internists, and six have been endorsed by the Ambulatory Care Quality Alliance. The measure set includes:
- three measures related to the care of patients with diabetes mellitus (blood pressure control, LDL control, hemoglobin A1c control);
- one measure assessing the care of patients with congestive heart failure (use of ACE inhibitors or ARB therapy);
- one measure on adherence to beta-blocker therapy post-myocardial infarction; and
- one measure each on assessing the risk for falls in elderly patients and the use of antidepressants for patients in the acute phase of a new major depression episode.
The CMS also announced that it intends to provide confidential reports to participants on how their care measures up to the data they report. Even though participation is voluntary, College leaders in a Jan. 3 press release pointed out that the program may become the prototype for a Medicare pay-for-performance program as early as next year.
Program modifications came after strong advocacy from ACP. The CMS had initially proposed using a much larger starter set of measures.
More information about the program is online.
The College press release is online.
For more information, see "CMS initiative paves way for physician pay-for-reporting" in the January-February ACP Observer.
The National Commission on Correctional Health Care (NCCHC) is inviting ACP members to its annual conference this April in Las Vegas.
The four-day conference, to be held April 8-11, (overlapping with ACP's Annual Session, which will be held April 6-8 in Philadelphia) will feature seminars, educational sessions, networking opportunities, continuing education credit and exhibits. While the conference offers a full schedule of plenary presentations, selected sessions will cover treatment of transgendered inmates, hypertension and self-injurious behaviors, as well as the creation of an in-custody pain management clinic. ACP is a supporting member of the NCCHC, with a representative on the commission's board of directors.
Registrants can get early registration discounts until March 1. The last day for pre-registration is March 29.
More information is online.
Two College subcommittees are accepting proposals for interactive skills workshops to be presented at Annual Session 2007. Annual Session 2007 will be held in San Diego, April 19-21, 2007.
The College's Clinical Skills Subcommittee is seeking interactive workshops designed to help physicians acquire or improve skills in physical examination, communication or specific procedures. Workshops should have a high likelihood of changing physician behavior using proven teaching techniques or new and innovative teaching strategies that have yet to be tested.
ACP's Medical Informatics Subcommittee is also seeking proposals, particularly for workshops that focus on the use of technology and computer applications in patient care and practice management.
Workshops should encourage use of technology and computer applications that have been shown to improve quality of care, patient safety and practice management efficiency.
Proposal forms are available online. The deadline for the Clinical Skills Subcommittee workshop proposal is April 1, 2006, and the deadline for Medical Informatics is May 1, 2006.
ACP has just released the "Living Life to the Fullest: A Guide for HIV Positive African Americans" patient education video, free to College members.
The video, featuring actress Veronica Webb and Super Bowl football champion Spencer Tillman, discusses how HIV positive African Americans can live a longer and more rewarding life. The video explains what HIV is and gives recommendations on how to prevent the spread of the disease, as well as tips for how those living with the disease can maximize their quality of life.
Members can order the free DVD and accompanying guidebook (a shipping and handling fee will apply) by contacting ACP Customer Service at 800-523-1546, ext. 2600, or online. Use product code 700450020.
For a limited time, you can purchase the complete set of 15 Update recordings from ACP’s 2005 Annual Session. By ordering now, you'll save $60 and receive a free CD-ROM of the handout material.
The Update recordings are an excellent way to stay current with advances that affect your practice. Nationally recognized faculty review important published papers in different internal medicine subspecialty fields, including:
- Critical Care
- Gastroenterology and Hepatology
- General Internal Medicine
- Geriatric Medicine
- Women’s Health
- Hospital Medicine
- Infectious Diseases
- Nephrology and Hypertension
- Pulmonary Medicine
Recordings are available in MP3 CD, audio CD and audiocassette formats. When ordering a complete set, you'll also get a free CD of the handouts from the Update and Multiple Small Feedings of the Mind sessions.
Details are online or call 800-241-7785. When ordering, refer to promo code 855-TUR.
The College's 14-member Council of Associates is looking for Associate members active in their chapters who want to get involved on a national level. Open seats include two seats in the Northeast, one each in the South, Midwest, and West, and one to represent the Latin American chapters.
Responsibilities include planning Associate programs during Annual Session; helping develop the ACP Online's resident/fellow/student sections; and providing a trainee's viewpoint on socioeconomic issues related to medicine. The Council meets two weekends a year, as well as at Annual Session and Leadership Day.
Nominations materials, including a statement of candidacy, an up-to-date curriculum vitae, and two letters of support, should be postmarked no later than Feb. 1, 2006, and sent to Tracey Henry, 190 N. Independence Mall West, Philadelphia, PA 19106.
For more information, contact Tracey Henry via e-mail or call 215-351-2727.
More information is online.
Nominations are being sought to fill seven seats on ACP's Council of Student Members (CSM) for the 2006-07 Council year.
Candidates may be self-nominated and will be accepted from ACP Medical Student Members in their first, second or third year of medical school. Council members serve one- to three-year terms, depending on where they are in their medical school careers.
Seats to be filled include:
Midwest Region (includes Arizona, Colorado, Kansas, Minnesota, Missouri, Nebraska, Nevada, North Dakota, South Dakota, Utah and Wisconsin)
New England Region (includes Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont)
North Central Region (includes Michigan, Ohio and Pennsylvania)
Osteopathic Representative (includes all Osteopathic schools)
Pacific Region (includes Alaska, California, Hawaii, Idaho, Montana, Oregon, Washington and Wyoming)
Southeastern Region (includes Florida, Georgia, North Carolina, South Carolina and Tennessee)
Southwestern Region (includes Alabama, Arkansas, Louisiana, Mississippi, New Mexico, Oklahoma and Texas)
Council members are required to attend three meetings a year and participate in several conference calls throughout the year. CSM representatives are reimbursed for travel expenses and other Council-related expenses.
Candidates should submit a statement of candidacy, curriculum vitae and one letter of recommendation by Feb. 1, 2006, to Patty Moore, ACP's Medical Student Coordinator, via e-mail or to ACP, 190 N. Independence Mall West, Philadelphia, PA 19106.
The CSM will conduct elections in early March. All candidates will be mailed the results by March 15, 2006.
More details about the nominations process and a sample nomination can be found on ACP Online.
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Copyright 2006 by the American College of Physicians.
A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?
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