Jennifer Lubell

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 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.

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.

“Having standards is good. It will provide a common language for anyone using this method,” 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, she said.

Unfortunately, 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.

Until there is some financial support to help doctors implement this technology, its use will not be widespread, she said.

Even if a physician does have the money to adopt e-prescribing, “he or she is at risk of purchasing a system that might not integrate” with a future electronic health record system, she said.

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 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.

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 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.

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.

“Having standards is good. It will provide a common language for anyone using this method,” 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, she said.

Unfortunately, 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.

Until there is some financial support to help doctors implement this technology, its use will not be widespread, she said.

Even if a physician does have the money to adopt e-prescribing, “he or she is at risk of purchasing a system that might not integrate” with a future electronic health record system, she said.

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 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.

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 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.

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.

“Having standards is good. It will provide a common language for anyone using this method,” 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, she said.

Unfortunately, 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.

Until there is some financial support to help doctors implement this technology, its use will not be widespread, she said.

Even if a physician does have the money to adopt e-prescribing, “he or she is at risk of purchasing a system that might not integrate” with a future electronic health record system, she said.

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 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.

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.

While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys. The numerous initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting. The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said the IOM's committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund. This amounts to less than one-tenth of 1 percent of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians—primary care physicians in particular—if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

This Month's Talk Back Question

How important is it to have a national, universally accepted set of clinical performance measures?

While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys. The numerous initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting. The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said the IOM's committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund. This amounts to less than one-tenth of 1 percent of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians—primary care physicians in particular—if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

This Month's Talk Back Question

How important is it to have a national, universally accepted set of clinical performance measures?

While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys. The numerous initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting. The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said the IOM's committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund. This amounts to less than one-tenth of 1 percent of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians—primary care physicians in particular—if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

This Month's Talk Back Question

How important is it to have a national, universally accepted set of clinical performance measures?

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 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.

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. “Having standards is good. It will provide a common language for anyone using this method,” 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, she said.

Unfortunately, few practices are using 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.

Only 25%–30% of the AAFP's members have electronic health records, Dr. Frank said. “They are, at present, the only ones who might be able to immediately adopt this approach. I say 'might' because not all EHR systems have the e-prescribing component.” Until there is some financial support to help doctors implement this technology, it will not be used widely, she said.

Even if a physician does have the money to adopt e-prescribing, “he or she is at risk of purchasing a system that might not integrate” with a future electronic health record system, she said.

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.

Although e-prescribing 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, said Dr. Frank. “We really have to push for a more integrated approach if we really want to improve care,” she said.

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; ASC X12N 270/271, Version 4010 and addenda; and NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1.

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 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.

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. “Having standards is good. It will provide a common language for anyone using this method,” 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, she said.

Unfortunately, few practices are using 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.

Only 25%–30% of the AAFP's members have electronic health records, Dr. Frank said. “They are, at present, the only ones who might be able to immediately adopt this approach. I say 'might' because not all EHR systems have the e-prescribing component.” Until there is some financial support to help doctors implement this technology, it will not be used widely, she said.

Even if a physician does have the money to adopt e-prescribing, “he or she is at risk of purchasing a system that might not integrate” with a future electronic health record system, she said.

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.

Although e-prescribing 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, said Dr. Frank. “We really have to push for a more integrated approach if we really want to improve care,” she said.

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; ASC X12N 270/271, Version 4010 and addenda; and NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1.

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 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.

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. “Having standards is good. It will provide a common language for anyone using this method,” 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, she said.

Unfortunately, few practices are using 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.

Only 25%–30% of the AAFP's members have electronic health records, Dr. Frank said. “They are, at present, the only ones who might be able to immediately adopt this approach. I say 'might' because not all EHR systems have the e-prescribing component.” Until there is some financial support to help doctors implement this technology, it will not be used widely, she said.

Even if a physician does have the money to adopt e-prescribing, “he or she is at risk of purchasing a system that might not integrate” with a future electronic health record system, she said.

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.

Although e-prescribing 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, said Dr. Frank. “We really have to push for a more integrated approach if we really want to improve care,” she said.

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; ASC X12N 270/271, Version 4010 and addenda; and NCPDP Telecommunication Standard, Version 5.1, and supporting NCPDP Batch Standard, Version 1.1.

AAP Policy on Pertussis

A new policy statement from the American Academy of Pediatrics (AAP) recommends universal immunization with the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine at the 11–12 year-age visit, as well as catch-up immunization of older adolescents, to boost individual and herd protection against pertussis. Tdap has replaced the Td (tetanus and reduced diphtheria toxoids) vaccine for adolescents in the childhood immunization schedule. In 2004, more than 25,000 cases of pertussis were reported in the United States—with more than a third occurring in adolescents—up from a low of 1,060 cases in 1976. Additionally, reported pertussis-related deaths among infants increased from about 10 per year in the 1990s to about 20 per year in this decade. “In infants, pertussis can be dangerous, and very severe. Parents need to know how important it is to vaccinate their children on time to prevent a serious and potentially life-threatening disease,” AAP President Dr. Eileen Ouellette said in a statement.

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 the 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 suffer from 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. “Consumers will benefit from improved food labels for products that contain food allergens.” 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.

Improving Food Marketing

Food and beverage marketing targeted to children aged 12 years and under encourages them to consume high-calorie, non-nutritious products, according to a report from the Institute of Medicine. Although some companies and restaurants have begun to develop and promote healthier choices, overall, food industries spend most of their resources on products with high amounts of added sugar, fat, and salt, and a lack of essential nutrients, the report said. The IOM recommended that these industries shift their resources to developing a wider array of products that are “nutritious, appealing, and affordable.” Lawmakers should look at the IOM report as a road map to help improve children's diets and address childhood obesity, said Center for Science in the Public Interest Nutrition Policy Director Margo G. Wootan, D.Sc. “Getting junk food out of schools, promoting fruits and vegetables, putting nutrition information on chain restaurant menus, and scrutinizing food ads on children's television programming are four things Congress could consider right now to advance the IOM's recommendations,” she said.

Mental Health Screening Snapshot

More than half the states provide education or information to primary care providers to help them focus on young children's mental health development, according to a survey from the National Academy for State Health Policy (NASHP). As part of the Assuring Better Child Health and Development (ABCD II) program, NASHP surveyed Medicaid, maternal and child health, and children's mental health agencies in all 50 states and the District of Columbia to gather information on how states were addressing the healthy mental development of children aged birth to 3 years. Mental health consultation was mentioned most frequently (48%), followed by state-funded care coordinators (33%), public health nursing consultation (30%), and lists of organizations for physician referrals (27%). However, “these low percentages suggest that none of these resources are readily available,” the survey indicated. States reported that providers raised a number of concerns regarding screening for social emotional development, such as a lack of referral resources, insufficient payment, and a lack of expertise.

Big Apple Tackles Obesity

New York City's Department of Health and Mental Hygiene (DOHMH) has launched a series of physical activity and education campaigns to prevent childhood obesity. Training has begun for close to 500 pre-kindergarten teachers in the SPARK program (Sport, Play and Active Recreation for Kids), which provides skills and equipment for structuring physical activity into a child's day. “Nearly half of the city's elementary school students are either overweight or obese, and 21% are obese as early as kindergarten,” said Dr. Thomas R. Frieden, the department's commissioner. “Our initiative makes healthy ideas and practices accessible for kids, because even a small increase in physical activity can help prevent excess weight gain and reduce risks later in life.”

Data on Youth Suicide Attempts

About 900,000 children aged 12–17 planned to commit suicide during their worst or most recent episode of major depression, according to data from the Substance Abuse and Mental Health Services Administration. Of those who planned suicide, 712,000 attempted it. The report, which was compiled using data from the 2004 National Survey on Drug Use and Health, defined a “major depressive episode” as a period of at least 2 weeks in which a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had at least five of nine symptoms of depression listed in the DSM-IV.

Video-Induced Seizure Risks

The Epilepsy Foundation has released recommendations for reducing seizures triggered by flashing images and other patterns on television and in video games and computers. The guidelines, which appeard in the September issue of Epilepsia and on the foundation's Web site, address light intensity, flicker, contrast, duration, and pattern and define the technical parameters within these factors that are most likely to provoke seizures in people who are susceptible to them. Although no numbers are available on how many people experience seizures while watching television or surfing the Internet, some epileptologists say they have noticed an increase in the number of young people coming to them with this complaint. “Children and young adults 7–19 years of age are especially susceptible to visually induced seizures,” the journal said in a statement

AAP Policy on Pertussis

A new policy statement from the American Academy of Pediatrics (AAP) recommends universal immunization with the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine at the 11–12 year-age visit, as well as catch-up immunization of older adolescents, to boost individual and herd protection against pertussis. Tdap has replaced the Td (tetanus and reduced diphtheria toxoids) vaccine for adolescents in the childhood immunization schedule. In 2004, more than 25,000 cases of pertussis were reported in the United States—with more than a third occurring in adolescents—up from a low of 1,060 cases in 1976. Additionally, reported pertussis-related deaths among infants increased from about 10 per year in the 1990s to about 20 per year in this decade. “In infants, pertussis can be dangerous, and very severe. Parents need to know how important it is to vaccinate their children on time to prevent a serious and potentially life-threatening disease,” AAP President Dr. Eileen Ouellette said in a statement.

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 the 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 suffer from 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. “Consumers will benefit from improved food labels for products that contain food allergens.” 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.

Improving Food Marketing

Food and beverage marketing targeted to children aged 12 years and under encourages them to consume high-calorie, non-nutritious products, according to a report from the Institute of Medicine. Although some companies and restaurants have begun to develop and promote healthier choices, overall, food industries spend most of their resources on products with high amounts of added sugar, fat, and salt, and a lack of essential nutrients, the report said. The IOM recommended that these industries shift their resources to developing a wider array of products that are “nutritious, appealing, and affordable.” Lawmakers should look at the IOM report as a road map to help improve children's diets and address childhood obesity, said Center for Science in the Public Interest Nutrition Policy Director Margo G. Wootan, D.Sc. “Getting junk food out of schools, promoting fruits and vegetables, putting nutrition information on chain restaurant menus, and scrutinizing food ads on children's television programming are four things Congress could consider right now to advance the IOM's recommendations,” she said.

Mental Health Screening Snapshot

More than half the states provide education or information to primary care providers to help them focus on young children's mental health development, according to a survey from the National Academy for State Health Policy (NASHP). As part of the Assuring Better Child Health and Development (ABCD II) program, NASHP surveyed Medicaid, maternal and child health, and children's mental health agencies in all 50 states and the District of Columbia to gather information on how states were addressing the healthy mental development of children aged birth to 3 years. Mental health consultation was mentioned most frequently (48%), followed by state-funded care coordinators (33%), public health nursing consultation (30%), and lists of organizations for physician referrals (27%). However, “these low percentages suggest that none of these resources are readily available,” the survey indicated. States reported that providers raised a number of concerns regarding screening for social emotional development, such as a lack of referral resources, insufficient payment, and a lack of expertise.

Big Apple Tackles Obesity

New York City's Department of Health and Mental Hygiene (DOHMH) has launched a series of physical activity and education campaigns to prevent childhood obesity. Training has begun for close to 500 pre-kindergarten teachers in the SPARK program (Sport, Play and Active Recreation for Kids), which provides skills and equipment for structuring physical activity into a child's day. “Nearly half of the city's elementary school students are either overweight or obese, and 21% are obese as early as kindergarten,” said Dr. Thomas R. Frieden, the department's commissioner. “Our initiative makes healthy ideas and practices accessible for kids, because even a small increase in physical activity can help prevent excess weight gain and reduce risks later in life.”

Data on Youth Suicide Attempts

About 900,000 children aged 12–17 planned to commit suicide during their worst or most recent episode of major depression, according to data from the Substance Abuse and Mental Health Services Administration. Of those who planned suicide, 712,000 attempted it. The report, which was compiled using data from the 2004 National Survey on Drug Use and Health, defined a “major depressive episode” as a period of at least 2 weeks in which a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had at least five of nine symptoms of depression listed in the DSM-IV.

Video-Induced Seizure Risks

The Epilepsy Foundation has released recommendations for reducing seizures triggered by flashing images and other patterns on television and in video games and computers. The guidelines, which appeard in the September issue of Epilepsia and on the foundation's Web site, address light intensity, flicker, contrast, duration, and pattern and define the technical parameters within these factors that are most likely to provoke seizures in people who are susceptible to them. Although no numbers are available on how many people experience seizures while watching television or surfing the Internet, some epileptologists say they have noticed an increase in the number of young people coming to them with this complaint. “Children and young adults 7–19 years of age are especially susceptible to visually induced seizures,” the journal said in a statement

AAP Policy on Pertussis

A new policy statement from the American Academy of Pediatrics (AAP) recommends universal immunization with the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine at the 11–12 year-age visit, as well as catch-up immunization of older adolescents, to boost individual and herd protection against pertussis. Tdap has replaced the Td (tetanus and reduced diphtheria toxoids) vaccine for adolescents in the childhood immunization schedule. In 2004, more than 25,000 cases of pertussis were reported in the United States—with more than a third occurring in adolescents—up from a low of 1,060 cases in 1976. Additionally, reported pertussis-related deaths among infants increased from about 10 per year in the 1990s to about 20 per year in this decade. “In infants, pertussis can be dangerous, and very severe. Parents need to know how important it is to vaccinate their children on time to prevent a serious and potentially life-threatening disease,” AAP President Dr. Eileen Ouellette said in a statement.

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 the 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 suffer from 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. “Consumers will benefit from improved food labels for products that contain food allergens.” 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.

Improving Food Marketing

Food and beverage marketing targeted to children aged 12 years and under encourages them to consume high-calorie, non-nutritious products, according to a report from the Institute of Medicine. Although some companies and restaurants have begun to develop and promote healthier choices, overall, food industries spend most of their resources on products with high amounts of added sugar, fat, and salt, and a lack of essential nutrients, the report said. The IOM recommended that these industries shift their resources to developing a wider array of products that are “nutritious, appealing, and affordable.” Lawmakers should look at the IOM report as a road map to help improve children's diets and address childhood obesity, said Center for Science in the Public Interest Nutrition Policy Director Margo G. Wootan, D.Sc. “Getting junk food out of schools, promoting fruits and vegetables, putting nutrition information on chain restaurant menus, and scrutinizing food ads on children's television programming are four things Congress could consider right now to advance the IOM's recommendations,” she said.

Mental Health Screening Snapshot

More than half the states provide education or information to primary care providers to help them focus on young children's mental health development, according to a survey from the National Academy for State Health Policy (NASHP). As part of the Assuring Better Child Health and Development (ABCD II) program, NASHP surveyed Medicaid, maternal and child health, and children's mental health agencies in all 50 states and the District of Columbia to gather information on how states were addressing the healthy mental development of children aged birth to 3 years. Mental health consultation was mentioned most frequently (48%), followed by state-funded care coordinators (33%), public health nursing consultation (30%), and lists of organizations for physician referrals (27%). However, “these low percentages suggest that none of these resources are readily available,” the survey indicated. States reported that providers raised a number of concerns regarding screening for social emotional development, such as a lack of referral resources, insufficient payment, and a lack of expertise.

Big Apple Tackles Obesity

New York City's Department of Health and Mental Hygiene (DOHMH) has launched a series of physical activity and education campaigns to prevent childhood obesity. Training has begun for close to 500 pre-kindergarten teachers in the SPARK program (Sport, Play and Active Recreation for Kids), which provides skills and equipment for structuring physical activity into a child's day. “Nearly half of the city's elementary school students are either overweight or obese, and 21% are obese as early as kindergarten,” said Dr. Thomas R. Frieden, the department's commissioner. “Our initiative makes healthy ideas and practices accessible for kids, because even a small increase in physical activity can help prevent excess weight gain and reduce risks later in life.”

Data on Youth Suicide Attempts

About 900,000 children aged 12–17 planned to commit suicide during their worst or most recent episode of major depression, according to data from the Substance Abuse and Mental Health Services Administration. Of those who planned suicide, 712,000 attempted it. The report, which was compiled using data from the 2004 National Survey on Drug Use and Health, defined a “major depressive episode” as a period of at least 2 weeks in which a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had at least five of nine symptoms of depression listed in the DSM-IV.

Video-Induced Seizure Risks

The Epilepsy Foundation has released recommendations for reducing seizures triggered by flashing images and other patterns on television and in video games and computers. The guidelines, which appeard in the September issue of Epilepsia and on the foundation's Web site, address light intensity, flicker, contrast, duration, and pattern and define the technical parameters within these factors that are most likely to provoke seizures in people who are susceptible to them. Although no numbers are available on how many people experience seizures while watching television or surfing the Internet, some epileptologists say they have noticed an increase in the number of young people coming to them with this complaint. “Children and young adults 7–19 years of age are especially susceptible to visually induced seizures,” the journal said in a statement

Outlook 2006

Facing yet another year with an unfixed sustainable growth rate that threatens to reduce Medicare payments, primary care physicians in 2006 will continue to focus on the developing pay-for-performance initiative, while advocating for funds to support health information technology. Medical liability reform was on the back burner in 2005, but fueled by a promise from Senate Majority Leader Bill Frist (R-Tenn.) it should appear on the table again in 2006.

Pay for Performance

Getting Congress and the federal government to understand the physician's point of view on pay for performance is a goal for primary care groups in 2006. The American Academy of Family Physicians plans to work with the Centers for Medicare and Medicaid Services to either moderate or do away with this approach in favor of more reliable data sets tied to payment reform. “Any pay-for-performance initiative that occurs should be tied to a positive Medicare update,” said AAFP President Dr. Larry Fields. The system should be simple and easy to comply with, regardless of the presence or absence of electronic health records. This is why primary care groups are advocating for a consistent data set, such as the 26 quality measures that have been vetted by the Ambulatory Care Quality Alliance. These measures have been widely accepted throughout the insurance industry, he said.

Resolving Coding Concerns

CMS should make changes to its new voluntary reporting program, which has fueled concerns about using unfamiliar G codes to measure physician performance. Until changes are made, the AAFP plans to educate its members on the voluntary reporting program. “We also want changes to the relative work values that go into evaluation and management codes, to more accurately reflect the work of physicians primarily engaged in cognitive versus procedural specialties,” Dr. Fields said.

Health Information Technology

The AAFP has made headway regarding the information technology boom—use of electronic records have increased among its members from 7% in 2003 to 30% in 2005, “a tribute to the academy's diligence,” Dr. Fields said. The federal government and private insurers should invest some money into the adoption of electronic medical records, however, “so implementation is not such a financial burden,” he said. Pay-for-performance funds, for example, should be directed at small physician offices to help them adopt this technology.

Medical Liability Reform

Sen. Frist has promised to have a medical liability reform bill on the floor in 2006, specifically one that includes a cap on noneconomic damages, Dr. Fields said. “What happens every year is the House passes a fairly reasonable bill and the Senate doesn't act.” A hard cap on pain and suffering damages at $350,000 or less “is the only proven way” to reduce skyrocketing medical liability premiums, he said. The AAFP would like state legislators to use the academy's 2005 “strike force” report on what is effective in controlling liability costs, he said.

Help for Low-Income Patients

More states should adopt North Carolina's approach to Medicaid reform, Dr. Fields said. Changes brought about by the state have improved Medicaid for patients and physicians by providing beneficiaries with a medical home. “It's been shown that primary care physicians are more cost efficient and provide better outcomes than subspecialists,” he said. The AAFP has also developed a new task force on health care coverage to look at updating its 5-year-old plan to provide coverage for all patients. Evidence pointing to a health care system breakdown continues to mount. A recent study by the Center for Studying Health System Change noted that unequal access to high-quality health care is widening the gap between rich and poor patients. “Increasingly, America is turning into a country of health care haves and have-nots, driven primarily by the type of—or lack of—health coverage people have,” said lead author Robert E. Hurley, Ph.D., a senior consulting researcher at the center. The study was published as a Web-exclusive article in the journal Health Affairs.

Medicare Drug Changes in 2007

The U.S. Pharmacopeia recently issued draft revisions to the voluntary model guidelines used by Medicare Part D prescription drug plans. The revisions will apply to formularies for 2007. The revised guidelines contain the same number of unique drug categories and classes as the previous version; however, the USP is proposing changes within and across several categories. For example, the document proposes to eliminate the distinction between NSAIDs and cyclo-oxygenase-2 inhibitors and between selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The document also proposes to add a number of medicines that might be covered either by Medicare Part B or Part D, depending on the setting. The revisions are based on the review of newly approved and discontinued drugs, changes to approved therapeutic uses, new information on the safety and efficacy of drugs, and comments since the first version of the model guidelines was issued in 2004. The 2004 model guidelines were widely used by Medicare prescription drug plans in designing their formularies, USP Vice President William A. Zeruld said at a press briefing. Three of every four formularies used the USP model guidelines in designing plans for 2006, Mr. Zeruld said. USP will submit its final proposal to CMS on Jan. 30.

Outlook 2006

Facing yet another year with an unfixed sustainable growth rate that threatens to reduce Medicare payments, primary care physicians in 2006 will continue to focus on the developing pay-for-performance initiative, while advocating for funds to support health information technology. Medical liability reform was on the back burner in 2005, but fueled by a promise from Senate Majority Leader Bill Frist (R-Tenn.) it should appear on the table again in 2006.

Pay for Performance

Getting Congress and the federal government to understand the physician's point of view on pay for performance is a goal for primary care groups in 2006. The American Academy of Family Physicians plans to work with the Centers for Medicare and Medicaid Services to either moderate or do away with this approach in favor of more reliable data sets tied to payment reform. “Any pay-for-performance initiative that occurs should be tied to a positive Medicare update,” said AAFP President Dr. Larry Fields. The system should be simple and easy to comply with, regardless of the presence or absence of electronic health records. This is why primary care groups are advocating for a consistent data set, such as the 26 quality measures that have been vetted by the Ambulatory Care Quality Alliance. These measures have been widely accepted throughout the insurance industry, he said.

Resolving Coding Concerns

CMS should make changes to its new voluntary reporting program, which has fueled concerns about using unfamiliar G codes to measure physician performance. Until changes are made, the AAFP plans to educate its members on the voluntary reporting program. “We also want changes to the relative work values that go into evaluation and management codes, to more accurately reflect the work of physicians primarily engaged in cognitive versus procedural specialties,” Dr. Fields said.

Health Information Technology

The AAFP has made headway regarding the information technology boom—use of electronic records have increased among its members from 7% in 2003 to 30% in 2005, “a tribute to the academy's diligence,” Dr. Fields said. The federal government and private insurers should invest some money into the adoption of electronic medical records, however, “so implementation is not such a financial burden,” he said. Pay-for-performance funds, for example, should be directed at small physician offices to help them adopt this technology.

Medical Liability Reform

Sen. Frist has promised to have a medical liability reform bill on the floor in 2006, specifically one that includes a cap on noneconomic damages, Dr. Fields said. “What happens every year is the House passes a fairly reasonable bill and the Senate doesn't act.” A hard cap on pain and suffering damages at $350,000 or less “is the only proven way” to reduce skyrocketing medical liability premiums, he said. The AAFP would like state legislators to use the academy's 2005 “strike force” report on what is effective in controlling liability costs, he said.

Help for Low-Income Patients

More states should adopt North Carolina's approach to Medicaid reform, Dr. Fields said. Changes brought about by the state have improved Medicaid for patients and physicians by providing beneficiaries with a medical home. “It's been shown that primary care physicians are more cost efficient and provide better outcomes than subspecialists,” he said. The AAFP has also developed a new task force on health care coverage to look at updating its 5-year-old plan to provide coverage for all patients. Evidence pointing to a health care system breakdown continues to mount. A recent study by the Center for Studying Health System Change noted that unequal access to high-quality health care is widening the gap between rich and poor patients. “Increasingly, America is turning into a country of health care haves and have-nots, driven primarily by the type of—or lack of—health coverage people have,” said lead author Robert E. Hurley, Ph.D., a senior consulting researcher at the center. The study was published as a Web-exclusive article in the journal Health Affairs.

Medicare Drug Changes in 2007

The U.S. Pharmacopeia recently issued draft revisions to the voluntary model guidelines used by Medicare Part D prescription drug plans. The revisions will apply to formularies for 2007. The revised guidelines contain the same number of unique drug categories and classes as the previous version; however, the USP is proposing changes within and across several categories. For example, the document proposes to eliminate the distinction between NSAIDs and cyclo-oxygenase-2 inhibitors and between selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The document also proposes to add a number of medicines that might be covered either by Medicare Part B or Part D, depending on the setting. The revisions are based on the review of newly approved and discontinued drugs, changes to approved therapeutic uses, new information on the safety and efficacy of drugs, and comments since the first version of the model guidelines was issued in 2004. The 2004 model guidelines were widely used by Medicare prescription drug plans in designing their formularies, USP Vice President William A. Zeruld said at a press briefing. Three of every four formularies used the USP model guidelines in designing plans for 2006, Mr. Zeruld said. USP will submit its final proposal to CMS on Jan. 30.

Outlook 2006

Facing yet another year with an unfixed sustainable growth rate that threatens to reduce Medicare payments, primary care physicians in 2006 will continue to focus on the developing pay-for-performance initiative, while advocating for funds to support health information technology. Medical liability reform was on the back burner in 2005, but fueled by a promise from Senate Majority Leader Bill Frist (R-Tenn.) it should appear on the table again in 2006.

Pay for Performance

Getting Congress and the federal government to understand the physician's point of view on pay for performance is a goal for primary care groups in 2006. The American Academy of Family Physicians plans to work with the Centers for Medicare and Medicaid Services to either moderate or do away with this approach in favor of more reliable data sets tied to payment reform. “Any pay-for-performance initiative that occurs should be tied to a positive Medicare update,” said AAFP President Dr. Larry Fields. The system should be simple and easy to comply with, regardless of the presence or absence of electronic health records. This is why primary care groups are advocating for a consistent data set, such as the 26 quality measures that have been vetted by the Ambulatory Care Quality Alliance. These measures have been widely accepted throughout the insurance industry, he said.

Resolving Coding Concerns

CMS should make changes to its new voluntary reporting program, which has fueled concerns about using unfamiliar G codes to measure physician performance. Until changes are made, the AAFP plans to educate its members on the voluntary reporting program. “We also want changes to the relative work values that go into evaluation and management codes, to more accurately reflect the work of physicians primarily engaged in cognitive versus procedural specialties,” Dr. Fields said.

Health Information Technology

The AAFP has made headway regarding the information technology boom—use of electronic records have increased among its members from 7% in 2003 to 30% in 2005, “a tribute to the academy's diligence,” Dr. Fields said. The federal government and private insurers should invest some money into the adoption of electronic medical records, however, “so implementation is not such a financial burden,” he said. Pay-for-performance funds, for example, should be directed at small physician offices to help them adopt this technology.

Medical Liability Reform

Sen. Frist has promised to have a medical liability reform bill on the floor in 2006, specifically one that includes a cap on noneconomic damages, Dr. Fields said. “What happens every year is the House passes a fairly reasonable bill and the Senate doesn't act.” A hard cap on pain and suffering damages at $350,000 or less “is the only proven way” to reduce skyrocketing medical liability premiums, he said. The AAFP would like state legislators to use the academy's 2005 “strike force” report on what is effective in controlling liability costs, he said.

Help for Low-Income Patients

More states should adopt North Carolina's approach to Medicaid reform, Dr. Fields said. Changes brought about by the state have improved Medicaid for patients and physicians by providing beneficiaries with a medical home. “It's been shown that primary care physicians are more cost efficient and provide better outcomes than subspecialists,” he said. The AAFP has also developed a new task force on health care coverage to look at updating its 5-year-old plan to provide coverage for all patients. Evidence pointing to a health care system breakdown continues to mount. A recent study by the Center for Studying Health System Change noted that unequal access to high-quality health care is widening the gap between rich and poor patients. “Increasingly, America is turning into a country of health care haves and have-nots, driven primarily by the type of—or lack of—health coverage people have,” said lead author Robert E. Hurley, Ph.D., a senior consulting researcher at the center. The study was published as a Web-exclusive article in the journal Health Affairs.

Medicare Drug Changes in 2007

The U.S. Pharmacopeia recently issued draft revisions to the voluntary model guidelines used by Medicare Part D prescription drug plans. The revisions will apply to formularies for 2007. The revised guidelines contain the same number of unique drug categories and classes as the previous version; however, the USP is proposing changes within and across several categories. For example, the document proposes to eliminate the distinction between NSAIDs and cyclo-oxygenase-2 inhibitors and between selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The document also proposes to add a number of medicines that might be covered either by Medicare Part B or Part D, depending on the setting. The revisions are based on the review of newly approved and discontinued drugs, changes to approved therapeutic uses, new information on the safety and efficacy of drugs, and comments since the first version of the model guidelines was issued in 2004. The 2004 model guidelines were widely used by Medicare prescription drug plans in designing their formularies, USP Vice President William A. Zeruld said at a press briefing. Three of every four formularies used the USP model guidelines in designing plans for 2006, Mr. Zeruld said. USP will submit its final proposal to CMS on Jan. 30.

While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys.

The problem is all of these independent initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting.

The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said IOM committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund. This amounts to less than one-tenth of 1 percent of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians–primary care physicians in particular–if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys.

The problem is all of these independent initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting.

The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said IOM committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund. This amounts to less than one-tenth of 1 percent of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians–primary care physicians in particular–if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys.

The problem is all of these independent initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting.

The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said IOM committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund. This amounts to less than one-tenth of 1 percent of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians–primary care physicians in particular–if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

The American College of Physicians is testing a new resource that would provide direct assistance to physicians interested in practice redesign.

Starting this month, the ACP's Center for Practice Innovation (CPI) will work with 25-50 small- and medium-sized internal medicine practices to help them prepare for the ever-developing pay-for-performance movement and technology boom, and the complexities of the new recertification process.

“Our belief,” said Dr. C. Anderson Hedberg, ACP president, “is that the financial concerns of physicians regarding the implementation and management of the changing practice environment will be addressed through office redesign, attention to quality innovation, enhanced patient satisfaction, and practice growth.”

Funding for the center was provided in a 2-year, $996,000 grant from the Physicians' Foundation for Health Systems Excellence (PFHSE). “The grant will enable ACP to provide new practice-level support and to test innovative approaches aimed at changes in practice management, physician education and patient safety/disease management, and patient satisfaction,” said Dr. Michael S. Barr, ACP's vice president of practice advocacy and improvement and director of the project.

In an interview, Dr. Barr said the center would be selecting practices from across the country, “probably in regional clusters.” Specifically, it wants to target practices of 10 physicians or smaller–practices that don't always have outside support to improve their practice environment.

“We will aim to have a group of practices that are fairly representative of the types of practices in the United States, and will seek to balance the set of practices based on fairly typical demographic factors,” he said.

The 2-year project includes an implementation phase, during which the 25-50 practices will be actively engaged in practice redesign efforts, Dr. Barr said. “We're not going into these practices with a specific, cookie cutter model,” he said. The idea is to adapt different tools and resources, and put together a “menu” of options for these practices based upon their unique situation. The practices will determine which interventions are right for them.

Success will be measured through data collected for selected clinical measures, as well as patient satisfaction, physician/staff satisfaction, and economic indicators of practice function.

Dr. Barr said the CPI will be urging practices to select clinical measures most appropriate for the populations they serve. The center will encourage practices to use clinical measures endorsed by the Ambulatory Care Quality Alliance. Those measures would allow for “adequate comparisons to be made across practices reporting on the same measures,” he said.

These measurements “will help us assess the outcomes for a final report,” he said. “Based on the lessons learned, we hope that the activities continue beyond this 2-year project.” The CPI plans to convene a steering committee to help guide its progress.

None of the practices will be getting direct monetary assistance from the center, he said. “The assistance will come in the form of on-the-ground consultation, support, giving them tools and services, connection with their peers,” and help with recertification.

For now, the project will be limited only to the selected practices, Dr. Barr said. “Unless we are able to obtain additional funding during this 2-year period, it will be difficult to provide the level of assistance to other practices. However, we'll certainly be sharing information along the way through the new CPI Web site.” ACP's Practice Management Center will continue to provide the advice and support that it currently offers for practices looking for more resources, he said.

The CPI is aware of the American Board of Internal Medicine's work with its practice improvement modules, Dr. Barr said. As it develops its own interventions, the center will be mindful of these developments in recertification.

Although health information technology won't be the central focus of the center's activities, there's no denying that health IT is a good way for practices to generate these types of quality improvement outcomes, Dr. Barr said.

“Health information technology and performance measurement have the potential to improve the consistency of outpatient medicine. This new approach will require some time for assimilation, but the external pressure for rapid change might cause future shock for established practitioners,” commented Dr. William Golden, a professor of medicine and public health at the University of Arkansas, who has also worked on a special liaison panel between the American College of Physicians and the ABIM to develop pathways to recertification.

The American College of Physicians is testing a new resource that would provide direct assistance to physicians interested in practice redesign.

Starting this month, the ACP's Center for Practice Innovation (CPI) will work with 25-50 small- and medium-sized internal medicine practices to help them prepare for the ever-developing pay-for-performance movement and technology boom, and the complexities of the new recertification process.

“Our belief,” said Dr. C. Anderson Hedberg, ACP president, “is that the financial concerns of physicians regarding the implementation and management of the changing practice environment will be addressed through office redesign, attention to quality innovation, enhanced patient satisfaction, and practice growth.”

Funding for the center was provided in a 2-year, $996,000 grant from the Physicians' Foundation for Health Systems Excellence (PFHSE). “The grant will enable ACP to provide new practice-level support and to test innovative approaches aimed at changes in practice management, physician education and patient safety/disease management, and patient satisfaction,” said Dr. Michael S. Barr, ACP's vice president of practice advocacy and improvement and director of the project.

In an interview, Dr. Barr said the center would be selecting practices from across the country, “probably in regional clusters.” Specifically, it wants to target practices of 10 physicians or smaller–practices that don't always have outside support to improve their practice environment.

“We will aim to have a group of practices that are fairly representative of the types of practices in the United States, and will seek to balance the set of practices based on fairly typical demographic factors,” he said.

The 2-year project includes an implementation phase, during which the 25-50 practices will be actively engaged in practice redesign efforts, Dr. Barr said. “We're not going into these practices with a specific, cookie cutter model,” he said. The idea is to adapt different tools and resources, and put together a “menu” of options for these practices based upon their unique situation. The practices will determine which interventions are right for them.

Success will be measured through data collected for selected clinical measures, as well as patient satisfaction, physician/staff satisfaction, and economic indicators of practice function.

Dr. Barr said the CPI will be urging practices to select clinical measures most appropriate for the populations they serve. The center will encourage practices to use clinical measures endorsed by the Ambulatory Care Quality Alliance. Those measures would allow for “adequate comparisons to be made across practices reporting on the same measures,” he said.

These measurements “will help us assess the outcomes for a final report,” he said. “Based on the lessons learned, we hope that the activities continue beyond this 2-year project.” The CPI plans to convene a steering committee to help guide its progress.

None of the practices will be getting direct monetary assistance from the center, he said. “The assistance will come in the form of on-the-ground consultation, support, giving them tools and services, connection with their peers,” and help with recertification.

For now, the project will be limited only to the selected practices, Dr. Barr said. “Unless we are able to obtain additional funding during this 2-year period, it will be difficult to provide the level of assistance to other practices. However, we'll certainly be sharing information along the way through the new CPI Web site.” ACP's Practice Management Center will continue to provide the advice and support that it currently offers for practices looking for more resources, he said.

The CPI is aware of the American Board of Internal Medicine's work with its practice improvement modules, Dr. Barr said. As it develops its own interventions, the center will be mindful of these developments in recertification.

Although health information technology won't be the central focus of the center's activities, there's no denying that health IT is a good way for practices to generate these types of quality improvement outcomes, Dr. Barr said.

“Health information technology and performance measurement have the potential to improve the consistency of outpatient medicine. This new approach will require some time for assimilation, but the external pressure for rapid change might cause future shock for established practitioners,” commented Dr. William Golden, a professor of medicine and public health at the University of Arkansas, who has also worked on a special liaison panel between the American College of Physicians and the ABIM to develop pathways to recertification.

The American College of Physicians is testing a new resource that would provide direct assistance to physicians interested in practice redesign.

Starting this month, the ACP's Center for Practice Innovation (CPI) will work with 25-50 small- and medium-sized internal medicine practices to help them prepare for the ever-developing pay-for-performance movement and technology boom, and the complexities of the new recertification process.

“Our belief,” said Dr. C. Anderson Hedberg, ACP president, “is that the financial concerns of physicians regarding the implementation and management of the changing practice environment will be addressed through office redesign, attention to quality innovation, enhanced patient satisfaction, and practice growth.”

Funding for the center was provided in a 2-year, $996,000 grant from the Physicians' Foundation for Health Systems Excellence (PFHSE). “The grant will enable ACP to provide new practice-level support and to test innovative approaches aimed at changes in practice management, physician education and patient safety/disease management, and patient satisfaction,” said Dr. Michael S. Barr, ACP's vice president of practice advocacy and improvement and director of the project.

In an interview, Dr. Barr said the center would be selecting practices from across the country, “probably in regional clusters.” Specifically, it wants to target practices of 10 physicians or smaller–practices that don't always have outside support to improve their practice environment.

“We will aim to have a group of practices that are fairly representative of the types of practices in the United States, and will seek to balance the set of practices based on fairly typical demographic factors,” he said.

The 2-year project includes an implementation phase, during which the 25-50 practices will be actively engaged in practice redesign efforts, Dr. Barr said. “We're not going into these practices with a specific, cookie cutter model,” he said. The idea is to adapt different tools and resources, and put together a “menu” of options for these practices based upon their unique situation. The practices will determine which interventions are right for them.

Success will be measured through data collected for selected clinical measures, as well as patient satisfaction, physician/staff satisfaction, and economic indicators of practice function.

Dr. Barr said the CPI will be urging practices to select clinical measures most appropriate for the populations they serve. The center will encourage practices to use clinical measures endorsed by the Ambulatory Care Quality Alliance. Those measures would allow for “adequate comparisons to be made across practices reporting on the same measures,” he said.

These measurements “will help us assess the outcomes for a final report,” he said. “Based on the lessons learned, we hope that the activities continue beyond this 2-year project.” The CPI plans to convene a steering committee to help guide its progress.

None of the practices will be getting direct monetary assistance from the center, he said. “The assistance will come in the form of on-the-ground consultation, support, giving them tools and services, connection with their peers,” and help with recertification.

For now, the project will be limited only to the selected practices, Dr. Barr said. “Unless we are able to obtain additional funding during this 2-year period, it will be difficult to provide the level of assistance to other practices. However, we'll certainly be sharing information along the way through the new CPI Web site.” ACP's Practice Management Center will continue to provide the advice and support that it currently offers for practices looking for more resources, he said.

The CPI is aware of the American Board of Internal Medicine's work with its practice improvement modules, Dr. Barr said. As it develops its own interventions, the center will be mindful of these developments in recertification.

Although health information technology won't be the central focus of the center's activities, there's no denying that health IT is a good way for practices to generate these types of quality improvement outcomes, Dr. Barr said.

“Health information technology and performance measurement have the potential to improve the consistency of outpatient medicine. This new approach will require some time for assimilation, but the external pressure for rapid change might cause future shock for established practitioners,” commented Dr. William Golden, a professor of medicine and public health at the University of Arkansas, who has also worked on a special liaison panel between the American College of Physicians and the ABIM to develop pathways to recertification.

Outlook 2006

Facing yet another year under the threat of lower Medicare payments, internists in 2006 will continue to focus on the developing pay-for-performance initiative, while advocating for funds to support health information technology. Medical liability reform was on the back burner in 2005, but fueled by a promise from Senate Majority Leader Bill Frist (R-Tenn.), it should appear on the table again in 2006.

Pay for Performance

Getting Congress and the federal government to understand the physician's point of view on pay for performance is a goal this year for the American College of Physicians. The ACP, along with other medical societies, is advocating for a consistent data set, such as the 26 quality measures that have been vetted by the Ambulatory Care Quality Alliance. In a document given to Congress, the ACP presented a time line for a pay-for-performance program. The program would be voluntary, but participating physicians would receive a higher payment update. Much of what will affect physician payment this year will be addressed in conference negotiations on the omnibus appropriations bill, which at press time have not been completed. Even if Congress stabilizes payments and provides a 1-year fix, “there still could be a long-term problem” with the sustainable growth rate, Robert B. Doherty, the ACP's senior vice president for governmental affairs and public policy, told INTERNAL MEDICINE NEWS. “We don't know if the conference agreement will include a legislative mandate for [the Centers for Medicare and Medicaid Services] to move forward on pay for performance in 2007” or whether the program would be punitive, he said. Based on current proposed language, physicians could receive an increase for participating in quality reporting, but those who aren't able to participate may get a 2% cut in payments, he said.

Voluntary Reporting Program

Primary care groups are pressing CMS to make changes to its new voluntary reporting program, which has fueled concerns about using unfamiliar G codes to measure physician performance. The ACP in particular wants CMS to agree on a smaller set of measures that are aligned with the Ambulatory Care Quality Alliance measures, Mr. Doherty said. Currently, the agency is calling for 36 measures, “which will load up physicians with too many measures,” he said. It's expected that this voluntary program will become the basis for a federal pay-for-performance program as early as 2007. For that reason, “it's really important to get this program right, once dollars are linked to it,” he said.

Health Information Technology

The ACP continues to support efforts to help small practices implement electronic health records, and is calling for payment incentives for health information technology. The ACP wants to keep breaking down the barriers to physicians using EHRs, Mr. Doherty said. It's not enough for the college to track how many internists use EHRs–what's more important is finding out how many of these electronic systems function well enough to allow internists to participate in a quality measurement reporting program. One tool to help track this trend is the Certification Commission on Health Information Technology, which was set up by the American Health Information Management Association to create voluntary standards for health information technology. The ACP was involved in the development of this commission on several levels, Mr. Doherty said. “It started out purely as a private sector initiative, but now it has the federal government behind it to develop these standards.” The standards, focusing on interoperability and functionality, are expected early this year. “For the first time, physicians will know that there's an independent commission that will be able to tell them whether the system they're purchasing is a quality EHR system, which will greatly ease anxiety,” he said. In addition, the ACP is pressing Congress to enact a bill (H.R. 747) that would reimburse physicians who have electronic medical record systems that meet these types of certification standards and who participate in a CMS-approved quality measurement reporting program.

Medicare Drug Changes in 2007

The U.S. Pharmacopeia recently issued draft revisions to the voluntary model guidelines used by Medicare Part D prescription drug plans. The revisions will apply to formularies for 2007. The revised guidelines contain the same number of unique drug categories and classes as the previous version; however, the USP is proposing changes within and across several categories. For example, the document proposes to eliminate the distinction between NSAIDs and cyclo-oxygenase-2 inhibitors and between selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The document also proposes to add a number of medicines that might be covered either by Medicare Part B or Part D, depending on the setting. The revisions are based on the review of newly approved and discontinued drugs, changes to approved therapeutic uses, new information on the safety and efficacy of drugs, and comments since the first version of the model guidelines was issued in 2004. The 2004 model guidelines were widely used by Medicare prescription drug plans in designing their formularies, USP Vice President William A. Zeruld said at a press briefing. Three of every four formularies used the USP model guidelines in designing plans for 2006, Mr. Zeruld said. USP will submit its final proposal to CMS on Jan. 30.

Outlook 2006

Facing yet another year under the threat of lower Medicare payments, internists in 2006 will continue to focus on the developing pay-for-performance initiative, while advocating for funds to support health information technology. Medical liability reform was on the back burner in 2005, but fueled by a promise from Senate Majority Leader Bill Frist (R-Tenn.), it should appear on the table again in 2006.

Pay for Performance

Getting Congress and the federal government to understand the physician's point of view on pay for performance is a goal this year for the American College of Physicians. The ACP, along with other medical societies, is advocating for a consistent data set, such as the 26 quality measures that have been vetted by the Ambulatory Care Quality Alliance. In a document given to Congress, the ACP presented a time line for a pay-for-performance program. The program would be voluntary, but participating physicians would receive a higher payment update. Much of what will affect physician payment this year will be addressed in conference negotiations on the omnibus appropriations bill, which at press time have not been completed. Even if Congress stabilizes payments and provides a 1-year fix, “there still could be a long-term problem” with the sustainable growth rate, Robert B. Doherty, the ACP's senior vice president for governmental affairs and public policy, told INTERNAL MEDICINE NEWS. “We don't know if the conference agreement will include a legislative mandate for [the Centers for Medicare and Medicaid Services] to move forward on pay for performance in 2007” or whether the program would be punitive, he said. Based on current proposed language, physicians could receive an increase for participating in quality reporting, but those who aren't able to participate may get a 2% cut in payments, he said.

Voluntary Reporting Program

Primary care groups are pressing CMS to make changes to its new voluntary reporting program, which has fueled concerns about using unfamiliar G codes to measure physician performance. The ACP in particular wants CMS to agree on a smaller set of measures that are aligned with the Ambulatory Care Quality Alliance measures, Mr. Doherty said. Currently, the agency is calling for 36 measures, “which will load up physicians with too many measures,” he said. It's expected that this voluntary program will become the basis for a federal pay-for-performance program as early as 2007. For that reason, “it's really important to get this program right, once dollars are linked to it,” he said.

Health Information Technology

The ACP continues to support efforts to help small practices implement electronic health records, and is calling for payment incentives for health information technology. The ACP wants to keep breaking down the barriers to physicians using EHRs, Mr. Doherty said. It's not enough for the college to track how many internists use EHRs–what's more important is finding out how many of these electronic systems function well enough to allow internists to participate in a quality measurement reporting program. One tool to help track this trend is the Certification Commission on Health Information Technology, which was set up by the American Health Information Management Association to create voluntary standards for health information technology. The ACP was involved in the development of this commission on several levels, Mr. Doherty said. “It started out purely as a private sector initiative, but now it has the federal government behind it to develop these standards.” The standards, focusing on interoperability and functionality, are expected early this year. “For the first time, physicians will know that there's an independent commission that will be able to tell them whether the system they're purchasing is a quality EHR system, which will greatly ease anxiety,” he said. In addition, the ACP is pressing Congress to enact a bill (H.R. 747) that would reimburse physicians who have electronic medical record systems that meet these types of certification standards and who participate in a CMS-approved quality measurement reporting program.

Medicare Drug Changes in 2007

The U.S. Pharmacopeia recently issued draft revisions to the voluntary model guidelines used by Medicare Part D prescription drug plans. The revisions will apply to formularies for 2007. The revised guidelines contain the same number of unique drug categories and classes as the previous version; however, the USP is proposing changes within and across several categories. For example, the document proposes to eliminate the distinction between NSAIDs and cyclo-oxygenase-2 inhibitors and between selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The document also proposes to add a number of medicines that might be covered either by Medicare Part B or Part D, depending on the setting. The revisions are based on the review of newly approved and discontinued drugs, changes to approved therapeutic uses, new information on the safety and efficacy of drugs, and comments since the first version of the model guidelines was issued in 2004. The 2004 model guidelines were widely used by Medicare prescription drug plans in designing their formularies, USP Vice President William A. Zeruld said at a press briefing. Three of every four formularies used the USP model guidelines in designing plans for 2006, Mr. Zeruld said. USP will submit its final proposal to CMS on Jan. 30.

Outlook 2006

Facing yet another year under the threat of lower Medicare payments, internists in 2006 will continue to focus on the developing pay-for-performance initiative, while advocating for funds to support health information technology. Medical liability reform was on the back burner in 2005, but fueled by a promise from Senate Majority Leader Bill Frist (R-Tenn.), it should appear on the table again in 2006.

Pay for Performance

Getting Congress and the federal government to understand the physician's point of view on pay for performance is a goal this year for the American College of Physicians. The ACP, along with other medical societies, is advocating for a consistent data set, such as the 26 quality measures that have been vetted by the Ambulatory Care Quality Alliance. In a document given to Congress, the ACP presented a time line for a pay-for-performance program. The program would be voluntary, but participating physicians would receive a higher payment update. Much of what will affect physician payment this year will be addressed in conference negotiations on the omnibus appropriations bill, which at press time have not been completed. Even if Congress stabilizes payments and provides a 1-year fix, “there still could be a long-term problem” with the sustainable growth rate, Robert B. Doherty, the ACP's senior vice president for governmental affairs and public policy, told INTERNAL MEDICINE NEWS. “We don't know if the conference agreement will include a legislative mandate for [the Centers for Medicare and Medicaid Services] to move forward on pay for performance in 2007” or whether the program would be punitive, he said. Based on current proposed language, physicians could receive an increase for participating in quality reporting, but those who aren't able to participate may get a 2% cut in payments, he said.

Voluntary Reporting Program

Primary care groups are pressing CMS to make changes to its new voluntary reporting program, which has fueled concerns about using unfamiliar G codes to measure physician performance. The ACP in particular wants CMS to agree on a smaller set of measures that are aligned with the Ambulatory Care Quality Alliance measures, Mr. Doherty said. Currently, the agency is calling for 36 measures, “which will load up physicians with too many measures,” he said. It's expected that this voluntary program will become the basis for a federal pay-for-performance program as early as 2007. For that reason, “it's really important to get this program right, once dollars are linked to it,” he said.

Health Information Technology

The ACP continues to support efforts to help small practices implement electronic health records, and is calling for payment incentives for health information technology. The ACP wants to keep breaking down the barriers to physicians using EHRs, Mr. Doherty said. It's not enough for the college to track how many internists use EHRs–what's more important is finding out how many of these electronic systems function well enough to allow internists to participate in a quality measurement reporting program. One tool to help track this trend is the Certification Commission on Health Information Technology, which was set up by the American Health Information Management Association to create voluntary standards for health information technology. The ACP was involved in the development of this commission on several levels, Mr. Doherty said. “It started out purely as a private sector initiative, but now it has the federal government behind it to develop these standards.” The standards, focusing on interoperability and functionality, are expected early this year. “For the first time, physicians will know that there's an independent commission that will be able to tell them whether the system they're purchasing is a quality EHR system, which will greatly ease anxiety,” he said. In addition, the ACP is pressing Congress to enact a bill (H.R. 747) that would reimburse physicians who have electronic medical record systems that meet these types of certification standards and who participate in a CMS-approved quality measurement reporting program.

Medicare Drug Changes in 2007

The U.S. Pharmacopeia recently issued draft revisions to the voluntary model guidelines used by Medicare Part D prescription drug plans. The revisions will apply to formularies for 2007. The revised guidelines contain the same number of unique drug categories and classes as the previous version; however, the USP is proposing changes within and across several categories. For example, the document proposes to eliminate the distinction between NSAIDs and cyclo-oxygenase-2 inhibitors and between selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The document also proposes to add a number of medicines that might be covered either by Medicare Part B or Part D, depending on the setting. The revisions are based on the review of newly approved and discontinued drugs, changes to approved therapeutic uses, new information on the safety and efficacy of drugs, and comments since the first version of the model guidelines was issued in 2004. The 2004 model guidelines were widely used by Medicare prescription drug plans in designing their formularies, USP Vice President William A. Zeruld said at a press briefing. Three of every four formularies used the USP model guidelines in designing plans for 2006, Mr. Zeruld said. USP will submit its final proposal to CMS on Jan. 30.

WASHINGTON – Physician-directed interventions can increase rates of colorectal cancer screening in patients with low literacy skills, Dr. Charles Bennett reported at a conference on health literacy sponsored by the American College of Physicians Foundation.

Patients with limited literacy “may not be able to understand basic cancer screening information and educational materials, many of which are written at a literacy level above that of a significant portion of the American population,” noted Dr. Bennett, a hematologist/oncologist who is an associate director for the Veterans Administration Midwest Center for Health Services and Policy Research.

In a randomized, controlled trial among veterans age 50 years and older seen in two general primary care clinics, the use of provider-directed interventions led to a 26% increase in screening completion among patients with low literacy skills, he said.

No prior study has evaluated the cost effectiveness of health-promotion efforts for colorectal cancer (CRC), but successful interventions have been shown to improve breast and cervical cancer screening rates, he said.

CRC is the third most common cancer in the United States, with the third highest mortality. The American Cancer Society predicts that more than 145,000 adults will be diagnosed with colorectal cancer in 2005 and that 56,000 will die from the disease.

Screening can reduce CRC-related mortality by detecting early-stage CRC. Screening strategies available include the fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, and double contrast barium enema.

The U.S. Preventive Services Task Force recommends CRC screening for average-risk individuals age 50 years and older, yet less than 53% of the eligible U.S. population has been screened for CRC. “Physician recommendation is the largest predictor of CRC screening guidance,” Dr. Bennett said.

The VA health care system measures screening rates at monthly intervals as part of its quality-enhancement research initiative. Of the 17 measures evaluated in this program, CRC screening has the lowest performance rates, he said. VA studies have not shown racial or ethnic differences in CRC survival rates, but African Americans insured by Medicare or private health insurance have lower 5-year survival rates than whites with the same insurance, Dr. Bennett said.

Veterans who use the VA health care services have especially low levels of health literacy. At the Jesse Brown VA Medical Center in Lakeside, Ill., only 42% of hospitalized VA patients have health literacy skills above the ninth-grade level, he said.

The trial to test health care provider-directed interventions took place at two primary care clinics at the Jesse Brown center from May 2001 to June 2003. One clinic served as the control site and the other was the intervention clinic. Each had three attending physicians and a staff of nurse practitioners and medical residents. Patients had to be at least age 50 years and be scheduled to be seen in one of the two outpatient clinics. Individuals were excluded if they had a personal or family history of polyps, CRC, or inflammatory bowel disease; had completed a FOBT in the preceding year; or had a flexible sigmoidoscopy or colonoscopy in the preceding 5 years.

In the intervention clinic, providers attended quarterly feedback sessions, focusing on individual and group feedback on CRC screening recommendation rates and patient adherence to recommended tests. The physicians and staff also received an overview of CRC screening guidelines as well as practical strategies to communicate with patients who have limited literacy skills. The “continuous quality improvement” (CQI) process–which applies scientific methods to the practice of medicine to help ease a physician's workload, increase patient satisfaction, and reduce malpractice exposure–was introduced to the participants.

Screening recommendation and completion were assessed by a review of electronic health records by research assistants.

Overall, the health care provider-directed intervention resulted in a 7% absolute increase in the rates of CRC screening recommendations, and a 9% absolute increase in the rates of CRC screening completion, Dr. Bennett reported.

Providers who attended at least one feedback session were more likely than those who attended no sessions to make a CRC screening recommendation. In addition, patients of providers who attended at least one feedback session were more likely than those who attended no sessions to adhere to CRC screening recommendations.

Respondents with limited literacy skills were more likely than others to be unfamiliar with CRC and other screening tests for CRC. They also appeared to be more skeptical about the screening process, complaining that an FOBT was inconvenient and messy, and stating they would not use an FOBT even if recommended by their physician. But they were more likely to believe that they were at average to high risk of developing CRC than higher literacy patients, Dr. Bennett said.

Among the patients with low literacy, the provider-directed intervention was associated with a 26% increase in screening completion, he reported.

“If information technology support could facilitate downloading of provider-specific CRC screening rates directly from the electronic medical records of the VA, then the intervention costs would substantially decrease,” Dr. Bennett said.

Because CRC screening rates have scored so low in the past within the VA, information technology improvements within the system are likely in the near future, he said.

WASHINGTON – Physician-directed interventions can increase rates of colorectal cancer screening in patients with low literacy skills, Dr. Charles Bennett reported at a conference on health literacy sponsored by the American College of Physicians Foundation.

Patients with limited literacy “may not be able to understand basic cancer screening information and educational materials, many of which are written at a literacy level above that of a significant portion of the American population,” noted Dr. Bennett, a hematologist/oncologist who is an associate director for the Veterans Administration Midwest Center for Health Services and Policy Research.

In a randomized, controlled trial among veterans age 50 years and older seen in two general primary care clinics, the use of provider-directed interventions led to a 26% increase in screening completion among patients with low literacy skills, he said.

No prior study has evaluated the cost effectiveness of health-promotion efforts for colorectal cancer (CRC), but successful interventions have been shown to improve breast and cervical cancer screening rates, he said.

CRC is the third most common cancer in the United States, with the third highest mortality. The American Cancer Society predicts that more than 145,000 adults will be diagnosed with colorectal cancer in 2005 and that 56,000 will die from the disease.

Screening can reduce CRC-related mortality by detecting early-stage CRC. Screening strategies available include the fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, and double contrast barium enema.

The U.S. Preventive Services Task Force recommends CRC screening for average-risk individuals age 50 years and older, yet less than 53% of the eligible U.S. population has been screened for CRC. “Physician recommendation is the largest predictor of CRC screening guidance,” Dr. Bennett said.

The VA health care system measures screening rates at monthly intervals as part of its quality-enhancement research initiative. Of the 17 measures evaluated in this program, CRC screening has the lowest performance rates, he said. VA studies have not shown racial or ethnic differences in CRC survival rates, but African Americans insured by Medicare or private health insurance have lower 5-year survival rates than whites with the same insurance, Dr. Bennett said.

Veterans who use the VA health care services have especially low levels of health literacy. At the Jesse Brown VA Medical Center in Lakeside, Ill., only 42% of hospitalized VA patients have health literacy skills above the ninth-grade level, he said.

The trial to test health care provider-directed interventions took place at two primary care clinics at the Jesse Brown center from May 2001 to June 2003. One clinic served as the control site and the other was the intervention clinic. Each had three attending physicians and a staff of nurse practitioners and medical residents. Patients had to be at least age 50 years and be scheduled to be seen in one of the two outpatient clinics. Individuals were excluded if they had a personal or family history of polyps, CRC, or inflammatory bowel disease; had completed a FOBT in the preceding year; or had a flexible sigmoidoscopy or colonoscopy in the preceding 5 years.

In the intervention clinic, providers attended quarterly feedback sessions, focusing on individual and group feedback on CRC screening recommendation rates and patient adherence to recommended tests. The physicians and staff also received an overview of CRC screening guidelines as well as practical strategies to communicate with patients who have limited literacy skills. The “continuous quality improvement” (CQI) process–which applies scientific methods to the practice of medicine to help ease a physician's workload, increase patient satisfaction, and reduce malpractice exposure–was introduced to the participants.

Screening recommendation and completion were assessed by a review of electronic health records by research assistants.

Overall, the health care provider-directed intervention resulted in a 7% absolute increase in the rates of CRC screening recommendations, and a 9% absolute increase in the rates of CRC screening completion, Dr. Bennett reported.

Providers who attended at least one feedback session were more likely than those who attended no sessions to make a CRC screening recommendation. In addition, patients of providers who attended at least one feedback session were more likely than those who attended no sessions to adhere to CRC screening recommendations.

Respondents with limited literacy skills were more likely than others to be unfamiliar with CRC and other screening tests for CRC. They also appeared to be more skeptical about the screening process, complaining that an FOBT was inconvenient and messy, and stating they would not use an FOBT even if recommended by their physician. But they were more likely to believe that they were at average to high risk of developing CRC than higher literacy patients, Dr. Bennett said.

Among the patients with low literacy, the provider-directed intervention was associated with a 26% increase in screening completion, he reported.

“If information technology support could facilitate downloading of provider-specific CRC screening rates directly from the electronic medical records of the VA, then the intervention costs would substantially decrease,” Dr. Bennett said.

Because CRC screening rates have scored so low in the past within the VA, information technology improvements within the system are likely in the near future, he said.

WASHINGTON – Physician-directed interventions can increase rates of colorectal cancer screening in patients with low literacy skills, Dr. Charles Bennett reported at a conference on health literacy sponsored by the American College of Physicians Foundation.

Patients with limited literacy “may not be able to understand basic cancer screening information and educational materials, many of which are written at a literacy level above that of a significant portion of the American population,” noted Dr. Bennett, a hematologist/oncologist who is an associate director for the Veterans Administration Midwest Center for Health Services and Policy Research.

In a randomized, controlled trial among veterans age 50 years and older seen in two general primary care clinics, the use of provider-directed interventions led to a 26% increase in screening completion among patients with low literacy skills, he said.

No prior study has evaluated the cost effectiveness of health-promotion efforts for colorectal cancer (CRC), but successful interventions have been shown to improve breast and cervical cancer screening rates, he said.

CRC is the third most common cancer in the United States, with the third highest mortality. The American Cancer Society predicts that more than 145,000 adults will be diagnosed with colorectal cancer in 2005 and that 56,000 will die from the disease.

Screening can reduce CRC-related mortality by detecting early-stage CRC. Screening strategies available include the fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, and double contrast barium enema.

The U.S. Preventive Services Task Force recommends CRC screening for average-risk individuals age 50 years and older, yet less than 53% of the eligible U.S. population has been screened for CRC. “Physician recommendation is the largest predictor of CRC screening guidance,” Dr. Bennett said.

The VA health care system measures screening rates at monthly intervals as part of its quality-enhancement research initiative. Of the 17 measures evaluated in this program, CRC screening has the lowest performance rates, he said. VA studies have not shown racial or ethnic differences in CRC survival rates, but African Americans insured by Medicare or private health insurance have lower 5-year survival rates than whites with the same insurance, Dr. Bennett said.

Veterans who use the VA health care services have especially low levels of health literacy. At the Jesse Brown VA Medical Center in Lakeside, Ill., only 42% of hospitalized VA patients have health literacy skills above the ninth-grade level, he said.

The trial to test health care provider-directed interventions took place at two primary care clinics at the Jesse Brown center from May 2001 to June 2003. One clinic served as the control site and the other was the intervention clinic. Each had three attending physicians and a staff of nurse practitioners and medical residents. Patients had to be at least age 50 years and be scheduled to be seen in one of the two outpatient clinics. Individuals were excluded if they had a personal or family history of polyps, CRC, or inflammatory bowel disease; had completed a FOBT in the preceding year; or had a flexible sigmoidoscopy or colonoscopy in the preceding 5 years.

In the intervention clinic, providers attended quarterly feedback sessions, focusing on individual and group feedback on CRC screening recommendation rates and patient adherence to recommended tests. The physicians and staff also received an overview of CRC screening guidelines as well as practical strategies to communicate with patients who have limited literacy skills. The “continuous quality improvement” (CQI) process–which applies scientific methods to the practice of medicine to help ease a physician's workload, increase patient satisfaction, and reduce malpractice exposure–was introduced to the participants.

Screening recommendation and completion were assessed by a review of electronic health records by research assistants.

Overall, the health care provider-directed intervention resulted in a 7% absolute increase in the rates of CRC screening recommendations, and a 9% absolute increase in the rates of CRC screening completion, Dr. Bennett reported.

Providers who attended at least one feedback session were more likely than those who attended no sessions to make a CRC screening recommendation. In addition, patients of providers who attended at least one feedback session were more likely than those who attended no sessions to adhere to CRC screening recommendations.

Respondents with limited literacy skills were more likely than others to be unfamiliar with CRC and other screening tests for CRC. They also appeared to be more skeptical about the screening process, complaining that an FOBT was inconvenient and messy, and stating they would not use an FOBT even if recommended by their physician. But they were more likely to believe that they were at average to high risk of developing CRC than higher literacy patients, Dr. Bennett said.

Among the patients with low literacy, the provider-directed intervention was associated with a 26% increase in screening completion, he reported.

“If information technology support could facilitate downloading of provider-specific CRC screening rates directly from the electronic medical records of the VA, then the intervention costs would substantially decrease,” Dr. Bennett said.

Because CRC screening rates have scored so low in the past within the VA, information technology improvements within the system are likely in the near future, he said.

WASHINGTON — Researchers with the Medicare Payment Advisory Commission are measuring the quality of care delivered by physicians as part of an overall analysis of physician resource use.

"We hope to look at variation in quality performance, to do this across conditions, regions, and to some extent across specialties," Karen Milgate, a research director for the commission (MedPAC) said at a recent commission meeting. "We also hope to identify any gaps in quality measurement development that we can."

The ongoing research supports the commission's long-term goal of identifying more "efficient" providers, as a tool to encourage greater efficiency in care.

Variation in resource use may include cost of a service, types of services provided, or types of specialists that patients see, Ms. Milgate said in an interview. It could also mean variation in resource use across regions.

Using preliminary computer models, MedPAC researchers found variation in the cost of certain conditions.

For example, treatment of end-stage renal disease is fairly well defined, as the patient either requires long-term dialysis or a kidney transplant to stay alive. For that reason, average versus median costs for end-stage renal disease episodes don't vary that much, said MedPAC researcher Niall Brennan.

Significantly more variation in cost was seen in the care of hypertension, diabetes, and heart failure. In areas where there is tremendous variation in resource use, "we might want to [see] if there are any guidelines in those areas that would better help us understand appropriate resource use levels," Ms. Milgate said.

MedPAC could identify conditions with variation in resource use where there might also be high variation in quality, Ms. Milgate said. Those might become priority areas for coordination of care.

Researchers hope to address questions such as "how do you attribute the care of a particular beneficiary to a specific physician?" she said. The minimum number of cases needed to get a reliable measurement and with whom you actually compare a physician's performance are other considerations, Ms. Milgate said.

Ms. Milgate clarified that these claims-based measures would not necessarily be used in a pay-for-performance system.

"That's a pretty easy decision because we don't have that information" yet, she said. Researchers are planning to base this analysis on currently available information: claims data.

More than 35 indicators on conditions important to Medicare will be used to measure quality, Ms. Milgate said. "Most of them are primarily what we've talked about before as process measures. For example, for beneficiaries with coronary artery disease, did they have an annual lipid profile?" Outcomes measures would also be used. For example, for beneficiaries with diabetes, what proportion of them ended up in the hospital with short- or long-term complications that were related to their diabetic conditions, she said.

MedPAC earlier this year advised the Department of Health and Human Services to test different types of provider payment differentials, which would essentially offer monetary rewards—bonuses, for example—for meeting certain goals on health care quality.

MedPAC Chair Glenn M. Hackbarth, J.D., said he hoped that Congress was prepared to move ahead with pay-for-performance legislation. Several bills are pending to link relief from the sustainable growth rate formula to the implementation of a pay-for-performance system for physicians, he said.

"Obviously we support both ends of that bargain. We have argued that in order to assure access to quality of care, there does need to be some relief from the SGR. But at the same time, we think that it should be not just more money into the existing system, but one that consistently, in a more focused way, rewards good practice and quality of care."

WASHINGTON — Researchers with the Medicare Payment Advisory Commission are measuring the quality of care delivered by physicians as part of an overall analysis of physician resource use.

"We hope to look at variation in quality performance, to do this across conditions, regions, and to some extent across specialties," Karen Milgate, a research director for the commission (MedPAC) said at a recent commission meeting. "We also hope to identify any gaps in quality measurement development that we can."

The ongoing research supports the commission's long-term goal of identifying more "efficient" providers, as a tool to encourage greater efficiency in care.

Variation in resource use may include cost of a service, types of services provided, or types of specialists that patients see, Ms. Milgate said in an interview. It could also mean variation in resource use across regions.

Using preliminary computer models, MedPAC researchers found variation in the cost of certain conditions.

For example, treatment of end-stage renal disease is fairly well defined, as the patient either requires long-term dialysis or a kidney transplant to stay alive. For that reason, average versus median costs for end-stage renal disease episodes don't vary that much, said MedPAC researcher Niall Brennan.

Significantly more variation in cost was seen in the care of hypertension, diabetes, and heart failure. In areas where there is tremendous variation in resource use, "we might want to [see] if there are any guidelines in those areas that would better help us understand appropriate resource use levels," Ms. Milgate said.

MedPAC could identify conditions with variation in resource use where there might also be high variation in quality, Ms. Milgate said. Those might become priority areas for coordination of care.

Researchers hope to address questions such as "how do you attribute the care of a particular beneficiary to a specific physician?" she said. The minimum number of cases needed to get a reliable measurement and with whom you actually compare a physician's performance are other considerations, Ms. Milgate said.

Ms. Milgate clarified that these claims-based measures would not necessarily be used in a pay-for-performance system.

"That's a pretty easy decision because we don't have that information" yet, she said. Researchers are planning to base this analysis on currently available information: claims data.

More than 35 indicators on conditions important to Medicare will be used to measure quality, Ms. Milgate said. "Most of them are primarily what we've talked about before as process measures. For example, for beneficiaries with coronary artery disease, did they have an annual lipid profile?" Outcomes measures would also be used. For example, for beneficiaries with diabetes, what proportion of them ended up in the hospital with short- or long-term complications that were related to their diabetic conditions, she said.

MedPAC earlier this year advised the Department of Health and Human Services to test different types of provider payment differentials, which would essentially offer monetary rewards—bonuses, for example—for meeting certain goals on health care quality.

MedPAC Chair Glenn M. Hackbarth, J.D., said he hoped that Congress was prepared to move ahead with pay-for-performance legislation. Several bills are pending to link relief from the sustainable growth rate formula to the implementation of a pay-for-performance system for physicians, he said.

"Obviously we support both ends of that bargain. We have argued that in order to assure access to quality of care, there does need to be some relief from the SGR. But at the same time, we think that it should be not just more money into the existing system, but one that consistently, in a more focused way, rewards good practice and quality of care."

WASHINGTON — Researchers with the Medicare Payment Advisory Commission are measuring the quality of care delivered by physicians as part of an overall analysis of physician resource use.

"We hope to look at variation in quality performance, to do this across conditions, regions, and to some extent across specialties," Karen Milgate, a research director for the commission (MedPAC) said at a recent commission meeting. "We also hope to identify any gaps in quality measurement development that we can."

The ongoing research supports the commission's long-term goal of identifying more "efficient" providers, as a tool to encourage greater efficiency in care.

Variation in resource use may include cost of a service, types of services provided, or types of specialists that patients see, Ms. Milgate said in an interview. It could also mean variation in resource use across regions.

Using preliminary computer models, MedPAC researchers found variation in the cost of certain conditions.

For example, treatment of end-stage renal disease is fairly well defined, as the patient either requires long-term dialysis or a kidney transplant to stay alive. For that reason, average versus median costs for end-stage renal disease episodes don't vary that much, said MedPAC researcher Niall Brennan.

Significantly more variation in cost was seen in the care of hypertension, diabetes, and heart failure. In areas where there is tremendous variation in resource use, "we might want to [see] if there are any guidelines in those areas that would better help us understand appropriate resource use levels," Ms. Milgate said.

MedPAC could identify conditions with variation in resource use where there might also be high variation in quality, Ms. Milgate said. Those might become priority areas for coordination of care.

Researchers hope to address questions such as "how do you attribute the care of a particular beneficiary to a specific physician?" she said. The minimum number of cases needed to get a reliable measurement and with whom you actually compare a physician's performance are other considerations, Ms. Milgate said.

Ms. Milgate clarified that these claims-based measures would not necessarily be used in a pay-for-performance system.

"That's a pretty easy decision because we don't have that information" yet, she said. Researchers are planning to base this analysis on currently available information: claims data.

More than 35 indicators on conditions important to Medicare will be used to measure quality, Ms. Milgate said. "Most of them are primarily what we've talked about before as process measures. For example, for beneficiaries with coronary artery disease, did they have an annual lipid profile?" Outcomes measures would also be used. For example, for beneficiaries with diabetes, what proportion of them ended up in the hospital with short- or long-term complications that were related to their diabetic conditions, she said.

MedPAC earlier this year advised the Department of Health and Human Services to test different types of provider payment differentials, which would essentially offer monetary rewards—bonuses, for example—for meeting certain goals on health care quality.

MedPAC Chair Glenn M. Hackbarth, J.D., said he hoped that Congress was prepared to move ahead with pay-for-performance legislation. Several bills are pending to link relief from the sustainable growth rate formula to the implementation of a pay-for-performance system for physicians, he said.

"Obviously we support both ends of that bargain. We have argued that in order to assure access to quality of care, there does need to be some relief from the SGR. But at the same time, we think that it should be not just more money into the existing system, but one that consistently, in a more focused way, rewards good practice and quality of care."