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

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In the News for the Week of 5-16-06

Clinical news in the headlines

  • Annals: distinguishing incontinence types; emerging hepatitis C consequences; treating Chagas disease
  • Study questions safety of frequent off-label prescribing

Medicare Part D

Medical liability

CMS update

Pay for performance

  • Blue Cross to double incentives for Massachusetts physicians

ACP news


Clinical news in the headlines

Annals: incontinence types; hepatitis C; treating Chagas disease

The following articles appear in the May 16 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.

  • Three simple questions reliably distinguish between types of incontinence. Instead of the battery of complicated tests currently recommended for diagnosing urinary incontinence in women, a new study found that answers to three simple questions can determine whether a woman has stress or urge incontinence.

    Asking patients the questions—f they leaked urine during the last three months, when they leaked urine and when they leaked urine most often—may help primary care physicians more easily distinguish between the two incontinence types.

  • Hepatitis C profile in U.S. suggests consequences of the disease are yet to come. An update to a large national health survey finds that the total number of people infected with hepatitis C (HCV) has not changed substantially between 1994 and 2002.

    However, the most frequent age bracket of those infected has shifted from age 30-39 in the earlier study to age 40-49 in the current study. Most infected people engaged in IV drug use in their youth and are now entering the age when the consequences of HCV infections, such as cirrhosis, liver cancer and kidney disease, begin.

  • Study: Drug is effective in treating long-term Chagas disease. A new controlled, long-term study finds that benznidazole, a drug used to treat early phases of Chagas disease, also appears to mitigate some of the consequences of chronic Chagas disease, such as heart failure. Chagas disease, a parasitic infection, is on the World Health Organization's list of neglected infectious diseases that disproportionately affect poor and marginalized people.

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Study questions safety of frequent off-label prescribing

Off-label prescribing is common in outpatient care in the U.S. even though many such prescriptions have little or no evidence to support them, according to a newly published study.

The study, published in the May 8 Archives of Internal Medicine, found that an estimated 150 million off-label prescriptions were written in 2001, based on IMS Health's "National Diseases and Therapeutic Index" data on 160 commonly prescribed drugs. Off-label prescribing accounted for 21% of the overall sampled medications.

Among classes of medications, off-label prescriptions were most common among cardiac drugs (46%), excluding antihyperlipidemic and antihypertensive agents, and anticonvulsants (46%), the authors said. Among specific agents, the anticonvulsant gabapentin was among the most commonly used. The authors noted that more research needs to be done on how pharmaceutical marketing affects off-label prescribing, especially considering that the maker of gabapentin was convicted for inappropriate marketing of off-label uses for that drug.

The study raises concerns because most of the off-label prescriptions were not backed by scientific evidence, said the May 9 Philadelphia Inquirer. The main issue is risk, the article said, because using a drug off-label that has little proof of effectiveness puts a patient at risk for experiencing more harm from side effects than benefit from the drug.

Study authors said the findings call for more post-marketing surveillance to identify non-evidence-based prescribing practices that lack FDA approval. Policy-makers, they continued, should consider policies such as those in Europe, where medications are monitored after initial approval and regulators track physicians’ prescribing experiences.

The Archives of Internal Medicine abstract is online.

The Philadelphia Inquirer is online.

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Medicare Part D

Low-income seniors won’t be penalized for late sign-ups

The federal government last week announced that low-income and disabled seniors will not face financial penalties if they sign up for the new prescription drug plan after yesterday’s deadline.

Medicare beneficiaries with incomes below $14,700 and assets worth no more than $11,500 would be affected by the ruling, said the May 10 Philadelphia Inquirer. For couples, the thresholds are $19,800 in annual income and assets of $23,000.

Medicare also recently announced that these very low-income seniors could sign up for drug coverage until Dec. 31, the article said. Beneficiaries who do not fall into the very low-income category face a 1% premium penalty for each month they wait to enroll beyond the May 15 deadline.

Extending the deadline for everyone until the end of the year could attract 1 million more enrollees, according to Congressional Budget Office estimates, but would also mean the government would forgo $100 million in late fees, the Philadelphia Inquirer reported. Medicare officials said they hope the new ruling will attract more of the 7.2 million poor beneficiaries who qualify for the most generous coverage—95% of their drug costs covered with minimal premiums and deductibles and no coverage gaps.

As of last week, the article said, only about 24% of those beneficiaries had been enrolled in the subsidized program.

The Philadelphia Inquirer is online.

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Medical liability

Groundless cases make up major proportion of liability suits

A study published last week concluded that close to 40% of medical malpractice cases filed in the United States were without merit. The study found, however, that most of those were dismissed with no payout.

In the study, physicians reviewed 1,452 closed malpractice claims between 1984 and 2004 from five insurers to determine whether injuries had occurred and, if so, whether they were due to medical errors. They found that only 3% of cases filed involved no injury to the patient and of claims that involved injuries, two-thirds were caused by medical errors. Overall, 37% of the claims did not involve medical mistakes and 72% of those were dismissed or resolved with no payout.

Overall, claims not involving errors accounted for between 13% and 16% of total payouts. The authors concluded that while meritless claims are not uncommon, most do not receive compensation and that litigation over errors accounts for the highest proportion of spending. The study appeared in the May 11 New England Journal of Medicine (NEJM).

The study also concluded that litigation expenses are exorbitant and that claims take a long time to resolve, five years on average, according to the May 11 Philadelphia Inquirer. For every dollar awarded in verdicts, half went to cover attorney fees and other administrative expenses.

The NEJM abstract is online.

The Philadelphia Inquirer is online.

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CMS update

New CMS rule allows all physicians to prescribe power mobility devices

A final rule published by the CMS last month will allow physicians of all specialties to prescribe power mobility devices, including power wheelchairs and power-operated vehicles such as scooters. The rule takes effect June 5, 2006.

In the past, only specialists in physical medicine, orthopedic surgery, neurology and rheumatology were allowed to prescribe power-operated vehicles. Previously, only electric wheelchairs could be prescribed by physicians of any specialty.

In addition, the CMS has introduced a new add-on code—G0372—to allow physicians to be paid for preparing documents required for these prescriptions. The code would be used in addition to the evaluation and management code used to assess the need for a device.

The full text of the rule is available in the Federal Register.

For more information, see "Medicare ramps up coverage of power mobility devices" in the November 2005 ACP Observer.

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Part B competitive acquisition program enrollment begins

The CMS has announced the opening of the election period for physicians to enroll in the Part B drug competitive acquisition program. The election period will end early next month.

The new program provides an alternative to the current practice of physicians buying and billing for Part B drugs under the average sales price system. The competitive acquisition program covers only drugs billed under Medicare Part B. These consist primarily of injectable and infused medications administered in a physician’s office that are “incident to” a physician’s service. A list of the medications currently available under the program is online.

Under the competitive acquisition program, the physician orders the drug from an approved vendor. The vendor then purchases the drug, bills Medicare, delivers the drug to the physician’s office within two business days (one business day in emergencies), and collects any deductibles and coinsurance from beneficiaries. The program provides an option for physician practices that want to be relieved of the administrative burden of purchasing Part B medications and collecting beneficiaries’ medication cost-shares.

The election period extends from May 8, 2006, through June 2, 2006, for physicians who voluntarily chose to participate in the program from July 1, 2006, through the end of the year. A new election period for participating in 2007 will extend from Oct. 1, 2006, to Nov. 15, 2006.

Additional information about the program is online.

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Pay for performance

Blue Cross to double incentives for Massachusetts physicians

Blue Cross Blue Shield of Massachusetts has announced that it would double the amount it spends on performance incentives for physicians and hospitals in Massachusetts this year.

The company plans to spend $189 million—or 4% of its 2005 provider payouts in the state—on incentives, making it a leader among insurers in the pay-for-performance movement nationally, said the May 10 Boston Globe. Under the program, incentives will make up as much as 13% of the insurer’s payments to 5,200 primary care physicians in the state—compared with 10% now—or about $10,000 per individual physician.

The move by the nonprofit company sparked some criticism from physician groups, the Boston Globe said. A representative of the Massachusetts Medical Society was quoted as saying that insurance companies should wait until nationally accepted quality measurements are in place and more physicians have installed electronic health records.

Blue Cross executives interviewed in the article said that the company may begin to replace its annual inflation updates with the pay-for-performance incentives. Even though a standardized measurement system is not yet in place, they said, payments based on quality and efficiency are necessary to stem rising costs and premiums, which have increased more than 10% annually for five years in a row.

Blue Cross is also developing programs that would base between 5% and 10% of payments to specialists on performance scores, said the Boston Globe. The company is expanding its hospital incentive program to include 60 hospitals, up from 29 last year.

The Boston Globe is online. (Subscription required.)

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ACP news

College supports legislation to boost insurance coverage

ACP last week voiced its support of a newly introduced bill in the U.S. Senate that would expand health insurance coverage through state-based health reform projects.

In a letter sent earlier this month, ACP President Lynne M. Kirk, FACP, applauded the introduction of the Health Partnership Act (S. 2772) by co-sponsors Sen. George V. Voinovich (R-Ohio) and Sen. Jeff Bingaman (D-N.M.). (In his remarks introducing the bill, Sen. Bingaman credited ACP for its "advice and support" in crafting the bill.)

If passed, the new legislation would allow Congress to authorize grants to individual states to try new strategies to increase health care coverage. Those grants would also be used to ensure that patients receive appropriate and high-quality care, improve the efficiency of health spending, and use information technology to improve health care infrastructure.

According to Dr. Kirk, the act would allow states to test different reforms that would “strengthen and support the role of primary care physicians."

More information about the legislation and letter is online.

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