Jennifer Lubell

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G-codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G-codes, CMS spokesman Peter Ashkenaz told this newspaper. "This will provide clinicians with the flexibility of utilizing either G-codes or CPT II codes" for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions "critically important." As reporting and pay-for-performance programs become more widespread, "uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program."

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet "this is still a voluntary program with no immediate benefit to patients or physicians."

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians "will be even less able to comply with any reporting, voluntary or not," Dr. Fields said. Without a positive incentive to participate, "I expect that CMs' announcement will be met with indifference."

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

"I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers" and to CMS, he said. "I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program."

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, "We want to make it beneficial to physicians." The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. "What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?"

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. "I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures."

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer programs, "PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded."

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, "and, like the hospital program, pay for data collection."

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G-codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G-codes, CMS spokesman Peter Ashkenaz told this newspaper. "This will provide clinicians with the flexibility of utilizing either G-codes or CPT II codes" for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions "critically important." As reporting and pay-for-performance programs become more widespread, "uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program."

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet "this is still a voluntary program with no immediate benefit to patients or physicians."

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians "will be even less able to comply with any reporting, voluntary or not," Dr. Fields said. Without a positive incentive to participate, "I expect that CMs' announcement will be met with indifference."

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

"I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers" and to CMS, he said. "I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program."

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, "We want to make it beneficial to physicians." The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. "What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?"

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. "I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures."

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer programs, "PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded."

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, "and, like the hospital program, pay for data collection."

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G-codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G-codes, CMS spokesman Peter Ashkenaz told this newspaper. "This will provide clinicians with the flexibility of utilizing either G-codes or CPT II codes" for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions "critically important." As reporting and pay-for-performance programs become more widespread, "uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program."

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet "this is still a voluntary program with no immediate benefit to patients or physicians."

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians "will be even less able to comply with any reporting, voluntary or not," Dr. Fields said. Without a positive incentive to participate, "I expect that CMs' announcement will be met with indifference."

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

"I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers" and to CMS, he said. "I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program."

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, "We want to make it beneficial to physicians." The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. "What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?"

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. "I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures."

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer programs, "PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded."

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, "and, like the hospital program, pay for data collection."

Without the proper technology, physician practices may find it difficult to participate in Medicare's new “e-prescribing” standards under the Part D drug benefit, physician groups claim.

“Most primary care physicians will be unable to afford to implement this technology on their own, particularly with the projected cuts in Medicare physician payments of 4.4% in 2006 and a cumulative 26% reduction from 2006 to 2011,” Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs with the American College of Physicians, said in an interview.

The Centers for Medicare and Medicaid Services in a final rule established the standards for electronic prescribing, or e-prescribing, of drugs covered by Medicare's prescription drug benefit that started Jan. 1, 2006, according to the Federal Register. CMS also plans to pilot test initial e-prescribing standards, which may be included in a final rule to be issued by April 2008.

“These standards will allow Medicare, physicians, hospitals, group practices, other health providers, and prescription drug plan sponsors and Medicare Advantage organizations to take advantage of e-prescribing technology to improve medication prescribing for Medicare beneficiaries that participate in the new prescription drug program,” said Mike Leavitt secretary of the Department of Health and Human Services.

For the most part, medical organizations expressed support for the agency's e-prescribing initiative.

But few practices are currently employing this technology, Dr. Kirshner said. “Surveys vary, but the percentage of practices using it ranges somewhere from 5% to 18%.” The number is even lower for the typical small practice, he added.

Dr. Kirschner said the recent release of safe harbor antikickback and Stark exception rules allowing hospitals, group practices, and Medicare Part D drug plan sponsors to provide necessary e-prescribing technology to physicians may help facilitate its use.

E-prescribing is optional for physicians and pharmacies under the new standards, but as of Jan. 1, 2006, Medicare required drug plans participating in the new prescription benefit to support electronic prescribing.

Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said PhRMA supported the development of a standardized e-prescribing system. In addition to reducing errors and the administrative costs associated with health care, the system would also promote more effective care of drug therapies for chronic conditions. He agreed, however, that such a system must be designed and implemented correctly. “Keep in mind that the systems needed to convert to an e-Rx system don't even exist yet.”

CMS's new standards for e-prescribing include the following technology:

▸ NCPDP SCRIPT, Version 5.0, for transactions between prescribers and dispensers for new prescriptions, refill requests and responses, prescription change requests and responses, prescription cancellation requests and responses, and related messaging and administrative transactions.

▸ ASC X12N 270/271, Version 4010 and addenda, for eligibility and benefits queries and responses between prescribers and Part D sponsors.

▸ NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1, for eligibility queries between dispensers and Part D sponsors.

Without the proper technology, physician practices may find it difficult to participate in Medicare's new “e-prescribing” standards under the Part D drug benefit, physician groups claim.

“Most primary care physicians will be unable to afford to implement this technology on their own, particularly with the projected cuts in Medicare physician payments of 4.4% in 2006 and a cumulative 26% reduction from 2006 to 2011,” Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs with the American College of Physicians, said in an interview.

The Centers for Medicare and Medicaid Services in a final rule established the standards for electronic prescribing, or e-prescribing, of drugs covered by Medicare's prescription drug benefit that started Jan. 1, 2006, according to the Federal Register. CMS also plans to pilot test initial e-prescribing standards, which may be included in a final rule to be issued by April 2008.

“These standards will allow Medicare, physicians, hospitals, group practices, other health providers, and prescription drug plan sponsors and Medicare Advantage organizations to take advantage of e-prescribing technology to improve medication prescribing for Medicare beneficiaries that participate in the new prescription drug program,” said Mike Leavitt secretary of the Department of Health and Human Services.

For the most part, medical organizations expressed support for the agency's e-prescribing initiative.

But few practices are currently employing this technology, Dr. Kirshner said. “Surveys vary, but the percentage of practices using it ranges somewhere from 5% to 18%.” The number is even lower for the typical small practice, he added.

Dr. Kirschner said the recent release of safe harbor antikickback and Stark exception rules allowing hospitals, group practices, and Medicare Part D drug plan sponsors to provide necessary e-prescribing technology to physicians may help facilitate its use.

E-prescribing is optional for physicians and pharmacies under the new standards, but as of Jan. 1, 2006, Medicare required drug plans participating in the new prescription benefit to support electronic prescribing.

Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said PhRMA supported the development of a standardized e-prescribing system. In addition to reducing errors and the administrative costs associated with health care, the system would also promote more effective care of drug therapies for chronic conditions. He agreed, however, that such a system must be designed and implemented correctly. “Keep in mind that the systems needed to convert to an e-Rx system don't even exist yet.”

CMS's new standards for e-prescribing include the following technology:

▸ NCPDP SCRIPT, Version 5.0, for transactions between prescribers and dispensers for new prescriptions, refill requests and responses, prescription change requests and responses, prescription cancellation requests and responses, and related messaging and administrative transactions.

▸ ASC X12N 270/271, Version 4010 and addenda, for eligibility and benefits queries and responses between prescribers and Part D sponsors.

▸ NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1, for eligibility queries between dispensers and Part D sponsors.

Without the proper technology, physician practices may find it difficult to participate in Medicare's new “e-prescribing” standards under the Part D drug benefit, physician groups claim.

“Most primary care physicians will be unable to afford to implement this technology on their own, particularly with the projected cuts in Medicare physician payments of 4.4% in 2006 and a cumulative 26% reduction from 2006 to 2011,” Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs with the American College of Physicians, said in an interview.

The Centers for Medicare and Medicaid Services in a final rule established the standards for electronic prescribing, or e-prescribing, of drugs covered by Medicare's prescription drug benefit that started Jan. 1, 2006, according to the Federal Register. CMS also plans to pilot test initial e-prescribing standards, which may be included in a final rule to be issued by April 2008.

“These standards will allow Medicare, physicians, hospitals, group practices, other health providers, and prescription drug plan sponsors and Medicare Advantage organizations to take advantage of e-prescribing technology to improve medication prescribing for Medicare beneficiaries that participate in the new prescription drug program,” said Mike Leavitt secretary of the Department of Health and Human Services.

For the most part, medical organizations expressed support for the agency's e-prescribing initiative.

But few practices are currently employing this technology, Dr. Kirshner said. “Surveys vary, but the percentage of practices using it ranges somewhere from 5% to 18%.” The number is even lower for the typical small practice, he added.

Dr. Kirschner said the recent release of safe harbor antikickback and Stark exception rules allowing hospitals, group practices, and Medicare Part D drug plan sponsors to provide necessary e-prescribing technology to physicians may help facilitate its use.

E-prescribing is optional for physicians and pharmacies under the new standards, but as of Jan. 1, 2006, Medicare required drug plans participating in the new prescription benefit to support electronic prescribing.

Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said PhRMA supported the development of a standardized e-prescribing system. In addition to reducing errors and the administrative costs associated with health care, the system would also promote more effective care of drug therapies for chronic conditions. He agreed, however, that such a system must be designed and implemented correctly. “Keep in mind that the systems needed to convert to an e-Rx system don't even exist yet.”

CMS's new standards for e-prescribing include the following technology:

▸ NCPDP SCRIPT, Version 5.0, for transactions between prescribers and dispensers for new prescriptions, refill requests and responses, prescription change requests and responses, prescription cancellation requests and responses, and related messaging and administrative transactions.

▸ ASC X12N 270/271, Version 4010 and addenda, for eligibility and benefits queries and responses between prescribers and Part D sponsors.

▸ NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1, for eligibility queries between dispensers and Part D sponsors.

Food Allergen Labeling

All food labels now must clearly state if a product contains any ingredients with protein derived from the eight major allergenic foods. Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), manufacturers are required to identify in plain English the presence of ingredients that contain protein derived from milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans in the list of ingredients or to say “contains” followed by name of the source of the food allergen after or adjacent to the list of ingredients. It is estimated that 2% of adults and about 5% of infants and young children in the United States have food allergies. Approximately 30,000 consumers require emergency department treatment, and 150 Americans die each year because of allergic reactions to food. “The eight major food allergens account for 90% of all documented food allergic reactions, and some reactions may be severe or life threatening,” said Robert E. Brackett, Ph.D., director of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. The statute, however, does not require manufacturers or retailers to relabel or remove products that don't have the labeling because they were labeled before the effective date. For that reason, there will be a period of time where consumers will see packaged food on store shelves and in their homes without the revised allergen labeling, the FDA cautioned.

Rural Access to Part B Drugs

Access problems may prevent rural providers from participating in the new Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Joan Sokolovsky, a senior analyst with the Medicare Payment Advisory Commission (MedPAC), said at a commission meeting last month. Physicians who elect to participate in the program will obtain drugs from a preselected list of vendors, who in turn will take on the responsibility of billing Medicare for the drugs and collecting coinsurance or deductibles from patients. Under CAP rules, drugs must be delivered to the facility where they will be administered. Chemotherapy in rural areas, however, is delivered through satellite facilities, where “sometimes drugs cannot be mixed,” Ms. Sokolovsky said. In a recommendation, MedPAC said that the Health and Human Services department should allow an exception to these delivery rules for rural satellite offices of providers.

Better Coordination for Medicare

Most Medicare beneficiaries see multiple physicians, pointing to a need for better care coordination, MedPAC research director Karen Milgate indicated at a commission meeting last month. Seeing multiple physicians puts beneficiaries at greater risk for duplication of services, increases the potential for adverse events, and may also increase health care costs, she said. In sampling inpatient, outpatient and physician supplier file claims from 2003, with various combinations of diabetes, coronary artery disease, and congestive heart failure, “we found that on average beneficiaries see five physicians. Those in our chronic condition groups on average saw seven physicians. And then, when we looked at those with all three conditions on average they saw 13 physicians” in 1 year, she said. Analysts also looked at the percentage of a patient's care that was billed to one physician. For patients with three conditions, only 25% had half or more of their care billed by one physician, “which of course means that they're seeing multiple physicians,” she said.

P4P: Not Local Yet

Despite the national buzz over pay for performance and the interest in Congress, such initiatives have yet to catch on in many local communities, the Center for Studying Health System Change reported in a study. “While there's been plenty of buzz about pay for performance as a way to improve health care quality, the reality is that these initiatives are off to a slow start in many communities,” said HSC President Paul B. Ginsburg, Ph.D. The study was based on site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Of these communities, only two, Orange County and Boston, had significant physician pay-for-performance programs. In the other communities, where to date almost no physicians had received quality-related payments, physician attitudes ranged from skeptical to hostile, according to study results.

Retiree Drug Coverage Continues

In a survey of 300 of the nation's largest private-sector employers, almost four in five (79%) said they would accept government subsidies to continue to provide retiree drug coverage, comparable with Medicare, when the new drug benefit started this month, according to a study by the Kaiser Family Foundation and Hewitt Associates. Another 10% will provide some drug coverage to supplement the new benefit. Only 9% said they planned to stop offering drug coverage to Medicare-eligible retirees. Firms accepting the retiree drug subsidy were less certain about whether they would continue to take this approach in future years, according to survey results. Among those firms that will accept the subsidy in 2006, about four in five (82%) said they were “very” or “somewhat” likely to accept the subsidy again in 2007. Looking ahead to 2010, only half (50%) said they were likely to maintain coverage and accept the subsidy, while 22% said they were unlikely to do so, and 28% said they didn't know.

Food Allergen Labeling

All food labels now must clearly state if a product contains any ingredients with protein derived from the eight major allergenic foods. Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), manufacturers are required to identify in plain English the presence of ingredients that contain protein derived from milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans in the list of ingredients or to say “contains” followed by name of the source of the food allergen after or adjacent to the list of ingredients. It is estimated that 2% of adults and about 5% of infants and young children in the United States have food allergies. Approximately 30,000 consumers require emergency department treatment, and 150 Americans die each year because of allergic reactions to food. “The eight major food allergens account for 90% of all documented food allergic reactions, and some reactions may be severe or life threatening,” said Robert E. Brackett, Ph.D., director of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. The statute, however, does not require manufacturers or retailers to relabel or remove products that don't have the labeling because they were labeled before the effective date. For that reason, there will be a period of time where consumers will see packaged food on store shelves and in their homes without the revised allergen labeling, the FDA cautioned.

Rural Access to Part B Drugs

Access problems may prevent rural providers from participating in the new Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Joan Sokolovsky, a senior analyst with the Medicare Payment Advisory Commission (MedPAC), said at a commission meeting last month. Physicians who elect to participate in the program will obtain drugs from a preselected list of vendors, who in turn will take on the responsibility of billing Medicare for the drugs and collecting coinsurance or deductibles from patients. Under CAP rules, drugs must be delivered to the facility where they will be administered. Chemotherapy in rural areas, however, is delivered through satellite facilities, where “sometimes drugs cannot be mixed,” Ms. Sokolovsky said. In a recommendation, MedPAC said that the Health and Human Services department should allow an exception to these delivery rules for rural satellite offices of providers.

Better Coordination for Medicare

Most Medicare beneficiaries see multiple physicians, pointing to a need for better care coordination, MedPAC research director Karen Milgate indicated at a commission meeting last month. Seeing multiple physicians puts beneficiaries at greater risk for duplication of services, increases the potential for adverse events, and may also increase health care costs, she said. In sampling inpatient, outpatient and physician supplier file claims from 2003, with various combinations of diabetes, coronary artery disease, and congestive heart failure, “we found that on average beneficiaries see five physicians. Those in our chronic condition groups on average saw seven physicians. And then, when we looked at those with all three conditions on average they saw 13 physicians” in 1 year, she said. Analysts also looked at the percentage of a patient's care that was billed to one physician. For patients with three conditions, only 25% had half or more of their care billed by one physician, “which of course means that they're seeing multiple physicians,” she said.

P4P: Not Local Yet

Despite the national buzz over pay for performance and the interest in Congress, such initiatives have yet to catch on in many local communities, the Center for Studying Health System Change reported in a study. “While there's been plenty of buzz about pay for performance as a way to improve health care quality, the reality is that these initiatives are off to a slow start in many communities,” said HSC President Paul B. Ginsburg, Ph.D. The study was based on site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Of these communities, only two, Orange County and Boston, had significant physician pay-for-performance programs. In the other communities, where to date almost no physicians had received quality-related payments, physician attitudes ranged from skeptical to hostile, according to study results.

Retiree Drug Coverage Continues

In a survey of 300 of the nation's largest private-sector employers, almost four in five (79%) said they would accept government subsidies to continue to provide retiree drug coverage, comparable with Medicare, when the new drug benefit started this month, according to a study by the Kaiser Family Foundation and Hewitt Associates. Another 10% will provide some drug coverage to supplement the new benefit. Only 9% said they planned to stop offering drug coverage to Medicare-eligible retirees. Firms accepting the retiree drug subsidy were less certain about whether they would continue to take this approach in future years, according to survey results. Among those firms that will accept the subsidy in 2006, about four in five (82%) said they were “very” or “somewhat” likely to accept the subsidy again in 2007. Looking ahead to 2010, only half (50%) said they were likely to maintain coverage and accept the subsidy, while 22% said they were unlikely to do so, and 28% said they didn't know.

Food Allergen Labeling

All food labels now must clearly state if a product contains any ingredients with protein derived from the eight major allergenic foods. Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), manufacturers are required to identify in plain English the presence of ingredients that contain protein derived from milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans in the list of ingredients or to say “contains” followed by name of the source of the food allergen after or adjacent to the list of ingredients. It is estimated that 2% of adults and about 5% of infants and young children in the United States have food allergies. Approximately 30,000 consumers require emergency department treatment, and 150 Americans die each year because of allergic reactions to food. “The eight major food allergens account for 90% of all documented food allergic reactions, and some reactions may be severe or life threatening,” said Robert E. Brackett, Ph.D., director of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. The statute, however, does not require manufacturers or retailers to relabel or remove products that don't have the labeling because they were labeled before the effective date. For that reason, there will be a period of time where consumers will see packaged food on store shelves and in their homes without the revised allergen labeling, the FDA cautioned.

Rural Access to Part B Drugs

Access problems may prevent rural providers from participating in the new Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Joan Sokolovsky, a senior analyst with the Medicare Payment Advisory Commission (MedPAC), said at a commission meeting last month. Physicians who elect to participate in the program will obtain drugs from a preselected list of vendors, who in turn will take on the responsibility of billing Medicare for the drugs and collecting coinsurance or deductibles from patients. Under CAP rules, drugs must be delivered to the facility where they will be administered. Chemotherapy in rural areas, however, is delivered through satellite facilities, where “sometimes drugs cannot be mixed,” Ms. Sokolovsky said. In a recommendation, MedPAC said that the Health and Human Services department should allow an exception to these delivery rules for rural satellite offices of providers.

Better Coordination for Medicare

Most Medicare beneficiaries see multiple physicians, pointing to a need for better care coordination, MedPAC research director Karen Milgate indicated at a commission meeting last month. Seeing multiple physicians puts beneficiaries at greater risk for duplication of services, increases the potential for adverse events, and may also increase health care costs, she said. In sampling inpatient, outpatient and physician supplier file claims from 2003, with various combinations of diabetes, coronary artery disease, and congestive heart failure, “we found that on average beneficiaries see five physicians. Those in our chronic condition groups on average saw seven physicians. And then, when we looked at those with all three conditions on average they saw 13 physicians” in 1 year, she said. Analysts also looked at the percentage of a patient's care that was billed to one physician. For patients with three conditions, only 25% had half or more of their care billed by one physician, “which of course means that they're seeing multiple physicians,” she said.

P4P: Not Local Yet

Despite the national buzz over pay for performance and the interest in Congress, such initiatives have yet to catch on in many local communities, the Center for Studying Health System Change reported in a study. “While there's been plenty of buzz about pay for performance as a way to improve health care quality, the reality is that these initiatives are off to a slow start in many communities,” said HSC President Paul B. Ginsburg, Ph.D. The study was based on site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Of these communities, only two, Orange County and Boston, had significant physician pay-for-performance programs. In the other communities, where to date almost no physicians had received quality-related payments, physician attitudes ranged from skeptical to hostile, according to study results.

Retiree Drug Coverage Continues

In a survey of 300 of the nation's largest private-sector employers, almost four in five (79%) said they would accept government subsidies to continue to provide retiree drug coverage, comparable with Medicare, when the new drug benefit started this month, according to a study by the Kaiser Family Foundation and Hewitt Associates. Another 10% will provide some drug coverage to supplement the new benefit. Only 9% said they planned to stop offering drug coverage to Medicare-eligible retirees. Firms accepting the retiree drug subsidy were less certain about whether they would continue to take this approach in future years, according to survey results. Among those firms that will accept the subsidy in 2006, about four in five (82%) said they were “very” or “somewhat” likely to accept the subsidy again in 2007. Looking ahead to 2010, only half (50%) said they were likely to maintain coverage and accept the subsidy, while 22% said they were unlikely to do so, and 28% said they didn't know.

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G codes, CMS spokesman Peter Ashkenaz told this newspaper. “This will provide clinicians with the flexibility of utilizing either G codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program.”

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMs' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. “I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures.”

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer program, “PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded.”

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G codes, CMS spokesman Peter Ashkenaz told this newspaper. “This will provide clinicians with the flexibility of utilizing either G codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program.”

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMs' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. “I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures.”

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer program, “PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded.”

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G codes, CMS spokesman Peter Ashkenaz told this newspaper. “This will provide clinicians with the flexibility of utilizing either G codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program.”

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMs' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. “I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures.”

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer program, “PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded.”

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

WASHINGTON — Delegates to the 2005 White House Conference on Aging made it clear that they weren't happy with Medicare's new prescription drug benefit.

Challenging administration claims that the benefit's tools were accessible and easy to use, delegates recommended that Part D be simplified to create one prescription drug program for beneficiaries.

The Medicare drug benefit was one of 50 resolutions chosen as the “top” issues on aging by the 1,200 delegates at the meeting. Delegates were then charged with drafting implementation strategies suggesting how these resolutions might be put into action.

Nearly half of the resolutions addressed health care issues, including Medicare and Medicaid, long-term care, and training health care personnel.

The new drug benefit is “clearly in line” with the principles of the White House Conference on Aging to promote the dignity, health, and economic security for current and future generations, Mike Leavitt, secretary of the Department of Health and Human Services, said in his address to the delegates.

“The benefit will be of immediate help to older Americans now,” plus the next group of rapidly expanding aging Americans, the baby boomers, said Mr. Leavitt, who said he helped his own parents enroll in the drug benefit.

“By having the medicines they need, seniors will have the ability to live longer lives. They will save money, they will stay healthy, and they will have peace of mind that their savings will never be eroded because of prescription drugs,” he said.

His remarks were a hard sell for the delegates, which included governors, members of Congress, and representatives from the National Congress of American Indians, national organizations, academia, business, and industry.

The main source of frustration has been the complexity of the plan, said Ellen Camerieri, a delegate from the Bronx, N.Y., and executive director of Riverdale Senior Services Inc. “Secretary Leavitt talked about how easy it is to sign up … and to get your family together to do it. But what if [you're an aging patient] and you don't have a family?”

In her own community, she said, there's a sense of “confusion and paralysis” over the drug benefit.

Opting into a new drug program under the benefit can be daunting, especially if a beneficiary has a Medigap policy that's not a union or government pension, “but a policy to help them bridge the gap between what Medicare covers and what the actual costs are. You have a vast number of seniors who have had a relationship with a policy, and now must decide whether to continue in the new version of that policy under Part D, or go to the [numerous] other odd policies [offered] within their state.”

Dr. Mark McClellan, CMS administrator, assured delegates that the agency is taking steps to ensure that there is not any lapse in drug coverage.

“For example, we have worked closely with states over the past year to obtain very high match rates between their enrollment information and Part D enrollment—match rates well over 99%,” Dr. McClellan said.

The agency also has developed a process for a “point of sale” solution, if the beneficiary somehow has not been automatically enrolled in Part D. In addition, multiple efforts are taking place to provide counseling and assistance to beneficiaries, he said.

Seniors can ask, before they sign up for the plan, whether all of the drugs they are taking now are covered, and the agency has tools so that patients can find the lowest cost for a particular drug, Dr. McClellan said. Yet his praise of the new 800-MEDICARE customer service line evoked jeers from some delegates.

“He claims that every call was answered right away,” said Steve Kofahl, a delegate from Seattle. But when one of Mr. Kofahl's employees tried to call the number to get information, that person “could not get through.”

The problem is a patient has to be able to predict the future to know which plan he or she should sign up for, Ms. Camerieri said. Certain plans under the new benefit cover certain drugs and not others “and you might not be on a medication you'll be needing in 6 months” when you sign up, she said. There's a limited ability to change your plan without some penalty, she said.

Many in the health care field would like to think that Part D is for the people, Ms. Camerieri said. “But the underlying suspicion is that it was drafted to benefit the pharmaceutical and insurance companies who are the people putting together these plans,” she said.

“We want Medicare—not the private insurance companies—to negotiate drug prices,” agreed Marilyn Askin, a delegate from West Orange, N.J.

But Mary Watts, a delegate from Washington, questioned whether it is useful to even debate the issue. The delegates “are trying to fix something that was done 2 years ago,” she said, referring to the Medicare Modernization Act of 2003.

Frustration toward the drug benefit was fairly reflective of the meeting's general tone. At one point, several delegates disrupted meeting proceedings to issue a petition to reinstate the “10% rule,” which allows for discussion of resolutions not approved by the conference if 10% of the delegates agree on the merits of a proposed resolution.

Dorcas Hardy, chair of the conference's policy committee, said the delegates had ample time to review the resolutions before the meeting. As for the 10% rule, applicable to previous White House Conference on Aging meetings, “this is a different meeting,” she said, adding that the conference organizers had the right to choose a new format.

Some delegates thought that the time taken up by speeches from administration officials and industry representatives could have been used toward the implementation sessions.

In particular, the delegates didn't get a chance to engage in dialogue with Secretary Leavitt or Dr. McClellan, Ms. Camerieri said. “The conference didn't offer much involvement except voting on a preselected list of items. This seems to be the opposite of what the White House Conference is supposed to be about—respect for your elders.”

Others felt slighted that President Bush didn't make an appearance at this White House-sponsored event. Pedro Rodriguez, a delegate from Philadelphia, said, “We wanted to create a momentum, a platform for policy, but people were prevented from coming up with alternative strategies. We were not allowed to go outside of the box.”

To perhaps put some muscle behind these implementation plans, delegates drew up language insisting that the White House recognize the work that comes out of the conference.

In the meantime, the delegates agreed to follow through on their own grassroots efforts and convene meetings to disseminate the recommendations.

WASHINGTON — Delegates to the 2005 White House Conference on Aging made it clear that they weren't happy with Medicare's new prescription drug benefit.

Challenging administration claims that the benefit's tools were accessible and easy to use, delegates recommended that Part D be simplified to create one prescription drug program for beneficiaries.

The Medicare drug benefit was one of 50 resolutions chosen as the “top” issues on aging by the 1,200 delegates at the meeting. Delegates were then charged with drafting implementation strategies suggesting how these resolutions might be put into action.

Nearly half of the resolutions addressed health care issues, including Medicare and Medicaid, long-term care, and training health care personnel.

The new drug benefit is “clearly in line” with the principles of the White House Conference on Aging to promote the dignity, health, and economic security for current and future generations, Mike Leavitt, secretary of the Department of Health and Human Services, said in his address to the delegates.

“The benefit will be of immediate help to older Americans now,” plus the next group of rapidly expanding aging Americans, the baby boomers, said Mr. Leavitt, who said he helped his own parents enroll in the drug benefit.

“By having the medicines they need, seniors will have the ability to live longer lives. They will save money, they will stay healthy, and they will have peace of mind that their savings will never be eroded because of prescription drugs,” he said.

His remarks were a hard sell for the delegates, which included governors, members of Congress, and representatives from the National Congress of American Indians, national organizations, academia, business, and industry.

The main source of frustration has been the complexity of the plan, said Ellen Camerieri, a delegate from the Bronx, N.Y., and executive director of Riverdale Senior Services Inc. “Secretary Leavitt talked about how easy it is to sign up … and to get your family together to do it. But what if [you're an aging patient] and you don't have a family?”

In her own community, she said, there's a sense of “confusion and paralysis” over the drug benefit.

Opting into a new drug program under the benefit can be daunting, especially if a beneficiary has a Medigap policy that's not a union or government pension, “but a policy to help them bridge the gap between what Medicare covers and what the actual costs are. You have a vast number of seniors who have had a relationship with a policy, and now must decide whether to continue in the new version of that policy under Part D, or go to the [numerous] other odd policies [offered] within their state.”

Dr. Mark McClellan, CMS administrator, assured delegates that the agency is taking steps to ensure that there is not any lapse in drug coverage.

“For example, we have worked closely with states over the past year to obtain very high match rates between their enrollment information and Part D enrollment—match rates well over 99%,” Dr. McClellan said.

The agency also has developed a process for a “point of sale” solution, if the beneficiary somehow has not been automatically enrolled in Part D. In addition, multiple efforts are taking place to provide counseling and assistance to beneficiaries, he said.

Seniors can ask, before they sign up for the plan, whether all of the drugs they are taking now are covered, and the agency has tools so that patients can find the lowest cost for a particular drug, Dr. McClellan said. Yet his praise of the new 800-MEDICARE customer service line evoked jeers from some delegates.

“He claims that every call was answered right away,” said Steve Kofahl, a delegate from Seattle. But when one of Mr. Kofahl's employees tried to call the number to get information, that person “could not get through.”

The problem is a patient has to be able to predict the future to know which plan he or she should sign up for, Ms. Camerieri said. Certain plans under the new benefit cover certain drugs and not others “and you might not be on a medication you'll be needing in 6 months” when you sign up, she said. There's a limited ability to change your plan without some penalty, she said.

Many in the health care field would like to think that Part D is for the people, Ms. Camerieri said. “But the underlying suspicion is that it was drafted to benefit the pharmaceutical and insurance companies who are the people putting together these plans,” she said.

“We want Medicare—not the private insurance companies—to negotiate drug prices,” agreed Marilyn Askin, a delegate from West Orange, N.J.

But Mary Watts, a delegate from Washington, questioned whether it is useful to even debate the issue. The delegates “are trying to fix something that was done 2 years ago,” she said, referring to the Medicare Modernization Act of 2003.

Frustration toward the drug benefit was fairly reflective of the meeting's general tone. At one point, several delegates disrupted meeting proceedings to issue a petition to reinstate the “10% rule,” which allows for discussion of resolutions not approved by the conference if 10% of the delegates agree on the merits of a proposed resolution.

Dorcas Hardy, chair of the conference's policy committee, said the delegates had ample time to review the resolutions before the meeting. As for the 10% rule, applicable to previous White House Conference on Aging meetings, “this is a different meeting,” she said, adding that the conference organizers had the right to choose a new format.

Some delegates thought that the time taken up by speeches from administration officials and industry representatives could have been used toward the implementation sessions.

In particular, the delegates didn't get a chance to engage in dialogue with Secretary Leavitt or Dr. McClellan, Ms. Camerieri said. “The conference didn't offer much involvement except voting on a preselected list of items. This seems to be the opposite of what the White House Conference is supposed to be about—respect for your elders.”

Others felt slighted that President Bush didn't make an appearance at this White House-sponsored event. Pedro Rodriguez, a delegate from Philadelphia, said, “We wanted to create a momentum, a platform for policy, but people were prevented from coming up with alternative strategies. We were not allowed to go outside of the box.”

To perhaps put some muscle behind these implementation plans, delegates drew up language insisting that the White House recognize the work that comes out of the conference.

In the meantime, the delegates agreed to follow through on their own grassroots efforts and convene meetings to disseminate the recommendations.

WASHINGTON — Delegates to the 2005 White House Conference on Aging made it clear that they weren't happy with Medicare's new prescription drug benefit.

Challenging administration claims that the benefit's tools were accessible and easy to use, delegates recommended that Part D be simplified to create one prescription drug program for beneficiaries.

The Medicare drug benefit was one of 50 resolutions chosen as the “top” issues on aging by the 1,200 delegates at the meeting. Delegates were then charged with drafting implementation strategies suggesting how these resolutions might be put into action.

Nearly half of the resolutions addressed health care issues, including Medicare and Medicaid, long-term care, and training health care personnel.

The new drug benefit is “clearly in line” with the principles of the White House Conference on Aging to promote the dignity, health, and economic security for current and future generations, Mike Leavitt, secretary of the Department of Health and Human Services, said in his address to the delegates.

“The benefit will be of immediate help to older Americans now,” plus the next group of rapidly expanding aging Americans, the baby boomers, said Mr. Leavitt, who said he helped his own parents enroll in the drug benefit.

“By having the medicines they need, seniors will have the ability to live longer lives. They will save money, they will stay healthy, and they will have peace of mind that their savings will never be eroded because of prescription drugs,” he said.

His remarks were a hard sell for the delegates, which included governors, members of Congress, and representatives from the National Congress of American Indians, national organizations, academia, business, and industry.

The main source of frustration has been the complexity of the plan, said Ellen Camerieri, a delegate from the Bronx, N.Y., and executive director of Riverdale Senior Services Inc. “Secretary Leavitt talked about how easy it is to sign up … and to get your family together to do it. But what if [you're an aging patient] and you don't have a family?”

In her own community, she said, there's a sense of “confusion and paralysis” over the drug benefit.

Opting into a new drug program under the benefit can be daunting, especially if a beneficiary has a Medigap policy that's not a union or government pension, “but a policy to help them bridge the gap between what Medicare covers and what the actual costs are. You have a vast number of seniors who have had a relationship with a policy, and now must decide whether to continue in the new version of that policy under Part D, or go to the [numerous] other odd policies [offered] within their state.”

Dr. Mark McClellan, CMS administrator, assured delegates that the agency is taking steps to ensure that there is not any lapse in drug coverage.

“For example, we have worked closely with states over the past year to obtain very high match rates between their enrollment information and Part D enrollment—match rates well over 99%,” Dr. McClellan said.

The agency also has developed a process for a “point of sale” solution, if the beneficiary somehow has not been automatically enrolled in Part D. In addition, multiple efforts are taking place to provide counseling and assistance to beneficiaries, he said.

Seniors can ask, before they sign up for the plan, whether all of the drugs they are taking now are covered, and the agency has tools so that patients can find the lowest cost for a particular drug, Dr. McClellan said. Yet his praise of the new 800-MEDICARE customer service line evoked jeers from some delegates.

“He claims that every call was answered right away,” said Steve Kofahl, a delegate from Seattle. But when one of Mr. Kofahl's employees tried to call the number to get information, that person “could not get through.”

The problem is a patient has to be able to predict the future to know which plan he or she should sign up for, Ms. Camerieri said. Certain plans under the new benefit cover certain drugs and not others “and you might not be on a medication you'll be needing in 6 months” when you sign up, she said. There's a limited ability to change your plan without some penalty, she said.

Many in the health care field would like to think that Part D is for the people, Ms. Camerieri said. “But the underlying suspicion is that it was drafted to benefit the pharmaceutical and insurance companies who are the people putting together these plans,” she said.

“We want Medicare—not the private insurance companies—to negotiate drug prices,” agreed Marilyn Askin, a delegate from West Orange, N.J.

But Mary Watts, a delegate from Washington, questioned whether it is useful to even debate the issue. The delegates “are trying to fix something that was done 2 years ago,” she said, referring to the Medicare Modernization Act of 2003.

Frustration toward the drug benefit was fairly reflective of the meeting's general tone. At one point, several delegates disrupted meeting proceedings to issue a petition to reinstate the “10% rule,” which allows for discussion of resolutions not approved by the conference if 10% of the delegates agree on the merits of a proposed resolution.

Dorcas Hardy, chair of the conference's policy committee, said the delegates had ample time to review the resolutions before the meeting. As for the 10% rule, applicable to previous White House Conference on Aging meetings, “this is a different meeting,” she said, adding that the conference organizers had the right to choose a new format.

Some delegates thought that the time taken up by speeches from administration officials and industry representatives could have been used toward the implementation sessions.

In particular, the delegates didn't get a chance to engage in dialogue with Secretary Leavitt or Dr. McClellan, Ms. Camerieri said. “The conference didn't offer much involvement except voting on a preselected list of items. This seems to be the opposite of what the White House Conference is supposed to be about—respect for your elders.”

Others felt slighted that President Bush didn't make an appearance at this White House-sponsored event. Pedro Rodriguez, a delegate from Philadelphia, said, “We wanted to create a momentum, a platform for policy, but people were prevented from coming up with alternative strategies. We were not allowed to go outside of the box.”

To perhaps put some muscle behind these implementation plans, delegates drew up language insisting that the White House recognize the work that comes out of the conference.

In the meantime, the delegates agreed to follow through on their own grassroots efforts and convene meetings to disseminate the recommendations.

Food Allergen Labeling

All food labels now must clearly state if a product contains any ingredients with protein derived from the eight major allergenic foods. Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), manufacturers are required to identify in plain English the presence of ingredients that contain protein derived from milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans in the list of ingredients or to say “contains” followed by name of the source of the food allergen after or adjacent to the list of ingredients. It is estimated that 2% of adults and about 5% of infants and young children in the United States have food allergies. Approximately 30,000 consumers require emergency department treatment, and 150 Americans die each year because of allergic reactions to food. “The eight major food allergens account for 90% of all documented food allergic reactions, and some reactions may be severe or life threatening,” said Robert E. Brackett, Ph.D., director of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. The statute, however, does not require manufacturers or retailers to relabel or remove products that don't have the labeling because they were labeled before the effective date. For that reason, there will be a period of time where consumers will see packaged food on store shelves and in their homes without the revised allergen labeling, the FDA cautioned.

Rural Access to Part B Drugs

Access problems may prevent rural providers from participating in the new Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Joan Sokolovsky, a senior analyst with the Medicare Payment Advisory Commission (MedPAC), said at a commission meeting last month. Physicians who elect to participate in the program will obtain drugs from a preselected list of vendors, who in turn will take on the responsibility of billing Medicare for the drugs and collecting coinsurance or deductibles from patients. Under CAP rules, drugs must be delivered to the facility where they will be administered. Chemotherapy in rural areas, however, is delivered through satellite facilities, where “sometimes drugs cannot be mixed,” Ms. Sokolovsky said. In a recommendation, MedPAC said that the Health and Human Services department should allow an exception to these delivery rules for rural satellite offices of providers.

Better Coordination for Medicare

Most Medicare beneficiaries see multiple physicians, pointing to a need for better care coordination, MedPAC research director Karen Milgate indicated at a commission meeting last month. Seeing multiple physicians puts beneficiaries at greater risk for duplication of services, increases the potential for adverse events, and may also increase health care costs, she said. In sampling inpatient, outpatient, and physician supplier file claims from 2003, with various combinations of diabetes, coronary artery disease, and congestive heart failure, “we found that on average beneficiaries see five physicians. Those in our chronic condition groups on average saw seven physicians. And then, when we looked at those with all three conditions on average they saw 13 physicians” in 1 year, she said. Analysts also looked at the percentage of a patient's care that was billed to one physician. For patients with three conditions, only 25% had half or more of their care billed by one physician, “which of course means that they're seeing multiple physicians,” she said.

P4P: Not Local Yet

Despite the national buzz over pay for performance and the interest in Congress, such initiatives have yet to catch on in many local communities, the Center for Studying Health System Change reported in a study. “While there's been plenty of buzz about pay for performance as a way to improve health care quality, the reality is that these initiatives are off to a slow start in many communities,” said HSC President Paul B. Ginsburg, Ph.D. The study was based on site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Of these communities, only two, Orange County and Boston, had significant physician pay-for-performance programs. In the other communities, where to date almost no physicians had received quality-related payments, physician attitudes ranged from skeptical to hostile, according to study results.

Retiree Drug Coverage Continues

In a survey of 300 of the nation's largest private-sector employers, almost four in five (79%) said they would accept government subsidies to continue to provide retiree drug coverage, comparable with Medicare, when the new drug benefit started this month, according to a study by the Kaiser Family Foundation and Hewitt Associates. Another 10% will provide some drug coverage to supplement the new benefit. Only 9% said they planned to stop offering drug coverage to Medicare-eligible retirees. Firms accepting the retiree drug subsidy were less certain about whether they would continue to take this approach in future years, according to survey results. Among those firms that will accept the subsidy in 2006, about four in five (82%) said they were “very” or “somewhat” likely to accept the subsidy again in 2007. Looking ahead to 2010, only half (50%) said they were likely to maintain coverage and accept the subsidy, while 22% said they were unlikely to do so, and 28% said they didn't know.

Food Allergen Labeling

All food labels now must clearly state if a product contains any ingredients with protein derived from the eight major allergenic foods. Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), manufacturers are required to identify in plain English the presence of ingredients that contain protein derived from milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans in the list of ingredients or to say “contains” followed by name of the source of the food allergen after or adjacent to the list of ingredients. It is estimated that 2% of adults and about 5% of infants and young children in the United States have food allergies. Approximately 30,000 consumers require emergency department treatment, and 150 Americans die each year because of allergic reactions to food. “The eight major food allergens account for 90% of all documented food allergic reactions, and some reactions may be severe or life threatening,” said Robert E. Brackett, Ph.D., director of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. The statute, however, does not require manufacturers or retailers to relabel or remove products that don't have the labeling because they were labeled before the effective date. For that reason, there will be a period of time where consumers will see packaged food on store shelves and in their homes without the revised allergen labeling, the FDA cautioned.

Rural Access to Part B Drugs

Access problems may prevent rural providers from participating in the new Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Joan Sokolovsky, a senior analyst with the Medicare Payment Advisory Commission (MedPAC), said at a commission meeting last month. Physicians who elect to participate in the program will obtain drugs from a preselected list of vendors, who in turn will take on the responsibility of billing Medicare for the drugs and collecting coinsurance or deductibles from patients. Under CAP rules, drugs must be delivered to the facility where they will be administered. Chemotherapy in rural areas, however, is delivered through satellite facilities, where “sometimes drugs cannot be mixed,” Ms. Sokolovsky said. In a recommendation, MedPAC said that the Health and Human Services department should allow an exception to these delivery rules for rural satellite offices of providers.

Better Coordination for Medicare

Most Medicare beneficiaries see multiple physicians, pointing to a need for better care coordination, MedPAC research director Karen Milgate indicated at a commission meeting last month. Seeing multiple physicians puts beneficiaries at greater risk for duplication of services, increases the potential for adverse events, and may also increase health care costs, she said. In sampling inpatient, outpatient, and physician supplier file claims from 2003, with various combinations of diabetes, coronary artery disease, and congestive heart failure, “we found that on average beneficiaries see five physicians. Those in our chronic condition groups on average saw seven physicians. And then, when we looked at those with all three conditions on average they saw 13 physicians” in 1 year, she said. Analysts also looked at the percentage of a patient's care that was billed to one physician. For patients with three conditions, only 25% had half or more of their care billed by one physician, “which of course means that they're seeing multiple physicians,” she said.

P4P: Not Local Yet

Despite the national buzz over pay for performance and the interest in Congress, such initiatives have yet to catch on in many local communities, the Center for Studying Health System Change reported in a study. “While there's been plenty of buzz about pay for performance as a way to improve health care quality, the reality is that these initiatives are off to a slow start in many communities,” said HSC President Paul B. Ginsburg, Ph.D. The study was based on site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Of these communities, only two, Orange County and Boston, had significant physician pay-for-performance programs. In the other communities, where to date almost no physicians had received quality-related payments, physician attitudes ranged from skeptical to hostile, according to study results.

Retiree Drug Coverage Continues

In a survey of 300 of the nation's largest private-sector employers, almost four in five (79%) said they would accept government subsidies to continue to provide retiree drug coverage, comparable with Medicare, when the new drug benefit started this month, according to a study by the Kaiser Family Foundation and Hewitt Associates. Another 10% will provide some drug coverage to supplement the new benefit. Only 9% said they planned to stop offering drug coverage to Medicare-eligible retirees. Firms accepting the retiree drug subsidy were less certain about whether they would continue to take this approach in future years, according to survey results. Among those firms that will accept the subsidy in 2006, about four in five (82%) said they were “very” or “somewhat” likely to accept the subsidy again in 2007. Looking ahead to 2010, only half (50%) said they were likely to maintain coverage and accept the subsidy, while 22% said they were unlikely to do so, and 28% said they didn't know.

Food Allergen Labeling

All food labels now must clearly state if a product contains any ingredients with protein derived from the eight major allergenic foods. Under the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA), manufacturers are required to identify in plain English the presence of ingredients that contain protein derived from milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, or soybeans in the list of ingredients or to say “contains” followed by name of the source of the food allergen after or adjacent to the list of ingredients. It is estimated that 2% of adults and about 5% of infants and young children in the United States have food allergies. Approximately 30,000 consumers require emergency department treatment, and 150 Americans die each year because of allergic reactions to food. “The eight major food allergens account for 90% of all documented food allergic reactions, and some reactions may be severe or life threatening,” said Robert E. Brackett, Ph.D., director of the Food and Drug Administration's Center for Food Safety and Applied Nutrition. The statute, however, does not require manufacturers or retailers to relabel or remove products that don't have the labeling because they were labeled before the effective date. For that reason, there will be a period of time where consumers will see packaged food on store shelves and in their homes without the revised allergen labeling, the FDA cautioned.

Rural Access to Part B Drugs

Access problems may prevent rural providers from participating in the new Competitive Acquisition Program (CAP) for Part B drugs and biologicals, Joan Sokolovsky, a senior analyst with the Medicare Payment Advisory Commission (MedPAC), said at a commission meeting last month. Physicians who elect to participate in the program will obtain drugs from a preselected list of vendors, who in turn will take on the responsibility of billing Medicare for the drugs and collecting coinsurance or deductibles from patients. Under CAP rules, drugs must be delivered to the facility where they will be administered. Chemotherapy in rural areas, however, is delivered through satellite facilities, where “sometimes drugs cannot be mixed,” Ms. Sokolovsky said. In a recommendation, MedPAC said that the Health and Human Services department should allow an exception to these delivery rules for rural satellite offices of providers.

Better Coordination for Medicare

Most Medicare beneficiaries see multiple physicians, pointing to a need for better care coordination, MedPAC research director Karen Milgate indicated at a commission meeting last month. Seeing multiple physicians puts beneficiaries at greater risk for duplication of services, increases the potential for adverse events, and may also increase health care costs, she said. In sampling inpatient, outpatient, and physician supplier file claims from 2003, with various combinations of diabetes, coronary artery disease, and congestive heart failure, “we found that on average beneficiaries see five physicians. Those in our chronic condition groups on average saw seven physicians. And then, when we looked at those with all three conditions on average they saw 13 physicians” in 1 year, she said. Analysts also looked at the percentage of a patient's care that was billed to one physician. For patients with three conditions, only 25% had half or more of their care billed by one physician, “which of course means that they're seeing multiple physicians,” she said.

P4P: Not Local Yet

Despite the national buzz over pay for performance and the interest in Congress, such initiatives have yet to catch on in many local communities, the Center for Studying Health System Change reported in a study. “While there's been plenty of buzz about pay for performance as a way to improve health care quality, the reality is that these initiatives are off to a slow start in many communities,” said HSC President Paul B. Ginsburg, Ph.D. The study was based on site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. Of these communities, only two, Orange County and Boston, had significant physician pay-for-performance programs. In the other communities, where to date almost no physicians had received quality-related payments, physician attitudes ranged from skeptical to hostile, according to study results.

Retiree Drug Coverage Continues

In a survey of 300 of the nation's largest private-sector employers, almost four in five (79%) said they would accept government subsidies to continue to provide retiree drug coverage, comparable with Medicare, when the new drug benefit started this month, according to a study by the Kaiser Family Foundation and Hewitt Associates. Another 10% will provide some drug coverage to supplement the new benefit. Only 9% said they planned to stop offering drug coverage to Medicare-eligible retirees. Firms accepting the retiree drug subsidy were less certain about whether they would continue to take this approach in future years, according to survey results. Among those firms that will accept the subsidy in 2006, about four in five (82%) said they were “very” or “somewhat” likely to accept the subsidy again in 2007. Looking ahead to 2010, only half (50%) said they were likely to maintain coverage and accept the subsidy, while 22% said they were unlikely to do so, and 28% said they didn't know.

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G codes, CMS spokesman Peter Ashkenaz told this newspaper. “This will provide clinicians with the flexibility of utilizing either G codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program.”

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMs' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. “I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures.”

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer program, “PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded.”

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G codes, CMS spokesman Peter Ashkenaz told this newspaper. “This will provide clinicians with the flexibility of utilizing either G codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program.”

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMs' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. “I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures.”

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer program, “PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded.”

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. CMS also is working to revise the program's reporting system to provide more options for physicians.

Primary care groups opposed CMs' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G codes—a system most physicians do not use. The agency is working with the American Medical Association to add the option to use CPT II codes as well as G codes, CMS spokesman Peter Ashkenaz told this newspaper. “This will provide clinicians with the flexibility of utilizing either G codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients.

The 20 measures removed from the original set won't necessarily be thrown out. In a fact sheet, CMS said it intended to pursue further development of those and other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, called the revisions “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program.”

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMs' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

Council member Dr. Laura Powers, a Knoxville neurologist, said outcomes measures wouldn't work well in a practice such as hers, where many patients have terminal illnesses. “I take care of patients who are going to die no matter what you do, but I have to make sure their quality of life is better for however long they have to live. That's why we need to have process measures.”

The council passed a resolution noting that because the voluntary reporting program will require additional staff, training on use of G codes, and reconfiguration of computer program, “PPAC advises that any effort at implementing quality measures and reporting must come after physician payment reform and a reduction in current regulatory and administrative demands. Otherwise, efforts to improve care will be impeded.”

The council also passed a resolution asking that CMS seek comments from the appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Physicians face at least a month's worth of Medicare payment reductions if Congress doesn't reconcile on the provisions of a spending bill by the end of January.

The 2006 Medicare physician payment cut of 4.4%, which began Jan. 1, is the first of 6 years of planned cuts totaling 26%. During this same time, practice costs will increase at least 15%, according to statistics from the American Medical Association.

A measure to stop the 4.4% cut went unaddressed when procedural issues in the Senate and House prevented final action on the 2005 budget reconciliation package.

Although both houses approved the pay freeze, the Senate accepted a number of procedural moves that altered the conference report, and the bill had to go back to the House for final approval.

“Instead of electing to let [House] leaders hash it out and then let the bill go through, Rep. Nancy Pelosi [D-Calif.] demanded a roll call vote—which cannot be taken into consideration until Jan. 31, when Congress returns,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

With no legislation passed by both houses and signed by the president, the Centers for Medicare and Medicaid Services is bound by law to put the cuts into place, Dr. Fields added. The hope is that Congress will wrap up its unfinished work on the omnibus appropriations bill by the end of January. Once the bill is signed, CMS would be required by law not to impose the cut.

“Patients and physicians will not understand why technicalities and politics are delaying congressional action to halt devastating Medicare cuts,” said Dr. C. Anderson Hedberg, president of the American College of Physicians. “We call on Congress and CMS to do whatever is necessary to stop the cuts. Both the House and Senate have agreed the cuts should be halted, and we appreciate their good intentions. Yet we are faced with uncertainty and confusion, instead of the decisive action in Washington that our patients require.”

Physicians cannot continue on the current path of being paid less than the cost of providing care, Dr. J. Edward Hill, president of the American Medical Association, said in a statement. “It is our hope that Congress will immediately take up this issue … to halt the payment cuts and retroactively adjust payments.” In the meantime, the AMA will continue to advocate for a fair physician payment formula based on practice costs, “as well as continue to advocate for sound quality improvement initiatives.”

The sustainable growth rate (SGR) is what's driving the cut in Medicare physician pay. It's a component in the Medicare payment formula that determines the conversion factor update each year. Errors made to the formula in 1998 and 1999 led to a 5.4% decrease in physician payments in 2002—decreases that will continue unless the payment formula is corrected. Short-term laws since that time have provided small increases in pay.

A national AMA survey found that 38% of physicians would be forced to limit the number of new Medicare patients they accept into their practice when the cut begins. Of those physicians who will continue to treat Medicare patients, 61% told the AMA they planned to defer purchase of new medical equipment, and 54% said they would defer purchase of information technology.

A freeze represents a slight loss to physicians because of inflation, “but certainly, it's better than a 4.4% cut,” Dr. Fields said. Congress should also work to restore money that would be lost by having a month of reductions.

There's always the slight possibility that they won't act at all, he said. However, he was confident that Congress would solve the SGR problem in the coming year, “so physicians won't have to face future cuts.”

Physicians face at least a month's worth of Medicare payment reductions if Congress doesn't reconcile on the provisions of a spending bill by the end of January.

The 2006 Medicare physician payment cut of 4.4%, which began Jan. 1, is the first of 6 years of planned cuts totaling 26%. During this same time, practice costs will increase at least 15%, according to statistics from the American Medical Association.

A measure to stop the 4.4% cut went unaddressed when procedural issues in the Senate and House prevented final action on the 2005 budget reconciliation package.

Although both houses approved the pay freeze, the Senate accepted a number of procedural moves that altered the conference report, and the bill had to go back to the House for final approval.

“Instead of electing to let [House] leaders hash it out and then let the bill go through, Rep. Nancy Pelosi [D-Calif.] demanded a roll call vote—which cannot be taken into consideration until Jan. 31, when Congress returns,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

With no legislation passed by both houses and signed by the president, the Centers for Medicare and Medicaid Services is bound by law to put the cuts into place, Dr. Fields added. The hope is that Congress will wrap up its unfinished work on the omnibus appropriations bill by the end of January. Once the bill is signed, CMS would be required by law not to impose the cut.

“Patients and physicians will not understand why technicalities and politics are delaying congressional action to halt devastating Medicare cuts,” said Dr. C. Anderson Hedberg, president of the American College of Physicians. “We call on Congress and CMS to do whatever is necessary to stop the cuts. Both the House and Senate have agreed the cuts should be halted, and we appreciate their good intentions. Yet we are faced with uncertainty and confusion, instead of the decisive action in Washington that our patients require.”

Physicians cannot continue on the current path of being paid less than the cost of providing care, Dr. J. Edward Hill, president of the American Medical Association, said in a statement. “It is our hope that Congress will immediately take up this issue … to halt the payment cuts and retroactively adjust payments.” In the meantime, the AMA will continue to advocate for a fair physician payment formula based on practice costs, “as well as continue to advocate for sound quality improvement initiatives.”

The sustainable growth rate (SGR) is what's driving the cut in Medicare physician pay. It's a component in the Medicare payment formula that determines the conversion factor update each year. Errors made to the formula in 1998 and 1999 led to a 5.4% decrease in physician payments in 2002—decreases that will continue unless the payment formula is corrected. Short-term laws since that time have provided small increases in pay.

A national AMA survey found that 38% of physicians would be forced to limit the number of new Medicare patients they accept into their practice when the cut begins. Of those physicians who will continue to treat Medicare patients, 61% told the AMA they planned to defer purchase of new medical equipment, and 54% said they would defer purchase of information technology.

A freeze represents a slight loss to physicians because of inflation, “but certainly, it's better than a 4.4% cut,” Dr. Fields said. Congress should also work to restore money that would be lost by having a month of reductions.

There's always the slight possibility that they won't act at all, he said. However, he was confident that Congress would solve the SGR problem in the coming year, “so physicians won't have to face future cuts.”

Physicians face at least a month's worth of Medicare payment reductions if Congress doesn't reconcile on the provisions of a spending bill by the end of January.

The 2006 Medicare physician payment cut of 4.4%, which began Jan. 1, is the first of 6 years of planned cuts totaling 26%. During this same time, practice costs will increase at least 15%, according to statistics from the American Medical Association.

A measure to stop the 4.4% cut went unaddressed when procedural issues in the Senate and House prevented final action on the 2005 budget reconciliation package.

Although both houses approved the pay freeze, the Senate accepted a number of procedural moves that altered the conference report, and the bill had to go back to the House for final approval.

“Instead of electing to let [House] leaders hash it out and then let the bill go through, Rep. Nancy Pelosi [D-Calif.] demanded a roll call vote—which cannot be taken into consideration until Jan. 31, when Congress returns,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

With no legislation passed by both houses and signed by the president, the Centers for Medicare and Medicaid Services is bound by law to put the cuts into place, Dr. Fields added. The hope is that Congress will wrap up its unfinished work on the omnibus appropriations bill by the end of January. Once the bill is signed, CMS would be required by law not to impose the cut.

“Patients and physicians will not understand why technicalities and politics are delaying congressional action to halt devastating Medicare cuts,” said Dr. C. Anderson Hedberg, president of the American College of Physicians. “We call on Congress and CMS to do whatever is necessary to stop the cuts. Both the House and Senate have agreed the cuts should be halted, and we appreciate their good intentions. Yet we are faced with uncertainty and confusion, instead of the decisive action in Washington that our patients require.”

Physicians cannot continue on the current path of being paid less than the cost of providing care, Dr. J. Edward Hill, president of the American Medical Association, said in a statement. “It is our hope that Congress will immediately take up this issue … to halt the payment cuts and retroactively adjust payments.” In the meantime, the AMA will continue to advocate for a fair physician payment formula based on practice costs, “as well as continue to advocate for sound quality improvement initiatives.”

The sustainable growth rate (SGR) is what's driving the cut in Medicare physician pay. It's a component in the Medicare payment formula that determines the conversion factor update each year. Errors made to the formula in 1998 and 1999 led to a 5.4% decrease in physician payments in 2002—decreases that will continue unless the payment formula is corrected. Short-term laws since that time have provided small increases in pay.

A national AMA survey found that 38% of physicians would be forced to limit the number of new Medicare patients they accept into their practice when the cut begins. Of those physicians who will continue to treat Medicare patients, 61% told the AMA they planned to defer purchase of new medical equipment, and 54% said they would defer purchase of information technology.

A freeze represents a slight loss to physicians because of inflation, “but certainly, it's better than a 4.4% cut,” Dr. Fields said. Congress should also work to restore money that would be lost by having a month of reductions.

There's always the slight possibility that they won't act at all, he said. However, he was confident that Congress would solve the SGR problem in the coming year, “so physicians won't have to face future cuts.”

Most practices lack the technology to participate in Medicare's new “e-prescribing” standards under the Part D drug benefit, physician groups claim.

“Surveys vary, but the percentage of practices using [e-prescribing] ranges somewhere from 5% to 18%.” The number is even lower for the typical small practice, Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs with the American College of Physicians, said in an interview. Further, most “will be unable to afford to implement this technology on their own, particularly with the projected cuts in Medicare physician payments of 4.4% in 2006 and a cumulative 26% reduction from 2006 to 2011.”

The Centers for Medicare and Medicaid Services in a final rule established the set of standards for electronic prescribing, or e-prescribing, of drugs covered by Medicare's prescription drug benefit that started Jan. 1, according to the Federal Register.

E-prescribing is optional for physicians and pharmacies under the new standards, but Medicare required drug plans participating in the new prescription benefit to support electronic prescribing.

CMS also plans to pilot test initial e-prescribing standards, which may be included in a final rule to be issued by April 2008.

For the most part, medical organizations support the agency's e-prescribing initiative.

Having standards will provide a common language for anyone using e-prescribing, Dr. Mary Frank, board chair of the American Academy of Family Physicians, said in an interview. E-prescribing would also reduce errors, increase patient safety and, when it is fully interoperable, increase quality in health care as well. But without financial support to implement this technology, e-prescribing will not be widespread.

And even a physician willing to adopt e-prescribing “is at risk of purchasing a system that might not integrate” with a future electronic health record system.

Dr. Kirschner noted that the recent release of safe harbor antikickback and Stark exception rules allowing hospitals, group practices, and Medicare Part D drug plan sponsors to provide necessary e-prescribing technology to physicians may help facilitate its use.

E-prescribing as an isolated technology, however, “just won't cut it,” Dr. Frank said. “It is only a small piece in the safety-quality continuum.” While it may eliminate issues such as bad handwriting and sound-alike medications, it doesn't necessarily address issues such as drug-drug interactions, alerts about possible problems related to existing illnesses, or abnormal lab results.

“We really have to push for a more integrated approach if we really want to improve care,” she said.

Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said PhRMA supported the development of a standardized e-prescribing system. In addition to reducing errors and the administrative costs associated with health care, the system would also promote more effective drug therapies for chronic conditions.

He agreed, however, that such a system must be designed and implemented correctly. “Keep in mind that the systems needed to convert to an e-Rx system don't even exist yet.”

Program Specifics

CMS's new standards for e-prescribing include the following technology:

▸ NCPDP SCRIPT, Version 5.0, for transactions between prescribers and dispensers for new prescriptions, refill requests and responses, prescription change requests and responses, prescription cancellation requests and responses, and related messaging and administrative transactions.

▸ ASC X12N 270/271, Version 4010 and addenda, for eligibility and benefits queries and responses between prescribers and Part D sponsors.

▸ NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1, for eligibility queries between dispensers and Part D sponsors.

Most practices lack the technology to participate in Medicare's new “e-prescribing” standards under the Part D drug benefit, physician groups claim.

“Surveys vary, but the percentage of practices using [e-prescribing] ranges somewhere from 5% to 18%.” The number is even lower for the typical small practice, Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs with the American College of Physicians, said in an interview. Further, most “will be unable to afford to implement this technology on their own, particularly with the projected cuts in Medicare physician payments of 4.4% in 2006 and a cumulative 26% reduction from 2006 to 2011.”

The Centers for Medicare and Medicaid Services in a final rule established the set of standards for electronic prescribing, or e-prescribing, of drugs covered by Medicare's prescription drug benefit that started Jan. 1, according to the Federal Register.

E-prescribing is optional for physicians and pharmacies under the new standards, but Medicare required drug plans participating in the new prescription benefit to support electronic prescribing.

CMS also plans to pilot test initial e-prescribing standards, which may be included in a final rule to be issued by April 2008.

For the most part, medical organizations support the agency's e-prescribing initiative.

Having standards will provide a common language for anyone using e-prescribing, Dr. Mary Frank, board chair of the American Academy of Family Physicians, said in an interview. E-prescribing would also reduce errors, increase patient safety and, when it is fully interoperable, increase quality in health care as well. But without financial support to implement this technology, e-prescribing will not be widespread.

And even a physician willing to adopt e-prescribing “is at risk of purchasing a system that might not integrate” with a future electronic health record system.

Dr. Kirschner noted that the recent release of safe harbor antikickback and Stark exception rules allowing hospitals, group practices, and Medicare Part D drug plan sponsors to provide necessary e-prescribing technology to physicians may help facilitate its use.

E-prescribing as an isolated technology, however, “just won't cut it,” Dr. Frank said. “It is only a small piece in the safety-quality continuum.” While it may eliminate issues such as bad handwriting and sound-alike medications, it doesn't necessarily address issues such as drug-drug interactions, alerts about possible problems related to existing illnesses, or abnormal lab results.

“We really have to push for a more integrated approach if we really want to improve care,” she said.

Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said PhRMA supported the development of a standardized e-prescribing system. In addition to reducing errors and the administrative costs associated with health care, the system would also promote more effective drug therapies for chronic conditions.

He agreed, however, that such a system must be designed and implemented correctly. “Keep in mind that the systems needed to convert to an e-Rx system don't even exist yet.”

Program Specifics

CMS's new standards for e-prescribing include the following technology:

▸ NCPDP SCRIPT, Version 5.0, for transactions between prescribers and dispensers for new prescriptions, refill requests and responses, prescription change requests and responses, prescription cancellation requests and responses, and related messaging and administrative transactions.

▸ ASC X12N 270/271, Version 4010 and addenda, for eligibility and benefits queries and responses between prescribers and Part D sponsors.

▸ NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1, for eligibility queries between dispensers and Part D sponsors.

Most practices lack the technology to participate in Medicare's new “e-prescribing” standards under the Part D drug benefit, physician groups claim.

“Surveys vary, but the percentage of practices using [e-prescribing] ranges somewhere from 5% to 18%.” The number is even lower for the typical small practice, Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs with the American College of Physicians, said in an interview. Further, most “will be unable to afford to implement this technology on their own, particularly with the projected cuts in Medicare physician payments of 4.4% in 2006 and a cumulative 26% reduction from 2006 to 2011.”

The Centers for Medicare and Medicaid Services in a final rule established the set of standards for electronic prescribing, or e-prescribing, of drugs covered by Medicare's prescription drug benefit that started Jan. 1, according to the Federal Register.

E-prescribing is optional for physicians and pharmacies under the new standards, but Medicare required drug plans participating in the new prescription benefit to support electronic prescribing.

CMS also plans to pilot test initial e-prescribing standards, which may be included in a final rule to be issued by April 2008.

For the most part, medical organizations support the agency's e-prescribing initiative.

Having standards will provide a common language for anyone using e-prescribing, Dr. Mary Frank, board chair of the American Academy of Family Physicians, said in an interview. E-prescribing would also reduce errors, increase patient safety and, when it is fully interoperable, increase quality in health care as well. But without financial support to implement this technology, e-prescribing will not be widespread.

And even a physician willing to adopt e-prescribing “is at risk of purchasing a system that might not integrate” with a future electronic health record system.

Dr. Kirschner noted that the recent release of safe harbor antikickback and Stark exception rules allowing hospitals, group practices, and Medicare Part D drug plan sponsors to provide necessary e-prescribing technology to physicians may help facilitate its use.

E-prescribing as an isolated technology, however, “just won't cut it,” Dr. Frank said. “It is only a small piece in the safety-quality continuum.” While it may eliminate issues such as bad handwriting and sound-alike medications, it doesn't necessarily address issues such as drug-drug interactions, alerts about possible problems related to existing illnesses, or abnormal lab results.

“We really have to push for a more integrated approach if we really want to improve care,” she said.

Jeff Trewhitt, a spokesperson for the Pharmaceutical Research and Manufacturers of America, said PhRMA supported the development of a standardized e-prescribing system. In addition to reducing errors and the administrative costs associated with health care, the system would also promote more effective drug therapies for chronic conditions.

He agreed, however, that such a system must be designed and implemented correctly. “Keep in mind that the systems needed to convert to an e-Rx system don't even exist yet.”

Program Specifics

CMS's new standards for e-prescribing include the following technology:

▸ NCPDP SCRIPT, Version 5.0, for transactions between prescribers and dispensers for new prescriptions, refill requests and responses, prescription change requests and responses, prescription cancellation requests and responses, and related messaging and administrative transactions.

▸ ASC X12N 270/271, Version 4010 and addenda, for eligibility and benefits queries and responses between prescribers and Part D sponsors.

▸ NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1, for eligibility queries between dispensers and Part D sponsors.

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. In addition, CMS is working to revise the program's reporting system to provide more options for physicians.

Primary care groups particularly opposed CMS' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G-codes—a system most physicians do not use. The agency now is working with the American Medical Association to add the option to use CPT II codes as well as G-codes, CMS spokesman Peter Ashkenaz said in an interview.

“This will provide clinicians with the flexibility of utilizing either G-codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients. They also include surgical measures such as preoperative β-blockers for patients with isolated coronary artery bypass grafts.

The 20 measures removed from the original set won't necessarily be thrown out, however. In a fact sheet, CMS said it intended to pursue further development of these remaining measures, as well as other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, said that he thought the revisions were “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program,” he said.

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet, “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMS' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I looked into it. I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

PPAC member Dr. Carlos Hamilton Jr., an endocrinologist in Houston, took issue with one of the measures to be reported for diabetes patients: patients with most recent hemoglobin A_1c level documented as 9% or less.

A result of 9% “is so high that you wouldn't come close to anything related to quality,” he said. But if the patient started out with an A_1c level of 12 and a physician reduced it to 9.5%, “that represents an heroic effort that should be rewarded. So the way that ought to be phrased is 'hemoglobin documented as less than or equal to 7% or 7.5%, or has been reduced by 1.5% over the last 6 months, or 12 months,” Dr. Hamilton said.

In response to why the 9% benchmark was used, Dr. Haywood commented that “there is a lot of debate currently about what is good control, so there has not been any consensus yet. So what we did was say, 'We'll look at poor control as a starting place, and to the extent that we can build toward what is a final determination toward good control, we'll revisit that particular method.'”

Dr. Hamilton disagreed, noting that physicians have held several consensus conferences and put out publications reinforcing that good control is somewhere around 7%–7.5%. “If you really want to measure quality, you need to measure quality,” he said.

Council member Dr. Anthony Senagore, a Cleveland surgeon, said CMS is taking the wrong approach entirely. “Rather than micromanage care, why not go for the 40,000-foot view?” he said. For example, “What is Dr. Hamilton's amputation rate? His patients' renal failure rate? If his amputation rate is zero, who cares what his patients' hemoglobin A_1c is—he's a superior provider.”

Dr. Haywood responded that many people disagree on whether it's better to measure process or outcomes. “We don't think it's one way or the other. At the end of the day, we want to get at outcomes, but in the interim, we have process measures that we believe the evidence shows lead to better outcomes.”

The council passed a resolution asking CMS to seek comment from appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. In addition, CMS is working to revise the program's reporting system to provide more options for physicians.

Primary care groups particularly opposed CMS' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G-codes—a system most physicians do not use. The agency now is working with the American Medical Association to add the option to use CPT II codes as well as G-codes, CMS spokesman Peter Ashkenaz said in an interview.

“This will provide clinicians with the flexibility of utilizing either G-codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients. They also include surgical measures such as preoperative β-blockers for patients with isolated coronary artery bypass grafts.

The 20 measures removed from the original set won't necessarily be thrown out, however. In a fact sheet, CMS said it intended to pursue further development of these remaining measures, as well as other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, said that he thought the revisions were “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program,” he said.

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet, “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMS' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I looked into it. I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

PPAC member Dr. Carlos Hamilton Jr., an endocrinologist in Houston, took issue with one of the measures to be reported for diabetes patients: patients with most recent hemoglobin A_1c level documented as 9% or less.

A result of 9% “is so high that you wouldn't come close to anything related to quality,” he said. But if the patient started out with an A_1c level of 12 and a physician reduced it to 9.5%, “that represents an heroic effort that should be rewarded. So the way that ought to be phrased is 'hemoglobin documented as less than or equal to 7% or 7.5%, or has been reduced by 1.5% over the last 6 months, or 12 months,” Dr. Hamilton said.

In response to why the 9% benchmark was used, Dr. Haywood commented that “there is a lot of debate currently about what is good control, so there has not been any consensus yet. So what we did was say, 'We'll look at poor control as a starting place, and to the extent that we can build toward what is a final determination toward good control, we'll revisit that particular method.'”

Dr. Hamilton disagreed, noting that physicians have held several consensus conferences and put out publications reinforcing that good control is somewhere around 7%–7.5%. “If you really want to measure quality, you need to measure quality,” he said.

Council member Dr. Anthony Senagore, a Cleveland surgeon, said CMS is taking the wrong approach entirely. “Rather than micromanage care, why not go for the 40,000-foot view?” he said. For example, “What is Dr. Hamilton's amputation rate? His patients' renal failure rate? If his amputation rate is zero, who cares what his patients' hemoglobin A_1c is—he's a superior provider.”

Dr. Haywood responded that many people disagree on whether it's better to measure process or outcomes. “We don't think it's one way or the other. At the end of the day, we want to get at outcomes, but in the interim, we have process measures that we believe the evidence shows lead to better outcomes.”

The council passed a resolution asking CMS to seek comment from appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”

Medicare is attempting to simplify the requirements of a new voluntary reporting system that physicians claim is too burdensome.

Under the latest revision from the Centers for Medicare and Medicaid Services, physicians participating in the Physician Voluntary Reporting Program (PVRP) will have only 16 measures to choose to report on instead of 36. In addition, CMS is working to revise the program's reporting system to provide more options for physicians.

Primary care groups particularly opposed CMS' decision to collect clinical data through a set of Healthcare Common Procedure Coding System (HCPCS) codes or G-codes—a system most physicians do not use. The agency now is working with the American Medical Association to add the option to use CPT II codes as well as G-codes, CMS spokesman Peter Ashkenaz said in an interview.

“This will provide clinicians with the flexibility of utilizing either G-codes or CPT II codes” for the program, he said.

The 16 starter measures address a wide spectrum of clinical care, including administration of aspirin at arrival for acute myocardial infarction; control of lipids, blood pressure, and glycosylated hemoglobin for patients with diabetes; and assessment of fall risk in elderly patients. They also include surgical measures such as preoperative β-blockers for patients with isolated coronary artery bypass grafts.

The 20 measures removed from the original set won't necessarily be thrown out, however. In a fact sheet, CMS said it intended to pursue further development of these remaining measures, as well as other measures suggested by physician groups.

Reactions to the changes varied. Dr. C. Anderson Hedberg, president of the American College of Physicians, said that he thought the revisions were “critically important.” As reporting and pay-for-performance programs become more widespread, “uniformity and a realistic set of measures that don't create huge administrative reporting burdens are essential for physician acceptance and the success of any quality improvement and measurement program,” he said.

Any simplification of reporting is welcome, Dr. Larry Fields, president of the American Academy of Family Physicians, noted in an interview. Yet, “this is still a voluntary program with no immediate benefit to patients or physicians.”

In light of the 4.4% cut in physician pay that went into effect Jan. 1, physicians “will be even less able to comply with any reporting, voluntary or not,” Dr. Fields said. Without a positive incentive to participate, “I expect that CMS' announcement will be met with indifference.”

At a meeting of Medicare's Practicing Physicians Advisory Council (PPAC) held before the changes were announced, several physicians said the program would be a hassle for them to implement. For instance, PPAC chair Dr. Ronald Castellanos said it would cost him $15,000 to make the necessary changes in his practice to accommodate the program.

“I looked into it. I'm going to have to redesign my workflow between the clinical and office buildings, change the clearinghouse software, and change the software I use to send things to other providers” and to CMS, he said. “I had [a company] give me an estimate, and it's about $15,000. That's a lot of money to do a voluntary program.”

In return for submitting data to the program, physicians get a report telling them how well they did on each measure within their own patient population, as well as a comparison of their performance with that of other physicians regionally and nationally. Although physicians do not need to register with CMS to submit data, they must register to receive the reports.

Dr. Michael Rapp, director of the quality measurement and health assessment group at CMS, said that although there was no money attached to the reporting process, “We want to make it beneficial to physicians.” The reports are one way of doing that, but CMS would welcome any other ideas, he added.

Council member Dr. Peter Grimm, a radiation oncologist in Seattle, asked why hospitals receive a 0.4% payment incentive to report data under another reporting program, but physicians do not. “What is the rationale for that? Doctors don't need [the money], or hospitals deserve it more?”

Dr. Trent Haywood, a deputy chief medical officer at CMS, said that when the hospital reporting program started in 2002, hospitals didn't get paid either—that started later on.

PPAC member Dr. Carlos Hamilton Jr., an endocrinologist in Houston, took issue with one of the measures to be reported for diabetes patients: patients with most recent hemoglobin A_1c level documented as 9% or less.

A result of 9% “is so high that you wouldn't come close to anything related to quality,” he said. But if the patient started out with an A_1c level of 12 and a physician reduced it to 9.5%, “that represents an heroic effort that should be rewarded. So the way that ought to be phrased is 'hemoglobin documented as less than or equal to 7% or 7.5%, or has been reduced by 1.5% over the last 6 months, or 12 months,” Dr. Hamilton said.

In response to why the 9% benchmark was used, Dr. Haywood commented that “there is a lot of debate currently about what is good control, so there has not been any consensus yet. So what we did was say, 'We'll look at poor control as a starting place, and to the extent that we can build toward what is a final determination toward good control, we'll revisit that particular method.'”

Dr. Hamilton disagreed, noting that physicians have held several consensus conferences and put out publications reinforcing that good control is somewhere around 7%–7.5%. “If you really want to measure quality, you need to measure quality,” he said.

Council member Dr. Anthony Senagore, a Cleveland surgeon, said CMS is taking the wrong approach entirely. “Rather than micromanage care, why not go for the 40,000-foot view?” he said. For example, “What is Dr. Hamilton's amputation rate? His patients' renal failure rate? If his amputation rate is zero, who cares what his patients' hemoglobin A_1c is—he's a superior provider.”

Dr. Haywood responded that many people disagree on whether it's better to measure process or outcomes. “We don't think it's one way or the other. At the end of the day, we want to get at outcomes, but in the interim, we have process measures that we believe the evidence shows lead to better outcomes.”

The council passed a resolution asking CMS to seek comment from appropriate specialty societies regarding the issues raised by the voluntary reporting program, “and, like the hospital program, pay for data collection.”