Alicia Ault

NEW ORLEANS – Patients tend to underestimate how long a cough should last, leading to unnecessary and inappropriate use of antibiotics, according to a review of the evidence and a survey of patient beliefs.

Cough is the third most frequent reason for physician office visits, and yet doctors and patients don’t seem to have an understanding of the natural history of cough and the expected duration, said Dr. Mark Ebell of the department of epidemiology at the University of Georgia College of Public Health in Athens.

The National Ambulatory Medical Survey in 2007 showed that there were 27 million outpatient visits for cough that year. That constitutes 2%-3% of all family practice visits, said Dr. Ebell. Half of patients received an antibiotic for their cough, and half the time, it was a broad spectrum antibiotic.

"There are some real issues with how we manage cough," said Dr. Ebell. Cough can indicate a condition that needs medical attention and a prescription therapy, but often, it is treated without evidence for antibiotics because the patient or doctor is uncomfortable with its duration.

Before patients ask their doctor how long a cough should last, they are likely to ask Google, he said. In conducting his own Google search, he found estimates ranging from 7 days to 14 days.

To get a sense of what patients think, Dr. Ebell and his colleagues surveyed Georgia residents by adding questions to the Georgia Poll, which is conducted twice a year by the Survey Research Center at the University of Georgia. Potential participants – aged 18 years or older – are randomly selected and contacted by phone. Almost 500 participated; 63% were women. It was an older population because the survey is conducted through landlines.

Participants were asked about their beliefs concerning antibiotics and the effectiveness of these drugs when the main symptom was a cough. They were asked how long they think it would take for the cough to get better if they were not taking any medicine, in six different scenarios: dry cough, coughing up yellow mucus or green mucus, or any of those kinds of cough with a slight fever, or no fever.

Patients with self-reported chronic lung disease or asthma were excluded from the survey.

Some respondents thought they would be better in as few as 2 days. Some thought the cough would last several months, but almost everyone thought it would take less than 2 weeks. There was not much difference between the scenarios, except when the scenario involved green phlegm.

The participants who had previously used antibiotics thought the cough would last longer, as did women, whites, and those with less education.

To determine how long a cough actually does last, Dr. Ebell conducted a literature search. After combing through several 100,000 potential studies, excluding those in sinusitis or people with a clear bacterial diagnosis, and focusing on those in community-dwelling, otherwise healthy adults with undifferentiated acute cough or bronchitis, he and his colleagues were left with 18 studies. In the end, only 5 of those 18 provided useful data.

The mean duration was 17-18 days. "So now we know how long a cough lasts," said Dr. Ebell.

Although the cough usually improves significantly in 2 weeks, most patients think it should be over in a week. "And that’s a big driver, or may be a big driver, of antibiotic use," he said. It may also lead to patients seeking repeat visits after 4 days, or asking for a "better" antibiotic after 8 or 9 days, which results in more prescriptions for broad spectrum antibiotics.

And the next time around, they are likely to say that the only drug that works for them is a broad spectrum antibiotic.

Dr. Ebell and his colleagues said they are exploring the clinical issue further, researching what physicians believe about cough, how messages in the media influence behavior, and whether there might be a discrepancy between the reality of an acute illness – its natural history – and perception.

Most importantly, he said he hopes to determine whether his findings can be used "to educate patients, to educate physicians, and hopefully create more realistic expectations about the duration of a cough [and] the duration of an acute illness, and thereby, hopefully reduce the demand for antibiotics."

Dr. Ebell reported having no relevant financial conflicts.

NEW ORLEANS – Patients tend to underestimate how long a cough should last, leading to unnecessary and inappropriate use of antibiotics, according to a review of the evidence and a survey of patient beliefs.

Cough is the third most frequent reason for physician office visits, and yet doctors and patients don’t seem to have an understanding of the natural history of cough and the expected duration, said Dr. Mark Ebell of the department of epidemiology at the University of Georgia College of Public Health in Athens.

The National Ambulatory Medical Survey in 2007 showed that there were 27 million outpatient visits for cough that year. That constitutes 2%-3% of all family practice visits, said Dr. Ebell. Half of patients received an antibiotic for their cough, and half the time, it was a broad spectrum antibiotic.

"There are some real issues with how we manage cough," said Dr. Ebell. Cough can indicate a condition that needs medical attention and a prescription therapy, but often, it is treated without evidence for antibiotics because the patient or doctor is uncomfortable with its duration.

Before patients ask their doctor how long a cough should last, they are likely to ask Google, he said. In conducting his own Google search, he found estimates ranging from 7 days to 14 days.

To get a sense of what patients think, Dr. Ebell and his colleagues surveyed Georgia residents by adding questions to the Georgia Poll, which is conducted twice a year by the Survey Research Center at the University of Georgia. Potential participants – aged 18 years or older – are randomly selected and contacted by phone. Almost 500 participated; 63% were women. It was an older population because the survey is conducted through landlines.

Participants were asked about their beliefs concerning antibiotics and the effectiveness of these drugs when the main symptom was a cough. They were asked how long they think it would take for the cough to get better if they were not taking any medicine, in six different scenarios: dry cough, coughing up yellow mucus or green mucus, or any of those kinds of cough with a slight fever, or no fever.

Patients with self-reported chronic lung disease or asthma were excluded from the survey.

Some respondents thought they would be better in as few as 2 days. Some thought the cough would last several months, but almost everyone thought it would take less than 2 weeks. There was not much difference between the scenarios, except when the scenario involved green phlegm.

The participants who had previously used antibiotics thought the cough would last longer, as did women, whites, and those with less education.

To determine how long a cough actually does last, Dr. Ebell conducted a literature search. After combing through several 100,000 potential studies, excluding those in sinusitis or people with a clear bacterial diagnosis, and focusing on those in community-dwelling, otherwise healthy adults with undifferentiated acute cough or bronchitis, he and his colleagues were left with 18 studies. In the end, only 5 of those 18 provided useful data.

The mean duration was 17-18 days. "So now we know how long a cough lasts," said Dr. Ebell.

Although the cough usually improves significantly in 2 weeks, most patients think it should be over in a week. "And that’s a big driver, or may be a big driver, of antibiotic use," he said. It may also lead to patients seeking repeat visits after 4 days, or asking for a "better" antibiotic after 8 or 9 days, which results in more prescriptions for broad spectrum antibiotics.

And the next time around, they are likely to say that the only drug that works for them is a broad spectrum antibiotic.

Dr. Ebell and his colleagues said they are exploring the clinical issue further, researching what physicians believe about cough, how messages in the media influence behavior, and whether there might be a discrepancy between the reality of an acute illness – its natural history – and perception.

Most importantly, he said he hopes to determine whether his findings can be used "to educate patients, to educate physicians, and hopefully create more realistic expectations about the duration of a cough [and] the duration of an acute illness, and thereby, hopefully reduce the demand for antibiotics."

Dr. Ebell reported having no relevant financial conflicts.

NEW ORLEANS – Patients tend to underestimate how long a cough should last, leading to unnecessary and inappropriate use of antibiotics, according to a review of the evidence and a survey of patient beliefs.

Cough is the third most frequent reason for physician office visits, and yet doctors and patients don’t seem to have an understanding of the natural history of cough and the expected duration, said Dr. Mark Ebell of the department of epidemiology at the University of Georgia College of Public Health in Athens.

The National Ambulatory Medical Survey in 2007 showed that there were 27 million outpatient visits for cough that year. That constitutes 2%-3% of all family practice visits, said Dr. Ebell. Half of patients received an antibiotic for their cough, and half the time, it was a broad spectrum antibiotic.

"There are some real issues with how we manage cough," said Dr. Ebell. Cough can indicate a condition that needs medical attention and a prescription therapy, but often, it is treated without evidence for antibiotics because the patient or doctor is uncomfortable with its duration.

Before patients ask their doctor how long a cough should last, they are likely to ask Google, he said. In conducting his own Google search, he found estimates ranging from 7 days to 14 days.

To get a sense of what patients think, Dr. Ebell and his colleagues surveyed Georgia residents by adding questions to the Georgia Poll, which is conducted twice a year by the Survey Research Center at the University of Georgia. Potential participants – aged 18 years or older – are randomly selected and contacted by phone. Almost 500 participated; 63% were women. It was an older population because the survey is conducted through landlines.

Participants were asked about their beliefs concerning antibiotics and the effectiveness of these drugs when the main symptom was a cough. They were asked how long they think it would take for the cough to get better if they were not taking any medicine, in six different scenarios: dry cough, coughing up yellow mucus or green mucus, or any of those kinds of cough with a slight fever, or no fever.

Patients with self-reported chronic lung disease or asthma were excluded from the survey.

Some respondents thought they would be better in as few as 2 days. Some thought the cough would last several months, but almost everyone thought it would take less than 2 weeks. There was not much difference between the scenarios, except when the scenario involved green phlegm.

The participants who had previously used antibiotics thought the cough would last longer, as did women, whites, and those with less education.

To determine how long a cough actually does last, Dr. Ebell conducted a literature search. After combing through several 100,000 potential studies, excluding those in sinusitis or people with a clear bacterial diagnosis, and focusing on those in community-dwelling, otherwise healthy adults with undifferentiated acute cough or bronchitis, he and his colleagues were left with 18 studies. In the end, only 5 of those 18 provided useful data.

The mean duration was 17-18 days. "So now we know how long a cough lasts," said Dr. Ebell.

Although the cough usually improves significantly in 2 weeks, most patients think it should be over in a week. "And that’s a big driver, or may be a big driver, of antibiotic use," he said. It may also lead to patients seeking repeat visits after 4 days, or asking for a "better" antibiotic after 8 or 9 days, which results in more prescriptions for broad spectrum antibiotics.

And the next time around, they are likely to say that the only drug that works for them is a broad spectrum antibiotic.

Dr. Ebell and his colleagues said they are exploring the clinical issue further, researching what physicians believe about cough, how messages in the media influence behavior, and whether there might be a discrepancy between the reality of an acute illness – its natural history – and perception.

Most importantly, he said he hopes to determine whether his findings can be used "to educate patients, to educate physicians, and hopefully create more realistic expectations about the duration of a cough [and] the duration of an acute illness, and thereby, hopefully reduce the demand for antibiotics."

Dr. Ebell reported having no relevant financial conflicts.

Psychiatrists are girding themselves for major changes in how they bill for their services starting Jan. 1, due to changes in the Current Procedural Terminology codes that were finalized in the 2013 Medicare Physician Fee Schedule.

The bottom line: Some psychiatrists, especially those who primarily do outpatient work, may have a steep learning curve with little additional payoff initially, according to Dr. Ronald Burd, chairman of the American Psychiatric Association committee on codes, RBRVS (Resource-Based Relative Value Scale), and reimbursement.

All psychiatrists will see increased pressure to start using evaluation and management (E&M) codes, which requires knowing the system and more documentation from the physician.

"If you’re used to using the E&M codes for inpatient work, it should translate pretty easily for outpatient work," said Dr. Jeremy S. Musher, who serves on the APA committee on codes, RBRVS, and reimbursement, and is the APA adviser to the American Medical Association (AMA) Relative Value Update Committee (RUC).

"But for psychiatrists who have not used E&M codes, there will be some learning involved in how to use, how to document, and how to bill," he said in an interview.

Reimbursement should eventually rise, but for the first year, the codes have been assigned interim values that aren’t much higher than current pay. Values may rise in 2014, after the professional societies have had a chance to survey psychiatrists on the new codes and the RUC looks at revaluing those codes, said Dr. Musher, medical director for psychiatric emergency services at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center and president and CEO of the consulting company the Musher Group.

The goal of the coding changes is for all psychiatrists to have "the opportunity to be appropriately reimbursed for the intensity of the work they do," Dr. Burd, who is also inpatient medical director for Sanford Health Services in Fargo, N.D., said in an interview.

The coding revision has been in process for several years, according to Dr. Musher. All codes are reviewed and revised periodically. When some of the psychiatric codes came up for review, the APA and other mental health societies suggested that the codes be revised to pay psychiatrists more appropriately.

Since the last major revision of the codes in 1998, psychiatrists have been locked into an outpatient medication management code (90862) that pays a flat rate, he explained. But patients have become more complex, presenting with an increasing number of comorbidities. Patients are also more complicated from a psychiatric standpoint because many have been shifted from the inpatient to the outpatient environment, he said. "The payment structure we are operating under does not account for that," Dr. Musher said.

The new codes more accurately reflect what psychiatrists do, he said. Under the new system, the 90862 pharmacologic management code has been deleted. There is a 90863 code now, which was created for psychologists in states where they have prescriptive privileges. But these codes should not be used by psychiatrists or midlevel providers, according to Dr. Burd.

Previously, the key intake code was 90801 and could be used when intake was done by a social worker, or a geriatric psychiatrist or a nurse practitioner. The argument was made that the level of work is different among those providers, Dr. Burd said. In recognition of that, in 2013 two intake codes will be available: 90792 for medical services, and 90791 for nonmedical services.

The psychiatric diagnostic evaluation code can be used in any setting, inpatient or outpatient. And it can be used more than once; if an evaluation spans several appointments, the code can be used for reassessments, Dr. Burd said.

In 2013, more psychiatric services will now be covered by E&M codes. Currently, E&M codes are used for psychotherapy, as these services are time based. For example, a psychiatrist can bill for 20-30 minutes of face-to-face contact, which would be mostly psychotherapy, and there would be a small amount of E&M involved, Dr. Burd said.

In the coming year, the situation is reversed. The psychiatrist will specify the level of E&M work done during the patient appointment and then add on codes for psychotherapy work, he said. Using a specific E&M will allow for greater accuracy for physician work during that time. Those codes require documenting the patient’s history, the exam, and the physician’s decision making for the E&M portion of the visit, with the psychotherapy component based on the time spent delivering psychotherapy.

It’s a bit ironic that in an era of bundling of services, there is unbundling for psychiatry – physicians will submit two codes for services that previously had a single value, Dr. Burd pointed out.

New codes also are available for crisis psychotherapy. The base code of 90839 will be used for the initial contact; the add-on code of 90840 will be available for every additional 30-minute increment.

Finally, the Current Procedural Terminology (CPT) eliminated a parallel set of codes that existed for interactive services such as play therapy or e-mailing patients, Dr. Burd said. Instead, "the modifier 90785 can be added to pretty much any code."

If a psychiatrist previously billed a 90802 as an intake with interaction, "I’d now bill at 90792 or 91 plus the interactive code of 90875," he said.

For psychiatrists trying to get up to speed, the APA conducts webinar "train the trainer" sessions so that psychiatrists can help bring local colleagues up to speed, Dr. Musher said. He also will present the new codes at the AMA’s annual CPT symposium for coders from physician practices. Subspecialty groups such as the American Association for Geriatric Psychiatry also will hold webinars.

The APA is set to provide documentation templates to members via its website. And the organization is working with payers to ensure they have a uniform interpretation of the new codes and that their systems will be set up to understand the new codes, Dr. Burd said.

He urged psychiatrists to educate themselves, starting by getting a copy of the CPT for 2013 and reading it, especially the section on E&M codes, he said.

Long term, there’s an upside for psychiatrists, Dr. Burd said. Many have been locked into low-value contracts, he noted. By using higher-level codes, "they’ll be able to bill for higher-level service."

Psychiatrists are girding themselves for major changes in how they bill for their services starting Jan. 1, due to changes in the Current Procedural Terminology codes that were finalized in the 2013 Medicare Physician Fee Schedule.

The bottom line: Some psychiatrists, especially those who primarily do outpatient work, may have a steep learning curve with little additional payoff initially, according to Dr. Ronald Burd, chairman of the American Psychiatric Association committee on codes, RBRVS (Resource-Based Relative Value Scale), and reimbursement.

All psychiatrists will see increased pressure to start using evaluation and management (E&M) codes, which requires knowing the system and more documentation from the physician.

"If you’re used to using the E&M codes for inpatient work, it should translate pretty easily for outpatient work," said Dr. Jeremy S. Musher, who serves on the APA committee on codes, RBRVS, and reimbursement, and is the APA adviser to the American Medical Association (AMA) Relative Value Update Committee (RUC).

"But for psychiatrists who have not used E&M codes, there will be some learning involved in how to use, how to document, and how to bill," he said in an interview.

Reimbursement should eventually rise, but for the first year, the codes have been assigned interim values that aren’t much higher than current pay. Values may rise in 2014, after the professional societies have had a chance to survey psychiatrists on the new codes and the RUC looks at revaluing those codes, said Dr. Musher, medical director for psychiatric emergency services at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center and president and CEO of the consulting company the Musher Group.

The goal of the coding changes is for all psychiatrists to have "the opportunity to be appropriately reimbursed for the intensity of the work they do," Dr. Burd, who is also inpatient medical director for Sanford Health Services in Fargo, N.D., said in an interview.

The coding revision has been in process for several years, according to Dr. Musher. All codes are reviewed and revised periodically. When some of the psychiatric codes came up for review, the APA and other mental health societies suggested that the codes be revised to pay psychiatrists more appropriately.

Since the last major revision of the codes in 1998, psychiatrists have been locked into an outpatient medication management code (90862) that pays a flat rate, he explained. But patients have become more complex, presenting with an increasing number of comorbidities. Patients are also more complicated from a psychiatric standpoint because many have been shifted from the inpatient to the outpatient environment, he said. "The payment structure we are operating under does not account for that," Dr. Musher said.

The new codes more accurately reflect what psychiatrists do, he said. Under the new system, the 90862 pharmacologic management code has been deleted. There is a 90863 code now, which was created for psychologists in states where they have prescriptive privileges. But these codes should not be used by psychiatrists or midlevel providers, according to Dr. Burd.

Previously, the key intake code was 90801 and could be used when intake was done by a social worker, or a geriatric psychiatrist or a nurse practitioner. The argument was made that the level of work is different among those providers, Dr. Burd said. In recognition of that, in 2013 two intake codes will be available: 90792 for medical services, and 90791 for nonmedical services.

The psychiatric diagnostic evaluation code can be used in any setting, inpatient or outpatient. And it can be used more than once; if an evaluation spans several appointments, the code can be used for reassessments, Dr. Burd said.

In 2013, more psychiatric services will now be covered by E&M codes. Currently, E&M codes are used for psychotherapy, as these services are time based. For example, a psychiatrist can bill for 20-30 minutes of face-to-face contact, which would be mostly psychotherapy, and there would be a small amount of E&M involved, Dr. Burd said.

In the coming year, the situation is reversed. The psychiatrist will specify the level of E&M work done during the patient appointment and then add on codes for psychotherapy work, he said. Using a specific E&M will allow for greater accuracy for physician work during that time. Those codes require documenting the patient’s history, the exam, and the physician’s decision making for the E&M portion of the visit, with the psychotherapy component based on the time spent delivering psychotherapy.

It’s a bit ironic that in an era of bundling of services, there is unbundling for psychiatry – physicians will submit two codes for services that previously had a single value, Dr. Burd pointed out.

New codes also are available for crisis psychotherapy. The base code of 90839 will be used for the initial contact; the add-on code of 90840 will be available for every additional 30-minute increment.

Finally, the Current Procedural Terminology (CPT) eliminated a parallel set of codes that existed for interactive services such as play therapy or e-mailing patients, Dr. Burd said. Instead, "the modifier 90785 can be added to pretty much any code."

If a psychiatrist previously billed a 90802 as an intake with interaction, "I’d now bill at 90792 or 91 plus the interactive code of 90875," he said.

For psychiatrists trying to get up to speed, the APA conducts webinar "train the trainer" sessions so that psychiatrists can help bring local colleagues up to speed, Dr. Musher said. He also will present the new codes at the AMA’s annual CPT symposium for coders from physician practices. Subspecialty groups such as the American Association for Geriatric Psychiatry also will hold webinars.

The APA is set to provide documentation templates to members via its website. And the organization is working with payers to ensure they have a uniform interpretation of the new codes and that their systems will be set up to understand the new codes, Dr. Burd said.

He urged psychiatrists to educate themselves, starting by getting a copy of the CPT for 2013 and reading it, especially the section on E&M codes, he said.

Long term, there’s an upside for psychiatrists, Dr. Burd said. Many have been locked into low-value contracts, he noted. By using higher-level codes, "they’ll be able to bill for higher-level service."

Psychiatrists are girding themselves for major changes in how they bill for their services starting Jan. 1, due to changes in the Current Procedural Terminology codes that were finalized in the 2013 Medicare Physician Fee Schedule.

The bottom line: Some psychiatrists, especially those who primarily do outpatient work, may have a steep learning curve with little additional payoff initially, according to Dr. Ronald Burd, chairman of the American Psychiatric Association committee on codes, RBRVS (Resource-Based Relative Value Scale), and reimbursement.

All psychiatrists will see increased pressure to start using evaluation and management (E&M) codes, which requires knowing the system and more documentation from the physician.

"If you’re used to using the E&M codes for inpatient work, it should translate pretty easily for outpatient work," said Dr. Jeremy S. Musher, who serves on the APA committee on codes, RBRVS, and reimbursement, and is the APA adviser to the American Medical Association (AMA) Relative Value Update Committee (RUC).

"But for psychiatrists who have not used E&M codes, there will be some learning involved in how to use, how to document, and how to bill," he said in an interview.

Reimbursement should eventually rise, but for the first year, the codes have been assigned interim values that aren’t much higher than current pay. Values may rise in 2014, after the professional societies have had a chance to survey psychiatrists on the new codes and the RUC looks at revaluing those codes, said Dr. Musher, medical director for psychiatric emergency services at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center and president and CEO of the consulting company the Musher Group.

The goal of the coding changes is for all psychiatrists to have "the opportunity to be appropriately reimbursed for the intensity of the work they do," Dr. Burd, who is also inpatient medical director for Sanford Health Services in Fargo, N.D., said in an interview.

The coding revision has been in process for several years, according to Dr. Musher. All codes are reviewed and revised periodically. When some of the psychiatric codes came up for review, the APA and other mental health societies suggested that the codes be revised to pay psychiatrists more appropriately.

Since the last major revision of the codes in 1998, psychiatrists have been locked into an outpatient medication management code (90862) that pays a flat rate, he explained. But patients have become more complex, presenting with an increasing number of comorbidities. Patients are also more complicated from a psychiatric standpoint because many have been shifted from the inpatient to the outpatient environment, he said. "The payment structure we are operating under does not account for that," Dr. Musher said.

The new codes more accurately reflect what psychiatrists do, he said. Under the new system, the 90862 pharmacologic management code has been deleted. There is a 90863 code now, which was created for psychologists in states where they have prescriptive privileges. But these codes should not be used by psychiatrists or midlevel providers, according to Dr. Burd.

Previously, the key intake code was 90801 and could be used when intake was done by a social worker, or a geriatric psychiatrist or a nurse practitioner. The argument was made that the level of work is different among those providers, Dr. Burd said. In recognition of that, in 2013 two intake codes will be available: 90792 for medical services, and 90791 for nonmedical services.

The psychiatric diagnostic evaluation code can be used in any setting, inpatient or outpatient. And it can be used more than once; if an evaluation spans several appointments, the code can be used for reassessments, Dr. Burd said.

In 2013, more psychiatric services will now be covered by E&M codes. Currently, E&M codes are used for psychotherapy, as these services are time based. For example, a psychiatrist can bill for 20-30 minutes of face-to-face contact, which would be mostly psychotherapy, and there would be a small amount of E&M involved, Dr. Burd said.

In the coming year, the situation is reversed. The psychiatrist will specify the level of E&M work done during the patient appointment and then add on codes for psychotherapy work, he said. Using a specific E&M will allow for greater accuracy for physician work during that time. Those codes require documenting the patient’s history, the exam, and the physician’s decision making for the E&M portion of the visit, with the psychotherapy component based on the time spent delivering psychotherapy.

It’s a bit ironic that in an era of bundling of services, there is unbundling for psychiatry – physicians will submit two codes for services that previously had a single value, Dr. Burd pointed out.

New codes also are available for crisis psychotherapy. The base code of 90839 will be used for the initial contact; the add-on code of 90840 will be available for every additional 30-minute increment.

Finally, the Current Procedural Terminology (CPT) eliminated a parallel set of codes that existed for interactive services such as play therapy or e-mailing patients, Dr. Burd said. Instead, "the modifier 90785 can be added to pretty much any code."

If a psychiatrist previously billed a 90802 as an intake with interaction, "I’d now bill at 90792 or 91 plus the interactive code of 90875," he said.

For psychiatrists trying to get up to speed, the APA conducts webinar "train the trainer" sessions so that psychiatrists can help bring local colleagues up to speed, Dr. Musher said. He also will present the new codes at the AMA’s annual CPT symposium for coders from physician practices. Subspecialty groups such as the American Association for Geriatric Psychiatry also will hold webinars.

The APA is set to provide documentation templates to members via its website. And the organization is working with payers to ensure they have a uniform interpretation of the new codes and that their systems will be set up to understand the new codes, Dr. Burd said.

He urged psychiatrists to educate themselves, starting by getting a copy of the CPT for 2013 and reading it, especially the section on E&M codes, he said.

Long term, there’s an upside for psychiatrists, Dr. Burd said. Many have been locked into low-value contracts, he noted. By using higher-level codes, "they’ll be able to bill for higher-level service."

NEW ORLEANS – Supply of primary care physicians is unlikely to meet demand when the Affordable Care Act is fully implemented in 2014 and shortages will be more acute in some regions that others.

Overall, the expansion of health insurance to a wider population is likely to mean that the United States will need an additional 8,000 primary care physicians over what is currently projected, or a 3% increase in the current workforce, by 2025, Stephen M. Petterson, Ph.D., reported at the annual meeting of the North American Primary Care Research Group.

thinkstockphotos.com

While that may not seem to be a huge increase, the nation will need 43,000 additional primary care doctors just to keep pace with population growth and the aging of that population.

Taking into account population growth, the aging of the population, and the impact of the ACA, the number of office visits in the United States will increase from 462 million in 2008 to 565 million in 2025 (Ann. Fam. Med. 2012;10:503-9). Dr. Petterson and his colleagues noted that their analysis is the first look at the ACA’s impact specifically on the primary care workforce and primary care services.

To get at that data, the authors used the Medical Expenditure Panel Survey (MEPS) to calculate the use of office-based primary care in 2008, U.S. Census Bureau projections for population estimates, and the American Medical Association Masterfile to calculate the number of primary care physicians and determine the number of visits per physician.

They determined that 46% of all physician office visits are to primary care physicians. MEPS data show that in 2008, there were 977 million office visits to physicians, 462 million of which were to primary care physicians. Women made more office visits than did men, older adults more than younger ones, and the insured more than the uninsured.

Previous studies have shown that when people gain insurance coverage, they tend to use more services, said Dr. Petterson, research director at the Robert Graham Center, a primary care think tank in Washington, D.C.

Based on their analysis, by 2025, an estimated 260,687 practicing primary care physicians will be needed – an increase of 51,880 from today. Most of the additional workforce can be built gradually, to accommodate aging and population growth, they said. But there will be a more urgent need in 2014 and 2015 when the ACA is fully implemented and there will be an additional 20 million primary care visits.

The ACA proposes to build the primary care workforce through expanding the number of primary care residents and increasing training for physician assistants and nurse practitioners. But that will only produce an estimated 500 additional physicians, said the authors, noting that "even if these positions were maintained for 10 years, only 5,000 additional primary care physicians would be trained."

The need for more primary care doctors varies geographically, Dr. Petterson said at the meeting.

Some states, those with a low number of uninsured, small populations, or a relatively high concentration of physicians, won’t need to bump up their numbers by much. Those states include Vermont, North Dakota, Wyoming, Delaware, the District of Columbia, South Dakota, Hawaii, Rhode Island, New Hampshire, and Montana.

The 10 states that will require the largest increase in the workforce are New Jersey, Pennsylvania, Ohio, North Carolina, Georgia, Illinois, New York, Florida, Texas, and California. These states have a high number of uninsured patients and a relatively low ratio of primary care physicians to the overall population, Dr. Petterson said. On the low end, New Jersey will need to increase its workforce by about 3%, or 200 or so new physicians. Texas and California are looking at a 7% and a 5% increase respectively, he said.

"The sudden influx of newly insured patients will exacerbate this situation," he said.

The authors had no relevant conflicts of interest; the study was funded in part by the Agency for Healthcare Research and Quality.

NEW ORLEANS – Supply of primary care physicians is unlikely to meet demand when the Affordable Care Act is fully implemented in 2014 and shortages will be more acute in some regions that others.

Overall, the expansion of health insurance to a wider population is likely to mean that the United States will need an additional 8,000 primary care physicians over what is currently projected, or a 3% increase in the current workforce, by 2025, Stephen M. Petterson, Ph.D., reported at the annual meeting of the North American Primary Care Research Group.

thinkstockphotos.com

While that may not seem to be a huge increase, the nation will need 43,000 additional primary care doctors just to keep pace with population growth and the aging of that population.

Taking into account population growth, the aging of the population, and the impact of the ACA, the number of office visits in the United States will increase from 462 million in 2008 to 565 million in 2025 (Ann. Fam. Med. 2012;10:503-9). Dr. Petterson and his colleagues noted that their analysis is the first look at the ACA’s impact specifically on the primary care workforce and primary care services.

To get at that data, the authors used the Medical Expenditure Panel Survey (MEPS) to calculate the use of office-based primary care in 2008, U.S. Census Bureau projections for population estimates, and the American Medical Association Masterfile to calculate the number of primary care physicians and determine the number of visits per physician.

They determined that 46% of all physician office visits are to primary care physicians. MEPS data show that in 2008, there were 977 million office visits to physicians, 462 million of which were to primary care physicians. Women made more office visits than did men, older adults more than younger ones, and the insured more than the uninsured.

Previous studies have shown that when people gain insurance coverage, they tend to use more services, said Dr. Petterson, research director at the Robert Graham Center, a primary care think tank in Washington, D.C.

Based on their analysis, by 2025, an estimated 260,687 practicing primary care physicians will be needed – an increase of 51,880 from today. Most of the additional workforce can be built gradually, to accommodate aging and population growth, they said. But there will be a more urgent need in 2014 and 2015 when the ACA is fully implemented and there will be an additional 20 million primary care visits.

The ACA proposes to build the primary care workforce through expanding the number of primary care residents and increasing training for physician assistants and nurse practitioners. But that will only produce an estimated 500 additional physicians, said the authors, noting that "even if these positions were maintained for 10 years, only 5,000 additional primary care physicians would be trained."

The need for more primary care doctors varies geographically, Dr. Petterson said at the meeting.

Some states, those with a low number of uninsured, small populations, or a relatively high concentration of physicians, won’t need to bump up their numbers by much. Those states include Vermont, North Dakota, Wyoming, Delaware, the District of Columbia, South Dakota, Hawaii, Rhode Island, New Hampshire, and Montana.

The 10 states that will require the largest increase in the workforce are New Jersey, Pennsylvania, Ohio, North Carolina, Georgia, Illinois, New York, Florida, Texas, and California. These states have a high number of uninsured patients and a relatively low ratio of primary care physicians to the overall population, Dr. Petterson said. On the low end, New Jersey will need to increase its workforce by about 3%, or 200 or so new physicians. Texas and California are looking at a 7% and a 5% increase respectively, he said.

"The sudden influx of newly insured patients will exacerbate this situation," he said.

The authors had no relevant conflicts of interest; the study was funded in part by the Agency for Healthcare Research and Quality.

NEW ORLEANS – Supply of primary care physicians is unlikely to meet demand when the Affordable Care Act is fully implemented in 2014 and shortages will be more acute in some regions that others.

Overall, the expansion of health insurance to a wider population is likely to mean that the United States will need an additional 8,000 primary care physicians over what is currently projected, or a 3% increase in the current workforce, by 2025, Stephen M. Petterson, Ph.D., reported at the annual meeting of the North American Primary Care Research Group.

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While that may not seem to be a huge increase, the nation will need 43,000 additional primary care doctors just to keep pace with population growth and the aging of that population.

Taking into account population growth, the aging of the population, and the impact of the ACA, the number of office visits in the United States will increase from 462 million in 2008 to 565 million in 2025 (Ann. Fam. Med. 2012;10:503-9). Dr. Petterson and his colleagues noted that their analysis is the first look at the ACA’s impact specifically on the primary care workforce and primary care services.

To get at that data, the authors used the Medical Expenditure Panel Survey (MEPS) to calculate the use of office-based primary care in 2008, U.S. Census Bureau projections for population estimates, and the American Medical Association Masterfile to calculate the number of primary care physicians and determine the number of visits per physician.

They determined that 46% of all physician office visits are to primary care physicians. MEPS data show that in 2008, there were 977 million office visits to physicians, 462 million of which were to primary care physicians. Women made more office visits than did men, older adults more than younger ones, and the insured more than the uninsured.

Previous studies have shown that when people gain insurance coverage, they tend to use more services, said Dr. Petterson, research director at the Robert Graham Center, a primary care think tank in Washington, D.C.

Based on their analysis, by 2025, an estimated 260,687 practicing primary care physicians will be needed – an increase of 51,880 from today. Most of the additional workforce can be built gradually, to accommodate aging and population growth, they said. But there will be a more urgent need in 2014 and 2015 when the ACA is fully implemented and there will be an additional 20 million primary care visits.

The ACA proposes to build the primary care workforce through expanding the number of primary care residents and increasing training for physician assistants and nurse practitioners. But that will only produce an estimated 500 additional physicians, said the authors, noting that "even if these positions were maintained for 10 years, only 5,000 additional primary care physicians would be trained."

The need for more primary care doctors varies geographically, Dr. Petterson said at the meeting.

Some states, those with a low number of uninsured, small populations, or a relatively high concentration of physicians, won’t need to bump up their numbers by much. Those states include Vermont, North Dakota, Wyoming, Delaware, the District of Columbia, South Dakota, Hawaii, Rhode Island, New Hampshire, and Montana.

The 10 states that will require the largest increase in the workforce are New Jersey, Pennsylvania, Ohio, North Carolina, Georgia, Illinois, New York, Florida, Texas, and California. These states have a high number of uninsured patients and a relatively low ratio of primary care physicians to the overall population, Dr. Petterson said. On the low end, New Jersey will need to increase its workforce by about 3%, or 200 or so new physicians. Texas and California are looking at a 7% and a 5% increase respectively, he said.

"The sudden influx of newly insured patients will exacerbate this situation," he said.

The authors had no relevant conflicts of interest; the study was funded in part by the Agency for Healthcare Research and Quality.

The Medicare physician fee schedule for 2013 is a mixed bag for cardiologists, with impending cuts based on the Sustainable Growth Rate formula as well as a cut to pay for imaging and certain procedures, and the possibility of a slight uptick for care coordination.

"This year’s final rule cuts payments for important cardiovascular services at a time when many cardiology practices are already vulnerable," said Dr. William Zoghbi, president of the American College of Cardiology, in a statement.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American College of Cardiology also called for pay predictability. "The ongoing uncertainties about Medicare payments that are a direct result of the SGR formula make it nearly impossible to plan and invest in the future," Dr. Zoghbi said.

Even with an SGR fix, cardiologists will see an average 2% reduction in pay because of an expansion of the multiple procedure payment reduction policy. Under that policy, the Centers for Medicare and Medicaid Services reduces payment for a second and subsequent advanced imaging service that is done in the same session or on the same day by the same provider. That policy now applies to the technical component of certain cardiovascular and ophthalmologic diagnostic tests and for imaging services. Essentially, it cuts pay for those services by 25%.

Among the services that will be affected: complete electrocardiogram (CPT code 93000), cardiovascular stress test (93015), and ambulatory blood pressure monitoring (93784).

The move was expected, but the ACC is "definitely disappointed," according to Brian Whitman, associate director of regulatory affairs at the College. The continuing reductions will help to push many cardiologists into hospital-based employment, he predicted.

The fee schedule final rule also outlined a new set of codes that pays physicians to coordinate care within 30 days of discharge from a hospital or nursing home. The rule creates two new CPT codes (99495 and 99496) that can be used for patient care that is not face to face, such as phone consults, chart reviews, and e-mail communications.

While primary care physicians are expected to report these codes most often, cardiologists will also be involved occasionally in these care transitions, Mr. Whitman said.

Cardiologists who run heart failure clinics or who are heart failure specialists, or who may be involved in post–myocardial infarction care are likely to use the transition codes, he added.

Starting next year, a physician using the codes can also conduct the discharge, but he or she must also have had an existing relationship with the patient, defined as having had at least one face-to-face visit within the previous 3 years.

Also included in the final rule: changes to the value-based modifier program. The modifier is designed to pay physicians based on the quality of care they deliver. In the proposed rule issued in July, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially. According to the CMS, the change was made so the agency – and physicians – could gain experience with the methodology and approach before the program is expanded to smaller physician groups.

The value-based modifier will be expanded to all physicians in 2017.

The final rule also outlines how the CMS will expand the Physician Compare website, which was launched in 2010 and currently includes basic information about approved Medicare providers, and whether they are considered successful prescribers under the Medicare Electronic Prescribing Incentive Program. The Affordable Care Act requires the CMS to start making physician performance data available in 2013.

The agency says that next year it will post the names of physicians who successfully report on the Physician Quality Reporting System’s Cardiovascular Prevention measures, as part of the Health and Human Services department’s Million Hearts campaign.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.

As called for under the Affordable Care Act, the CMS will pay Medicare rates for evaluation and management codes between 99201 and 99499 when they are used by physicians who are board certified by the American Board of Medical Specialties, the American Osteopathic Association, and the American Board of Physician Specialties.

The codes cover not just primary care, but also hospital observation and consultation for inpatient services provided by nonadmitting physicians, emergency department services, and critical care services.

The CMS estimated that increasing the Medicaid pay will cost $5.6 billion in 2013 and $5.7 billion in 2014.

Since the rule is written to cover subspecialists, cardiologists – especially pediatric cardiologists – are likely to benefit from this pay parity rule, Mr. Whitman said.

The rules will be published in the Federal Register on Nov. 16 and comments will close on Dec. 31. Both rules take effect Jan. 1, 2013.

The Medicare physician fee schedule for 2013 is a mixed bag for cardiologists, with impending cuts based on the Sustainable Growth Rate formula as well as a cut to pay for imaging and certain procedures, and the possibility of a slight uptick for care coordination.

"This year’s final rule cuts payments for important cardiovascular services at a time when many cardiology practices are already vulnerable," said Dr. William Zoghbi, president of the American College of Cardiology, in a statement.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American College of Cardiology also called for pay predictability. "The ongoing uncertainties about Medicare payments that are a direct result of the SGR formula make it nearly impossible to plan and invest in the future," Dr. Zoghbi said.

Even with an SGR fix, cardiologists will see an average 2% reduction in pay because of an expansion of the multiple procedure payment reduction policy. Under that policy, the Centers for Medicare and Medicaid Services reduces payment for a second and subsequent advanced imaging service that is done in the same session or on the same day by the same provider. That policy now applies to the technical component of certain cardiovascular and ophthalmologic diagnostic tests and for imaging services. Essentially, it cuts pay for those services by 25%.

Among the services that will be affected: complete electrocardiogram (CPT code 93000), cardiovascular stress test (93015), and ambulatory blood pressure monitoring (93784).

The move was expected, but the ACC is "definitely disappointed," according to Brian Whitman, associate director of regulatory affairs at the College. The continuing reductions will help to push many cardiologists into hospital-based employment, he predicted.

The fee schedule final rule also outlined a new set of codes that pays physicians to coordinate care within 30 days of discharge from a hospital or nursing home. The rule creates two new CPT codes (99495 and 99496) that can be used for patient care that is not face to face, such as phone consults, chart reviews, and e-mail communications.

While primary care physicians are expected to report these codes most often, cardiologists will also be involved occasionally in these care transitions, Mr. Whitman said.

Cardiologists who run heart failure clinics or who are heart failure specialists, or who may be involved in post–myocardial infarction care are likely to use the transition codes, he added.

Starting next year, a physician using the codes can also conduct the discharge, but he or she must also have had an existing relationship with the patient, defined as having had at least one face-to-face visit within the previous 3 years.

Also included in the final rule: changes to the value-based modifier program. The modifier is designed to pay physicians based on the quality of care they deliver. In the proposed rule issued in July, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially. According to the CMS, the change was made so the agency – and physicians – could gain experience with the methodology and approach before the program is expanded to smaller physician groups.

The value-based modifier will be expanded to all physicians in 2017.

The final rule also outlines how the CMS will expand the Physician Compare website, which was launched in 2010 and currently includes basic information about approved Medicare providers, and whether they are considered successful prescribers under the Medicare Electronic Prescribing Incentive Program. The Affordable Care Act requires the CMS to start making physician performance data available in 2013.

The agency says that next year it will post the names of physicians who successfully report on the Physician Quality Reporting System’s Cardiovascular Prevention measures, as part of the Health and Human Services department’s Million Hearts campaign.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.

As called for under the Affordable Care Act, the CMS will pay Medicare rates for evaluation and management codes between 99201 and 99499 when they are used by physicians who are board certified by the American Board of Medical Specialties, the American Osteopathic Association, and the American Board of Physician Specialties.

The codes cover not just primary care, but also hospital observation and consultation for inpatient services provided by nonadmitting physicians, emergency department services, and critical care services.

The CMS estimated that increasing the Medicaid pay will cost $5.6 billion in 2013 and $5.7 billion in 2014.

Since the rule is written to cover subspecialists, cardiologists – especially pediatric cardiologists – are likely to benefit from this pay parity rule, Mr. Whitman said.

The rules will be published in the Federal Register on Nov. 16 and comments will close on Dec. 31. Both rules take effect Jan. 1, 2013.

The Medicare physician fee schedule for 2013 is a mixed bag for cardiologists, with impending cuts based on the Sustainable Growth Rate formula as well as a cut to pay for imaging and certain procedures, and the possibility of a slight uptick for care coordination.

"This year’s final rule cuts payments for important cardiovascular services at a time when many cardiology practices are already vulnerable," said Dr. William Zoghbi, president of the American College of Cardiology, in a statement.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American College of Cardiology also called for pay predictability. "The ongoing uncertainties about Medicare payments that are a direct result of the SGR formula make it nearly impossible to plan and invest in the future," Dr. Zoghbi said.

Even with an SGR fix, cardiologists will see an average 2% reduction in pay because of an expansion of the multiple procedure payment reduction policy. Under that policy, the Centers for Medicare and Medicaid Services reduces payment for a second and subsequent advanced imaging service that is done in the same session or on the same day by the same provider. That policy now applies to the technical component of certain cardiovascular and ophthalmologic diagnostic tests and for imaging services. Essentially, it cuts pay for those services by 25%.

Among the services that will be affected: complete electrocardiogram (CPT code 93000), cardiovascular stress test (93015), and ambulatory blood pressure monitoring (93784).

The move was expected, but the ACC is "definitely disappointed," according to Brian Whitman, associate director of regulatory affairs at the College. The continuing reductions will help to push many cardiologists into hospital-based employment, he predicted.

The fee schedule final rule also outlined a new set of codes that pays physicians to coordinate care within 30 days of discharge from a hospital or nursing home. The rule creates two new CPT codes (99495 and 99496) that can be used for patient care that is not face to face, such as phone consults, chart reviews, and e-mail communications.

While primary care physicians are expected to report these codes most often, cardiologists will also be involved occasionally in these care transitions, Mr. Whitman said.

Cardiologists who run heart failure clinics or who are heart failure specialists, or who may be involved in post–myocardial infarction care are likely to use the transition codes, he added.

Starting next year, a physician using the codes can also conduct the discharge, but he or she must also have had an existing relationship with the patient, defined as having had at least one face-to-face visit within the previous 3 years.

Also included in the final rule: changes to the value-based modifier program. The modifier is designed to pay physicians based on the quality of care they deliver. In the proposed rule issued in July, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially. According to the CMS, the change was made so the agency – and physicians – could gain experience with the methodology and approach before the program is expanded to smaller physician groups.

The value-based modifier will be expanded to all physicians in 2017.

The final rule also outlines how the CMS will expand the Physician Compare website, which was launched in 2010 and currently includes basic information about approved Medicare providers, and whether they are considered successful prescribers under the Medicare Electronic Prescribing Incentive Program. The Affordable Care Act requires the CMS to start making physician performance data available in 2013.

The agency says that next year it will post the names of physicians who successfully report on the Physician Quality Reporting System’s Cardiovascular Prevention measures, as part of the Health and Human Services department’s Million Hearts campaign.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.

As called for under the Affordable Care Act, the CMS will pay Medicare rates for evaluation and management codes between 99201 and 99499 when they are used by physicians who are board certified by the American Board of Medical Specialties, the American Osteopathic Association, and the American Board of Physician Specialties.

The codes cover not just primary care, but also hospital observation and consultation for inpatient services provided by nonadmitting physicians, emergency department services, and critical care services.

The CMS estimated that increasing the Medicaid pay will cost $5.6 billion in 2013 and $5.7 billion in 2014.

Since the rule is written to cover subspecialists, cardiologists – especially pediatric cardiologists – are likely to benefit from this pay parity rule, Mr. Whitman said.

The rules will be published in the Federal Register on Nov. 16 and comments will close on Dec. 31. Both rules take effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and otherwise flat payments for rheumatologists.

Dr. Charles King, a rheumatologist in Tupelo, Miss., and chair of the American College of Rheumatology’s Committee on Rheumatologic Care, said that even if the SGR formula cut is averted, the 0% change in reimbursement based on 2013 coding changes is essentially a pay cut since Medicare officials are simultaneously asking physicians to make investments in health information technology.

"It is a salary cut by default," Dr. King said.

In more bad news for rheumatologists, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rulealso includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

Dr. King urged rheumatologists to pay close attention to the value-based modifier program since all physicians will be subject to the program by 2017, regardless of the size of their practice. He also advised physicians to begin participating in the Physician Quality Reporting System, since the Centers for Medicare and Medicaid Services (CMS) will use that program as the basis for the quality reporting in the value-based modifier program.

In the meantime, the ACR is asking CMS to slow down its implementation until there are better quality measures across a wider spectrum of conditions.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

The rule was published in the Federal Register on Nov. 16, and comments will close on Dec. 31. It will take effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and otherwise flat payments for rheumatologists.

Dr. Charles King, a rheumatologist in Tupelo, Miss., and chair of the American College of Rheumatology’s Committee on Rheumatologic Care, said that even if the SGR formula cut is averted, the 0% change in reimbursement based on 2013 coding changes is essentially a pay cut since Medicare officials are simultaneously asking physicians to make investments in health information technology.

"It is a salary cut by default," Dr. King said.

In more bad news for rheumatologists, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rulealso includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

Dr. King urged rheumatologists to pay close attention to the value-based modifier program since all physicians will be subject to the program by 2017, regardless of the size of their practice. He also advised physicians to begin participating in the Physician Quality Reporting System, since the Centers for Medicare and Medicaid Services (CMS) will use that program as the basis for the quality reporting in the value-based modifier program.

In the meantime, the ACR is asking CMS to slow down its implementation until there are better quality measures across a wider spectrum of conditions.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

The rule was published in the Federal Register on Nov. 16, and comments will close on Dec. 31. It will take effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and otherwise flat payments for rheumatologists.

Dr. Charles King, a rheumatologist in Tupelo, Miss., and chair of the American College of Rheumatology’s Committee on Rheumatologic Care, said that even if the SGR formula cut is averted, the 0% change in reimbursement based on 2013 coding changes is essentially a pay cut since Medicare officials are simultaneously asking physicians to make investments in health information technology.

"It is a salary cut by default," Dr. King said.

In more bad news for rheumatologists, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rulealso includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

Dr. King urged rheumatologists to pay close attention to the value-based modifier program since all physicians will be subject to the program by 2017, regardless of the size of their practice. He also advised physicians to begin participating in the Physician Quality Reporting System, since the Centers for Medicare and Medicaid Services (CMS) will use that program as the basis for the quality reporting in the value-based modifier program.

In the meantime, the ACR is asking CMS to slow down its implementation until there are better quality measures across a wider spectrum of conditions.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

The rule was published in the Federal Register on Nov. 16, and comments will close on Dec. 31. It will take effect Jan. 1, 2013.

A St. Louis dermatologist and several colleagues have succeeded in convincing the American Academy of Dermatology to vote at its March annual meeting on whether to change the organization’s name to the American Academy of Dermatology and Dermatologic Surgery.

Dr. Lee Portnoff, who is in private practice and is an assistant professor of clinical medicine at Washington University in St. Louis, said in an interview that he and his colleagues were calling for the change because "it is important that our largest dermatology umbrella organization has a name that represents and promotes the surgical aspect of our practices."

In a position paper submitted to the AAD, Dr. Portnoff and the three signatories – Dr. Harold J. Brody, Dr. William P. Coleman III, and Dr. Raymond L. Cornelison Jr. – noted that a simple majority of AAD members approved just such a name change 14 years ago at an annual meeting but that a two-thirds majority was required for passage.

In addition, even though the AAD Advisory Board backed resolutions over the past 2 years urging the AAD Board of Directors to add "dermatologic surgery" to the academy’s name, the Board of Directors declined to have such a change considered at the annual meeting, saying that it would be too expensive to change and that it would mean establishing a new "brand" for dermatology. Dr. Portnoff said, however, that many specialties are now performing dermatologic surgery and that dermatology should reclaim the distinction.

The position paper calling for the change also says that "we do not see how the addition of the surgical name will alter the branding that exists." Instead, it could make the branding more successful, and also "enhance our specialty tremendously."

The AAD will be taking comments on the proposal until Dec. 1, according to a spokeswoman for the organization.

Members who want to comment can do so via the AAD website, by e-mail, or by mail to the attention of the Secretary Treasurer, Bylaws Statements, 930 E. Woodfield Road, Schaumburg, IL 60173-4729.

Statements cannot be any longer than two typewritten, double-spaced pages.

If the academy votes to change the name, it would take effect 12 months later, unless the Board of Directors and the AAD voted to change the effective date.

A St. Louis dermatologist and several colleagues have succeeded in convincing the American Academy of Dermatology to vote at its March annual meeting on whether to change the organization’s name to the American Academy of Dermatology and Dermatologic Surgery.

Dr. Lee Portnoff, who is in private practice and is an assistant professor of clinical medicine at Washington University in St. Louis, said in an interview that he and his colleagues were calling for the change because "it is important that our largest dermatology umbrella organization has a name that represents and promotes the surgical aspect of our practices."

In a position paper submitted to the AAD, Dr. Portnoff and the three signatories – Dr. Harold J. Brody, Dr. William P. Coleman III, and Dr. Raymond L. Cornelison Jr. – noted that a simple majority of AAD members approved just such a name change 14 years ago at an annual meeting but that a two-thirds majority was required for passage.

In addition, even though the AAD Advisory Board backed resolutions over the past 2 years urging the AAD Board of Directors to add "dermatologic surgery" to the academy’s name, the Board of Directors declined to have such a change considered at the annual meeting, saying that it would be too expensive to change and that it would mean establishing a new "brand" for dermatology. Dr. Portnoff said, however, that many specialties are now performing dermatologic surgery and that dermatology should reclaim the distinction.

The position paper calling for the change also says that "we do not see how the addition of the surgical name will alter the branding that exists." Instead, it could make the branding more successful, and also "enhance our specialty tremendously."

The AAD will be taking comments on the proposal until Dec. 1, according to a spokeswoman for the organization.

Members who want to comment can do so via the AAD website, by e-mail, or by mail to the attention of the Secretary Treasurer, Bylaws Statements, 930 E. Woodfield Road, Schaumburg, IL 60173-4729.

Statements cannot be any longer than two typewritten, double-spaced pages.

If the academy votes to change the name, it would take effect 12 months later, unless the Board of Directors and the AAD voted to change the effective date.

A St. Louis dermatologist and several colleagues have succeeded in convincing the American Academy of Dermatology to vote at its March annual meeting on whether to change the organization’s name to the American Academy of Dermatology and Dermatologic Surgery.

Dr. Lee Portnoff, who is in private practice and is an assistant professor of clinical medicine at Washington University in St. Louis, said in an interview that he and his colleagues were calling for the change because "it is important that our largest dermatology umbrella organization has a name that represents and promotes the surgical aspect of our practices."

In a position paper submitted to the AAD, Dr. Portnoff and the three signatories – Dr. Harold J. Brody, Dr. William P. Coleman III, and Dr. Raymond L. Cornelison Jr. – noted that a simple majority of AAD members approved just such a name change 14 years ago at an annual meeting but that a two-thirds majority was required for passage.

In addition, even though the AAD Advisory Board backed resolutions over the past 2 years urging the AAD Board of Directors to add "dermatologic surgery" to the academy’s name, the Board of Directors declined to have such a change considered at the annual meeting, saying that it would be too expensive to change and that it would mean establishing a new "brand" for dermatology. Dr. Portnoff said, however, that many specialties are now performing dermatologic surgery and that dermatology should reclaim the distinction.

The position paper calling for the change also says that "we do not see how the addition of the surgical name will alter the branding that exists." Instead, it could make the branding more successful, and also "enhance our specialty tremendously."

The AAD will be taking comments on the proposal until Dec. 1, according to a spokeswoman for the organization.

Members who want to comment can do so via the AAD website, by e-mail, or by mail to the attention of the Secretary Treasurer, Bylaws Statements, 930 E. Woodfield Road, Schaumburg, IL 60173-4729.

Statements cannot be any longer than two typewritten, double-spaced pages.

If the academy votes to change the name, it would take effect 12 months later, unless the Board of Directors and the AAD voted to change the effective date.

As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.

Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.

The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.

"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.

Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.

"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.

Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.

Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.

The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.

"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.

According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."

The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.

The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.

As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.

Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.

The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.

"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.

Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.

"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.

Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.

Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.

The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.

"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.

According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."

The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.

The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.

As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.

Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.

The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.

"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.

Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.

"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.

Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.

Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.

The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.

"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.

According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."

The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.

The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.

BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.

The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.

Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.

MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.

In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.

Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.

While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.

A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.

The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.

If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.

Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.

The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.

As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.

Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.

Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.

The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.

Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.

The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.

About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.

As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.

Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.

Maryland will contract with certain entities who will then hire individual navigators. Those navigators will not be employees of the exchange. The aim is to have a full cadre of navigators by late spring and to have them completely trained by late summer, said Danielle Davis, director of communications and outreach for the Maryland Health Connection.

What Will Plans Look Like in Maryland?

The ACA requires each state health insurance exchange to establish an essential benefits package; every plan for sale in the exchange must offer these benefits. In Maryland, plans must offer:

• Ambulatory services.

• Emergency services.

• Hospitalization.

• Maternity and newborn care.

• Mental health and substance use disorder services.

• Prescription drugs.

• Rehabilitative and habilitative services and devices.

• Laboratory services.

• Preventive and wellness services and chronic disease management.

• Pediatric services, including oral and vision care.

Each state exchange must choose a benchmark plan that covers the essential benefits; insurance carriers build upon that plan. Maryland chose its state employees’ health benefits plan as its benchmark.

So far, all 12 insurers in Maryland’s small group and individual markets have indicated they want to participate in the exchange, Ms. Pearce said. Consumers can begin enrolling on Oct. 1, 2013; coverage starts on Jan. 1, 2014.

For physicians, the transition should be seamless, said Ms. Pearce. Patients who gain coverage through the exchange will have benefits and identification cards from insurance carriers, just like every insured patient.

BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.

The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.

Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.

MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.

In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.

Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.

While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.

A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.

The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.

If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.

Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.

The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.

As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.

Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.

Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.

The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.

Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.

The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.

About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.

As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.

Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.

Maryland will contract with certain entities who will then hire individual navigators. Those navigators will not be employees of the exchange. The aim is to have a full cadre of navigators by late spring and to have them completely trained by late summer, said Danielle Davis, director of communications and outreach for the Maryland Health Connection.

What Will Plans Look Like in Maryland?

The ACA requires each state health insurance exchange to establish an essential benefits package; every plan for sale in the exchange must offer these benefits. In Maryland, plans must offer:

• Ambulatory services.

• Emergency services.

• Hospitalization.

• Maternity and newborn care.

• Mental health and substance use disorder services.

• Prescription drugs.

• Rehabilitative and habilitative services and devices.

• Laboratory services.

• Preventive and wellness services and chronic disease management.

• Pediatric services, including oral and vision care.

Each state exchange must choose a benchmark plan that covers the essential benefits; insurance carriers build upon that plan. Maryland chose its state employees’ health benefits plan as its benchmark.

So far, all 12 insurers in Maryland’s small group and individual markets have indicated they want to participate in the exchange, Ms. Pearce said. Consumers can begin enrolling on Oct. 1, 2013; coverage starts on Jan. 1, 2014.

For physicians, the transition should be seamless, said Ms. Pearce. Patients who gain coverage through the exchange will have benefits and identification cards from insurance carriers, just like every insured patient.

BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.

The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.

Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.

MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.

In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.

Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.

While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.

A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.

The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.

If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.

Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.

The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.

As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.

Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.

Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.

The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.

Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.

The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.

About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.

As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.

Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.

Maryland will contract with certain entities who will then hire individual navigators. Those navigators will not be employees of the exchange. The aim is to have a full cadre of navigators by late spring and to have them completely trained by late summer, said Danielle Davis, director of communications and outreach for the Maryland Health Connection.

What Will Plans Look Like in Maryland?

The ACA requires each state health insurance exchange to establish an essential benefits package; every plan for sale in the exchange must offer these benefits. In Maryland, plans must offer:

• Ambulatory services.

• Emergency services.

• Hospitalization.

• Maternity and newborn care.

• Mental health and substance use disorder services.

• Prescription drugs.

• Rehabilitative and habilitative services and devices.

• Laboratory services.

• Preventive and wellness services and chronic disease management.

• Pediatric services, including oral and vision care.

Each state exchange must choose a benchmark plan that covers the essential benefits; insurance carriers build upon that plan. Maryland chose its state employees’ health benefits plan as its benchmark.

So far, all 12 insurers in Maryland’s small group and individual markets have indicated they want to participate in the exchange, Ms. Pearce said. Consumers can begin enrolling on Oct. 1, 2013; coverage starts on Jan. 1, 2014.

For physicians, the transition should be seamless, said Ms. Pearce. Patients who gain coverage through the exchange will have benefits and identification cards from insurance carriers, just like every insured patient.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

Courtesy AMA

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.

Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.

ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.

"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."

The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.

The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

Courtesy AMA

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.

Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.

ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.

"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."

The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.

The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

Courtesy AMA

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.

Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.

ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.

"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."

The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.

The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.