Jennifer Silverman

Cardiologist John Levinson, M.D., has a multifaceted approach to health care.

In 2001, he established the first “concierge” practice in New England. But unlike other practices of this type, Dr. Levinson runs a “hybrid” practice that cares for retainer and regular insurance patients. Plus, he still finds time to see patients in the hospital.

This seems like an ambitious way to practice medicine, but in an interview, Dr. Levinson insisted that his hours have never been more manageable—and his patients are happier than they used to be.

Traditionally associated with high fees and a limited and wealthy patient base, concierge care—now often called “retainer care”—is morphing into a number of different types of practices, according to Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics.

Some practices are offering special programs for the indigent or providing various payment options for their patients. Or, in Dr. Levinson's case, they're providing specific types of care, such as cardiology/primary care.

The seeds of Dr. Levinson's practice evolved from the complaints of one very ill cardiac patient who had been under his care at Massachusetts General Hospital, Harvard Medical School, Boston, for several years. The patient ran a large corporation. In 2001, after an extended hospital stay, “he came into my office furious. I was sitting my desk, wondering if I'd done something wrong.” It turned out the patient was angry with the insurance company.

“He'd gotten the explanation of benefits statement which said the insurer had paid 25% of my charges.” Most doctors in Massachusetts get around 25%–30% of their charges, he said.

“But the bottom line was this patient felt he would not have made it through that hospital stay if it weren't for me, and he was worried about me working too hard. He wanted me to slow down so I wouldn't die before him, and he wanted me to be his primary care doctor, not just his cardiologist.”

While his practice initially started with this one patient in mind, it eventually turned into several practices, catering to different types of patients.

“The way my day works is, I drive to the hospital at 5 in the morning, see my inpatients until 8 a.m., then have a regular office day,” where he sees his retainer patients, along with the regular patients who are on Medicaid and other types of insurance. “That's one of my values, to accept patients into my practice regardless of whether they can pay or who's paying,” he said. At the end of the day, he goes back to the hospital to check on in his inpatients.

Overall, his practice includes approximately 7,500 patients, 40 of whom are retainer patients. There are two groups among the retainer patients. The first group uses Dr. Levinson as the primary care physician. Upon request, he later developed a cardiology-only retainer practice. “Some—about 25—use me for primary and cardiology care and the others are just cardiology patients.”

Those who want primary and cardiac care pay a higher annual fee than do the cardiac patients, he said. He would not disclose the fee, but said the retainer patients generally pay the fee annually.

“For every patient in my practice, retainer or otherwise, myself or another cardiologist is always available 24–7. That, of course, is the law in this country; it's only appropriate that patients get their doctor or some covering doctor when they need them. The difference with retainer care is there's never a covering physician between me and the patient. I'm personally available 24-7. They can arrange for a Saturday house call. When they make a routine visit, the appointments are always longer for patients in the retainer practice.”

This doesn't mean he neglects his regular patients, he said. Retainer patients know they might have to wait if they make a same-day appointment and he is busy treating an indigent patient in his regular practice. “I don't skip lines ethically.”

Dr. Levinson said he now has more time for all of his patients. “Oddly, I'm more available for everyone. I'm more relaxed in each session.” With more time for patients, it's like taking care of friends and family, he said.

Retainer practices have often been criticized for “double billing” patients—charging an access fee on top of regular services covered by insurance. According to BlueCross BlueShield of Massachusetts, “If you're an active member of our network you can't charge an access fee to patients,” Chris Murphy, spokesman for BCBS in Massachusetts, said in an interview. To charge such a fee, the physician would have to charge for services beyond the insurance company, he said.

Legislators in Massachusetts on several occasions have introduced a bill to limit these types of practices, requiring that any preferred-provider arrangement contain a provision barring the physician from charging an access fee to a covered person.

Dr. Levinson insists that his concierge fee pays for services not covered by the insurance contract, or by Medicare.

It pays for 24-7 access, which includes access at unusual times of the day, “but even if they come to my office for a normal medical visit, I'd bill [their insurer] for medical care provided.” In other words, his fee does not cover medical care.

As for the Massachusetts legislation, “so far it hasn't gone anywhere,” Dr. Levinson said.

At the time of the interview with Dr. Levinson, the Government Accountability Office was planning to issue a report on the impact of retainer medicine on Medicare.

“We are hopeful it will show that retainer care is a very small part of American health care without any significant impact across the board,” he said.

And indeed, the GAO's report, issued in August, concluded: “The small number of concierge physicians at the time of our review, along with information from available measures of access to services, suggests that concierge care does not present a systemic access problem for Medicare beneficiaries at this time.”

Cardiologist John Levinson, M.D., has a multifaceted approach to health care.

In 2001, he established the first “concierge” practice in New England. But unlike other practices of this type, Dr. Levinson runs a “hybrid” practice that cares for retainer and regular insurance patients. Plus, he still finds time to see patients in the hospital.

This seems like an ambitious way to practice medicine, but in an interview, Dr. Levinson insisted that his hours have never been more manageable—and his patients are happier than they used to be.

Traditionally associated with high fees and a limited and wealthy patient base, concierge care—now often called “retainer care”—is morphing into a number of different types of practices, according to Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics.

Some practices are offering special programs for the indigent or providing various payment options for their patients. Or, in Dr. Levinson's case, they're providing specific types of care, such as cardiology/primary care.

The seeds of Dr. Levinson's practice evolved from the complaints of one very ill cardiac patient who had been under his care at Massachusetts General Hospital, Harvard Medical School, Boston, for several years. The patient ran a large corporation. In 2001, after an extended hospital stay, “he came into my office furious. I was sitting my desk, wondering if I'd done something wrong.” It turned out the patient was angry with the insurance company.

“He'd gotten the explanation of benefits statement which said the insurer had paid 25% of my charges.” Most doctors in Massachusetts get around 25%–30% of their charges, he said.

“But the bottom line was this patient felt he would not have made it through that hospital stay if it weren't for me, and he was worried about me working too hard. He wanted me to slow down so I wouldn't die before him, and he wanted me to be his primary care doctor, not just his cardiologist.”

While his practice initially started with this one patient in mind, it eventually turned into several practices, catering to different types of patients.

“The way my day works is, I drive to the hospital at 5 in the morning, see my inpatients until 8 a.m., then have a regular office day,” where he sees his retainer patients, along with the regular patients who are on Medicaid and other types of insurance. “That's one of my values, to accept patients into my practice regardless of whether they can pay or who's paying,” he said. At the end of the day, he goes back to the hospital to check on in his inpatients.

Overall, his practice includes approximately 7,500 patients, 40 of whom are retainer patients. There are two groups among the retainer patients. The first group uses Dr. Levinson as the primary care physician. Upon request, he later developed a cardiology-only retainer practice. “Some—about 25—use me for primary and cardiology care and the others are just cardiology patients.”

Those who want primary and cardiac care pay a higher annual fee than do the cardiac patients, he said. He would not disclose the fee, but said the retainer patients generally pay the fee annually.

“For every patient in my practice, retainer or otherwise, myself or another cardiologist is always available 24–7. That, of course, is the law in this country; it's only appropriate that patients get their doctor or some covering doctor when they need them. The difference with retainer care is there's never a covering physician between me and the patient. I'm personally available 24-7. They can arrange for a Saturday house call. When they make a routine visit, the appointments are always longer for patients in the retainer practice.”

This doesn't mean he neglects his regular patients, he said. Retainer patients know they might have to wait if they make a same-day appointment and he is busy treating an indigent patient in his regular practice. “I don't skip lines ethically.”

Dr. Levinson said he now has more time for all of his patients. “Oddly, I'm more available for everyone. I'm more relaxed in each session.” With more time for patients, it's like taking care of friends and family, he said.

Retainer practices have often been criticized for “double billing” patients—charging an access fee on top of regular services covered by insurance. According to BlueCross BlueShield of Massachusetts, “If you're an active member of our network you can't charge an access fee to patients,” Chris Murphy, spokesman for BCBS in Massachusetts, said in an interview. To charge such a fee, the physician would have to charge for services beyond the insurance company, he said.

Legislators in Massachusetts on several occasions have introduced a bill to limit these types of practices, requiring that any preferred-provider arrangement contain a provision barring the physician from charging an access fee to a covered person.

Dr. Levinson insists that his concierge fee pays for services not covered by the insurance contract, or by Medicare.

It pays for 24-7 access, which includes access at unusual times of the day, “but even if they come to my office for a normal medical visit, I'd bill [their insurer] for medical care provided.” In other words, his fee does not cover medical care.

As for the Massachusetts legislation, “so far it hasn't gone anywhere,” Dr. Levinson said.

At the time of the interview with Dr. Levinson, the Government Accountability Office was planning to issue a report on the impact of retainer medicine on Medicare.

“We are hopeful it will show that retainer care is a very small part of American health care without any significant impact across the board,” he said.

And indeed, the GAO's report, issued in August, concluded: “The small number of concierge physicians at the time of our review, along with information from available measures of access to services, suggests that concierge care does not present a systemic access problem for Medicare beneficiaries at this time.”

Cardiologist John Levinson, M.D., has a multifaceted approach to health care.

In 2001, he established the first “concierge” practice in New England. But unlike other practices of this type, Dr. Levinson runs a “hybrid” practice that cares for retainer and regular insurance patients. Plus, he still finds time to see patients in the hospital.

This seems like an ambitious way to practice medicine, but in an interview, Dr. Levinson insisted that his hours have never been more manageable—and his patients are happier than they used to be.

Traditionally associated with high fees and a limited and wealthy patient base, concierge care—now often called “retainer care”—is morphing into a number of different types of practices, according to Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics.

Some practices are offering special programs for the indigent or providing various payment options for their patients. Or, in Dr. Levinson's case, they're providing specific types of care, such as cardiology/primary care.

The seeds of Dr. Levinson's practice evolved from the complaints of one very ill cardiac patient who had been under his care at Massachusetts General Hospital, Harvard Medical School, Boston, for several years. The patient ran a large corporation. In 2001, after an extended hospital stay, “he came into my office furious. I was sitting my desk, wondering if I'd done something wrong.” It turned out the patient was angry with the insurance company.

“He'd gotten the explanation of benefits statement which said the insurer had paid 25% of my charges.” Most doctors in Massachusetts get around 25%–30% of their charges, he said.

“But the bottom line was this patient felt he would not have made it through that hospital stay if it weren't for me, and he was worried about me working too hard. He wanted me to slow down so I wouldn't die before him, and he wanted me to be his primary care doctor, not just his cardiologist.”

While his practice initially started with this one patient in mind, it eventually turned into several practices, catering to different types of patients.

“The way my day works is, I drive to the hospital at 5 in the morning, see my inpatients until 8 a.m., then have a regular office day,” where he sees his retainer patients, along with the regular patients who are on Medicaid and other types of insurance. “That's one of my values, to accept patients into my practice regardless of whether they can pay or who's paying,” he said. At the end of the day, he goes back to the hospital to check on in his inpatients.

Overall, his practice includes approximately 7,500 patients, 40 of whom are retainer patients. There are two groups among the retainer patients. The first group uses Dr. Levinson as the primary care physician. Upon request, he later developed a cardiology-only retainer practice. “Some—about 25—use me for primary and cardiology care and the others are just cardiology patients.”

Those who want primary and cardiac care pay a higher annual fee than do the cardiac patients, he said. He would not disclose the fee, but said the retainer patients generally pay the fee annually.

“For every patient in my practice, retainer or otherwise, myself or another cardiologist is always available 24–7. That, of course, is the law in this country; it's only appropriate that patients get their doctor or some covering doctor when they need them. The difference with retainer care is there's never a covering physician between me and the patient. I'm personally available 24-7. They can arrange for a Saturday house call. When they make a routine visit, the appointments are always longer for patients in the retainer practice.”

This doesn't mean he neglects his regular patients, he said. Retainer patients know they might have to wait if they make a same-day appointment and he is busy treating an indigent patient in his regular practice. “I don't skip lines ethically.”

Dr. Levinson said he now has more time for all of his patients. “Oddly, I'm more available for everyone. I'm more relaxed in each session.” With more time for patients, it's like taking care of friends and family, he said.

Retainer practices have often been criticized for “double billing” patients—charging an access fee on top of regular services covered by insurance. According to BlueCross BlueShield of Massachusetts, “If you're an active member of our network you can't charge an access fee to patients,” Chris Murphy, spokesman for BCBS in Massachusetts, said in an interview. To charge such a fee, the physician would have to charge for services beyond the insurance company, he said.

Legislators in Massachusetts on several occasions have introduced a bill to limit these types of practices, requiring that any preferred-provider arrangement contain a provision barring the physician from charging an access fee to a covered person.

Dr. Levinson insists that his concierge fee pays for services not covered by the insurance contract, or by Medicare.

It pays for 24-7 access, which includes access at unusual times of the day, “but even if they come to my office for a normal medical visit, I'd bill [their insurer] for medical care provided.” In other words, his fee does not cover medical care.

As for the Massachusetts legislation, “so far it hasn't gone anywhere,” Dr. Levinson said.

At the time of the interview with Dr. Levinson, the Government Accountability Office was planning to issue a report on the impact of retainer medicine on Medicare.

“We are hopeful it will show that retainer care is a very small part of American health care without any significant impact across the board,” he said.

And indeed, the GAO's report, issued in August, concluded: “The small number of concierge physicians at the time of our review, along with information from available measures of access to services, suggests that concierge care does not present a systemic access problem for Medicare beneficiaries at this time.”

Preparing for a Pandemic

The Department of Health and Human Services is taking steps to avoid a flu pandemic this year, purchasing additional vaccine and antiviral medications that will be placed in the nation's Strategic National Stockpile. Sanofi Pasteur received a $100 million contract to manufacture avian influenza vaccine designed to protect against the H5N1 influenza virus strain, which has caused an epidemic of avian flu in Asia. The number of individuals who could be protected by the newly contracted vaccine is still to be determined by ongoing clinical studies, HHS said. In addition, HHS awarded a $2.8 million contract to GlaxoSmithKline for 84,300 treatment courses of zanamivir (Relenza). These purchases build upon a plan to buy enough vaccine for 20 million people and enough antivirals for another 20 million people. “These countermeasures provide us with tools that we have never had prior to previous influenza pandemics,” HHS Secretary Mike Leavitt said in a statement.

Most Likely to Be Uninsured

The proportion and number of uninsured children did not change in 2004, remaining at 11.2% or 8.3 million, the Census Bureau reported in its annual survey on income, poverty, and health insurance. With the 2004 uninsured rate at 19%, children in poverty were more likely to be uninsured than other children not classified as being in poverty. Children with special health care needs are also at risk, the Center for Studying Health System Change concluded in a separate report. In 2003, an estimated 13.5 million children had a special health care need, defined as an ongoing physical, emotional, behavioral, developmental, or other condition causing them to use more health services or limit their activities. While public health insurance covered nearly two out of five of these children, about 650,000 were uninsured. Children with special health care needs also are less likely to have private insurance, and almost twice as likely to have had an unmet need for medical care in the past year.

Greater Folic Acid Fortification

Officials at the March of Dimes are calling on the U.S. government to require higher levels of folic acid fortification in grain foods. The request, which reflects a long-held policy of the March of Dimes, comes on the heels of research showing that folic acid fortification in grain foods has resulted in a one-third drop in serious birth defects of the brain and spine. The Food and Drug Administration requires 140 mcg of folic acid per 100 g of grain. Since 1996, the March of Dimes has recommended the FDA set the level in enriched grain foods at 350 mcg per 100 g of grain.

Reporting Neonatal Herpes

A group of experts in obstetrics and gynecology and pediatrics is calling on the Centers for Disease Control and Prevention to request reporting of cases of neonatal herpes from all states and U.S. territories. The call to action, which was published in the September issue of the journal Sexually Transmitted Diseases, notes that a lack of reliable epidemiological data may be partly responsible for the continued development of neonatal herpes cases. While diseases such as congenital syphilis are reportable in 47 states, only 7 states—Connecticut, Florida, Massachusetts, Nebraska, Ohio, South Dakota, and Washington—require reporting of neonatal herpes. The CDC can request reports on various conditions, but the states have the regulatory authority to require reporting. The epidemiological data from reported cases of neonatal herpes would help to resolve debates over testing, treatment, and prevention strategies, the researchers wrote. The analysis was supported by GlaxoSmithKline Inc.

Obesity in California

California's children seem to have a weight problem, especially in the largest cities, a study from the California Center for Public Health Advocacy reported. Using data from the California Physical Fitness Test, which is administered in public schools to grades 5, 7, and 9, the study showed overweight rates rose 6% over 3 years, to 28.1 per 100 children in 2004 from 26.5 per 100 children in 2001. The increase occurred among boys and girls and among children of all racial/ethnic backgrounds. Seven of the 10 largest cities in California had rates of childhood overweight in 2004 that were higher than the statewide average, with rates from 36% in Los Angeles to 24% in San Francisco. In 65% of California counties, at least one in four children was overweight. The center called for policies to support parents in providing opportunities for their children to make healthy choices about eating and activity, and for state and local leaders to address the problem in schools and communities.

Preparing for a Pandemic

The Department of Health and Human Services is taking steps to avoid a flu pandemic this year, purchasing additional vaccine and antiviral medications that will be placed in the nation's Strategic National Stockpile. Sanofi Pasteur received a $100 million contract to manufacture avian influenza vaccine designed to protect against the H5N1 influenza virus strain, which has caused an epidemic of avian flu in Asia. The number of individuals who could be protected by the newly contracted vaccine is still to be determined by ongoing clinical studies, HHS said. In addition, HHS awarded a $2.8 million contract to GlaxoSmithKline for 84,300 treatment courses of zanamivir (Relenza). These purchases build upon a plan to buy enough vaccine for 20 million people and enough antivirals for another 20 million people. “These countermeasures provide us with tools that we have never had prior to previous influenza pandemics,” HHS Secretary Mike Leavitt said in a statement.

Most Likely to Be Uninsured

The proportion and number of uninsured children did not change in 2004, remaining at 11.2% or 8.3 million, the Census Bureau reported in its annual survey on income, poverty, and health insurance. With the 2004 uninsured rate at 19%, children in poverty were more likely to be uninsured than other children not classified as being in poverty. Children with special health care needs are also at risk, the Center for Studying Health System Change concluded in a separate report. In 2003, an estimated 13.5 million children had a special health care need, defined as an ongoing physical, emotional, behavioral, developmental, or other condition causing them to use more health services or limit their activities. While public health insurance covered nearly two out of five of these children, about 650,000 were uninsured. Children with special health care needs also are less likely to have private insurance, and almost twice as likely to have had an unmet need for medical care in the past year.

Greater Folic Acid Fortification

Officials at the March of Dimes are calling on the U.S. government to require higher levels of folic acid fortification in grain foods. The request, which reflects a long-held policy of the March of Dimes, comes on the heels of research showing that folic acid fortification in grain foods has resulted in a one-third drop in serious birth defects of the brain and spine. The Food and Drug Administration requires 140 mcg of folic acid per 100 g of grain. Since 1996, the March of Dimes has recommended the FDA set the level in enriched grain foods at 350 mcg per 100 g of grain.

Reporting Neonatal Herpes

A group of experts in obstetrics and gynecology and pediatrics is calling on the Centers for Disease Control and Prevention to request reporting of cases of neonatal herpes from all states and U.S. territories. The call to action, which was published in the September issue of the journal Sexually Transmitted Diseases, notes that a lack of reliable epidemiological data may be partly responsible for the continued development of neonatal herpes cases. While diseases such as congenital syphilis are reportable in 47 states, only 7 states—Connecticut, Florida, Massachusetts, Nebraska, Ohio, South Dakota, and Washington—require reporting of neonatal herpes. The CDC can request reports on various conditions, but the states have the regulatory authority to require reporting. The epidemiological data from reported cases of neonatal herpes would help to resolve debates over testing, treatment, and prevention strategies, the researchers wrote. The analysis was supported by GlaxoSmithKline Inc.

Obesity in California

California's children seem to have a weight problem, especially in the largest cities, a study from the California Center for Public Health Advocacy reported. Using data from the California Physical Fitness Test, which is administered in public schools to grades 5, 7, and 9, the study showed overweight rates rose 6% over 3 years, to 28.1 per 100 children in 2004 from 26.5 per 100 children in 2001. The increase occurred among boys and girls and among children of all racial/ethnic backgrounds. Seven of the 10 largest cities in California had rates of childhood overweight in 2004 that were higher than the statewide average, with rates from 36% in Los Angeles to 24% in San Francisco. In 65% of California counties, at least one in four children was overweight. The center called for policies to support parents in providing opportunities for their children to make healthy choices about eating and activity, and for state and local leaders to address the problem in schools and communities.

Preparing for a Pandemic

The Department of Health and Human Services is taking steps to avoid a flu pandemic this year, purchasing additional vaccine and antiviral medications that will be placed in the nation's Strategic National Stockpile. Sanofi Pasteur received a $100 million contract to manufacture avian influenza vaccine designed to protect against the H5N1 influenza virus strain, which has caused an epidemic of avian flu in Asia. The number of individuals who could be protected by the newly contracted vaccine is still to be determined by ongoing clinical studies, HHS said. In addition, HHS awarded a $2.8 million contract to GlaxoSmithKline for 84,300 treatment courses of zanamivir (Relenza). These purchases build upon a plan to buy enough vaccine for 20 million people and enough antivirals for another 20 million people. “These countermeasures provide us with tools that we have never had prior to previous influenza pandemics,” HHS Secretary Mike Leavitt said in a statement.

Most Likely to Be Uninsured

The proportion and number of uninsured children did not change in 2004, remaining at 11.2% or 8.3 million, the Census Bureau reported in its annual survey on income, poverty, and health insurance. With the 2004 uninsured rate at 19%, children in poverty were more likely to be uninsured than other children not classified as being in poverty. Children with special health care needs are also at risk, the Center for Studying Health System Change concluded in a separate report. In 2003, an estimated 13.5 million children had a special health care need, defined as an ongoing physical, emotional, behavioral, developmental, or other condition causing them to use more health services or limit their activities. While public health insurance covered nearly two out of five of these children, about 650,000 were uninsured. Children with special health care needs also are less likely to have private insurance, and almost twice as likely to have had an unmet need for medical care in the past year.

Greater Folic Acid Fortification

Officials at the March of Dimes are calling on the U.S. government to require higher levels of folic acid fortification in grain foods. The request, which reflects a long-held policy of the March of Dimes, comes on the heels of research showing that folic acid fortification in grain foods has resulted in a one-third drop in serious birth defects of the brain and spine. The Food and Drug Administration requires 140 mcg of folic acid per 100 g of grain. Since 1996, the March of Dimes has recommended the FDA set the level in enriched grain foods at 350 mcg per 100 g of grain.

Reporting Neonatal Herpes

A group of experts in obstetrics and gynecology and pediatrics is calling on the Centers for Disease Control and Prevention to request reporting of cases of neonatal herpes from all states and U.S. territories. The call to action, which was published in the September issue of the journal Sexually Transmitted Diseases, notes that a lack of reliable epidemiological data may be partly responsible for the continued development of neonatal herpes cases. While diseases such as congenital syphilis are reportable in 47 states, only 7 states—Connecticut, Florida, Massachusetts, Nebraska, Ohio, South Dakota, and Washington—require reporting of neonatal herpes. The CDC can request reports on various conditions, but the states have the regulatory authority to require reporting. The epidemiological data from reported cases of neonatal herpes would help to resolve debates over testing, treatment, and prevention strategies, the researchers wrote. The analysis was supported by GlaxoSmithKline Inc.

Obesity in California

California's children seem to have a weight problem, especially in the largest cities, a study from the California Center for Public Health Advocacy reported. Using data from the California Physical Fitness Test, which is administered in public schools to grades 5, 7, and 9, the study showed overweight rates rose 6% over 3 years, to 28.1 per 100 children in 2004 from 26.5 per 100 children in 2001. The increase occurred among boys and girls and among children of all racial/ethnic backgrounds. Seven of the 10 largest cities in California had rates of childhood overweight in 2004 that were higher than the statewide average, with rates from 36% in Los Angeles to 24% in San Francisco. In 65% of California counties, at least one in four children was overweight. The center called for policies to support parents in providing opportunities for their children to make healthy choices about eating and activity, and for state and local leaders to address the problem in schools and communities.

Christopher Magiera, M.D., said he paid $30,000 a year for malpractice insurance when he worked as a gastroenterologist in Cleveland.

Since his 2003 move to Wisconsin—a state known for its desirable practice climate, its tort reforms, and its cap on noneconomic damages—Dr. Magiera watched that premium shrink to about $5,000 a year, which included a contribution to the state's compensation fund for patients.

“Private insurers had been giving us low rates because they knew the medical liability environment was very stable,” he said.

His premiums soon may go up again, due to a recent decision by the Wisconsin Supreme Court to remove the longstanding cap on noneconomic damages in malpractice cases.

The cap was instituted decades ago, but was reduced to $250,000 in 1995. With inflation adjustments, the cap had increased to $445,775 in 2005.

The case that killed the cap involved a patient who suffered a brachial plexus injury during birth, David Lowe, a partner with Jacquart & Lowe S.C., a Milwaukee firm that specializes in medical malpractice, told this newspaper. Although a lower court had sustained the cap, the Wisconsin high court ruled that the cap was unconstitutional beyond a reasonable doubt.

“We'll have to see what the climate does and how the situation changes,” Mark Belknap, M.D., president of Wisconsin Medical Society, said in an interview. But without a limit on pain and suffering, physicians are already concerned that their future may involve higher claims and that plaintiff attorneys will be encouraged to file more lawsuits.

Like many physicians, Dr. Magiera and his wife, Pamela Galloway, M.D., a general surgeon, considered moving when malpractice premiums in their state shot up.

Premiums in Ohio, a state the American Medical Association classifies as a “crisis state” for malpractice, were getting out of control, Dr. Magiera said in an interview. An insurance agent had told Dr. Galloway that her annual premiums were going to increase from $33,000 to $100,000.

“We didn't see a future in Cleveland. It was going to be economically unfeasible for my wife to maintain a profit, and while that's not what medicine is all about, you don't want to work for a zero balance, either,” Dr. Magiera said.

Wisconsin, one of six states that the AMA classified as the best for tort reform, “had the most perfect of all conditions,” he said.

The state requires that physicians carry $1 million worth of liability insurance, then contribute to a compensation fund for injured patients and their families.

“If you have a judgment against you, your insurance picks up the first million, and the fund picks up everything else,” Dr. Magiera said.

A physician's contribution to the fund depends on the risk of the specialty, said Dr. Belknap, an internist in Ashland, Wis.

These favorable practice conditions had encouraged physicians to relocate to Dr. Belknap's town on Lake Superior. For example, “we recruited two general surgeons from states that didn't have good climates.” Ashland had also acquired an ob.gyn. who practices obstetrics. “They wouldn't have come, had the caps been eliminated.”

Shawn Hennigan, M.D., an orthopedic surgeon in Green Bay, is another transplant. In 2003 he moved from Pennsylvania, one of the liability hotbeds of the country, leaving behind a potential annual premium of $100,000.

But if claims and payouts begin to increase under this new ruling in Wisconsin, so will the premiums, Dr. Hennigan predicted.

The cap's elimination may change the way insurance companies approach these cases, Mr. Lowe said. “Until now, the insurers knew that the cap would be their worst day in court … and they'd force plaintiffs to trial, hoping there would be a result [that would be] less than the cap.” Its elimination may not bode well for insurers, but from the patient's perspective, it means that meritorious claims will settle rather than being forced to trial, he said.

The cap's removal will also permit elderly, retired victims, who have less economic damages (such as wage loss) to have their cases accepted, “because their pain and suffering may now be compensated at a higher level.” At the same time, attorneys may be more willing to represent these patients, because “the upside potential for compensation in these cases is somewhat greater,” Dr. Belknap said.

Insurers are still assessing the situation, he said. However, “if the climate worsens, people reaching middle age or near retirement will retire early if they see the risks are going up.”

Dr. Magiera said he isn't sorry he moved to Wisconsin. Because the tort reforms were approved more than a decade ago, the public in Wisconsin has not been culturally indoctrinated into the lawsuit mentality, he said. “I think there is the potential of restoring stability here.”

Efforts currently are underway to have the cap reinstated.

Rep. John Gard (R-Peshtigo), speaker of the Wisconsin state assembly, recently formed a medical malpractice task force to examine the issue.

“This shortsighted ruling jeopardizes quality health care for every resident in the state, especially for folks in rural areas,” Rep. Gard said in a statement. “Wisconsin was a nationwide model for medical malpractice reform. That law made us a destination state for good doctors. We will work hard this fall to regain that title.”

The task force should come up with legislation in time for the fall session that would restore Wisconsin's reputation for quality health care, he said.

The key is to craft legislation that would pass the muster of the Supreme Court, Dr. Magiera said, adding that another option would be to push for a constitutional amendment that would allow reinstatement of the cap.

This Month's Talk Back Question

How do you view the role of state-imposed caps on noneconomic damages in malpractice cases?

Christopher Magiera, M.D., said he paid $30,000 a year for malpractice insurance when he worked as a gastroenterologist in Cleveland.

Since his 2003 move to Wisconsin—a state known for its desirable practice climate, its tort reforms, and its cap on noneconomic damages—Dr. Magiera watched that premium shrink to about $5,000 a year, which included a contribution to the state's compensation fund for patients.

“Private insurers had been giving us low rates because they knew the medical liability environment was very stable,” he said.

His premiums soon may go up again, due to a recent decision by the Wisconsin Supreme Court to remove the longstanding cap on noneconomic damages in malpractice cases.

The cap was instituted decades ago, but was reduced to $250,000 in 1995. With inflation adjustments, the cap had increased to $445,775 in 2005.

The case that killed the cap involved a patient who suffered a brachial plexus injury during birth, David Lowe, a partner with Jacquart & Lowe S.C., a Milwaukee firm that specializes in medical malpractice, told this newspaper. Although a lower court had sustained the cap, the Wisconsin high court ruled that the cap was unconstitutional beyond a reasonable doubt.

“We'll have to see what the climate does and how the situation changes,” Mark Belknap, M.D., president of Wisconsin Medical Society, said in an interview. But without a limit on pain and suffering, physicians are already concerned that their future may involve higher claims and that plaintiff attorneys will be encouraged to file more lawsuits.

Like many physicians, Dr. Magiera and his wife, Pamela Galloway, M.D., a general surgeon, considered moving when malpractice premiums in their state shot up.

Premiums in Ohio, a state the American Medical Association classifies as a “crisis state” for malpractice, were getting out of control, Dr. Magiera said in an interview. An insurance agent had told Dr. Galloway that her annual premiums were going to increase from $33,000 to $100,000.

“We didn't see a future in Cleveland. It was going to be economically unfeasible for my wife to maintain a profit, and while that's not what medicine is all about, you don't want to work for a zero balance, either,” Dr. Magiera said.

Wisconsin, one of six states that the AMA classified as the best for tort reform, “had the most perfect of all conditions,” he said.

The state requires that physicians carry $1 million worth of liability insurance, then contribute to a compensation fund for injured patients and their families.

“If you have a judgment against you, your insurance picks up the first million, and the fund picks up everything else,” Dr. Magiera said.

A physician's contribution to the fund depends on the risk of the specialty, said Dr. Belknap, an internist in Ashland, Wis.

These favorable practice conditions had encouraged physicians to relocate to Dr. Belknap's town on Lake Superior. For example, “we recruited two general surgeons from states that didn't have good climates.” Ashland had also acquired an ob.gyn. who practices obstetrics. “They wouldn't have come, had the caps been eliminated.”

Shawn Hennigan, M.D., an orthopedic surgeon in Green Bay, is another transplant. In 2003 he moved from Pennsylvania, one of the liability hotbeds of the country, leaving behind a potential annual premium of $100,000.

But if claims and payouts begin to increase under this new ruling in Wisconsin, so will the premiums, Dr. Hennigan predicted.

The cap's elimination may change the way insurance companies approach these cases, Mr. Lowe said. “Until now, the insurers knew that the cap would be their worst day in court … and they'd force plaintiffs to trial, hoping there would be a result [that would be] less than the cap.” Its elimination may not bode well for insurers, but from the patient's perspective, it means that meritorious claims will settle rather than being forced to trial, he said.

The cap's removal will also permit elderly, retired victims, who have less economic damages (such as wage loss) to have their cases accepted, “because their pain and suffering may now be compensated at a higher level.” At the same time, attorneys may be more willing to represent these patients, because “the upside potential for compensation in these cases is somewhat greater,” Dr. Belknap said.

Insurers are still assessing the situation, he said. However, “if the climate worsens, people reaching middle age or near retirement will retire early if they see the risks are going up.”

Dr. Magiera said he isn't sorry he moved to Wisconsin. Because the tort reforms were approved more than a decade ago, the public in Wisconsin has not been culturally indoctrinated into the lawsuit mentality, he said. “I think there is the potential of restoring stability here.”

Efforts currently are underway to have the cap reinstated.

Rep. John Gard (R-Peshtigo), speaker of the Wisconsin state assembly, recently formed a medical malpractice task force to examine the issue.

“This shortsighted ruling jeopardizes quality health care for every resident in the state, especially for folks in rural areas,” Rep. Gard said in a statement. “Wisconsin was a nationwide model for medical malpractice reform. That law made us a destination state for good doctors. We will work hard this fall to regain that title.”

The task force should come up with legislation in time for the fall session that would restore Wisconsin's reputation for quality health care, he said.

The key is to craft legislation that would pass the muster of the Supreme Court, Dr. Magiera said, adding that another option would be to push for a constitutional amendment that would allow reinstatement of the cap.

This Month's Talk Back Question

How do you view the role of state-imposed caps on noneconomic damages in malpractice cases?

Christopher Magiera, M.D., said he paid $30,000 a year for malpractice insurance when he worked as a gastroenterologist in Cleveland.

Since his 2003 move to Wisconsin—a state known for its desirable practice climate, its tort reforms, and its cap on noneconomic damages—Dr. Magiera watched that premium shrink to about $5,000 a year, which included a contribution to the state's compensation fund for patients.

“Private insurers had been giving us low rates because they knew the medical liability environment was very stable,” he said.

His premiums soon may go up again, due to a recent decision by the Wisconsin Supreme Court to remove the longstanding cap on noneconomic damages in malpractice cases.

The cap was instituted decades ago, but was reduced to $250,000 in 1995. With inflation adjustments, the cap had increased to $445,775 in 2005.

The case that killed the cap involved a patient who suffered a brachial plexus injury during birth, David Lowe, a partner with Jacquart & Lowe S.C., a Milwaukee firm that specializes in medical malpractice, told this newspaper. Although a lower court had sustained the cap, the Wisconsin high court ruled that the cap was unconstitutional beyond a reasonable doubt.

“We'll have to see what the climate does and how the situation changes,” Mark Belknap, M.D., president of Wisconsin Medical Society, said in an interview. But without a limit on pain and suffering, physicians are already concerned that their future may involve higher claims and that plaintiff attorneys will be encouraged to file more lawsuits.

Like many physicians, Dr. Magiera and his wife, Pamela Galloway, M.D., a general surgeon, considered moving when malpractice premiums in their state shot up.

Premiums in Ohio, a state the American Medical Association classifies as a “crisis state” for malpractice, were getting out of control, Dr. Magiera said in an interview. An insurance agent had told Dr. Galloway that her annual premiums were going to increase from $33,000 to $100,000.

“We didn't see a future in Cleveland. It was going to be economically unfeasible for my wife to maintain a profit, and while that's not what medicine is all about, you don't want to work for a zero balance, either,” Dr. Magiera said.

Wisconsin, one of six states that the AMA classified as the best for tort reform, “had the most perfect of all conditions,” he said.

The state requires that physicians carry $1 million worth of liability insurance, then contribute to a compensation fund for injured patients and their families.

“If you have a judgment against you, your insurance picks up the first million, and the fund picks up everything else,” Dr. Magiera said.

A physician's contribution to the fund depends on the risk of the specialty, said Dr. Belknap, an internist in Ashland, Wis.

These favorable practice conditions had encouraged physicians to relocate to Dr. Belknap's town on Lake Superior. For example, “we recruited two general surgeons from states that didn't have good climates.” Ashland had also acquired an ob.gyn. who practices obstetrics. “They wouldn't have come, had the caps been eliminated.”

Shawn Hennigan, M.D., an orthopedic surgeon in Green Bay, is another transplant. In 2003 he moved from Pennsylvania, one of the liability hotbeds of the country, leaving behind a potential annual premium of $100,000.

But if claims and payouts begin to increase under this new ruling in Wisconsin, so will the premiums, Dr. Hennigan predicted.

The cap's elimination may change the way insurance companies approach these cases, Mr. Lowe said. “Until now, the insurers knew that the cap would be their worst day in court … and they'd force plaintiffs to trial, hoping there would be a result [that would be] less than the cap.” Its elimination may not bode well for insurers, but from the patient's perspective, it means that meritorious claims will settle rather than being forced to trial, he said.

The cap's removal will also permit elderly, retired victims, who have less economic damages (such as wage loss) to have their cases accepted, “because their pain and suffering may now be compensated at a higher level.” At the same time, attorneys may be more willing to represent these patients, because “the upside potential for compensation in these cases is somewhat greater,” Dr. Belknap said.

Insurers are still assessing the situation, he said. However, “if the climate worsens, people reaching middle age or near retirement will retire early if they see the risks are going up.”

Dr. Magiera said he isn't sorry he moved to Wisconsin. Because the tort reforms were approved more than a decade ago, the public in Wisconsin has not been culturally indoctrinated into the lawsuit mentality, he said. “I think there is the potential of restoring stability here.”

Efforts currently are underway to have the cap reinstated.

Rep. John Gard (R-Peshtigo), speaker of the Wisconsin state assembly, recently formed a medical malpractice task force to examine the issue.

“This shortsighted ruling jeopardizes quality health care for every resident in the state, especially for folks in rural areas,” Rep. Gard said in a statement. “Wisconsin was a nationwide model for medical malpractice reform. That law made us a destination state for good doctors. We will work hard this fall to regain that title.”

The task force should come up with legislation in time for the fall session that would restore Wisconsin's reputation for quality health care, he said.

The key is to craft legislation that would pass the muster of the Supreme Court, Dr. Magiera said, adding that another option would be to push for a constitutional amendment that would allow reinstatement of the cap.

This Month's Talk Back Question

How do you view the role of state-imposed caps on noneconomic damages in malpractice cases?

An obesity-prevention initiative chartered by the American Diabetes Association aims provide leadership and information “to help families and communities make improved nutrition and greater physical activity a priority, especially for children,” said Michael Jensen, M.D., president of the new organization called Shaping America's Health: Association for Weight Management and Obesity Prevention.

The group plans to develop clinical guidelines and best practices for health care professionals to use when working to help individuals better manage their weight, said Dr. Jensen, professor of medicine at the Mayo Clinic, Rochester, Minn.

The new group will incorporate the “Shaping America's Youth” program, a public-private partnership launched in 2003 in cooperation with the ADA, the Office of the Surgeon General, and other organizations.

“Science-based solutions and public-private partnerships like Shaping America's Health [the umbrella organization] are intensifying our ongoing nationwide efforts to increase disease prevention,” said Surgeon General Richard H. Carmona, M.D., in a statement.

The youth program plans to hold regional town hall meetings in the coming months, to provide grassroots input into a national action plan to combat obesity.

An obesity-prevention initiative chartered by the American Diabetes Association aims provide leadership and information “to help families and communities make improved nutrition and greater physical activity a priority, especially for children,” said Michael Jensen, M.D., president of the new organization called Shaping America's Health: Association for Weight Management and Obesity Prevention.

The group plans to develop clinical guidelines and best practices for health care professionals to use when working to help individuals better manage their weight, said Dr. Jensen, professor of medicine at the Mayo Clinic, Rochester, Minn.

The new group will incorporate the “Shaping America's Youth” program, a public-private partnership launched in 2003 in cooperation with the ADA, the Office of the Surgeon General, and other organizations.

“Science-based solutions and public-private partnerships like Shaping America's Health [the umbrella organization] are intensifying our ongoing nationwide efforts to increase disease prevention,” said Surgeon General Richard H. Carmona, M.D., in a statement.

The youth program plans to hold regional town hall meetings in the coming months, to provide grassroots input into a national action plan to combat obesity.

An obesity-prevention initiative chartered by the American Diabetes Association aims provide leadership and information “to help families and communities make improved nutrition and greater physical activity a priority, especially for children,” said Michael Jensen, M.D., president of the new organization called Shaping America's Health: Association for Weight Management and Obesity Prevention.

The group plans to develop clinical guidelines and best practices for health care professionals to use when working to help individuals better manage their weight, said Dr. Jensen, professor of medicine at the Mayo Clinic, Rochester, Minn.

The new group will incorporate the “Shaping America's Youth” program, a public-private partnership launched in 2003 in cooperation with the ADA, the Office of the Surgeon General, and other organizations.

“Science-based solutions and public-private partnerships like Shaping America's Health [the umbrella organization] are intensifying our ongoing nationwide efforts to increase disease prevention,” said Surgeon General Richard H. Carmona, M.D., in a statement.

The youth program plans to hold regional town hall meetings in the coming months, to provide grassroots input into a national action plan to combat obesity.

WASHINGTON — The Centers for Medicare and Medicaid Services should not institute the 4.3% decrease proposed in the 2006 physician fee schedule, a federal advisory panel recommended.

As it works to fix the sustainable growth rate, CMS should, instead, adopt the Medicare Payment Advisory Commission's recent recommendation to increase payments by 2.7% to keep pace with the cost of care, the Practicing Physicians Advisory Council recommended

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services. MedPAC advises Congress in a similar manner.

Physician reimbursements under Medicare will be cut 26% over the next 6 years unless the sustainable growth rate (SGR) formula is changed. Although the PPAC recommendation calls on CMS to take action, only Congress has the statutory authority to fix the formula.

The average physician facing these cuts “is stuck,” Ronald Castellanos, M.D., PPAC chairman, told CMS officials who presented a summary of the proposed fee schedule at the meeting. Reductions in Medicare payments have forced some physicians to do ancillary procedures in their offices to make up for the lost income, he said.

Leroy Sprang, M.D., an ob.gyn. who was recently named to the panel, said he's seen at least a dozen ob.gyns. in his area of Evanston, Ill., leave the profession due to the pressures of medical malpractice combined with reduced Medicare payments. While they don't deal with older patients as much as do other primary care physicians, some ob.gyn. practices have stopped seeing Medicare patients, he said.

In another avenue for addressing low physician reimbursement, the PPAC asked CMS for a report on whether Medicare Part B drugs could be removed retrospectively, using an administrative methodology. The council asked that the report be ready in time for its December meeting.

“We've been talking about this for the past 2 years,” said PPAC member Gregory Przybylski, M.D. The question is whether CMS could do this administratively by a certain date, he said.

Testifying before the panel, Ardis Hoven, M.D., who spoke on behalf of the American Medical Association, said the AMA was confident of CMS' authority to remove the drugs. “Drugs are not paid under the Medicare physician fee schedule, and it is illogical to include them in calculating the SGR,” Dr. Hoven said in her testimony. If CMS adopted a revised definition of “physicians' services” that excludes drugs, it could revise its SGR calculations going back to 1996 using its revised definition, although the revisions would affect payment updates in future years, she said.

Leslie Norwalk, CMS deputy administrator, conceded that Congress needed to institute a more rational approach to physician payments.

Addressing other possible options, HHS' Office of Inspector General may take another look at “gainsharing,” an arrangement where physicians could make suggestions on ways to improve care, and in return receive a portion of the cost savings achieved when their ideas are implemented. “The OIG has permitted physicians to engage in this, but only with respect to supplies, not specifically to medical savings,” Ms. Norwalk said.

To her knowledge, Congress has engaged in some ideas where physicians would be able to share in hospital savings for instance, “without it being a kickback violation,” she told the advisory panel.

CMS also has the ability to change payment systems statutorily through its practice group demonstration projects, Ms. Norwalk said. Several projects are currently testing pay-for-performance systems.

WASHINGTON — The Centers for Medicare and Medicaid Services should not institute the 4.3% decrease proposed in the 2006 physician fee schedule, a federal advisory panel recommended.

As it works to fix the sustainable growth rate, CMS should, instead, adopt the Medicare Payment Advisory Commission's recent recommendation to increase payments by 2.7% to keep pace with the cost of care, the Practicing Physicians Advisory Council recommended

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services. MedPAC advises Congress in a similar manner.

Physician reimbursements under Medicare will be cut 26% over the next 6 years unless the sustainable growth rate (SGR) formula is changed. Although the PPAC recommendation calls on CMS to take action, only Congress has the statutory authority to fix the formula.

The average physician facing these cuts “is stuck,” Ronald Castellanos, M.D., PPAC chairman, told CMS officials who presented a summary of the proposed fee schedule at the meeting. Reductions in Medicare payments have forced some physicians to do ancillary procedures in their offices to make up for the lost income, he said.

Leroy Sprang, M.D., an ob.gyn. who was recently named to the panel, said he's seen at least a dozen ob.gyns. in his area of Evanston, Ill., leave the profession due to the pressures of medical malpractice combined with reduced Medicare payments. While they don't deal with older patients as much as do other primary care physicians, some ob.gyn. practices have stopped seeing Medicare patients, he said.

In another avenue for addressing low physician reimbursement, the PPAC asked CMS for a report on whether Medicare Part B drugs could be removed retrospectively, using an administrative methodology. The council asked that the report be ready in time for its December meeting.

“We've been talking about this for the past 2 years,” said PPAC member Gregory Przybylski, M.D. The question is whether CMS could do this administratively by a certain date, he said.

Testifying before the panel, Ardis Hoven, M.D., who spoke on behalf of the American Medical Association, said the AMA was confident of CMS' authority to remove the drugs. “Drugs are not paid under the Medicare physician fee schedule, and it is illogical to include them in calculating the SGR,” Dr. Hoven said in her testimony. If CMS adopted a revised definition of “physicians' services” that excludes drugs, it could revise its SGR calculations going back to 1996 using its revised definition, although the revisions would affect payment updates in future years, she said.

Leslie Norwalk, CMS deputy administrator, conceded that Congress needed to institute a more rational approach to physician payments.

Addressing other possible options, HHS' Office of Inspector General may take another look at “gainsharing,” an arrangement where physicians could make suggestions on ways to improve care, and in return receive a portion of the cost savings achieved when their ideas are implemented. “The OIG has permitted physicians to engage in this, but only with respect to supplies, not specifically to medical savings,” Ms. Norwalk said.

To her knowledge, Congress has engaged in some ideas where physicians would be able to share in hospital savings for instance, “without it being a kickback violation,” she told the advisory panel.

CMS also has the ability to change payment systems statutorily through its practice group demonstration projects, Ms. Norwalk said. Several projects are currently testing pay-for-performance systems.

WASHINGTON — The Centers for Medicare and Medicaid Services should not institute the 4.3% decrease proposed in the 2006 physician fee schedule, a federal advisory panel recommended.

As it works to fix the sustainable growth rate, CMS should, instead, adopt the Medicare Payment Advisory Commission's recent recommendation to increase payments by 2.7% to keep pace with the cost of care, the Practicing Physicians Advisory Council recommended

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services. MedPAC advises Congress in a similar manner.

Physician reimbursements under Medicare will be cut 26% over the next 6 years unless the sustainable growth rate (SGR) formula is changed. Although the PPAC recommendation calls on CMS to take action, only Congress has the statutory authority to fix the formula.

The average physician facing these cuts “is stuck,” Ronald Castellanos, M.D., PPAC chairman, told CMS officials who presented a summary of the proposed fee schedule at the meeting. Reductions in Medicare payments have forced some physicians to do ancillary procedures in their offices to make up for the lost income, he said.

Leroy Sprang, M.D., an ob.gyn. who was recently named to the panel, said he's seen at least a dozen ob.gyns. in his area of Evanston, Ill., leave the profession due to the pressures of medical malpractice combined with reduced Medicare payments. While they don't deal with older patients as much as do other primary care physicians, some ob.gyn. practices have stopped seeing Medicare patients, he said.

In another avenue for addressing low physician reimbursement, the PPAC asked CMS for a report on whether Medicare Part B drugs could be removed retrospectively, using an administrative methodology. The council asked that the report be ready in time for its December meeting.

“We've been talking about this for the past 2 years,” said PPAC member Gregory Przybylski, M.D. The question is whether CMS could do this administratively by a certain date, he said.

Testifying before the panel, Ardis Hoven, M.D., who spoke on behalf of the American Medical Association, said the AMA was confident of CMS' authority to remove the drugs. “Drugs are not paid under the Medicare physician fee schedule, and it is illogical to include them in calculating the SGR,” Dr. Hoven said in her testimony. If CMS adopted a revised definition of “physicians' services” that excludes drugs, it could revise its SGR calculations going back to 1996 using its revised definition, although the revisions would affect payment updates in future years, she said.

Leslie Norwalk, CMS deputy administrator, conceded that Congress needed to institute a more rational approach to physician payments.

Addressing other possible options, HHS' Office of Inspector General may take another look at “gainsharing,” an arrangement where physicians could make suggestions on ways to improve care, and in return receive a portion of the cost savings achieved when their ideas are implemented. “The OIG has permitted physicians to engage in this, but only with respect to supplies, not specifically to medical savings,” Ms. Norwalk said.

To her knowledge, Congress has engaged in some ideas where physicians would be able to share in hospital savings for instance, “without it being a kickback violation,” she told the advisory panel.

CMS also has the ability to change payment systems statutorily through its practice group demonstration projects, Ms. Norwalk said. Several projects are currently testing pay-for-performance systems.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on the Benefit

Patients' optimism of Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three seniors (32%) has a favorable impression of the benefit and an equal number (32%) have a negative one. This figured can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Working-age adults incur significantly higher rates of medical bill and debt problems than adults aged 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the President agrees with the recommendations he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and must be completed within 6 years, according to the Base Realignment and Closure statute.

Obesity Rankings

It pays to live in the mountains and ski: Trust for America's Health reported that Mississippi has the “heaviest” obesity rate in the country, Colorado the lightest. More than 25% of adults in 10 states are obese, including Mississippi, Alabama, West Virginia, Louisiana, Tennessee, Texas, Michigan, Kentucky, Indiana, and South Carolina. Rates have stayed the same in Oregon. A majority of governors have taken steps to initiate antiobesity programs for state employees. But most state initiatives aimed at the general public are limited to information campaigns, said Trust for America's Health, a nonprofit organization that focuses on disease prevention.

Impact of Concierge Care

Due to their small numbers, it is unlikely that concierge care practices will contribute to widespread access problems for Medicare beneficiaries, the Government Accountability Office reported. In a recent survey, GAO identified 146 concierge physicians and analyzed responses from 112. According to the survey, most concierge practices are located on the East and West coasts, and nearly all respondents reported practicing primary care medicine. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500-$1,999. The Department of Health and Human Services has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements. For example, the membership fee must not result in additional charges for items or services that Medicare already reimburses. Some concierge physicians reported to GAO that they would like more HHS guidance.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on the Benefit

Patients' optimism of Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three seniors (32%) has a favorable impression of the benefit and an equal number (32%) have a negative one. This figured can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Working-age adults incur significantly higher rates of medical bill and debt problems than adults aged 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the President agrees with the recommendations he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and must be completed within 6 years, according to the Base Realignment and Closure statute.

Obesity Rankings

It pays to live in the mountains and ski: Trust for America's Health reported that Mississippi has the “heaviest” obesity rate in the country, Colorado the lightest. More than 25% of adults in 10 states are obese, including Mississippi, Alabama, West Virginia, Louisiana, Tennessee, Texas, Michigan, Kentucky, Indiana, and South Carolina. Rates have stayed the same in Oregon. A majority of governors have taken steps to initiate antiobesity programs for state employees. But most state initiatives aimed at the general public are limited to information campaigns, said Trust for America's Health, a nonprofit organization that focuses on disease prevention.

Impact of Concierge Care

Due to their small numbers, it is unlikely that concierge care practices will contribute to widespread access problems for Medicare beneficiaries, the Government Accountability Office reported. In a recent survey, GAO identified 146 concierge physicians and analyzed responses from 112. According to the survey, most concierge practices are located on the East and West coasts, and nearly all respondents reported practicing primary care medicine. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500-$1,999. The Department of Health and Human Services has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements. For example, the membership fee must not result in additional charges for items or services that Medicare already reimburses. Some concierge physicians reported to GAO that they would like more HHS guidance.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on the Benefit

Patients' optimism of Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three seniors (32%) has a favorable impression of the benefit and an equal number (32%) have a negative one. This figured can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Working-age adults incur significantly higher rates of medical bill and debt problems than adults aged 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the President agrees with the recommendations he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and must be completed within 6 years, according to the Base Realignment and Closure statute.

Obesity Rankings

It pays to live in the mountains and ski: Trust for America's Health reported that Mississippi has the “heaviest” obesity rate in the country, Colorado the lightest. More than 25% of adults in 10 states are obese, including Mississippi, Alabama, West Virginia, Louisiana, Tennessee, Texas, Michigan, Kentucky, Indiana, and South Carolina. Rates have stayed the same in Oregon. A majority of governors have taken steps to initiate antiobesity programs for state employees. But most state initiatives aimed at the general public are limited to information campaigns, said Trust for America's Health, a nonprofit organization that focuses on disease prevention.

Impact of Concierge Care

Due to their small numbers, it is unlikely that concierge care practices will contribute to widespread access problems for Medicare beneficiaries, the Government Accountability Office reported. In a recent survey, GAO identified 146 concierge physicians and analyzed responses from 112. According to the survey, most concierge practices are located on the East and West coasts, and nearly all respondents reported practicing primary care medicine. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500-$1,999. The Department of Health and Human Services has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements. For example, the membership fee must not result in additional charges for items or services that Medicare already reimburses. Some concierge physicians reported to GAO that they would like more HHS guidance.

WASHINGTON — Mental health organizations called for greater parity in treating emergency psychiatric conditions before a technical advisory group on the Emergency Medical Treatment and Labor Act.

So many things have not been thoroughly discussed or defined in the EMTALA regulations regarding psychiatric conditions, Kathleen McCann, R.N., director of clinical services with the National Association of Psychiatric Health Systems, said in an interview.

“Emergency psychiatric conditions weren't well thought out when the original regulations were promulgated.” Medical conditions—such as a head injury, or child convulsing inexplicably—are easier to pinpoint, in terms of emergency treatment.

“What we need to develop are the psychiatric correlates” or equivalents of those medical conditions, she said.

EMTALA obligations end when an emergency medical condition has been stabilized, yet there is “significant anxiety” in the field about what constitutes stabilization of an emergency medical condition of psychiatric patients, Ms. McCann told the technical advisory group, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA.

The terms “expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others,” are not clinically precise, she testified. “Many psychiatric patients have suicidal thinking that does not necessarily constitute an emergency medical condition or require stabilization at the inpatient level,” she said. “For some clinicians, this can be a difficult distinction.”

These ambiguities often result in unnecessary transfers of patients, witnesses testified. “It is all too easy for an emergency department without its own mental health staff on site to casually make a determination of a psychiatric emergency medical condition as a way of forcing a transfer of a patient to a psychiatric emergency service,” Jon Berlin, M.D., president of the American Association of Emergency Psychiatry, noted in his testimony.

Right now, insurance coverage is dictating how psychiatric patients are treated in the emergency department, observed Mark Pearlmutter, M.D., an emergency physician and member of the technical advisory group.

“If a patient with pneumonia has Blue Cross Blue Shield of Wisconsin, and his or her insurance company doesn't have a contract with that hospital, we don't start calling around the state to find a bed with that insurance,” he said. The patient is treated immediately.

However, if a patient comes to the emergency department with depression and requires inpatient admission, “even though we might have a bed upstairs, we can't treat the patient if the hospital doesn't have a contract with the patient's insurance company. If we do admit, we won't get paid,” Dr. Pearlmutter explained.

For these reasons, psychiatric patients sometimes get shipped unnecessarily across one, two, or more primary service zones, he told the technical advisory group.

Dr. Berlin spoke of a colleague at Bellevue Hospital in Manhattan who received a patient all the way from Baltimore “because he had the appropriate service, and they didn't.”

In some cases, these patients aren't even transferred from Hospital A to Hospital B directly, but to an inpatient ward of a psychiatric hospital, Dr. Pearlmutter said in an interview. Depending on the patient's condition, they may or may not truly need an inpatient stay, “and it's expensive to transfer these patients to such a facility, and take care of them overnight.”

Physicians are somehow given the opportunity to do things to psychiatric patients that they would never do to a patient with pneumonia or a heart attack, Dr. Pearlmutter continued. “Stabilization” or resolution of an emergency medical condition means that the patient no longer presents harm to himself/herself or others, he said.

However, “if I have to put agitated patients in restraints or give them medication in order to drive them for 3 hours to another hospital, is that stabilization? Is that rational or reasonable? I don't think so,” said Dr. Pearlmutter.

Several issues are compounding these problems, such as declining bed supply for psychiatric patients and a steep rise in the number of individuals with psychiatric disorders who are visiting emergency departments, Ms. McCann said.

To achieve some consistency in the handling of these patients, Julie Mathis Nelson, a lawyer and member of the technical advisory group, suggested that hospitals should employ qualified medical professionals to evaluate each psychiatric patient who presents to the emergency department. These personnel would be able to determine whether the patient has an emergency psychiatric condition within the context of EMTALA.

“We have to treat psychiatric patients in the same way we do medical patients. Anything short of that will be a disservice to these patients,” Dr. Pearlmutter said.

The National Association of Psychiatric Health Systems and other psychiatric groups in their testimony urged the technical advisory group to convene a national work group, with a goal of developing better definitions of “stabilization” and “emergency medical condition” as they relate to individuals with psychiatric disorders.

The work group could also provide more specific interpretive guidelines to the field related to psychiatric care, and offer more specific provider education, Ms. McCann said.

Although no formal recommendations were made, the technical advisory group did vote for its action subcommittee to further study the definition of emergency psychiatric medical conditions and the definition of stabilization, and to seek more public testimony and outside expertise on the issue.

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — Mental health organizations called for greater parity in treating emergency psychiatric conditions before a technical advisory group on the Emergency Medical Treatment and Labor Act.

So many things have not been thoroughly discussed or defined in the EMTALA regulations regarding psychiatric conditions, Kathleen McCann, R.N., director of clinical services with the National Association of Psychiatric Health Systems, said in an interview.

“Emergency psychiatric conditions weren't well thought out when the original regulations were promulgated.” Medical conditions—such as a head injury, or child convulsing inexplicably—are easier to pinpoint, in terms of emergency treatment.

“What we need to develop are the psychiatric correlates” or equivalents of those medical conditions, she said.

EMTALA obligations end when an emergency medical condition has been stabilized, yet there is “significant anxiety” in the field about what constitutes stabilization of an emergency medical condition of psychiatric patients, Ms. McCann told the technical advisory group, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA.

The terms “expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others,” are not clinically precise, she testified. “Many psychiatric patients have suicidal thinking that does not necessarily constitute an emergency medical condition or require stabilization at the inpatient level,” she said. “For some clinicians, this can be a difficult distinction.”

These ambiguities often result in unnecessary transfers of patients, witnesses testified. “It is all too easy for an emergency department without its own mental health staff on site to casually make a determination of a psychiatric emergency medical condition as a way of forcing a transfer of a patient to a psychiatric emergency service,” Jon Berlin, M.D., president of the American Association of Emergency Psychiatry, noted in his testimony.

Right now, insurance coverage is dictating how psychiatric patients are treated in the emergency department, observed Mark Pearlmutter, M.D., an emergency physician and member of the technical advisory group.

“If a patient with pneumonia has Blue Cross Blue Shield of Wisconsin, and his or her insurance company doesn't have a contract with that hospital, we don't start calling around the state to find a bed with that insurance,” he said. The patient is treated immediately.

However, if a patient comes to the emergency department with depression and requires inpatient admission, “even though we might have a bed upstairs, we can't treat the patient if the hospital doesn't have a contract with the patient's insurance company. If we do admit, we won't get paid,” Dr. Pearlmutter explained.

For these reasons, psychiatric patients sometimes get shipped unnecessarily across one, two, or more primary service zones, he told the technical advisory group.

Dr. Berlin spoke of a colleague at Bellevue Hospital in Manhattan who received a patient all the way from Baltimore “because he had the appropriate service, and they didn't.”

In some cases, these patients aren't even transferred from Hospital A to Hospital B directly, but to an inpatient ward of a psychiatric hospital, Dr. Pearlmutter said in an interview. Depending on the patient's condition, they may or may not truly need an inpatient stay, “and it's expensive to transfer these patients to such a facility, and take care of them overnight.”

Physicians are somehow given the opportunity to do things to psychiatric patients that they would never do to a patient with pneumonia or a heart attack, Dr. Pearlmutter continued. “Stabilization” or resolution of an emergency medical condition means that the patient no longer presents harm to himself/herself or others, he said.

However, “if I have to put agitated patients in restraints or give them medication in order to drive them for 3 hours to another hospital, is that stabilization? Is that rational or reasonable? I don't think so,” said Dr. Pearlmutter.

Several issues are compounding these problems, such as declining bed supply for psychiatric patients and a steep rise in the number of individuals with psychiatric disorders who are visiting emergency departments, Ms. McCann said.

To achieve some consistency in the handling of these patients, Julie Mathis Nelson, a lawyer and member of the technical advisory group, suggested that hospitals should employ qualified medical professionals to evaluate each psychiatric patient who presents to the emergency department. These personnel would be able to determine whether the patient has an emergency psychiatric condition within the context of EMTALA.

“We have to treat psychiatric patients in the same way we do medical patients. Anything short of that will be a disservice to these patients,” Dr. Pearlmutter said.

The National Association of Psychiatric Health Systems and other psychiatric groups in their testimony urged the technical advisory group to convene a national work group, with a goal of developing better definitions of “stabilization” and “emergency medical condition” as they relate to individuals with psychiatric disorders.

The work group could also provide more specific interpretive guidelines to the field related to psychiatric care, and offer more specific provider education, Ms. McCann said.

Although no formal recommendations were made, the technical advisory group did vote for its action subcommittee to further study the definition of emergency psychiatric medical conditions and the definition of stabilization, and to seek more public testimony and outside expertise on the issue.

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — Mental health organizations called for greater parity in treating emergency psychiatric conditions before a technical advisory group on the Emergency Medical Treatment and Labor Act.

So many things have not been thoroughly discussed or defined in the EMTALA regulations regarding psychiatric conditions, Kathleen McCann, R.N., director of clinical services with the National Association of Psychiatric Health Systems, said in an interview.

“Emergency psychiatric conditions weren't well thought out when the original regulations were promulgated.” Medical conditions—such as a head injury, or child convulsing inexplicably—are easier to pinpoint, in terms of emergency treatment.

“What we need to develop are the psychiatric correlates” or equivalents of those medical conditions, she said.

EMTALA obligations end when an emergency medical condition has been stabilized, yet there is “significant anxiety” in the field about what constitutes stabilization of an emergency medical condition of psychiatric patients, Ms. McCann told the technical advisory group, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA.

The terms “expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others,” are not clinically precise, she testified. “Many psychiatric patients have suicidal thinking that does not necessarily constitute an emergency medical condition or require stabilization at the inpatient level,” she said. “For some clinicians, this can be a difficult distinction.”

These ambiguities often result in unnecessary transfers of patients, witnesses testified. “It is all too easy for an emergency department without its own mental health staff on site to casually make a determination of a psychiatric emergency medical condition as a way of forcing a transfer of a patient to a psychiatric emergency service,” Jon Berlin, M.D., president of the American Association of Emergency Psychiatry, noted in his testimony.

Right now, insurance coverage is dictating how psychiatric patients are treated in the emergency department, observed Mark Pearlmutter, M.D., an emergency physician and member of the technical advisory group.

“If a patient with pneumonia has Blue Cross Blue Shield of Wisconsin, and his or her insurance company doesn't have a contract with that hospital, we don't start calling around the state to find a bed with that insurance,” he said. The patient is treated immediately.

However, if a patient comes to the emergency department with depression and requires inpatient admission, “even though we might have a bed upstairs, we can't treat the patient if the hospital doesn't have a contract with the patient's insurance company. If we do admit, we won't get paid,” Dr. Pearlmutter explained.

For these reasons, psychiatric patients sometimes get shipped unnecessarily across one, two, or more primary service zones, he told the technical advisory group.

Dr. Berlin spoke of a colleague at Bellevue Hospital in Manhattan who received a patient all the way from Baltimore “because he had the appropriate service, and they didn't.”

In some cases, these patients aren't even transferred from Hospital A to Hospital B directly, but to an inpatient ward of a psychiatric hospital, Dr. Pearlmutter said in an interview. Depending on the patient's condition, they may or may not truly need an inpatient stay, “and it's expensive to transfer these patients to such a facility, and take care of them overnight.”

Physicians are somehow given the opportunity to do things to psychiatric patients that they would never do to a patient with pneumonia or a heart attack, Dr. Pearlmutter continued. “Stabilization” or resolution of an emergency medical condition means that the patient no longer presents harm to himself/herself or others, he said.

However, “if I have to put agitated patients in restraints or give them medication in order to drive them for 3 hours to another hospital, is that stabilization? Is that rational or reasonable? I don't think so,” said Dr. Pearlmutter.

Several issues are compounding these problems, such as declining bed supply for psychiatric patients and a steep rise in the number of individuals with psychiatric disorders who are visiting emergency departments, Ms. McCann said.

To achieve some consistency in the handling of these patients, Julie Mathis Nelson, a lawyer and member of the technical advisory group, suggested that hospitals should employ qualified medical professionals to evaluate each psychiatric patient who presents to the emergency department. These personnel would be able to determine whether the patient has an emergency psychiatric condition within the context of EMTALA.

“We have to treat psychiatric patients in the same way we do medical patients. Anything short of that will be a disservice to these patients,” Dr. Pearlmutter said.

The National Association of Psychiatric Health Systems and other psychiatric groups in their testimony urged the technical advisory group to convene a national work group, with a goal of developing better definitions of “stabilization” and “emergency medical condition” as they relate to individuals with psychiatric disorders.

The work group could also provide more specific interpretive guidelines to the field related to psychiatric care, and offer more specific provider education, Ms. McCann said.

Although no formal recommendations were made, the technical advisory group did vote for its action subcommittee to further study the definition of emergency psychiatric medical conditions and the definition of stabilization, and to seek more public testimony and outside expertise on the issue.

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay. The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — The full cost of drugs obtained through patient-assistance programs should be counted as out-of-pocket expenses under the new Medicare Part D prescription drug benefit, according to council members at a meeting of the Practicing Physicians Advisory Council.

The Centers for Medicare and Medicaid Services (CMS) should work with the Health and Human Services Department's Office of Inspector General to give final guidance on this issue, the panel stated.

Under the coming Part D benefit, until the patient has met his or her out-of-pocket expense limit, the patient has to pay for the drug, said PPAC member Barbara McAneny, M.D., an oncologist from Albuquerque. If the patient can't afford it, but “we obtain it for free from the pharmaceutical companies, and if it doesn't count toward true out-of-pocket expenses, the patient will never get through the out-of-pocket [limit] and into the benefit.”

Jeffrey Kelman, M.D., medical officer with the CMS Center for Beneficiary Choices told the council that there are circumstances in which out-of-pocket expenses would be covered: Payments made by qualified state pharmaceutical assistance programs toward copays or other cost sharing would count toward true out-of-pocket expenses, for example, in terms of reaching the $3,600 out-of-pocket limit before reinsurance, he said.

However, payments from a third-party insurance company—or from government agency policies—would not, he said.

“There needs to be guidance as to what that means,” he acknowledged.

For the Part D benefit, CMS has divided the country into 34 regions, and all will have robust coverage with several Part D drug plans available for beneficiaries of all incomes and for dual eligible patients in the Medicare and Medicaid programs, Dr. Kelman told the PPAC.

He expressed confidence that beneficiaries would be able to afford the benefit. The average monthly premium for the benefit is $32.30 nationally, lower than what the agency expected, he said.

“All regions will have plans with premiums well below that average,” he said. (See box.) In addition, all of the formularies submitted for the program are much more robust than most commercial formularies or any state formulary. “That's going to make the transition in January much easier,” Dr. Kelman said.

Dr. McAneny noted that rumors were floating around regarding whether Part B drugs—such as oral chemotherapy agents that are covered under the medical benefit as opposed to the pharmacy benefit—would be moving over to Part D.

“At the moment, those drugs aren't moving anywhere,” Dr. Kelman said. “There's talk of it because, starting in January, there will be two drug benefits, and there is a potential for confusion, particularly over the oral drugs or chemo drugs, because all those drugs in theory could be [Part] B or D drugs.”

It's an issue that will be looked at again, he said.

In the months leading up to the January start of Part D, CMS has actively been spending time on the education of, communication with, and enrollment of beneficiaries, but outreach to physicians about the drug benefit is an area that needs work, Dr. Kelman said. “Is it toolkits, training sessions, CME?” he asked the panel.

Such tools are important, he noted, as “it's very clear that the practicing physician will be the point of contact for the beneficiary” who needs guidance on what to do about the new benefit.

No physician wants patients to miss out on the Part D benefit, Dr. Kelman noted, “especially because the low-income subsidy is a good benefit. There [are] no premiums, no gap, a minimum copay, no deductible, and a full catastrophic benefit.”

Medicare also needs input on how it could interact with physicians on formulary changes, such as matching the formulary with the patient's current drug list, Dr. Kelman said.

In a resolution, PPAC indicated it would complement the efforts of CMS to disseminate information to the public about the Part D benefit program.

CMS, meanwhile, is developing a new Web tool aimed at making it easier for patients to navigate the process for enrolling to receive the Part D benefit, he said.

This new tool “will allow the beneficiary and the physician to identify the plans that the [beneficiary] has been auto-enrolled into or has actively enrolled into,” with additional information on the Medicare drug cards.

Auto-enrollment has been a big question in particular for the full-benefit dual-eligibles (those patients who are eligible for Medicare and Medicaid), he said. “Now they can do it on the Web or, more likely, their physician, pharmacist, or social worker can do it on the Web.”

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services.

KEVIN FOLEY, RESEARCH

WASHINGTON — The full cost of drugs obtained through patient-assistance programs should be counted as out-of-pocket expenses under the new Medicare Part D prescription drug benefit, according to council members at a meeting of the Practicing Physicians Advisory Council.

The Centers for Medicare and Medicaid Services (CMS) should work with the Health and Human Services Department's Office of Inspector General to give final guidance on this issue, the panel stated.

Under the coming Part D benefit, until the patient has met his or her out-of-pocket expense limit, the patient has to pay for the drug, said PPAC member Barbara McAneny, M.D., an oncologist from Albuquerque. If the patient can't afford it, but “we obtain it for free from the pharmaceutical companies, and if it doesn't count toward true out-of-pocket expenses, the patient will never get through the out-of-pocket [limit] and into the benefit.”

Jeffrey Kelman, M.D., medical officer with the CMS Center for Beneficiary Choices told the council that there are circumstances in which out-of-pocket expenses would be covered: Payments made by qualified state pharmaceutical assistance programs toward copays or other cost sharing would count toward true out-of-pocket expenses, for example, in terms of reaching the $3,600 out-of-pocket limit before reinsurance, he said.

However, payments from a third-party insurance company—or from government agency policies—would not, he said.

“There needs to be guidance as to what that means,” he acknowledged.

For the Part D benefit, CMS has divided the country into 34 regions, and all will have robust coverage with several Part D drug plans available for beneficiaries of all incomes and for dual eligible patients in the Medicare and Medicaid programs, Dr. Kelman told the PPAC.

He expressed confidence that beneficiaries would be able to afford the benefit. The average monthly premium for the benefit is $32.30 nationally, lower than what the agency expected, he said.

“All regions will have plans with premiums well below that average,” he said. (See box.) In addition, all of the formularies submitted for the program are much more robust than most commercial formularies or any state formulary. “That's going to make the transition in January much easier,” Dr. Kelman said.

Dr. McAneny noted that rumors were floating around regarding whether Part B drugs—such as oral chemotherapy agents that are covered under the medical benefit as opposed to the pharmacy benefit—would be moving over to Part D.

“At the moment, those drugs aren't moving anywhere,” Dr. Kelman said. “There's talk of it because, starting in January, there will be two drug benefits, and there is a potential for confusion, particularly over the oral drugs or chemo drugs, because all those drugs in theory could be [Part] B or D drugs.”

It's an issue that will be looked at again, he said.

In the months leading up to the January start of Part D, CMS has actively been spending time on the education of, communication with, and enrollment of beneficiaries, but outreach to physicians about the drug benefit is an area that needs work, Dr. Kelman said. “Is it toolkits, training sessions, CME?” he asked the panel.

Such tools are important, he noted, as “it's very clear that the practicing physician will be the point of contact for the beneficiary” who needs guidance on what to do about the new benefit.

No physician wants patients to miss out on the Part D benefit, Dr. Kelman noted, “especially because the low-income subsidy is a good benefit. There [are] no premiums, no gap, a minimum copay, no deductible, and a full catastrophic benefit.”

Medicare also needs input on how it could interact with physicians on formulary changes, such as matching the formulary with the patient's current drug list, Dr. Kelman said.

In a resolution, PPAC indicated it would complement the efforts of CMS to disseminate information to the public about the Part D benefit program.

CMS, meanwhile, is developing a new Web tool aimed at making it easier for patients to navigate the process for enrolling to receive the Part D benefit, he said.

This new tool “will allow the beneficiary and the physician to identify the plans that the [beneficiary] has been auto-enrolled into or has actively enrolled into,” with additional information on the Medicare drug cards.

Auto-enrollment has been a big question in particular for the full-benefit dual-eligibles (those patients who are eligible for Medicare and Medicaid), he said. “Now they can do it on the Web or, more likely, their physician, pharmacist, or social worker can do it on the Web.”

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services.

KEVIN FOLEY, RESEARCH

WASHINGTON — The full cost of drugs obtained through patient-assistance programs should be counted as out-of-pocket expenses under the new Medicare Part D prescription drug benefit, according to council members at a meeting of the Practicing Physicians Advisory Council.

The Centers for Medicare and Medicaid Services (CMS) should work with the Health and Human Services Department's Office of Inspector General to give final guidance on this issue, the panel stated.

Under the coming Part D benefit, until the patient has met his or her out-of-pocket expense limit, the patient has to pay for the drug, said PPAC member Barbara McAneny, M.D., an oncologist from Albuquerque. If the patient can't afford it, but “we obtain it for free from the pharmaceutical companies, and if it doesn't count toward true out-of-pocket expenses, the patient will never get through the out-of-pocket [limit] and into the benefit.”

Jeffrey Kelman, M.D., medical officer with the CMS Center for Beneficiary Choices told the council that there are circumstances in which out-of-pocket expenses would be covered: Payments made by qualified state pharmaceutical assistance programs toward copays or other cost sharing would count toward true out-of-pocket expenses, for example, in terms of reaching the $3,600 out-of-pocket limit before reinsurance, he said.

However, payments from a third-party insurance company—or from government agency policies—would not, he said.

“There needs to be guidance as to what that means,” he acknowledged.

For the Part D benefit, CMS has divided the country into 34 regions, and all will have robust coverage with several Part D drug plans available for beneficiaries of all incomes and for dual eligible patients in the Medicare and Medicaid programs, Dr. Kelman told the PPAC.

He expressed confidence that beneficiaries would be able to afford the benefit. The average monthly premium for the benefit is $32.30 nationally, lower than what the agency expected, he said.

“All regions will have plans with premiums well below that average,” he said. (See box.) In addition, all of the formularies submitted for the program are much more robust than most commercial formularies or any state formulary. “That's going to make the transition in January much easier,” Dr. Kelman said.

Dr. McAneny noted that rumors were floating around regarding whether Part B drugs—such as oral chemotherapy agents that are covered under the medical benefit as opposed to the pharmacy benefit—would be moving over to Part D.

“At the moment, those drugs aren't moving anywhere,” Dr. Kelman said. “There's talk of it because, starting in January, there will be two drug benefits, and there is a potential for confusion, particularly over the oral drugs or chemo drugs, because all those drugs in theory could be [Part] B or D drugs.”

It's an issue that will be looked at again, he said.

In the months leading up to the January start of Part D, CMS has actively been spending time on the education of, communication with, and enrollment of beneficiaries, but outreach to physicians about the drug benefit is an area that needs work, Dr. Kelman said. “Is it toolkits, training sessions, CME?” he asked the panel.

Such tools are important, he noted, as “it's very clear that the practicing physician will be the point of contact for the beneficiary” who needs guidance on what to do about the new benefit.

No physician wants patients to miss out on the Part D benefit, Dr. Kelman noted, “especially because the low-income subsidy is a good benefit. There [are] no premiums, no gap, a minimum copay, no deductible, and a full catastrophic benefit.”

Medicare also needs input on how it could interact with physicians on formulary changes, such as matching the formulary with the patient's current drug list, Dr. Kelman said.

In a resolution, PPAC indicated it would complement the efforts of CMS to disseminate information to the public about the Part D benefit program.

CMS, meanwhile, is developing a new Web tool aimed at making it easier for patients to navigate the process for enrolling to receive the Part D benefit, he said.

This new tool “will allow the beneficiary and the physician to identify the plans that the [beneficiary] has been auto-enrolled into or has actively enrolled into,” with additional information on the Medicare drug cards.

Auto-enrollment has been a big question in particular for the full-benefit dual-eligibles (those patients who are eligible for Medicare and Medicaid), he said. “Now they can do it on the Web or, more likely, their physician, pharmacist, or social worker can do it on the Web.”

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services.

KEVIN FOLEY, RESEARCH

WASHINGTON — The Centers for Medicare and Medicaid Services should not institute the 4.3% decrease proposed in the 2006 physician fee schedule, a federal advisory panel recommended.

As it works to fix the sustainable growth rate, CMS should, instead, adopt the Medicare Payment Advisory Commission's recent recommendation to increase payments by 2.7% to keep pace with the cost of care, the Practicing Physicians Advisory Council recommended.

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services.

MedPAC advises Congress in a similar manner.

Physician reimbursements under Medicare will be cut 26% over the next 6 years unless the sustainable growth rate (SGR) formula is changed. Although the PPAC recommendation calls on CMS to take action, only Congress has the statutory authority to fix the formula.

The average physician facing these cuts “is stuck” Ronald Castellanos, M.D., PPAC chairman, told CMS officials who presented a summary of the proposed fee schedule at the meeting. Reductions in Medicare payments have forced some physicians to do ancillary procedures in their offices to make up for the lost income, he said.

Leroy Sprang, M.D., an ob.gyn. who was recently named to the panel, said he's seen at least a dozen ob.gyns. in his area of Evanston, Ill., leave the profession due to the pressures of medical malpractice combined with reduced Medicare payments. While they don't deal with older patients as much as other primary care physicians do, some ob.gyn. practices have stopped seeing Medicare patients, he said.

In another avenue for addressing low physician reimbursement, the PPAC asked CMS for a report on whether Medicare Part B drugs could be removed retrospectively, using an administrative methodology. The council asked that the report be ready in time for its December meeting.

“We've been talking about this for the past 2 years,” said PPAC member Gregory Przybylski, M.D. The question is whether CMS could do this administratively by a certain date, he said.

Testifying before the panel, Ardis Hoven, M.D., who spoke on behalf of the American Medical Association, said the AMA was confident of CMS' authority to remove the drugs. “Drugs are not paid under the Medicare physician fee schedule, and it is illogical to include them in calculating the SGR,” Dr. Hoven said in her testimony. If CMS adopted a revised definition of “physicians' services” that excludes drugs, it could revise its SGR calculations going back to 1996 using its revised definition, although the revisions would affect payment updates in future years, she said.

Leslie Norwalk, CMS deputy administrator, conceded that Congress needed to institute a more rational approach to determining physician payments. Addressing other possible options, HHS' Office of Inspector General may take another look at “gainsharing,” an arrangement where physicians could make suggestions on ways to improve care, and in return receive a portion of the cost savings achieved when their ideas are implemented. “The OIG has permitted physicians to engage in this, but only with respect to supplies, not specifically to medical savings,” Ms. Norwalk said.

To her knowledge, Congress has engaged in some ideas where physicians would be able to share in hospital savings for instance, “without it being a kickback violation,” she told the advisory panel.

CMS also has the ability to change payment systems statutorily through its practice group demonstration projects, Ms. Norwalk said. Several projects are currently testing pay-for-performance systems.

For the first time, Congress, MedPAC, CMS, PPAC, and all of the medical specialties are in agreement about something: that the SGR is flawed, Dr. Castellanos said. For that reason, “maybe something constructive can come out of this.”

WASHINGTON — The Centers for Medicare and Medicaid Services should not institute the 4.3% decrease proposed in the 2006 physician fee schedule, a federal advisory panel recommended.

As it works to fix the sustainable growth rate, CMS should, instead, adopt the Medicare Payment Advisory Commission's recent recommendation to increase payments by 2.7% to keep pace with the cost of care, the Practicing Physicians Advisory Council recommended.

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services.

MedPAC advises Congress in a similar manner.

Physician reimbursements under Medicare will be cut 26% over the next 6 years unless the sustainable growth rate (SGR) formula is changed. Although the PPAC recommendation calls on CMS to take action, only Congress has the statutory authority to fix the formula.

The average physician facing these cuts “is stuck” Ronald Castellanos, M.D., PPAC chairman, told CMS officials who presented a summary of the proposed fee schedule at the meeting. Reductions in Medicare payments have forced some physicians to do ancillary procedures in their offices to make up for the lost income, he said.

Leroy Sprang, M.D., an ob.gyn. who was recently named to the panel, said he's seen at least a dozen ob.gyns. in his area of Evanston, Ill., leave the profession due to the pressures of medical malpractice combined with reduced Medicare payments. While they don't deal with older patients as much as other primary care physicians do, some ob.gyn. practices have stopped seeing Medicare patients, he said.

In another avenue for addressing low physician reimbursement, the PPAC asked CMS for a report on whether Medicare Part B drugs could be removed retrospectively, using an administrative methodology. The council asked that the report be ready in time for its December meeting.

“We've been talking about this for the past 2 years,” said PPAC member Gregory Przybylski, M.D. The question is whether CMS could do this administratively by a certain date, he said.

Testifying before the panel, Ardis Hoven, M.D., who spoke on behalf of the American Medical Association, said the AMA was confident of CMS' authority to remove the drugs. “Drugs are not paid under the Medicare physician fee schedule, and it is illogical to include them in calculating the SGR,” Dr. Hoven said in her testimony. If CMS adopted a revised definition of “physicians' services” that excludes drugs, it could revise its SGR calculations going back to 1996 using its revised definition, although the revisions would affect payment updates in future years, she said.

Leslie Norwalk, CMS deputy administrator, conceded that Congress needed to institute a more rational approach to determining physician payments. Addressing other possible options, HHS' Office of Inspector General may take another look at “gainsharing,” an arrangement where physicians could make suggestions on ways to improve care, and in return receive a portion of the cost savings achieved when their ideas are implemented. “The OIG has permitted physicians to engage in this, but only with respect to supplies, not specifically to medical savings,” Ms. Norwalk said.

To her knowledge, Congress has engaged in some ideas where physicians would be able to share in hospital savings for instance, “without it being a kickback violation,” she told the advisory panel.

CMS also has the ability to change payment systems statutorily through its practice group demonstration projects, Ms. Norwalk said. Several projects are currently testing pay-for-performance systems.

For the first time, Congress, MedPAC, CMS, PPAC, and all of the medical specialties are in agreement about something: that the SGR is flawed, Dr. Castellanos said. For that reason, “maybe something constructive can come out of this.”

WASHINGTON — The Centers for Medicare and Medicaid Services should not institute the 4.3% decrease proposed in the 2006 physician fee schedule, a federal advisory panel recommended.

As it works to fix the sustainable growth rate, CMS should, instead, adopt the Medicare Payment Advisory Commission's recent recommendation to increase payments by 2.7% to keep pace with the cost of care, the Practicing Physicians Advisory Council recommended.

The council meets quarterly to advise the Department of Health and Human Services on proposed changes in Medicare regulations and carrier manual instructions related to physicians' services.

MedPAC advises Congress in a similar manner.

Physician reimbursements under Medicare will be cut 26% over the next 6 years unless the sustainable growth rate (SGR) formula is changed. Although the PPAC recommendation calls on CMS to take action, only Congress has the statutory authority to fix the formula.

The average physician facing these cuts “is stuck” Ronald Castellanos, M.D., PPAC chairman, told CMS officials who presented a summary of the proposed fee schedule at the meeting. Reductions in Medicare payments have forced some physicians to do ancillary procedures in their offices to make up for the lost income, he said.

Leroy Sprang, M.D., an ob.gyn. who was recently named to the panel, said he's seen at least a dozen ob.gyns. in his area of Evanston, Ill., leave the profession due to the pressures of medical malpractice combined with reduced Medicare payments. While they don't deal with older patients as much as other primary care physicians do, some ob.gyn. practices have stopped seeing Medicare patients, he said.

In another avenue for addressing low physician reimbursement, the PPAC asked CMS for a report on whether Medicare Part B drugs could be removed retrospectively, using an administrative methodology. The council asked that the report be ready in time for its December meeting.

“We've been talking about this for the past 2 years,” said PPAC member Gregory Przybylski, M.D. The question is whether CMS could do this administratively by a certain date, he said.

Testifying before the panel, Ardis Hoven, M.D., who spoke on behalf of the American Medical Association, said the AMA was confident of CMS' authority to remove the drugs. “Drugs are not paid under the Medicare physician fee schedule, and it is illogical to include them in calculating the SGR,” Dr. Hoven said in her testimony. If CMS adopted a revised definition of “physicians' services” that excludes drugs, it could revise its SGR calculations going back to 1996 using its revised definition, although the revisions would affect payment updates in future years, she said.

Leslie Norwalk, CMS deputy administrator, conceded that Congress needed to institute a more rational approach to determining physician payments. Addressing other possible options, HHS' Office of Inspector General may take another look at “gainsharing,” an arrangement where physicians could make suggestions on ways to improve care, and in return receive a portion of the cost savings achieved when their ideas are implemented. “The OIG has permitted physicians to engage in this, but only with respect to supplies, not specifically to medical savings,” Ms. Norwalk said.

To her knowledge, Congress has engaged in some ideas where physicians would be able to share in hospital savings for instance, “without it being a kickback violation,” she told the advisory panel.

CMS also has the ability to change payment systems statutorily through its practice group demonstration projects, Ms. Norwalk said. Several projects are currently testing pay-for-performance systems.

For the first time, Congress, MedPAC, CMS, PPAC, and all of the medical specialties are in agreement about something: that the SGR is flawed, Dr. Castellanos said. For that reason, “maybe something constructive can come out of this.”

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on the Benefit

Patients' optimism of Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three seniors (32%) has a favorable impression of the benefit and an equal number (32%) have a negative one. This figure can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Working-age adults incur significantly higher rates of medical bill and debt problems than adults aged 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the President agrees with the recommendations he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to a Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and must be completed within 6 years, according to the Base Realignment and Closure statute.

Obesity Rankings

It pays to live in the mountains and ski: Trust for America's Health reported that Mississippi has the “heaviest” obesity rate in the country, Colorado the least heavy. More than 25% of adults in 10 states are obese, including Mississippi, Alabama, West Virginia, Louisiana, Tennessee, Texas, Michigan, Kentucky, Indiana, and South Carolina. Rates have stayed the same in Oregon. A majority of governors have taken steps to initiate obesity reduction and control programs for state employees. However, most statewide initiatives aimed at the general public are limited to public information campaigns, said Trust for America's Health, a nonprofit organization that focuses on disease prevention.

Impact of Concierge Care

Due to their small numbers, it is unlikely that concierge care practices will contribute to widespread access problems for Medicare beneficiaries, the Government Accountability Office reported. In a recent survey, GAO identified 146 concierge physicians and analyzed responses from 112. According to the survey, most concierge practices are located on the East and West coasts, and nearly all respondents reported practicing primary care medicine. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500–$1,999.The Department of Health and Human Services has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements. Some concierge physicians reported to GAO that they would like more HHS guidance.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on the Benefit

Patients' optimism of Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three seniors (32%) has a favorable impression of the benefit and an equal number (32%) have a negative one. This figure can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Working-age adults incur significantly higher rates of medical bill and debt problems than adults aged 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the President agrees with the recommendations he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to a Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and must be completed within 6 years, according to the Base Realignment and Closure statute.

Obesity Rankings

It pays to live in the mountains and ski: Trust for America's Health reported that Mississippi has the “heaviest” obesity rate in the country, Colorado the least heavy. More than 25% of adults in 10 states are obese, including Mississippi, Alabama, West Virginia, Louisiana, Tennessee, Texas, Michigan, Kentucky, Indiana, and South Carolina. Rates have stayed the same in Oregon. A majority of governors have taken steps to initiate obesity reduction and control programs for state employees. However, most statewide initiatives aimed at the general public are limited to public information campaigns, said Trust for America's Health, a nonprofit organization that focuses on disease prevention.

Impact of Concierge Care

Due to their small numbers, it is unlikely that concierge care practices will contribute to widespread access problems for Medicare beneficiaries, the Government Accountability Office reported. In a recent survey, GAO identified 146 concierge physicians and analyzed responses from 112. According to the survey, most concierge practices are located on the East and West coasts, and nearly all respondents reported practicing primary care medicine. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500–$1,999.The Department of Health and Human Services has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements. Some concierge physicians reported to GAO that they would like more HHS guidance.

Census Bureau Statistics

The Census Bureau reports that 45.8 million Americans were without health insurance in 2004, up from 45 million in 2003. While the increase is statistically small, it means that “an additional 860,000 Americans live without the safety net of health insurance,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement. “As the decrease in employment-based health insurance continues, the AMA renews its call for health insurance solutions that put patients in the driver's seat, along with their physicians,” Dr. Hill said. Some of these solutions may include refundable tax credits inversely related to income and individually selected and owned health insurance, he said. In other statistics, the number of people with health insurance increased by 2 million to 245.3 million between 2003 and 2004. Those covered by government health insurance rose from 76.8 million in 2003 to 79 million—driven by increases in the percentage and number of people covered by Medicaid.

Split on the Benefit

Patients' optimism of Medicare's new prescription drug benefit has improved over the last few months, although beneficiaries remain split on their support, an August poll conducted by the Kaiser Family Foundation indicated. About one in three seniors (32%) has a favorable impression of the benefit and an equal number (32%) have a negative one. This figure can be compared with April, when only one in five (21%) had a favorable impression of it. Comprehension of the benefit has improved: Overall, 37% of seniors now say they understand the new benefit “very” or “somewhat” well, up from 29% in April. Six in 10 seniors (60%) say they don't understand the benefit well or at all. Slightly more than one in five seniors (22%) say they plan to enroll in the benefit, up from 9% in April. The poll represented 1,205 adults aged 18 and older, including 300 respondents aged 65 years and older, interviewed by telephone by Princeton Survey Research Associates, on behalf of Kaiser.

Driven Into Debt

An estimated 77 million Americans aged 19 years and older—nearly two of five adults—have had difficulty paying medical bills, have accrued medical debt, or both, according to an analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey. Working-age adults incur significantly higher rates of medical bill and debt problems than adults aged 65 and older, with rates highest among the uninsured. “Even working-age adults who are continually insured have problems paying their medical bills and have medical debt,” the analysis stated. Two-thirds of people with a medical bill or debt problem went without needed care because of cost—nearly three times the rate of those without these financial problems.

Walter Reed to Close

Walter Reed Army Medical Center in Washington, which has cared for hundreds of thousands of soldiers and dignitaries for the past 96 years, is slated to close as part of the base realignment and closure process. The medical center was tapped by the Department of Defense to be closed, and that recommendation was recently approved by members of the Defense Base Realignment and Closure Commission. The commission sent its final report to President Bush on Sept. 8. If the President agrees with the recommendations he will send the entire list to Congress for a vote. Congress must accept or reject the list in full, but they cannot amend it. If the closure is approved, most of the staff and services from the army hospital will be combined with services at the National Naval Medical Center in Bethesda, Md., and renamed the Walter Reed National Military Medical Center. Other services will be moved to a Fort Belvoir, Va. Closures and realignments must begin within 2 years of Congressional approval and must be completed within 6 years, according to the Base Realignment and Closure statute.

Obesity Rankings

It pays to live in the mountains and ski: Trust for America's Health reported that Mississippi has the “heaviest” obesity rate in the country, Colorado the least heavy. More than 25% of adults in 10 states are obese, including Mississippi, Alabama, West Virginia, Louisiana, Tennessee, Texas, Michigan, Kentucky, Indiana, and South Carolina. Rates have stayed the same in Oregon. A majority of governors have taken steps to initiate obesity reduction and control programs for state employees. However, most statewide initiatives aimed at the general public are limited to public information campaigns, said Trust for America's Health, a nonprofit organization that focuses on disease prevention.

Impact of Concierge Care

Due to their small numbers, it is unlikely that concierge care practices will contribute to widespread access problems for Medicare beneficiaries, the Government Accountability Office reported. In a recent survey, GAO identified 146 concierge physicians and analyzed responses from 112. According to the survey, most concierge practices are located on the East and West coasts, and nearly all respondents reported practicing primary care medicine. Annual patient membership fees ranged from $60 to $15,000 a year, with about half of respondents reporting fees of $1,500–$1,999.The Department of Health and Human Services has determined that concierge care arrangements are allowed as long as they do not violate any Medicare requirements. Some concierge physicians reported to GAO that they would like more HHS guidance.