In the News for the Week of 8-1-06
Payment system reform
- ACP President testifies on Capitol Hill
Flu vaccine update
- Drugmaker announces progress on bird flu vaccine
Pay for performance
- U.K. sees success—and high costs—of P4P
Clinical news in the headlines
- Lower peak thrombin generation may mean lower risk for VTE
- PIER launches online quality measurement tool
- Letter urges Senate leadership to avoid Medicare cuts
- College featured on Kaiser's price transparency webcast
Payment system reform
College President Lynne Kirk, FACP, appeared before the House Energy and Commerce Committee's Subcommittee on Health last week to testify on reforming the Medicare payment system.
During the hearing, “Medicare Physician Payment: How to Build a Payment System that Provides Quality, Efficient Care for Medicare Beneficiaries,” Dr. Kirk recommended that Medicare pilot test a patient-centered medical home model of care.
She urged Congress to direct Medicare to institute the new model of financing and delivering care. The patient-centered medical home would give patients incentive to connect with a personal physician who is part of a team of health care professionals providing continuous and comprehensive care.
“Congress can maintain a flawed system that rewards fragmented, high volume, over-specialized and inefficient care,” Dr. Kirk said in concluding her testimony. “Or, it can put Medicare on a pathway to a payment system that facilitates high quality and efficient care centered on patients’ relationships with their primary and principal care physicians.”
Dr. Kirk’s full written statement is available online.
Flu vaccine update
Early tests show that a new vaccine formulation provides more effective seroprotection against the H5N1 influenza virus while using a smaller dose than any other existing bird flu vaccine.
The results of the latest clinical trial represent “a significant breakthrough” in the development of a pandemic flu vaccine, reported drug maker GlaxoSmithKline (GSK) in a July 26 news release posted on its Web site. The company said it expects to file for regulatory approval of the new vaccine within the next few months.
According to the company, by combining an adjuvant with a small dose—3.8 micrograms—of an antigen made from inactivated H5N1 virus, more than 80% of people tested during the trial demonstrated a seroprotective immune response after two shots. The clinical trial took place in Belgium and involved 400 healthy adults between age 18 and 60.
Previously, a vaccine produced by drug maker Sanofi Pasteur protected 50% of the people who received two shots, each of which contained much higher doses—90 micrograms—of the antigen, said the July 27 New York Times. A GSK spokeswoman quoted in the article said that the new vaccine, if approved, would sell for the same price as a standard flu shot—about $8-$12 a shot.
Finding a way to make a low-dose vaccine is considered essential to producing enough vaccine to protect the majority of the population during a pandemic. While GSK's results are impressive, health officials interviewed by the New York Times cautioned that the results were based on blood tests, not real-life exposure, and that it is not yet known whether the vaccine would be effective if the virus mutated.
Avian flu has spread throughout Asia, Europe and Africa, infecting more than 200 million birds and 232 people to date, mainly in Southeast Asia. Just over 130 people have died from the virus.
The GlaxoSmithKline news release is online.
The New York Times is online.
States can now apply for federal grants to help elderly and disabled Medicaid recipients stay in their communities rather than move to nursing homes, under a new program launched by the Department of Health and Human Services (HHS).
The idea is to shift Medicaid from its historical emphasis on institutional long-term care to a system that offers more choices for seniors and the disabled, said a July 26 HHS news release. A total of $1.75 billion over five years is available to states through competitive grants, which will cover 75%-90% of the costs of transitioning individuals from nursing homes to community settings.
The grant money can be used to pay for home health care, home modification costs, respite services to augment informal or unpaid caregivers, personal care and assistive devices, said the HHS. States are encouraged to work with their local and state housing authorities in applying for the money. The deadline for 2007 grant applications is Nov. 1, 2006.
Information and application forms are available online.
The HHS news release is online.
A June Kaiser Family Foundation poll of over 1,500 seniors, including 623 who are enrolled in a new Medicare Part D drug plan, revealed that most initial experiences under the drug benefit have been positive. More specifically:
- More than eight in 10 seniors who are enrolled in a Medicare drug plan are satisfied with their plan
- About three in four seniors who are enrolled in a drug plan would choose the same plan again
- Nearly half of seniors enrolled in a drug plan say they are saving money on their prescription drugs.
About a third of polled seniors who have used their Medicare drug plans reported negative experiences, including having to pay unexpected costs, leaving the pharmacy without being able to fill a prescription, not receiving their enrollment card, having to switch drugs because one wasn’t covered, and having to switch from a brand-name to a generic drug.
The survey further indicated that those seniors in poorer health were significantly more likely to encounter a problem they perceived as “major.” Respondents indicated that most problems encountered had been resolved.
A full copy of the report is online.
Pay for performance
The first data from a closely watched, wide-reaching effort to improve the quality of care provided by general practitioners in the British National Health System (NHS) show that substantially increasing physicians’ pay based on their success in meeting quality performance measures works—but at a high cost.
In the first year of the pay-for-performance (P4P) program, the 8,000 family practitioners included in the study earned an average of $40,000 more by collecting nearly 97% of the points available for meeting 146 quality indicators covering 10 chronic diseases. Participating physicians met their quality targets for 83% of eligible patients.
The high performance scores came at a significant cost to NHS, which had projected that general practitioners would earn 75% of the possible points. The data was published in the July 27 New England Journal of Medicine.
Whether the British success might have been due to setting low targets or to some physicians gaming the system should be the subject of further research, said Arnold M. Epstein, MD, a professor of medicine and health care policy at Harvard Medical School, and one of the nation’s leading experts on health care quality, in an accompanying editorial.
Nonetheless, he said, the British experience offers many lessons for the U.S. Most importantly, he said, the experiment shows that proponents need to consider issues such as accounting for case-mix and how great a percentage of physicians’ salaries should be at risk. In addition, American P4P programs should account for the fact that much of American medicine is specialist-driven while the U.K. program was aimed at general practitioners.
The authors suggested several other tips on instituting pay-for-performance systems:
Anticipate and budget for high costs, both to pay doctors for achieving quality targets at higher-than-expected rates and to develop and implement the types of information technology systems needed to monitor the program.
Set a baseline to avoid paying for improvements that have already occurred.
Stagger introduction of the program geographically to enable study of the effects.
Begin incrementally to reduce risks for providers and payers.
Allow physicians to exclude some patients from the program to reduce the risk of promoting inappropriate treatment, but monitor how those exceptions occur to prevent physicians from gaming the system.
Clinical news in the headlines
A recent study found that ordering a simple measurement of thrombin generation for patients at high risk for recurrent VTE was effective in preventing patients from being put on long-term anticoagulation therapy.
The study followed 914 patients who had had a first spontaneous VTE for 47 months after discontinuation of vitamin K antagonist therapy. They found that patients were less likely to have a recurrence of VTE if they had a lower peak thrombin generation. The study appears in the July 26 Journal of the American Medical Association (JAMA).
A top goal in thrombosis research is how to identify patients at higher risk for recurrent VTE—who require indefinite anticoagulant treatment—versus those patients who do not need treatment beyond three to six months. About 5% of patients who experience VTE recurrence die five to eight years after anticoagulation therapy is stopped.
The study suggests that a simple commercially available laboratory method to measure thrombin generation will help physicians identify patients at low long-term risk of recurrent VTE. Extensive thrombophilia screening, which is costly and inconclusive, said the authors, appears to be unnecessary in this low-risk group.
The JAMA abstract is online.
The College's Physicians' Information and Education Resource (PIER) now includes a quality measurement tool designed to help physicians understand and navigate the approximately 26 "starter set" measures issued and approved by the Ambulatory Care Quality Alliance (AQA).
The measures were developed in an effort to improve preventive health services and patient outcomes when managing such conditions as asthma, coronary artery disease, diabetes, depression, falls and heart failure. The PIER tool provides a list of quality measures, the criteria for applying them and links to supporting recommendations and evidence.
“The new PIER tool was developed to help physicians by consolidating the list of AQA quality measures with supporting administrative and clinical information in one easily accessible place," said David Goldmann, FACP, Vice President and Editor-in-Chief of PIER.
PIER now contains 425 modules that provide guidance and information on more than 300 diseases and conditions. PIER modules also contain information on ethical and legal issues; complementary and alternative medicine; and screening, prevention and procedures. PIER is available as a free benefit of membership.
PIER's Quality Measures Tool is online.
On July 17, 80 of the U.S. Senate’s 100 members signed a letter to Senator Majority Leader Bill Frist (R-TN) and Senate Minority Leader Harry Reid (D-NV) urging them to address the Medicare physician payment cut, and provide physicians with a positive Medicare payment update for 2007, before Congress adjourns in October.
"Physicians are the foundation of the American health-care system," the letter states, adding that a stable payment structure for physician services is critical. The average 2006 Medicare rates for paying physicians are about the same as they were in 2001. If the 2007 cut is imposed, the aggregate payment rates since 2001 will have fallen 20% below the government’s conservative measure of inflation for medical practice costs.
"These projected cuts will destabilize the Medicare program," the letter concludes, "and put at risk all patents’ access to health care.”
ACP's Washington office assisted in collecting signatures for the letter, which was initiated by Senators Jon Kyl (R-AZ) and Debbie Stabenow (D-MI).
The complete letter is available online.
There have been 533 responses to an alert on ACP’s Legislative Action Center site asking ACP members to thank senators who have signed on to the letter. The alert is online.
Robert Doherty, ACP’s Senior Vice President of governmental affairs and public policy, last week participated in the Kaiser Family Foundation’s Ask the Experts webcast on price transparency.
During the webcast, broadcast June 25, experts discussed efforts already underway to move towards transparent pricing and challenges in implementing a new system. On the panel with Mr. Doherty were Gerard Anderson, PhD, professor, health policy and management, Johns Hopkins Bloomberg School of Public Health; and Charles M. Cutler, MD, vice president, national medical director, quality and clinical Integration for Aetna.
"The idea of transparency has merit, particularly if we can develop very good quality indicators," Mr. Doherty said during the webcast. "We believe that that is at least as, or more important than, pricing.”
ACP has in the past supported the goal of price transparency. In a May 2006 letter to the White House, ACP sent recommendations on how best to disclose fee information to patients, and noted obstacles inherent to price transparency in health care. The full text of the letter can be found online.
The archived webcast and a complete transcript can be viewed on the Kaiser Family Foundation website.
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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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