American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News for the Week of 4-18-06

Access to care

Medicare Part D

Public health

Clinical news in the headlines

  • Annals: new post-surgery guidelines; ethnic differences in mammography screening
  • Studies question standard approaches to breast cancer treatment

Quality improvement

Information technology

ACP news

Access to care

Massachusetts passes universal coverage legislation

Massachusetts last week adopted landmark legislation that paves the way for providing universal health care coverage in the state.

The law would provide coverage for more than 99%, or 515,000, of the state’s 550,000 uninsured, said the April 13 New York Times. It calls for residents who can afford insurance to obtain coverage by July 1, 2007, or face penalties on their state income taxes.

The state’s $1 billion free-care pool will provide subsidies for those who cannot afford coverage. The law also allows people to buy insurance with pre-tax dollars and provides incentives for insurers to offer cheaper plans with higher deductibles or fewer benefits.

In a move that almost derailed the legislation, Gov. Matt Romney vetoed a provision that would tax businesses that do not provide insurance, the article said. The provision would require employers who do not provide coverage for their employees to pay an annual fee of up to $295 per worker to the state.

The state legislature has vowed to override the veto within the next few weeks, said the New York Times. The plan can be funded without the business charge, the article noted, but there are still questions about whether enough affordable plans will be created to achieve universal coverage.

The New York Times is online.

In 2002, the College issued comprehensive guidelines for achieving universal coverage. ACP's "Achieving Affordable Health Insurance Coverage for All within Seven Years" plan is online.


Medicare Part D

Part D standardized exceptions/appeals form now available

The CMS last week posted a new and standardized Part D exceptions/appeals form that was developed by an AMA Part D work group and the health insurance industry. The form will be accepted for determination decisions involving most commonly-used prescription drugs. ACP actively participated in the form development process.

The CMS is requesting that all Part D plans use this form, and health insurance industry representatives said they expect wide acceptance. The standardized form was developed in response to physician complaints about the hassles involved in each plan having a different exceptions/appeals form.

The form can be used to request either approval for a drug not in a plan’s formulary or an exception to a formulary tier, and for providing data to meet prior authorization requirements. The form should be used in those instances for all drugs except those specifically not covered under the Part D benefit and biotech or high-cost specialty drugs. Drugs not covered by Part D include barbiturates; benzodiazepines; fertility drugs; weight loss, weight gain or hair growth drugs; over-the-counter drugs or prescription vitamins other than prenatal vitamins; and fluoride preparations.

The form will be available on most plan Web sites within the next several weeks and can be downloaded from the CMS site. Prescribing physicians should complete the form and fax it to the Part D drug plan. (The CMS has also posted the exceptions/appeals contact information for all plans.)

Because it may take a few weeks for plans to change procedures and accept the new form, you should contact the specific plan prior to using the form if it is not available on that plan's Web site.


CMS needs physicians' help with 'Part B/D' drug guidance

The CMS last week asked physicians to help the agency resolve a major problem with the new Medicare Part D prescription benefit program.

At issue are prescriptions that have become problematic under Part D coverage because the same drugs are also used in conditions covered under Medicare Part B. Since Jan. 1, Part D plans have been requiring physicians to complete a prior authorization for drugs payable under both Part B and Part D coverage to ensure that Part D coverage applies for a particular prescription. Physicians have repeatedly complained that these Part B vs. Part D prior authorizations add a significant administrative burden and, in many cases, cause delays in patients receiving required medications.

Examples of drugs that fall into this Part B/D category include prednisone, frequently used as an immunosuppressant after an organ transplant and paid under Part B, but also used to treat minor conditions and paid for under Part D coverage. Another example is methotrexate, used both to treat breast cancer (payable under Part B) and arthritis (payable under Part D).

To resolve these problems, the CMS recently instructed Part D plans to cover prescriptions for a "B/D" drug without a prior authorization to verify Part D coverage if the prescribing physician writes a Part D diagnosis on the prescription and the words "Part D."

To verify that plans are complying with this guidance, the CMS is asking all physicians to alert the CMS if they are still being required to submit a prior authorization on a "B/D" drug under the Part D benefit, despite indicating a Part D diagnosis and the words "Part D" on the prescription. Physicians should e-mail the agency with the following information: the name of the drug, the drug plan, the state and the diagnosis used. The CMS will then instruct plans to change their procedure.

This request applies only to prior authorizations required for the verification of Part B vs. Part D coverage and not for prior authorizations required for other purposes. For more information about Medicare Part B vs. Part D, visit the Medicare site.


Public health

Midwest mumps epidemic is largest since 1988

Health officials last week rushed to contain an epidemic of mumps that started in Iowa and has spread to at least eight other Midwestern states. It is the largest mumps outbreak since a 1988 flare-up in Kansas.

Iowa, which typically sees about five cases a year, has logged more than 500 cases so far this year, said the April 13 Washington Post. That far outpaces the typical 200 to 300 cases a year seen nationally. At least 100 more cases have surfaced in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska and Wisconsin.

The outbreak appears to be concentrated among young, otherwise healthy adults, many of them living in college residences, said the Washington Post. CDC investigators have been tracking the outbreak but so far have not been able to determine its cause. In Iowa, about 12 people have been hospitalized, with one developing encephalitis. All have recovered.

Health officials are looking into whether some affected patients failed to respond to the mumps vaccine or whether the vaccine’s protection diminishes over time. They are also considering whether this particular virus is more infectious or less susceptible to the vaccine.

Experts speculated that the disease might have been imported from Britain, where an epidemic has been raging for several years, said the Washington Post. The case may not have been immediately recognized because physicians see it so rarely.

While the U.S. has higher mumps vaccination rates than in Britain, 68% of the cases here have been among people who received the recommended immunizations, the Washington Post said.

The Iowa Department of Public Health has posted mumps resources—including prevention and control measures, testing protocols and information on the scope of the outbreak—online.

The Washington Post is online.


Clinical news in the headlines

Annals: new post-surgery guidelines; ethnic differences in mammography screening

The following articles appear in the April 18 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.

  • Guidelines for non-cardiac surgery patients issued. ACP has issued new guidelines that spell out how patients undergoing non-cardiac surgery should be evaluated for postoperative pulmonary complications risk factors. These factors include chronic obstructive pulmonary disease, being older than age 60, an anesthesiology risk class of II or greater, functional dependency and congestive heart failure.

    Patients undergoing certain procedures are at risk for pulmonary complications and should receive pre- and postoperative therapy to reduce these complications, the guidelines state. Such procedures include abdominal, thoracic, neurosurgery, head, neck and vascular surgery, and aortic aneurysm emergency repair. Patients in surgery more than three hours or who undergo any procedure requiring general anesthesia should also be evaluated, according to the new guidelines.

    The guidelines also address albumin levels in certain patients, the use of deep breathing exercises or incentive spirometry, and the selective use of a nasogastric tube.

  • Ethnic differences found in mammography screening. A new study of more than 1 million women looked at relationships between racial and ethnic backgrounds, screening rates, and severity of breast cancer tumors.

    Nearly 17,500 women were diagnosed with breast cancer during the study period. Researchers found that African-American women received the fewest mammography screenings. White women received the most and were more likely than other groups to be adequately screened.

    African-American and Hispanic women were more likely than their white counterparts to be diagnosed with advanced-stage and high-grade tumors. When the authors compared women with similar screening rates, those of different racial and ethnic backgrounds had the same frequency of advanced-stage cancer. However, the frequency of high-grade cancer remained elevated in African-American women with screening rates similar to white women. Screening rates and intrinsic properties of the cancer are both involved in explaining different rates of advanced stage breast cancer in African-American women.

  • Telephone reminders increase cancer-screening rates among low-income women. Minority and low-income women receiving care in community and migrant health centers were more apt to get appropriate screening tests for several cancers when they received a series of telephone reminders, according to results of an 18-month study.

  • Green tea and total caffeine consumption linked to reduced risk for type 2 diabetes. A study of nearly 17,000 Japanese adults found that those who drank more than six cups of green tea per day or three cups of coffee per day were less likely to develop diabetes than those who drank less than one cup of these beverages per week. Higher total caffeine intake was also associated with lower diabetes risk. Researchers found no reduced risk for diabetes associated with black and oolong teas.


Studies question standard approaches to breast cancer treatment

A major study published last week on breast cancer concluded that whether or not a woman’s tumor is fed by estrogen may determine if she will benefit from chemotherapy.

One study included three large trials involving a total of 6,644 women who were put on different chemotherapy regimens. In one trial, women received cyclophosphamide, doxorubicin and fluorouracil; in a second, patients were given doxorubicin with cyclophosphamide with or without paclitaxel; the third group received doxorubicin, paclitaxel and cyclophosphamide followed by paclitaxel.

Researchers found a marked difference between women with estrogen-receptor (ER) negative vs. ER-positive tumors. Those with ER-negative tumors who received any type of chemotherapy reduced their relative risk of recurrence by up to 55%, compared with up to only 26% for women with ER-positive tumors. The overall mortality rate similarly was reduced by 55% in the ER-negative group compared with 23% in the ER-positive group. The study appeared in the April 12 Journal of the American Medical Association.

Results suggest that women with ER-positive tumors may not need chemotherapy because they are already deriving substantial benefits from estrogen-blocking hormonal therapies with drugs such as tamoxifen, said the April 12 New York Times. That may explain the study’s findings that women with ER-negative tumors who had chemotherapy had a 23% chance of surviving five years, compared with only 7% for women with ER-positive tumors, which was not statistically significant.

Until reliable tests are developed, physicians should stick to existing treatment recommendations, said experts interviewed by the New York Times. While the study demonstrated that, on average, women with ER-positive tumors benefit less from chemotherapy than those with ER-negative tumors, there is currently no reliable way to identify those who would fare better with a combination of hormonal treatments and chemotherapy.

A second study in the same JAMA issue involved 10,739 postmenopausal women age 50-79 with hysterectomies, who were part of the federal Women’s Health Initiative. The study was stopped early in February 2004 because of increased stroke incidence among women taking estrogen alone.

The study found that estrogen did not increase the risk of breast cancer but that women in the study had more abnormal mammograms, requiring more repeat testing and biopsies, said the New York Times. Another branch of the study, involving women who had not had a hysterectomy, found that the combination of estrogen and progesterone increased the risk of breast cancer and heart disease.

The JAMA abstract on estrogen and chemotherapy is online.

The JAMA Women’s Health Initiative study is free online.

The New York Times is online.


Quality improvement

New Web site offers state-to-state quality comparison

A federal agency has launched a new Web site that provides state-by-state comparisons of performance on selected quality measures. Tables for each state rank its performance on 15 quality measures and compare that state's performance to regional and national benchmarks.

The "State Snapshots 2005" site is sponsored by the Agency for Healthcare Research and Quality, (AHRQ), a federal agency that supports health services research. Data used in the state rankings were drawn from the AHRQ's National Healthcare Quality Report, which presents data on the quality of services for numerous illnesses, including cancer, end-stage renal disease, HIV and AIDS. The report data are compiled from state and federal health care databases, including those of the CDC and the CMS.

Quality indicators used in the rankings include the use of beta-blockers within 24 hours of heart attack admission and the percentage of state nursing home residents who have declining mobility. Rankings indicate each state's strongest and weakest performance on the different indicators, as well as a comparison of preventive, acute and chronic care resources within each state.

The AHRQ's State Snapshots 2005 tool is online.


Information technology

National group seeks jurors for certification program

The Certification Commission for Healthcare Technology (CCHIT) is looking for 30 qualified jurors to test ambulatory electronic health record products. The goal of the jurying program is to determine how well those products conform to certification criteria.

CCHIT is a private-sector company working to certify information technology products to improve interoperability and implementation. A team of three clinical jurors—one of whom must be a physician—and an information technology evaluator will critique a product's performance during a series of tests and review documentation supplied by product vendors. Testing is Web-based and should take only one day with an additional day for retesting, if necessary, plus documentation review and survey completion.

Jurors must be able to participate in a minimum of six tests during a six-month period, preferably completing a minimum of one test each month. Jurors will be compensated and must execute a contract with CCHIT covering conflict of interest and confidentiality.

Both a juror job description and application form are online.


ACP news

College leaders warn about primary care problems in live nationwide broadcast

On Friday, April 7, College leaders participated in 20 live broadcast interviews about the looming collapse of the country's primary care systems and ACP’s proposals to fix the problem.

During Annual Session 2006 in Philadelphia, C. Anderson Hedberg, MACP, then ACP President, and Donna E. Sweet, MACP, then Regent Chair, spoke to reporters from television and radio stations across the U.S. about the upcoming shortage of primary care physicians and the factors behindwhy fewer physicians are specializing in primary care.

Drs. Hedberg and Sweet also discussed concepts developed in several new ACP policy papers. Issues addressed during the interview included the need to create a new national workforce for internal medicine, reform of the dysfunctional health care payment and delivery system, the redesign of internal medicine training, and the need to implement the advanced medical home model of care.

The interviews went out to millions of viewers and listeners in New York, Philadelphia, Boston, Minneapolis, Dallas, Denver, Tulsa, Santa Barbara and Austin.

A press release about the media tour and video vignettes are available online.


Renew your ACP membership online

Watch for an e-mail dues notice later this month inviting you to renew your ACP membership for the next fiscal year.

ACP membership keeps you up to date on the latest medical information, provides substantial discounts on many College educational tools and activities, and helps support ACP’s public policy efforts to improve the health care environment for you and your patients.

This month's e-mail will direct you to pay membership dues online via a "Pay Your Dues Link" on a secure, encrypted ACP Web site. If you’d rather pay by phone, call ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600 (Monday-Friday, 9 a.m.- 5 p.m. ET).

All members who pay online or by phone before May 5 will not receive a print bill. All others will receive a printed renewal form around mid-May.

Details about ACP activities and member benefits are available on ACPOnline.


College, others, comment on CMS' 'medically unbelievable' program

ACP has told CMS officials that the agency's recent proposal to create a medically unbelievable edits (MUE) program will require much more time to review before that program can be implemented.

The CMS initially designed the MUE program to prevent payment of Medicare claims that contain obvious errors or gross fraud. The proposal has grown to include more than 10,000 edits that review claims for anatomic appropriateness and frequency on individual patients. Medically unbelievable edits are distinguished from correct coding initiative edits because they cannot be overridden through the use of a modifier.

The College joined more than 90 other medical societies in signing an April 10 letter to the CMS administrator. The letter applauded the CMS' decision to push back implementation of the MUE program to no sooner than Jan. 1, 2007, instead of July 1, 2006, as was previously proposed.

But the letter lodged several serious reservations concerning the CMS' planned MUE rollout. Problems noted included:

  • A confusing review process. The sheer number of edits, the letter said, will require a very lengthy review process. The CMS wants to implement two review processes, with the first review deadline this June and the second this fall. The College, however, is asking the CMS to implement only one review process with a Sept. 15 deadline. The CMS' staggered review approach will discourage a thorough review, the letter said.

  • Lack of transparency in rationale and frequency data. The letter urged the CMS to make available the rationale and frequency data behind the MUEs, saying that initial comments from specialty societies suggest the units assigned contradict current evidence-based practices.

  • The lack of modifiers and of an appeals process. Both the use of modifiers and of an appeals process are essential, the letter said, to put a workable edits process in place.

The letter is online.


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