In the News for the Week of 2-7-06
- House reinstates physician payments at 2005 levels
- ACP's "Nation’s Health Care" report gets widespread coverage
Part D update
- Transitional drug coverage gets new extension
Clinical news in the headlines
- Annals: Diagnosis and management of pulmonary embolism
- Angiograms miss signs of heart disease in some high-risk women
- College touts Medicare 'buy-in' plan to extend coverage
- New edition of popular ACP book puts thousands of quotes at hand
The House of Representatives last week approved a revised budget bill that removes the 4.4% physician pay cuts that took effect Jan. 1 and reinstates 2005 payment levels for Medicare claims.
The bill has been sent to the president for his signature and should take effect this week. According to the College's Web page on the reform measures, all 2006 claims submitted prior to the bill's enactment will be reprocessed and adjusted to the 2005 rate.
The CMS plans to automatically reprocess all submitted 2006 claims and send physicians those additional amounts by June. Physicians will not have to resubmit these claims and will receive remittance statements showing the adjustments.
More information on submitting claims is online.
The College's "State of the Nation's Health Care" report, which was issued last week and outlined the impending collapse of the nation's primary care system absent major reform, received extensive coverage in the national media. Details of solutions put forward by ACP—including the establishment of the advanced medical home model in which physicians would be reimbursed for coordinating patient care—were also part of that coverage.
News items on the ACP report included articles in the Wall Street Journal as well as in the Boston Globe and the Washington Post. Broadcast coverage appeared on CNN, and on television and radio news in several major metropolitan areas, including Chicago, Denver, Philadelphia, San Diego, San Francisco and Washington.
There also has been widespread ACP member interest in helping the College make the case for fundamental reforms to sustain primary care. Members are urged to sign up as a Key Contact to get regular updates on how the College advocating for reforms to support physician-directed care coordination and information on how they can help.
Part D update
In response to ongoing problems with the Medicare Part D implementation, the HHS secretary last week announced that transitional coverage for Medicare patients' current drugs has been extended to up to 90 days.
Previously, that coverage had been in effect for only 30 days. The new coverage period is designed to give patients and physicians more time to align medication regimens with Part D plan formularies.
If patients' current medication is not on their new Part D plan's formulary, physicians can choose to make a therapeutic drug change by prescribing a therapeutic equivalent on the formulary. Another alternative is for patients or their physician to request an exception from the Part D plan.
The announcement was part of a Feb. 1 progress report that pointed to significant improvement in wait times for patients using the 800-MEDICARE helpline. The report also noted that the average beneficiary premium payment of $25 is about one-third less than had been estimated.
The full report is available online.
In other Part D news, the Medicare administrator last week said officials are working to simplify the new program and are considering extending the program's enrollment deadline.
CMS administrator Mark B. McClellan, FACP, conceded that the new program is too complicated for many seniors, according to the Feb. 3 Chicago Tribune. Simplifying it is a top priority, he said at a recent Senate hearing.
While a measure to extend the enrollment deadline to Dec. 31 failed last week in the Senate, Dr. McClellan suggested that an extension is still possible. Currently, Medicare beneficiaries face permanent higher monthly premiums if they do not enroll by May 15.
The federal government recently agreed to reimburse approximately 20 states that have issued guarantees that beneficiaries will get their medications.
The Chicago Tribune is online.
Clinical news in the headlines
The following articles appear in the Feb. 7 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Pulmonary embolism: management guidelines; new predictive tool. One article reports on decisions to confirm or rule out pulmonary embolism (PE). The study followed 1,529 consecutive patients who went to more than 100 different emergency departments with suspected PE. Researchers found that emergency departments failed to use recommended evaluation procedures for 662 of these patients.
Departments followed established guidelines to confirm PE more often than they followed guidelines for ruling it out. In the three months following discharge, rates of PE, deep vein thrombosis or death were markedly lower among patients who received appropriate diagnostic management (1.2%) than among those who did not (7.7%).
Another article describes a new clinical prediction rule for estimating PE probability. The new rule is standardized, based on clinical variables and independent of physicians’ clinical judgment. It also identifies people at low risk—less than 10%—of developing PE or high risk (more than 60%), which can indicate the need for tests to confirm clinical suspicion of PE.
The new rule uses criteria such as age, previous deep venous thrombosis or PE, surgery or fracture within the prior month, or an active malignant condition.
A new study has found that heart disease may go undetected in some women with hidden plaque buildup that does not show up on angiograms.
The condition, called coronary microvascular syndrome, affects up to 3 million women in the U.S., according to a Jan. 31 news release from the National Institutes of Health (NIH), reporting on findings from the National Heart, Lung, and Blood Institute’s Women’s Ischemic Syndrome Evaluation (WISE) study. Angiograms do not detect artery blockages in these women because plaque is evenly distributed along the inside of the artery wall.
As a result, these women are thought to be at low risk when in reality many are at high risk for a heart attack, the NIH release said. The condition is characterized by narrowing of the arteries due to plaque buildup in very small arteries of the heart. Highlights of the WISE study appear in a special supplement on heart disease in the Feb. 6 Journal of the American College of Cardiology (JACC).
The main symptom of the syndrome is chest pain or discomfort, which often leads doctors to order further testing, said the release. When an X-ray reveals no blockages, physicians usually forgo treatment for angina or high cholesterol, leaving the women at high risk for an attack.
The findings are part of a series of articles in the February issues of JACC and Circulation on the differences in heart disease between men and women, said the Feb. 1 New York Times. The WISE study, begun in 1996, included 936 women, age 58 on average, who had symptoms of heart disease. When tested, only one-third of the women had obvious artery blockages, compared with three-quarters or more in a similar group of men.
However, in the two-thirds of women where blockages were not detected, more than half had abnormalities in the coronary arteries and microvasculature, said the New York Times. Further testing revealed that the artery walls had expanded to accommodate plaque buildup, making the arteries appear normal on the angiogram. After four years, there was a 10% rate of death or heart attack among the group without blockages.
The findings suggest that women with symptoms, severe risk factors or a family history of heart disease should undergo stress tests in addition to X-rays, the New York Times reported. The article noted that more than half of the 910,600 deaths from cardiovascular disease in the U.S. in 2003 were among women.
The NIH news release is online.
The New York Times is online.
Also see “Taking the pulse of women’s heart health” in the January-February ACP Observer.
The FDA last week approved a new drug for treating chronic angina, the first such drug to go on the market in more than a decade.
Ranolazine, marketed as Ranexa by CV Therapeutics, is a molecular entity recommended for patients who have not responded to other anti-anginal drugs, including long-acting nitrates, calcium channel blockers and beta-blockers, said a Jan. 31 FDA news release. The new drug is not recommended for all patients because it affects electrical conduction in the heart.
Many of the 6.8 million Americans diagnosed with angina each year respond to other treatments, including surgery and other drugs, according to the release. However, some continue to suffer episodes of chest pain, pressure or discomfort, limiting their activities.
The approval is based on clinical trial results showing that patients who did not respond to other anti-anginal drugs experienced a reduction in angina attacks and improvement in exercise stamina after taking ranolazine, said the FDA release. The agency noted that the drug appeared to be less effective in women than in men and that side effects included dizziness, headache, constipation and nausea.
The FDA release is online.
While last month’s approval of the first inhaled insulin drug offers a long-awaited option for diabetics, that option may cost much more than traditional insulin.
Analysts predicted last week that Pfizer Inc.’s Exubera could cost two to four times as much as injectable insulin, said the Feb. 2 Chicago Tribune. The new drug is expected to cost $4 a day, the article said, three to four times what someone with Type 1 diabetes currently pays for injectable insulin.
It is not yet known whether managed care plans will cover Exubera, which patients would take at least three times a day, the article said. Analysts interviewed by the Chicago Tribune predicted that Exubera would be placed on plans’ preferred drug formulary and that patients might have to pay $40 to $50 in monthly copays for it, compared with $10 to $25 for injected insulin.
The Chicago Tribune is online.
ACP has released a new position paper, outlining an ambitious plan to extend health care coverage through Medicare to adults age 55-64.
While nondisabled adults under age 65 are currently not eligible for Medicare, the ACP paper points out that half of all adult Americans in this age range make less than 200% of the federal poverty level—and that 2.6 million people in this age category are uninsured.
The paper, entitled "Developing a Medicare Buy-in Program," argues that covering these individuals would save taxpayers money in the long run by ensuring that chronic disease is managed outside hospitals and by providing key preventive services.
The paper focuses on four key points of the College's Medicare buy-in plan:
Financing. ACP has proposed a financing structure for the buy-in plan that would be separate from the other Medicare trust funds. Arguing that existing funds would not cover this new level of care, ACP advocates for additional funding to come from higher payroll taxes and other federal revenue sources, or by linking premiums to income.
Subsidies for lower-income recipients. The paper argues that a buy-in should initially target American adults age 55-64 whose income falls between 100% and 200% of the federal poverty level.
Eligibility. The paper proposes making all adults age 55-64 eligible for a Medicare buy-in plan, regardless of their insurance status. Such a program is needed, the paper stated, because fewer employers are offering health care coverage to retirees.
Enrollment. While enrollment in such a plan should be optional, the College recommends that any such program should provide enrollees with the full menu of Medicare benefits, including new prescription drug coverage.
The paper is online.
The poet W. H. Auden claimed that healing is "an intuitive wooing of nature." And physician and playwright Anton Chekov offered this wry view: "Medicine is my lawful wedded wife, and literature my mistress. When one gets on my nerves, I spend the night with the other."
These sayings and many more can be found in the just-released second edition of "Medicine in Quotations: Views of Health and Disease Through the Ages." The book, edited by former Annals Editor Edward J. Huth, MACP, and medical humanities professor Jock Murray, MACP, contains more than 3,000 quotations (with more than 450 new entries) about medicine, illness and treatment. Together, the passages paint a remarkable portrait of medicine throughout history.
Quotations are organized by topic, and each is fully referenced, allowing curious readers to find the original source. Subject and author indices make it easy to find quotations of interest.
"Medicine in Quotations" is an invaluable resource for writers, speakers and all those interested in the history of medicine. The 350-page hardcover book costs $47 for members, $52 for nonmembers. It can be ordered online or by calling ACP Customer Service at 800-523-1546, ext. 2600 (product code # 330351040).
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Copyright 2006 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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