In the News for the Week of 6-6-06
- Shortage puts internists at top of ‘most-recruited’ list
- First vaccine for shingles gets FDA nod
Clinical news in the headlines
- Annals: beta-agonists increase asthma complication risks; naps and caffeine can combat fatigue
- Drug benefit caps lead to poorer outcomes for chronically ill
- Part B competitive acquisition program enrollment extended
The business of medicine
- Low Medicare payments shift costs to private payers, consumers
- College makes recommendations on price transparency
General internists and family practitioners topped a list of the most recruited physicians last year, according to a survey by a national physician search firm.
Requests for internists by hospitals and medical groups rose by 46% while requests for family physicians went up 55% over the past year, according to the survey by Irving, Texas-based search firm Merritt, Hawkins & Associates, which tracked 3,000 requests from clients.
Internists and family physicians were in higher demand than radiologists, orthopedic surgeons, cardiologists and general surgeons. Average annual salary offers for an internist were $162,000 and $145,000 for a family physician.
It is the first time in a decade that primary care physicians topped the firm’s most-requested list, according to survey results. The firm attributed the upturn to tightened supply due to fewer medical graduates going into primary care specialties, along with a growing older population.
Over the past several months, the College has been warning about the impending collapse of primary care and advocating for reforms needed to make general internal medicine again a compelling career choice.
Survey results for "Physician Recruiting Trends" are online.
ACP's "Creating a New National Workforce for Internal Medicine" highlights the looming crisis in primary care.
More information on the threat to the viability of primary care is online.
The FDA gave final approval last month to a new vaccine that reduces the risk of herpes zoster (shingles) in people over age 60. The vaccine's manufacturer—Merck & Co.—is now accepting physician orders.
Zostavax, a live virus vaccine, is given as a single injection under the skin, according to a May 26 FDA news release. The vaccine was tested on about 38,000 older adults and was found to reduce the occurrence of shingles by about 50%, based on three years of follow up. The vaccine also reduced pain in those who developed the disease despite being vaccinated.
The most common side effects of the vaccine are redness, pain and tenderness at the injection site, as well as itching and headache, said the FDA release. The manufacturer, Merck & Co., will perform a phase 4 post-market study to provide additional safety information. Shingles is estimated to affect two in every 10 people in their lifetime, according to the FDA release.
In a May 26 news release, Merck said it would begin shipping vaccines orders "soon" and that the vaccine must be stored frozen until ready for use.
The FDA release is online.
The Merck news release is online.
Clinical news in the headlines
The following articles appear in the June 6 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Inhaled long-acting beta-agonists increase risk for asthma complications, including death. A meta-analysis of 19 published studies involving 33,826 asthma patients found that those receiving inhaled long-acting beta-agonists were 2.5 times more likely to be hospitalized and about two times more likely to have life-threatening asthma attacks than those on placebo.
Fifty-three of 3,083 patients receiving beta-agonists were hospitalized for an asthma attack compared to 12 of 2,008 patients on placebo. The absolute increase in hospitalizations was one event per 71 patients treated per year.
Fifty of 15,443 patients receiving beta-agonists had life-threatening asthma attacks compared to 25 of the 14,538 on placebo. While death from asthma was rare (13 deaths in the beta-agonist group and three in the placebo group), those taking long-acting beta-agonists died about 3.5 times as often as those receiving placebo.
An editorial noted that this analysis was not able to fully account for the effects of disease severity, co-treatments, adherence to treatment or racial profile on the risk of poor outcomes. The editorial suggests that physicians follow current guidelines, which advise not using long-acting beta-agonists as first line treatment for patients with mild to moderate persistent asthma symptoms.
Naps and caffeine can combat fatigue in the hospital and on the road. Two studies in this issue show that naps and caffeine can combat fatigue and sleepiness.
In one study, a hospital divided a group of medical interns into a group that could take an uninterrupted nap during long shifts and a group that did not have that opportunity. Sleep time was measured by a special wristwatch.
At the end of the work shift and the next day, the nap group was much less tired, even after only a short nap. One alternative to shortening work shifts for doctors would be to build naps into the work schedule.
Another study—on the effects of drinking coffee and napping on night driving—found that driving performance was better after drinking half a cup of coffee or taking a 30- minute nap than when drinking decaffeinated coffee or not taking a nap. While previous studies have used driving simulators, 12 participants in this study drove 125 miles on a highway in four sessions, accompanied by a professional driving instructor, in a car equipped with dual controls. An editorial concludes that as the U.S. moves toward a 24-hour society, sleep deprivation is a growing problem in the workplace.
A study reported last week that capping Medicare drug benefits saved money on prescription drugs but found those savings were canceled out by increases in hospital and emergency room costs for chronically ill patients.
The study compared the costs and clinical outcomes for Medicare beneficiaries who had a $1,000 cap on their annual drug benefits with a control group with Medicare plus supplemental coverage through their employers. All participants were covered by HMO Kaiser Permanente’s Medicare+Choice program in 2003. The study was published in the June 1 New England Journal of Medicine (NEJM).
The authors reported that beneficiaries in the capped group used fewer medications and had poorer control of blood pressure, lipid and glucose levels.
In addition, investigators found that drug costs in the capped group were 31% lower than in the other group but that their total medical costs were about the same. That’s because participants with capped coverage had a 13% higher rate of non-elective hospitalizations, a 9% higher rate of emergency room visits and a 22% higher death rate.
Capping drug benefits has the biggest impact on the sickest patients because those patients tend to reach their coverage limits early in the plan year, an accompanying editorial pointed out. The editorial noted that caps are not an effective cost-containment method and that future strategies must address appropriate treatment for the chronically ill, who account for 75% of health care spending.
Medicare’s Part D drug benefit, which took effect after the study was completed, may result in lower out-of-pocket costs for some beneficiaries, the authors noted, but it still calls for substantial cost-sharing.
Instead of controlling spending through limiting benefits, said the editorial, a better route would be to identify patients at risk for chronic illness early and pay physicians for coordinating their care, as opposed to the current fee-for-service model.
The CMS last week announced an extension to the physician election period for the Medicare Part B Drug competitive acquisition program. The voluntary program allows physicians to obtain drugs they use in their offices directly from vendors, who would bill Medicare and collect coinsurance from beneficiaries. In the current system, physicians buy the drugs from distributors and bill Medicare themselves.
The program's physician election period’s extension began June 3 and will continue through June 30. Physicians must return their completed election forms to their local carrier by mail. Physicians whose completed physician election forms are postmarked by June 30 can begin participating in the program starting Aug. 1.
The initial program implementation is still scheduled for July 1. Physicians whose completed election forms were postmarked on or before June 2 can begin participating in the program July 1.
More information and a downloadable election form are online.
The business of medicine
Recent studies found that private insurers and consumers are paying billions more in health care costs to make up for shortfalls in Medicare payments to hospitals and physicians.
One study in Washington State found that hospitals shifted $738 million, or 14.3% of their revenue, to private payers in 2004 to compensate for insufficient payments from Medicare and Medicaid, according to the June 1 New York Times. Doctors in the state similarly shifted $620 million in fees, or 12% of revenue, to private payers, in the form of higher negotiated fees. The study was commissioned by Seattle-based Premera Blue Cross.
Another study that focused on hospitals in California, commissioned by Blue Shield of California, similarly found that an additional $l4.5 billion was charged to health plans and consumers in 2004 to make up for low government payments, the New York Times said. An economist interviewed in the article noted that the findings are in line with national figures showing that unpaid hospital bills for uninsured patients amount to approximately $45 billion a year, adding 8.5% to costs borne by insured patients.
As the numbers of uninsured rise and Medicare holds down payment increases, the problem will only get worse, said a spokesman for the National Business Group on Health—a nonprofit representing large employers—who was interviewed by the New York Times. A group of business leaders, health plans and medical groups plans to meet in July, the article said, to make policy recommendations on how to stop the growth of cost-shifting.
The New York Times is online.
The College has sent recommendations to the Bush administration on price "transparency," which refers to consumers' ability to find out the cost of health care services.
While ACP expressed support for transparency in a recent letter to the administration, the College pointed out problems with current approaches. The letter was sent from Joseph W. Stubbs, FACP, Chair of ACP’s Medical Services Committee, to follow up on a Feb. 14 meeting between ACP leaders and administration officials.
Dr. Stubbs expressed ACP’s commitment to the goal of transparency in health care pricing. However, he pointed out the current complexities of introducing price transparency, saying that physician fees for a specific service have little relationship to the total cost of care, and that some physicians practice in different settings, with different fees for each setting.
The letter made short-term recommendations for introducing price transparency on a voluntary basis, including:
Modifying the publicly accessible Medicare physician fee schedule database to offer a Web site with physician fees for Medicare enrollees.
Having private insurers publish negotiated rates they pay physicians for individual services.
Having physicians post on their practice Web site the retail price of their 10 most commonly furnished services or procedures, to help self-pay patients.
Writing that "price data, alone, is a poor proxy for determining the total cost of care," Dr. Stubbs said new payment models proposed by ACP—such as the advanced medical home model—would allow consumers to make a more comprehensive assessment of both the cost and quality of physician services. He also said the College supports linking payment to performance.
The letter is online.
For more information, see "The promise and challenge of health care 'transparency' " in the May ACP Observer.
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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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