Jennifer Silverman

Uninsured Projections

The plight of the uninsured isn't likely to be resolved anytime soon. More than one in four American workers under the age of 65 will be uninsured in 2013—nearly 56 million people—driven by the increasing inability to afford health insurance, reports a Health Affairs Web-exclusive article. Because growth in per capita health spending is expected to outpace median personal income by 2.4% every year, health care coverage will continue to decline because more Americans will find it unaffordable. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study indicated. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Seniors Don't Take Their Medicine

Four in 10 seniors don't take their medications as prescribed—either because the drug regimens were too complex and costly, they didn't think the drugs were helping them, or they didn't think they needed them, a survey of 17,685 Medicare beneficiaries aged 65 years and older revealed. The 2003 survey, which was conducted prior to the enactment of the Medicare Modernization Act, found that drug coverage made a substantial difference in adherence rates. Thirty-seven percent of seniors without drug coverage reported cost-related nonadherence, compared with 22% of seniors with drug coverage. “Urging doctors and patients to talk more about these issues and developing systems to monitor quality and safety” could improve compliance, said Commonwealth Fund President Karen Davis. The survey was conducted by the Kaiser Family Foundation, the Commonwealth Fund, and Tufts-New England Medical Center and was posted as a Health Affairs online article.

Unreadable Privacy Forms

Privacy forms used by major health care institutions are often lengthy and too difficult for patients to read, according to a study published in the Journal of the American Medical Association (2005;293:1593–4). The Health Insurance Portability and Accountability Act requires that health care institutions inform patients in detail about the use of information obtained during medical care, through a notice of privacy form “written in plain English.” The median length of the forms was six pages, and often used inappropriately small type, and complex language that was unlikely to be understood by a “considerable proportion” of the populations served by these institutions, the report said. Privacy practice notices from 185 institutions listed in the 2004 U.S. News & World Report “best hospitals” issue were collected for the study.

Obesity in African Americans

Officials at the Department of Health and Human Services have awarded $1.2 million to fight obesity among African Americans. The money will be used by a coalition of national organizations to fund prevention, education, public awareness, and outreach activities aimed at promoting a greater understanding of the impact of obesity. Nearly two-thirds of Americans are considered overweight or obese but the problem appears to be more prevalent in the African American community. Adult African American women have age-adjusted obesity rates of 49%, compared with 31% for adult white women, according to 1999–2002 data from the Centers for Disease Control and Prevention. African American girls and boys also had higher rates of overweight than did white children in the same age groups. HHS plans a second phase of the initiative targeting the Hispanic community.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia J. Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, and persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proved harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured isn't likely to be resolved anytime soon. More than one in four American workers under the age of 65 will be uninsured in 2013—nearly 56 million people—driven by the increasing inability to afford health insurance, reports a Health Affairs Web-exclusive article. Because growth in per capita health spending is expected to outpace median personal income by 2.4% every year, health care coverage will continue to decline because more Americans will find it unaffordable. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study indicated. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Seniors Don't Take Their Medicine

Four in 10 seniors don't take their medications as prescribed—either because the drug regimens were too complex and costly, they didn't think the drugs were helping them, or they didn't think they needed them, a survey of 17,685 Medicare beneficiaries aged 65 years and older revealed. The 2003 survey, which was conducted prior to the enactment of the Medicare Modernization Act, found that drug coverage made a substantial difference in adherence rates. Thirty-seven percent of seniors without drug coverage reported cost-related nonadherence, compared with 22% of seniors with drug coverage. “Urging doctors and patients to talk more about these issues and developing systems to monitor quality and safety” could improve compliance, said Commonwealth Fund President Karen Davis. The survey was conducted by the Kaiser Family Foundation, the Commonwealth Fund, and Tufts-New England Medical Center and was posted as a Health Affairs online article.

Unreadable Privacy Forms

Privacy forms used by major health care institutions are often lengthy and too difficult for patients to read, according to a study published in the Journal of the American Medical Association (2005;293:1593–4). The Health Insurance Portability and Accountability Act requires that health care institutions inform patients in detail about the use of information obtained during medical care, through a notice of privacy form “written in plain English.” The median length of the forms was six pages, and often used inappropriately small type, and complex language that was unlikely to be understood by a “considerable proportion” of the populations served by these institutions, the report said. Privacy practice notices from 185 institutions listed in the 2004 U.S. News & World Report “best hospitals” issue were collected for the study.

Obesity in African Americans

Officials at the Department of Health and Human Services have awarded $1.2 million to fight obesity among African Americans. The money will be used by a coalition of national organizations to fund prevention, education, public awareness, and outreach activities aimed at promoting a greater understanding of the impact of obesity. Nearly two-thirds of Americans are considered overweight or obese but the problem appears to be more prevalent in the African American community. Adult African American women have age-adjusted obesity rates of 49%, compared with 31% for adult white women, according to 1999–2002 data from the Centers for Disease Control and Prevention. African American girls and boys also had higher rates of overweight than did white children in the same age groups. HHS plans a second phase of the initiative targeting the Hispanic community.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia J. Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, and persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proved harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured isn't likely to be resolved anytime soon. More than one in four American workers under the age of 65 will be uninsured in 2013—nearly 56 million people—driven by the increasing inability to afford health insurance, reports a Health Affairs Web-exclusive article. Because growth in per capita health spending is expected to outpace median personal income by 2.4% every year, health care coverage will continue to decline because more Americans will find it unaffordable. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study indicated. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Seniors Don't Take Their Medicine

Four in 10 seniors don't take their medications as prescribed—either because the drug regimens were too complex and costly, they didn't think the drugs were helping them, or they didn't think they needed them, a survey of 17,685 Medicare beneficiaries aged 65 years and older revealed. The 2003 survey, which was conducted prior to the enactment of the Medicare Modernization Act, found that drug coverage made a substantial difference in adherence rates. Thirty-seven percent of seniors without drug coverage reported cost-related nonadherence, compared with 22% of seniors with drug coverage. “Urging doctors and patients to talk more about these issues and developing systems to monitor quality and safety” could improve compliance, said Commonwealth Fund President Karen Davis. The survey was conducted by the Kaiser Family Foundation, the Commonwealth Fund, and Tufts-New England Medical Center and was posted as a Health Affairs online article.

Unreadable Privacy Forms

Privacy forms used by major health care institutions are often lengthy and too difficult for patients to read, according to a study published in the Journal of the American Medical Association (2005;293:1593–4). The Health Insurance Portability and Accountability Act requires that health care institutions inform patients in detail about the use of information obtained during medical care, through a notice of privacy form “written in plain English.” The median length of the forms was six pages, and often used inappropriately small type, and complex language that was unlikely to be understood by a “considerable proportion” of the populations served by these institutions, the report said. Privacy practice notices from 185 institutions listed in the 2004 U.S. News & World Report “best hospitals” issue were collected for the study.

Obesity in African Americans

Officials at the Department of Health and Human Services have awarded $1.2 million to fight obesity among African Americans. The money will be used by a coalition of national organizations to fund prevention, education, public awareness, and outreach activities aimed at promoting a greater understanding of the impact of obesity. Nearly two-thirds of Americans are considered overweight or obese but the problem appears to be more prevalent in the African American community. Adult African American women have age-adjusted obesity rates of 49%, compared with 31% for adult white women, according to 1999–2002 data from the Centers for Disease Control and Prevention. African American girls and boys also had higher rates of overweight than did white children in the same age groups. HHS plans a second phase of the initiative targeting the Hispanic community.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia J. Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, and persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proved harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured isn't likely to be resolved anytime soon. More than one in four American workers under the age of 65 will be uninsured in 2013—nearly 56 million people—driven by the increasing inability to afford health insurance, reports a Health Affairs Web-exclusive article. Because growth in per capita health spending is expected to outpace median personal income by 2.4% every year, health care coverage will continue to decline because more Americans will find it unaffordable. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study indicated. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Unreadable Privacy Forms

Privacy forms used by major health care institutions are often lengthy and too difficult for patients to read, according to a study published in the Journal of the American Medical Association (2005;293:1593-4). The Health Insurance Portability and Accountability Act requires that health care institutions inform patients in detail about the use of information obtained during medical care, through a notice of privacy form “written in plain English.” The median length of the forms was six pages, and often used inappropriately small type, and complex language that was unlikely to be understood by a “considerable proportion” of the populations served by these institutions, the report said. Privacy practice notices from 185 institutions listed in the 2004 U.S. News & World Report “best hospitals” issue were collected for the study.

Banishing Bad Bugs From Food

Food-borne illnesses continue to decline, according to the latest report from the CDC and other federal agencies. From 1996 through 2004, the time period in which the agency's FoodNet surveillance system has been tracking the incidence of food-borne illness, Escherichia coli O157 infections decreased by 47%, whereas Cryptosporidium infections dropped 40%, and Yersinia, 45%. Campylobacter infections declined by 31%, possibly because of greater consumer awareness of safe poultry handling and cooking methods. Not all food-borne infections have shown a downward trend. Vibrio infections caused by consumption of certain types of raw shellfish increased by 47% during this time period, and salmonella infections declined by only 8%, the CDC reported.

Obesity in African Americans

Officials at the Department of Health and Human Services have awarded $1.2 million to fight obesity in African Americans. The money will be used by a coalition of national organizations to fund prevention, education, public awareness, and outreach activities aimed at promoting understanding of the impact of obesity. Nearly two-thirds of Americans are overweight or obese, but the problem appears to be more prevalent in the African American community. Adult African American women have age-adjusted obesity rates of 49%, compared with 31% for adult white women, according to 1999-2002 data from the Centers for Disease Control and Prevention. African American girls and boys also had higher rates of overweight than did white children in the same age groups. HHS plans a second phase of the initiative targeting the Hispanic community.

Seniors Don't Take Their Medicine

Four in 10 seniors don't take their medications as prescribed—either because the drug regimens were too complex and costly, they didn't think the drugs were helping them, or they didn't think they needed them, a survey of 17,685 Medicare beneficiaries aged 65 years and older revealed. The 2003 survey, which was conducted prior to the enactment of the Medicare Modernization Act, found that drug coverage made a substantial difference in adherence rates. Of seniors without drug coverage, 37% reported cost-related nonadherence, compared with 22% of seniors with drug coverage. “Urging doctors and patients to talk more about these issues and developing systems to monitor quality and safety” could improve compliance, said Commonwealth Fund President Karen Davis. The survey was conducted by the Kaiser Family Foundation, the Commonwealth Fund, and Tufts-New England Medical Center and was posted as a Health Affairs online article.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia J. Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, and persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proved harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured isn't likely to be resolved anytime soon. More than one in four American workers under the age of 65 will be uninsured in 2013—nearly 56 million people—driven by the increasing inability to afford health insurance, reports a Health Affairs Web-exclusive article. Because growth in per capita health spending is expected to outpace median personal income by 2.4% every year, health care coverage will continue to decline because more Americans will find it unaffordable. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study indicated. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Unreadable Privacy Forms

Privacy forms used by major health care institutions are often lengthy and too difficult for patients to read, according to a study published in the Journal of the American Medical Association (2005;293:1593-4). The Health Insurance Portability and Accountability Act requires that health care institutions inform patients in detail about the use of information obtained during medical care, through a notice of privacy form “written in plain English.” The median length of the forms was six pages, and often used inappropriately small type, and complex language that was unlikely to be understood by a “considerable proportion” of the populations served by these institutions, the report said. Privacy practice notices from 185 institutions listed in the 2004 U.S. News & World Report “best hospitals” issue were collected for the study.

Banishing Bad Bugs From Food

Food-borne illnesses continue to decline, according to the latest report from the CDC and other federal agencies. From 1996 through 2004, the time period in which the agency's FoodNet surveillance system has been tracking the incidence of food-borne illness, Escherichia coli O157 infections decreased by 47%, whereas Cryptosporidium infections dropped 40%, and Yersinia, 45%. Campylobacter infections declined by 31%, possibly because of greater consumer awareness of safe poultry handling and cooking methods. Not all food-borne infections have shown a downward trend. Vibrio infections caused by consumption of certain types of raw shellfish increased by 47% during this time period, and salmonella infections declined by only 8%, the CDC reported.

Obesity in African Americans

Officials at the Department of Health and Human Services have awarded $1.2 million to fight obesity in African Americans. The money will be used by a coalition of national organizations to fund prevention, education, public awareness, and outreach activities aimed at promoting understanding of the impact of obesity. Nearly two-thirds of Americans are overweight or obese, but the problem appears to be more prevalent in the African American community. Adult African American women have age-adjusted obesity rates of 49%, compared with 31% for adult white women, according to 1999-2002 data from the Centers for Disease Control and Prevention. African American girls and boys also had higher rates of overweight than did white children in the same age groups. HHS plans a second phase of the initiative targeting the Hispanic community.

Seniors Don't Take Their Medicine

Four in 10 seniors don't take their medications as prescribed—either because the drug regimens were too complex and costly, they didn't think the drugs were helping them, or they didn't think they needed them, a survey of 17,685 Medicare beneficiaries aged 65 years and older revealed. The 2003 survey, which was conducted prior to the enactment of the Medicare Modernization Act, found that drug coverage made a substantial difference in adherence rates. Of seniors without drug coverage, 37% reported cost-related nonadherence, compared with 22% of seniors with drug coverage. “Urging doctors and patients to talk more about these issues and developing systems to monitor quality and safety” could improve compliance, said Commonwealth Fund President Karen Davis. The survey was conducted by the Kaiser Family Foundation, the Commonwealth Fund, and Tufts-New England Medical Center and was posted as a Health Affairs online article.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia J. Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, and persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proved harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured isn't likely to be resolved anytime soon. More than one in four American workers under the age of 65 will be uninsured in 2013—nearly 56 million people—driven by the increasing inability to afford health insurance, reports a Health Affairs Web-exclusive article. Because growth in per capita health spending is expected to outpace median personal income by 2.4% every year, health care coverage will continue to decline because more Americans will find it unaffordable. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study indicated. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Unreadable Privacy Forms

Privacy forms used by major health care institutions are often lengthy and too difficult for patients to read, according to a study published in the Journal of the American Medical Association (2005;293:1593-4). The Health Insurance Portability and Accountability Act requires that health care institutions inform patients in detail about the use of information obtained during medical care, through a notice of privacy form “written in plain English.” The median length of the forms was six pages, and often used inappropriately small type, and complex language that was unlikely to be understood by a “considerable proportion” of the populations served by these institutions, the report said. Privacy practice notices from 185 institutions listed in the 2004 U.S. News & World Report “best hospitals” issue were collected for the study.

Banishing Bad Bugs From Food

Food-borne illnesses continue to decline, according to the latest report from the CDC and other federal agencies. From 1996 through 2004, the time period in which the agency's FoodNet surveillance system has been tracking the incidence of food-borne illness, Escherichia coli O157 infections decreased by 47%, whereas Cryptosporidium infections dropped 40%, and Yersinia, 45%. Campylobacter infections declined by 31%, possibly because of greater consumer awareness of safe poultry handling and cooking methods. Not all food-borne infections have shown a downward trend. Vibrio infections caused by consumption of certain types of raw shellfish increased by 47% during this time period, and salmonella infections declined by only 8%, the CDC reported.

Obesity in African Americans

Officials at the Department of Health and Human Services have awarded $1.2 million to fight obesity in African Americans. The money will be used by a coalition of national organizations to fund prevention, education, public awareness, and outreach activities aimed at promoting understanding of the impact of obesity. Nearly two-thirds of Americans are overweight or obese, but the problem appears to be more prevalent in the African American community. Adult African American women have age-adjusted obesity rates of 49%, compared with 31% for adult white women, according to 1999-2002 data from the Centers for Disease Control and Prevention. African American girls and boys also had higher rates of overweight than did white children in the same age groups. HHS plans a second phase of the initiative targeting the Hispanic community.

Seniors Don't Take Their Medicine

Four in 10 seniors don't take their medications as prescribed—either because the drug regimens were too complex and costly, they didn't think the drugs were helping them, or they didn't think they needed them, a survey of 17,685 Medicare beneficiaries aged 65 years and older revealed. The 2003 survey, which was conducted prior to the enactment of the Medicare Modernization Act, found that drug coverage made a substantial difference in adherence rates. Of seniors without drug coverage, 37% reported cost-related nonadherence, compared with 22% of seniors with drug coverage. “Urging doctors and patients to talk more about these issues and developing systems to monitor quality and safety” could improve compliance, said Commonwealth Fund President Karen Davis. The survey was conducted by the Kaiser Family Foundation, the Commonwealth Fund, and Tufts-New England Medical Center and was posted as a Health Affairs online article.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia J. Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, and persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proved harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the American Board of Internal Medicine (ABIM) show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed certification in general or core internal medicine. Many in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, William E. Golden, M.D., an American College of Physicians regent and professor of medicine and public health at the University of Arkansas, Little Rock, said in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said. The latest ABIM figures show that only 21% of cardiologists are renewing their core certificate.

Subspecialists may shy away from core internal medicine because they don't find it relevant, or are concerned they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, a panel that was formed several years ago to advise the board on new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine. This includes physicians certified between 1990 and 1994, whose certificates otherwise would have expired by now.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 are no longer practicing in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, ABIM announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence in the new system. “In the past, people have been anxious and uncertain about what it would mean,” but they became more comfortable as the process became clearer.

Dr. Golden said that in his recent presentations at American College of Physicians regional meetings, he never gets a “single question or complaint” when he explains the maintenance of certification program. “It sounds complicated, but when you look at it, it's pretty straightforward.”

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine. Also, more options will be available to meet the ABIM's new standard for practice performance, which entails practice improvement modules.

Diplomates will be able to use their own data or data they receive from a valid outside source—such as a group practice or insurer—toward credit for self-evaluation of practice performance. Credit will be available for participating in a quality improvement program, such as through a hospital or medical group, that meets ABIM standards. The program will retain its basic requirements, such as holding a clean license and passing a secure exam of medical knowledge.

Maintenance of certification is relatively new, so it's not surprising that some people find it overwhelming, Christine Cassel, M.D., president of the ABIM, told this newspaper. Some insurance companies may require maintenance of certification, and it may be necessary for physician privileges at hospitals, Dr. Golden said. Also, “licensure boards are increasingly looking for mechanisms to verify that physicians maintain competency, and there's been some talk that recertification would serve as a proxy for documentation for relicensure.”

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the American Board of Internal Medicine (ABIM) show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed certification in general or core internal medicine. Many in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, William E. Golden, M.D., an American College of Physicians regent and professor of medicine and public health at the University of Arkansas, Little Rock, said in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said. The latest ABIM figures show that only 21% of cardiologists are renewing their core certificate.

Subspecialists may shy away from core internal medicine because they don't find it relevant, or are concerned they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, a panel that was formed several years ago to advise the board on new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine. This includes physicians certified between 1990 and 1994, whose certificates otherwise would have expired by now.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 are no longer practicing in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, ABIM announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence in the new system. “In the past, people have been anxious and uncertain about what it would mean,” but they became more comfortable as the process became clearer.

Dr. Golden said that in his recent presentations at American College of Physicians regional meetings, he never gets a “single question or complaint” when he explains the maintenance of certification program. “It sounds complicated, but when you look at it, it's pretty straightforward.”

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine. Also, more options will be available to meet the ABIM's new standard for practice performance, which entails practice improvement modules.

Diplomates will be able to use their own data or data they receive from a valid outside source—such as a group practice or insurer—toward credit for self-evaluation of practice performance. Credit will be available for participating in a quality improvement program, such as through a hospital or medical group, that meets ABIM standards. The program will retain its basic requirements, such as holding a clean license and passing a secure exam of medical knowledge.

Maintenance of certification is relatively new, so it's not surprising that some people find it overwhelming, Christine Cassel, M.D., president of the ABIM, told this newspaper. Some insurance companies may require maintenance of certification, and it may be necessary for physician privileges at hospitals, Dr. Golden said. Also, “licensure boards are increasingly looking for mechanisms to verify that physicians maintain competency, and there's been some talk that recertification would serve as a proxy for documentation for relicensure.”

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the American Board of Internal Medicine (ABIM) show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed certification in general or core internal medicine. Many in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, William E. Golden, M.D., an American College of Physicians regent and professor of medicine and public health at the University of Arkansas, Little Rock, said in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said. The latest ABIM figures show that only 21% of cardiologists are renewing their core certificate.

Subspecialists may shy away from core internal medicine because they don't find it relevant, or are concerned they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, a panel that was formed several years ago to advise the board on new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine. This includes physicians certified between 1990 and 1994, whose certificates otherwise would have expired by now.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 are no longer practicing in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, ABIM announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence in the new system. “In the past, people have been anxious and uncertain about what it would mean,” but they became more comfortable as the process became clearer.

Dr. Golden said that in his recent presentations at American College of Physicians regional meetings, he never gets a “single question or complaint” when he explains the maintenance of certification program. “It sounds complicated, but when you look at it, it's pretty straightforward.”

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine. Also, more options will be available to meet the ABIM's new standard for practice performance, which entails practice improvement modules.

Diplomates will be able to use their own data or data they receive from a valid outside source—such as a group practice or insurer—toward credit for self-evaluation of practice performance. Credit will be available for participating in a quality improvement program, such as through a hospital or medical group, that meets ABIM standards. The program will retain its basic requirements, such as holding a clean license and passing a secure exam of medical knowledge.

Maintenance of certification is relatively new, so it's not surprising that some people find it overwhelming, Christine Cassel, M.D., president of the ABIM, told this newspaper. Some insurance companies may require maintenance of certification, and it may be necessary for physician privileges at hospitals, Dr. Golden said. Also, “licensure boards are increasingly looking for mechanisms to verify that physicians maintain competency, and there's been some talk that recertification would serve as a proxy for documentation for relicensure.”

WASHINGTON — Federal regulations should recognize the expertise of nurse-midwives in certifying false-labor cases in the hospital, Deanne Williams, a certified nurse-midwife, testified at a meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

Under EMTALA, “only a physician is recognized to certify that a woman who presents to a hospital for evaluation is actually experiencing false labor,” said Ms. Williams, executive director of the American College of Nurse-Midwives (ACNM). In the college's view, the regulation fails to acknowledge the scope of practice under which certified nurse-midwives and certified midwives are authorized to treat patients, she said.

“Midwives have a very long history of working collaboratively with physicians to provide women's health care, with a particular focus on care during the maternity cycle,” Ms. Williams said, adding that midwives attend more than 10% of the vaginal births in the United States, and 98% of the births attended by midwives occur in hospitals.

EMTALA's requirement for physician certification “places unnecessary costs on the hospital, which is required to take physicians away from other matters to certify that the woman is in false labor, when a certified nurse-midwife or certified midwife is also licensed to make that decision,” Ms. Williams testified.

While EMTALA regulations require a signed certification that a woman is experiencing false labor and may be discharged, “there is no requirement in the regulations that a physician must personally examine the patient,” noted one advisory group member, Charlotte Yeh, M.D., who is an emergency physician and the CMS regional administrator for Region I in Boston.

The law's interpretive guidelines explain further that a physician must be contacted by the qualified medical professional—i.e. nurse-midwife—to ensure that the woman with contractions has false labor. The guidelines leave it up to the individual hospitals to determine whether physicians should personally examine the patient, she said.

The issue before the technical advisory group is whether the latitude provided by EMTALA's interpretive guidelines is sufficient to protect patients, yet recognizes the value that nurse-midwives bring to labor and delivery, Dr. Yeh told this newspaper. “Or, the [technical advisory group] could say that the regulations are too prescriptive, and that certification should be removed altogether, letting individual hospitals decide who's qualified to determine emergency medical conditions” in patients.

It's clear that ACNM's request “would necessitate a change,” David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, indicated.

Dr. Siegel asked that the panel seek formal input from the American College of Obstetricians and Gynecologists and other appropriate medical specialty organizations on their policies regarding this issue.

Warren Jones, M.D., Medicaid director for the state of Mississippi and a past president of the American Academy of Family Physicians, emphasized that the panel should seek input from the AAFP on this issue.

“There needs to be a recognition that ob.gyns. are not the only physicians who deliver babies and provide maternity care. Family physicians do a lot of that. Many of them work with nurse-midwives, and many of them provide it in rural areas where it's really needed,” Dr. Jones said in an interview with this newspaper.

The advisory committee also will need to consider that in some states, nurse-midwives are already recognized as qualified to determine false labor, Dr. Yeh said. What the nurse-midwives want is for those qualifications to be recognized by CMS, she said.

Robert Bitterman, M.D., a representative of the American College of Emergency Physicians, and a participant at the meeting, noted that the regulations might not have to be changed at all.

“If you hearken back to the actual statute, the word 'labor' does not appear anywhere in the definition of an emergency medical physician in EMTALA. Therefore, whether someone is in actual labor or in false labor, is entirely irrelevant,” he stated.

EMTALA is meant to be a limited law, Dr. Bitterman continued. “It asks: Is this pregnant woman having contractions, and if so, is it safe to go home, and if doing so would pose a hardship to the baby or the mother.”

Therefore, it's perfectly appropriate under EMTALA for nurses, physicians, family physicians, or pathologists to perform the screening exam if they're the ones designated by the hospital to make those types of decisions, he said.

“It's a myth to think that physicians and hospitals don't send home patients if they have active labor. We do it every day because it's an early active labor, and because it's safe to do so—and it meets the elements of the statute,” Dr. Bitterman said.

Dr. Yeh clarified that the word “labor” did in fact appear in the EMTALA statute under the definition of a transfer, and that a false-labor discharge qualified as a transfer.

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 the Department of Health and Human Services establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

The group will advise HHS and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA. It is comprised of representatives of hospital, physician, and patient groups, plus CMS staff and state government officials.

WASHINGTON — Federal regulations should recognize the expertise of nurse-midwives in certifying false-labor cases in the hospital, Deanne Williams, a certified nurse-midwife, testified at a meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

Under EMTALA, “only a physician is recognized to certify that a woman who presents to a hospital for evaluation is actually experiencing false labor,” said Ms. Williams, executive director of the American College of Nurse-Midwives (ACNM). In the college's view, the regulation fails to acknowledge the scope of practice under which certified nurse-midwives and certified midwives are authorized to treat patients, she said.

“Midwives have a very long history of working collaboratively with physicians to provide women's health care, with a particular focus on care during the maternity cycle,” Ms. Williams said, adding that midwives attend more than 10% of the vaginal births in the United States, and 98% of the births attended by midwives occur in hospitals.

EMTALA's requirement for physician certification “places unnecessary costs on the hospital, which is required to take physicians away from other matters to certify that the woman is in false labor, when a certified nurse-midwife or certified midwife is also licensed to make that decision,” Ms. Williams testified.

While EMTALA regulations require a signed certification that a woman is experiencing false labor and may be discharged, “there is no requirement in the regulations that a physician must personally examine the patient,” noted one advisory group member, Charlotte Yeh, M.D., who is an emergency physician and the CMS regional administrator for Region I in Boston.

The law's interpretive guidelines explain further that a physician must be contacted by the qualified medical professional—i.e. nurse-midwife—to ensure that the woman with contractions has false labor. The guidelines leave it up to the individual hospitals to determine whether physicians should personally examine the patient, she said.

The issue before the technical advisory group is whether the latitude provided by EMTALA's interpretive guidelines is sufficient to protect patients, yet recognizes the value that nurse-midwives bring to labor and delivery, Dr. Yeh told this newspaper. “Or, the [technical advisory group] could say that the regulations are too prescriptive, and that certification should be removed altogether, letting individual hospitals decide who's qualified to determine emergency medical conditions” in patients.

It's clear that ACNM's request “would necessitate a change,” David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, indicated.

Dr. Siegel asked that the panel seek formal input from the American College of Obstetricians and Gynecologists and other appropriate medical specialty organizations on their policies regarding this issue.

Warren Jones, M.D., Medicaid director for the state of Mississippi and a past president of the American Academy of Family Physicians, emphasized that the panel should seek input from the AAFP on this issue.

“There needs to be a recognition that ob.gyns. are not the only physicians who deliver babies and provide maternity care. Family physicians do a lot of that. Many of them work with nurse-midwives, and many of them provide it in rural areas where it's really needed,” Dr. Jones said in an interview with this newspaper.

The advisory committee also will need to consider that in some states, nurse-midwives are already recognized as qualified to determine false labor, Dr. Yeh said. What the nurse-midwives want is for those qualifications to be recognized by CMS, she said.

Robert Bitterman, M.D., a representative of the American College of Emergency Physicians, and a participant at the meeting, noted that the regulations might not have to be changed at all.

“If you hearken back to the actual statute, the word 'labor' does not appear anywhere in the definition of an emergency medical physician in EMTALA. Therefore, whether someone is in actual labor or in false labor, is entirely irrelevant,” he stated.

EMTALA is meant to be a limited law, Dr. Bitterman continued. “It asks: Is this pregnant woman having contractions, and if so, is it safe to go home, and if doing so would pose a hardship to the baby or the mother.”

Therefore, it's perfectly appropriate under EMTALA for nurses, physicians, family physicians, or pathologists to perform the screening exam if they're the ones designated by the hospital to make those types of decisions, he said.

“It's a myth to think that physicians and hospitals don't send home patients if they have active labor. We do it every day because it's an early active labor, and because it's safe to do so—and it meets the elements of the statute,” Dr. Bitterman said.

Dr. Yeh clarified that the word “labor” did in fact appear in the EMTALA statute under the definition of a transfer, and that a false-labor discharge qualified as a transfer.

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 the Department of Health and Human Services establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

The group will advise HHS and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA. It is comprised of representatives of hospital, physician, and patient groups, plus CMS staff and state government officials.

WASHINGTON — Federal regulations should recognize the expertise of nurse-midwives in certifying false-labor cases in the hospital, Deanne Williams, a certified nurse-midwife, testified at a meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

Under EMTALA, “only a physician is recognized to certify that a woman who presents to a hospital for evaluation is actually experiencing false labor,” said Ms. Williams, executive director of the American College of Nurse-Midwives (ACNM). In the college's view, the regulation fails to acknowledge the scope of practice under which certified nurse-midwives and certified midwives are authorized to treat patients, she said.

“Midwives have a very long history of working collaboratively with physicians to provide women's health care, with a particular focus on care during the maternity cycle,” Ms. Williams said, adding that midwives attend more than 10% of the vaginal births in the United States, and 98% of the births attended by midwives occur in hospitals.

EMTALA's requirement for physician certification “places unnecessary costs on the hospital, which is required to take physicians away from other matters to certify that the woman is in false labor, when a certified nurse-midwife or certified midwife is also licensed to make that decision,” Ms. Williams testified.

While EMTALA regulations require a signed certification that a woman is experiencing false labor and may be discharged, “there is no requirement in the regulations that a physician must personally examine the patient,” noted one advisory group member, Charlotte Yeh, M.D., who is an emergency physician and the CMS regional administrator for Region I in Boston.

The law's interpretive guidelines explain further that a physician must be contacted by the qualified medical professional—i.e. nurse-midwife—to ensure that the woman with contractions has false labor. The guidelines leave it up to the individual hospitals to determine whether physicians should personally examine the patient, she said.

The issue before the technical advisory group is whether the latitude provided by EMTALA's interpretive guidelines is sufficient to protect patients, yet recognizes the value that nurse-midwives bring to labor and delivery, Dr. Yeh told this newspaper. “Or, the [technical advisory group] could say that the regulations are too prescriptive, and that certification should be removed altogether, letting individual hospitals decide who's qualified to determine emergency medical conditions” in patients.

It's clear that ACNM's request “would necessitate a change,” David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, indicated.

Dr. Siegel asked that the panel seek formal input from the American College of Obstetricians and Gynecologists and other appropriate medical specialty organizations on their policies regarding this issue.

Warren Jones, M.D., Medicaid director for the state of Mississippi and a past president of the American Academy of Family Physicians, emphasized that the panel should seek input from the AAFP on this issue.

“There needs to be a recognition that ob.gyns. are not the only physicians who deliver babies and provide maternity care. Family physicians do a lot of that. Many of them work with nurse-midwives, and many of them provide it in rural areas where it's really needed,” Dr. Jones said in an interview with this newspaper.

The advisory committee also will need to consider that in some states, nurse-midwives are already recognized as qualified to determine false labor, Dr. Yeh said. What the nurse-midwives want is for those qualifications to be recognized by CMS, she said.

Robert Bitterman, M.D., a representative of the American College of Emergency Physicians, and a participant at the meeting, noted that the regulations might not have to be changed at all.

“If you hearken back to the actual statute, the word 'labor' does not appear anywhere in the definition of an emergency medical physician in EMTALA. Therefore, whether someone is in actual labor or in false labor, is entirely irrelevant,” he stated.

EMTALA is meant to be a limited law, Dr. Bitterman continued. “It asks: Is this pregnant woman having contractions, and if so, is it safe to go home, and if doing so would pose a hardship to the baby or the mother.”

Therefore, it's perfectly appropriate under EMTALA for nurses, physicians, family physicians, or pathologists to perform the screening exam if they're the ones designated by the hospital to make those types of decisions, he said.

“It's a myth to think that physicians and hospitals don't send home patients if they have active labor. We do it every day because it's an early active labor, and because it's safe to do so—and it meets the elements of the statute,” Dr. Bitterman said.

Dr. Yeh clarified that the word “labor” did in fact appear in the EMTALA statute under the definition of a transfer, and that a false-labor discharge qualified as a transfer.

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 the Department of Health and Human Services establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

The group will advise HHS and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA. It is comprised of representatives of hospital, physician, and patient groups, plus CMS staff and state government officials.

WASHINGTON — Rewarding states based on quality is one way to cover more uninsured Americans, Henry J. Aaron said at the annual meeting of the National Governors Association.

Following up on a trend that has already affected the physician community, Mr. Aaron proposed a “pay-for-performance” system, where states could receive federal grants based on their “actual measured progress of increasing the number and proportion of state residents covered by health insurance.”

The grants would be designed to cover much or all of the costs of extending coverage.

“Any state that succeeded in boosting the fraction of its population [covered by] health insurance would receive federal support. The states that made no such progress would receive nothing,” said Mr. Aaron, senior fellow for economic studies at the Brookings Institution.

The federal government should first define a standard for health insurance coverage, Mr. Aaron said, suggesting that the minimum be “similar to the actuarial value of the Federal Employees Health Benefits Program.”

His plan also would include a “first do no harm” standard, prohibiting states from materially eroding coverage for the current Medicaid population.

“Even now, Medicaid is substantially less costly than private insurance of the same scope. Still, state costs for long-term care [are] on track to rise relentlessly as baby boomers age.”

This means that states need continued financial protection from adverse trends—and not a cap on federal support.

“[States] also need flexibility to modernize Medicaid but within the limits that maintain the per capita protection of the most vulnerable populations in our nation,” Mr. Aaron said.

Within these broad guidelines, states should be encouraged to pursue any approach that would increase the proportion of state residents who have health insurance coverage, he continued. Depending on local conditions and political preferences, states could use refundable tax credits or vouchers in order to promote individual health insurance.

Some additional strategies that states could use to boost coverage for the uninsured include extending Medicaid or the State Children's Health Insurance Program, imposing employer mandates, and trying to create an intrastate single-payer plan.

States could also facilitate new insurance groups by allowing churches, unions, and the like to create association health plans.

None of these options would be mandatory, Mr. Aaron said.

Another panelist, Stuart M. Butler, Ph.D., suggested that Congress should enact a policy “toolbox” that would make a range of ideas available to states, on a voluntary basis. Dr. Butler is vice president of domestic and economic policy studies at the Heritage Foundation, Washington.

Under such an approach, states could propose an initiative for preserving coverage, selecting certain elements from the toolbox, and negotiating with the U.S. Department of Health and Human Services regarding appropriate waivers to pull such an option together, Dr. Butler explained.

In an attempt to maintain and extend the functional equivalent of Medicaid during these very tight budget times, states could utilize an enhanced federal refundable tax credit from the policy toolbox, using additional federal funds to create purchasing alliances or pools, he added.

One of the most important goals is to make sure that Medicaid populations are protected, Dr. Butler said. He recommended “encouraging innovations through the states [and] rewarding pay-for-performance successes by the states, to reach these goals.”

WASHINGTON — Rewarding states based on quality is one way to cover more uninsured Americans, Henry J. Aaron said at the annual meeting of the National Governors Association.

Following up on a trend that has already affected the physician community, Mr. Aaron proposed a “pay-for-performance” system, where states could receive federal grants based on their “actual measured progress of increasing the number and proportion of state residents covered by health insurance.”

The grants would be designed to cover much or all of the costs of extending coverage.

“Any state that succeeded in boosting the fraction of its population [covered by] health insurance would receive federal support. The states that made no such progress would receive nothing,” said Mr. Aaron, senior fellow for economic studies at the Brookings Institution.

The federal government should first define a standard for health insurance coverage, Mr. Aaron said, suggesting that the minimum be “similar to the actuarial value of the Federal Employees Health Benefits Program.”

His plan also would include a “first do no harm” standard, prohibiting states from materially eroding coverage for the current Medicaid population.

“Even now, Medicaid is substantially less costly than private insurance of the same scope. Still, state costs for long-term care [are] on track to rise relentlessly as baby boomers age.”

This means that states need continued financial protection from adverse trends—and not a cap on federal support.

“[States] also need flexibility to modernize Medicaid but within the limits that maintain the per capita protection of the most vulnerable populations in our nation,” Mr. Aaron said.

Within these broad guidelines, states should be encouraged to pursue any approach that would increase the proportion of state residents who have health insurance coverage, he continued. Depending on local conditions and political preferences, states could use refundable tax credits or vouchers in order to promote individual health insurance.

Some additional strategies that states could use to boost coverage for the uninsured include extending Medicaid or the State Children's Health Insurance Program, imposing employer mandates, and trying to create an intrastate single-payer plan.

States could also facilitate new insurance groups by allowing churches, unions, and the like to create association health plans.

None of these options would be mandatory, Mr. Aaron said.

Another panelist, Stuart M. Butler, Ph.D., suggested that Congress should enact a policy “toolbox” that would make a range of ideas available to states, on a voluntary basis. Dr. Butler is vice president of domestic and economic policy studies at the Heritage Foundation, Washington.

Under such an approach, states could propose an initiative for preserving coverage, selecting certain elements from the toolbox, and negotiating with the U.S. Department of Health and Human Services regarding appropriate waivers to pull such an option together, Dr. Butler explained.

In an attempt to maintain and extend the functional equivalent of Medicaid during these very tight budget times, states could utilize an enhanced federal refundable tax credit from the policy toolbox, using additional federal funds to create purchasing alliances or pools, he added.

One of the most important goals is to make sure that Medicaid populations are protected, Dr. Butler said. He recommended “encouraging innovations through the states [and] rewarding pay-for-performance successes by the states, to reach these goals.”

WASHINGTON — Rewarding states based on quality is one way to cover more uninsured Americans, Henry J. Aaron said at the annual meeting of the National Governors Association.

Following up on a trend that has already affected the physician community, Mr. Aaron proposed a “pay-for-performance” system, where states could receive federal grants based on their “actual measured progress of increasing the number and proportion of state residents covered by health insurance.”

The grants would be designed to cover much or all of the costs of extending coverage.

“Any state that succeeded in boosting the fraction of its population [covered by] health insurance would receive federal support. The states that made no such progress would receive nothing,” said Mr. Aaron, senior fellow for economic studies at the Brookings Institution.

The federal government should first define a standard for health insurance coverage, Mr. Aaron said, suggesting that the minimum be “similar to the actuarial value of the Federal Employees Health Benefits Program.”

His plan also would include a “first do no harm” standard, prohibiting states from materially eroding coverage for the current Medicaid population.

“Even now, Medicaid is substantially less costly than private insurance of the same scope. Still, state costs for long-term care [are] on track to rise relentlessly as baby boomers age.”

This means that states need continued financial protection from adverse trends—and not a cap on federal support.

“[States] also need flexibility to modernize Medicaid but within the limits that maintain the per capita protection of the most vulnerable populations in our nation,” Mr. Aaron said.

Within these broad guidelines, states should be encouraged to pursue any approach that would increase the proportion of state residents who have health insurance coverage, he continued. Depending on local conditions and political preferences, states could use refundable tax credits or vouchers in order to promote individual health insurance.

Some additional strategies that states could use to boost coverage for the uninsured include extending Medicaid or the State Children's Health Insurance Program, imposing employer mandates, and trying to create an intrastate single-payer plan.

States could also facilitate new insurance groups by allowing churches, unions, and the like to create association health plans.

None of these options would be mandatory, Mr. Aaron said.

Another panelist, Stuart M. Butler, Ph.D., suggested that Congress should enact a policy “toolbox” that would make a range of ideas available to states, on a voluntary basis. Dr. Butler is vice president of domestic and economic policy studies at the Heritage Foundation, Washington.

Under such an approach, states could propose an initiative for preserving coverage, selecting certain elements from the toolbox, and negotiating with the U.S. Department of Health and Human Services regarding appropriate waivers to pull such an option together, Dr. Butler explained.

In an attempt to maintain and extend the functional equivalent of Medicaid during these very tight budget times, states could utilize an enhanced federal refundable tax credit from the policy toolbox, using additional federal funds to create purchasing alliances or pools, he added.

One of the most important goals is to make sure that Medicaid populations are protected, Dr. Butler said. He recommended “encouraging innovations through the states [and] rewarding pay-for-performance successes by the states, to reach these goals.”

Child Well-Being Index 2005

Violence and risky behaviors among children, such as teen birth, smoking, and use of alcohol and illegal drugs, have declined dramatically in the last 30 years, but obesity is still a problem, according to the 2005 Index of Child Well-Being, released by the Foundation for Child Development. The overall child health score is 17% below 1975 levels, mainly because of obesity. “It took a generation for overweight and obesity to reach these extreme levels, and it's going to take at least a generation to turn those levels back,” said Kenneth Land, Ph.D., the Duke University sociologist who developed the index. In the meantime, violent crime has dropped by more than 64% since 1975, and childhood victimization by violent crime has fallen by more than 38%. But these figures may rise again, given that increased federal funding for community policing and a strong national economy are no longer in effect, Dr. Land said. Births to teenage mothers have dropped by nearly 37%. Though smoking continues to decline, the rate of binge drinking increased slightly, from nearly 28% in 2003, to 29.2% in 2004, the study found.

Senator Takes on Junk Food Ads

Sen. Tom Harkin (D-Iowa) is taking on the food industry and broadcasters with legislation that would restore the Federal Trade Commission's authority to restrict “junk food” advertising to children under age 18 years, and give the Secretary of Agriculture the authority to prohibit all junk food advertising in schools. In addition, he called on the food industry to set age-appropriate guidelines for marketing to children. Earlier this year, the Center for Science in the Public Interest issued guidelines calling on companies not to market drinks such as sodas, sports drinks, and sweetened iced teas to children.

Television Promotes Bullying

Too much television can lead to bullying, a study of the viewing habits of young children from the University of Washington determined (Arch. Pediatr. Adolesc. Med. 2005;159:384-8). “The early home environment, including cognitive stimulation, emotional support and exposure to television, has a significant impact on bullying in grade school,” concluded Frederick J. Zimmerman, Ph.D., who found that each hour of television viewed per day at age 4 increased the odds for subsequent bullying at a later age. Reading to children and spending time with them decreases their chances of becoming bullies. The findings were based on data from 1,266 4-year-olds whose bullying was tracked at ages 6-11.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, [and] persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proven harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured won't likely be resolved anytime soon. More than 1 in 4 American workers—nearly 56 million—under age 65 will be uninsured in 2013 because of the increasing unaffordability of health insurance, a health affairs Web-exclusive article reported. Growth in per capita health spending is expected to outpace median personal income by 2.4% every year, making health insurance unaffordable for more Americans and causing health care coverage to continue its decline. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study said. Children have fared slightly better than adults, mostly because of coverage provided by the State Children's Health Insurance Program. The researchers estimated that for every 1% increase in the percentage of uninsured adult workers from 1979 to 2002, there was only a 0.45% increase in the percentage of uninsured children. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Child Well-Being Index 2005

Violence and risky behaviors among children, such as teen birth, smoking, and use of alcohol and illegal drugs, have declined dramatically in the last 30 years, but obesity is still a problem, according to the 2005 Index of Child Well-Being, released by the Foundation for Child Development. The overall child health score is 17% below 1975 levels, mainly because of obesity. “It took a generation for overweight and obesity to reach these extreme levels, and it's going to take at least a generation to turn those levels back,” said Kenneth Land, Ph.D., the Duke University sociologist who developed the index. In the meantime, violent crime has dropped by more than 64% since 1975, and childhood victimization by violent crime has fallen by more than 38%. But these figures may rise again, given that increased federal funding for community policing and a strong national economy are no longer in effect, Dr. Land said. Births to teenage mothers have dropped by nearly 37%. Though smoking continues to decline, the rate of binge drinking increased slightly, from nearly 28% in 2003, to 29.2% in 2004, the study found.

Senator Takes on Junk Food Ads

Sen. Tom Harkin (D-Iowa) is taking on the food industry and broadcasters with legislation that would restore the Federal Trade Commission's authority to restrict “junk food” advertising to children under age 18 years, and give the Secretary of Agriculture the authority to prohibit all junk food advertising in schools. In addition, he called on the food industry to set age-appropriate guidelines for marketing to children. Earlier this year, the Center for Science in the Public Interest issued guidelines calling on companies not to market drinks such as sodas, sports drinks, and sweetened iced teas to children.

Television Promotes Bullying

Too much television can lead to bullying, a study of the viewing habits of young children from the University of Washington determined (Arch. Pediatr. Adolesc. Med. 2005;159:384-8). “The early home environment, including cognitive stimulation, emotional support and exposure to television, has a significant impact on bullying in grade school,” concluded Frederick J. Zimmerman, Ph.D., who found that each hour of television viewed per day at age 4 increased the odds for subsequent bullying at a later age. Reading to children and spending time with them decreases their chances of becoming bullies. The findings were based on data from 1,266 4-year-olds whose bullying was tracked at ages 6-11.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, [and] persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proven harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured won't likely be resolved anytime soon. More than 1 in 4 American workers—nearly 56 million—under age 65 will be uninsured in 2013 because of the increasing unaffordability of health insurance, a health affairs Web-exclusive article reported. Growth in per capita health spending is expected to outpace median personal income by 2.4% every year, making health insurance unaffordable for more Americans and causing health care coverage to continue its decline. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study said. Children have fared slightly better than adults, mostly because of coverage provided by the State Children's Health Insurance Program. The researchers estimated that for every 1% increase in the percentage of uninsured adult workers from 1979 to 2002, there was only a 0.45% increase in the percentage of uninsured children. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

Child Well-Being Index 2005

Violence and risky behaviors among children, such as teen birth, smoking, and use of alcohol and illegal drugs, have declined dramatically in the last 30 years, but obesity is still a problem, according to the 2005 Index of Child Well-Being, released by the Foundation for Child Development. The overall child health score is 17% below 1975 levels, mainly because of obesity. “It took a generation for overweight and obesity to reach these extreme levels, and it's going to take at least a generation to turn those levels back,” said Kenneth Land, Ph.D., the Duke University sociologist who developed the index. In the meantime, violent crime has dropped by more than 64% since 1975, and childhood victimization by violent crime has fallen by more than 38%. But these figures may rise again, given that increased federal funding for community policing and a strong national economy are no longer in effect, Dr. Land said. Births to teenage mothers have dropped by nearly 37%. Though smoking continues to decline, the rate of binge drinking increased slightly, from nearly 28% in 2003, to 29.2% in 2004, the study found.

Senator Takes on Junk Food Ads

Sen. Tom Harkin (D-Iowa) is taking on the food industry and broadcasters with legislation that would restore the Federal Trade Commission's authority to restrict “junk food” advertising to children under age 18 years, and give the Secretary of Agriculture the authority to prohibit all junk food advertising in schools. In addition, he called on the food industry to set age-appropriate guidelines for marketing to children. Earlier this year, the Center for Science in the Public Interest issued guidelines calling on companies not to market drinks such as sodas, sports drinks, and sweetened iced teas to children.

Television Promotes Bullying

Too much television can lead to bullying, a study of the viewing habits of young children from the University of Washington determined (Arch. Pediatr. Adolesc. Med. 2005;159:384-8). “The early home environment, including cognitive stimulation, emotional support and exposure to television, has a significant impact on bullying in grade school,” concluded Frederick J. Zimmerman, Ph.D., who found that each hour of television viewed per day at age 4 increased the odds for subsequent bullying at a later age. Reading to children and spending time with them decreases their chances of becoming bullies. The findings were based on data from 1,266 4-year-olds whose bullying was tracked at ages 6-11.

Bill on Livestock Antibiotics

Sen. Edward M. Kennedy (D-Mass.) and Sen. Olympia Snowe (R-Maine) have introduced a bill to cut down on the amount of antibiotics used in livestock, citing evidence that increased antibiotic use in animals leads to reduced effectiveness in humans. “Antibiotics are among the greatest miracles of modern medicine, yet we are destroying them faster than the pharmaceutical industry can create replacements,” Sen. Kennedy said in a statement. “If doctors lose these critical remedies, the most vulnerable among us will suffer the most—children, the elderly, [and] persons with HIV/AIDS, who are most in danger of resistant infections.” The measure would require the Food and Drug Administration to withdraw approval for nontherapeutic use of eight classes of antibiotics in food-producing animals after 2 years if the use has not been proven harmless during that time. It also requires manufacturers of animal drugs or drug-containing feed to make their sales records available to government regulators for tracking emerging antimicrobial resistance.

Uninsured Projections

The plight of the uninsured won't likely be resolved anytime soon. More than 1 in 4 American workers—nearly 56 million—under age 65 will be uninsured in 2013 because of the increasing unaffordability of health insurance, a health affairs Web-exclusive article reported. Growth in per capita health spending is expected to outpace median personal income by 2.4% every year, making health insurance unaffordable for more Americans and causing health care coverage to continue its decline. “It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,” the study said. Children have fared slightly better than adults, mostly because of coverage provided by the State Children's Health Insurance Program. The researchers estimated that for every 1% increase in the percentage of uninsured adult workers from 1979 to 2002, there was only a 0.45% increase in the percentage of uninsured children. The researchers based the estimates of the uninsured on federal projections of health spending, personal income, and other population characteristics.

WASHINGTON — Mix a little money with solid incentives physicians can relate to, and you've got a successful recipe for a pay-for-performance program, Ronald P. Bangasser, M.D., said at the annual National Managed Health Care Congress.

Physicians try to deliver the highest level of medical care they can, but most can't keep track of the needs of every patient, said Dr. Bangasser, a family physician and immediate past president of the California Medical Association.

Studies show that 50% of patients don't get what they need in quality of care, he said. “Most patients rate their doctor a four out of five, but they hate the health care system.”

That's one reason physician groups need a data-based approach to help reduce errors and improve care, he continued. A new program in California has yielded positive results, and is “certainly one way to pay for quality,” Dr. Bangasser said.

Backed by a state foundation grant, the statewide Integrated Healthcare Association (IHA) got together with medical groups, health plans, purchasers, and consumer groups several years ago to collaborate on a plan to reduce expenses for physician reporting.

The program was able to achieve this savings “by accumulating all of the health plans together, so physician groups only had one reporting mechanism instead of seven or eight,” said Dr. Bangasser, medical director of the wound care department of the Beaver Medical Group L.P., at Redlands (Calif.) Community Hospital. The group participates in the IHA program.

All of the health plans and medical groups had to agree on a common set of measures and a common way to report those measures. The IHA in turn acted as a “neutral convener,” in coming up with standards for reporting the data, he said.

Technical and steering committees were formed to work with technical experts on proposing measures.

The measures had to be valid and accurate, meaningful to consumers and physicians, and important to public health in California. “They also had to get harder over time,” Dr. Bangasser said. In the IHA program, physicians get paid not just for performance, but also for performance improvement. “We actually have a calculator [that determines whether] people are improving.”

The first payout took place in 2004, based on first-year data from 2003.

Physicians are assessed on three types of measures: clinical, patient experience, and information-technology investment.

First-year results saw little variation among the participating groups on patient experience, although variations were seen among clinical and IT measures.

There was room for improvement in both of these areas, Dr. Bangasser said. Fewer groups participated in IT measures than in the other measures, and of those who tried, “only two-thirds of them got full credit for it. It showed us that we had a huge IT deficit.”

Variations occurred in the clinical measures because not all of the groups used a registry-type system—a list that details the specific diagnoses of each patient. Physicians using a registry can find out if a patient got a certain test or if they need one, Dr. Bangasser said. To date, groups that use registries “are doing much better on these measures than groups that don't.”

One of the biggest improvement areas was in cervical cancer screening, he said. Based on data comparisons between 2002 and 2003—the year the program got started—nearly 150,000 more women were screened for cervical cancer, and 35,000 more women were screened for breast cancer.

An additional 10,000 children got two needed immunizations, and 180,000 more patients were tested for diabetes.

Although some groups scored fairly high, specialists didn't fare as well. Patients cited access problems to specialists as a specific complaint in the satisfaction surveys, Dr. Bangasser said.

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said. There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be.

It was also determined that groups serving large Hispanic or Native American populations should get “extra credit” for having to deal with more diverse, culturally different populations.

Applying the right types of incentives is key, he said. “If a physician thinks the measure is a good idea, putting a little money behind it will speed quality improvement. However, if the physician thinks the measure is not going to improve quality, $1 million will not change behavior.”

Sometimes, the simplest incentives can produce good results.

Dr. Bangasser mentioned a particularly bad influenza season in 1998, when patients had to wait in long lines to see physicians in his group practice.

“I asked all of the doctors if they'd take on two more patients a day. That's a long day, but I gave them two tickets to a movie theater for Christmas,” Dr. Bangasser said.

All but two physicians took on the extra patients. “This meant that over 60 physicians saw an extra 120 patients per day,” he said.

WASHINGTON — Mix a little money with solid incentives physicians can relate to, and you've got a successful recipe for a pay-for-performance program, Ronald P. Bangasser, M.D., said at the annual National Managed Health Care Congress.

Physicians try to deliver the highest level of medical care they can, but most can't keep track of the needs of every patient, said Dr. Bangasser, a family physician and immediate past president of the California Medical Association.

Studies show that 50% of patients don't get what they need in quality of care, he said. “Most patients rate their doctor a four out of five, but they hate the health care system.”

That's one reason physician groups need a data-based approach to help reduce errors and improve care, he continued. A new program in California has yielded positive results, and is “certainly one way to pay for quality,” Dr. Bangasser said.

Backed by a state foundation grant, the statewide Integrated Healthcare Association (IHA) got together with medical groups, health plans, purchasers, and consumer groups several years ago to collaborate on a plan to reduce expenses for physician reporting.

The program was able to achieve this savings “by accumulating all of the health plans together, so physician groups only had one reporting mechanism instead of seven or eight,” said Dr. Bangasser, medical director of the wound care department of the Beaver Medical Group L.P., at Redlands (Calif.) Community Hospital. The group participates in the IHA program.

All of the health plans and medical groups had to agree on a common set of measures and a common way to report those measures. The IHA in turn acted as a “neutral convener,” in coming up with standards for reporting the data, he said.

Technical and steering committees were formed to work with technical experts on proposing measures.

The measures had to be valid and accurate, meaningful to consumers and physicians, and important to public health in California. “They also had to get harder over time,” Dr. Bangasser said. In the IHA program, physicians get paid not just for performance, but also for performance improvement. “We actually have a calculator [that determines whether] people are improving.”

The first payout took place in 2004, based on first-year data from 2003.

Physicians are assessed on three types of measures: clinical, patient experience, and information-technology investment.

First-year results saw little variation among the participating groups on patient experience, although variations were seen among clinical and IT measures.

There was room for improvement in both of these areas, Dr. Bangasser said. Fewer groups participated in IT measures than in the other measures, and of those who tried, “only two-thirds of them got full credit for it. It showed us that we had a huge IT deficit.”

Variations occurred in the clinical measures because not all of the groups used a registry-type system—a list that details the specific diagnoses of each patient. Physicians using a registry can find out if a patient got a certain test or if they need one, Dr. Bangasser said. To date, groups that use registries “are doing much better on these measures than groups that don't.”

One of the biggest improvement areas was in cervical cancer screening, he said. Based on data comparisons between 2002 and 2003—the year the program got started—nearly 150,000 more women were screened for cervical cancer, and 35,000 more women were screened for breast cancer.

An additional 10,000 children got two needed immunizations, and 180,000 more patients were tested for diabetes.

Although some groups scored fairly high, specialists didn't fare as well. Patients cited access problems to specialists as a specific complaint in the satisfaction surveys, Dr. Bangasser said.

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said. There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be.

It was also determined that groups serving large Hispanic or Native American populations should get “extra credit” for having to deal with more diverse, culturally different populations.

Applying the right types of incentives is key, he said. “If a physician thinks the measure is a good idea, putting a little money behind it will speed quality improvement. However, if the physician thinks the measure is not going to improve quality, $1 million will not change behavior.”

Sometimes, the simplest incentives can produce good results.

Dr. Bangasser mentioned a particularly bad influenza season in 1998, when patients had to wait in long lines to see physicians in his group practice.

“I asked all of the doctors if they'd take on two more patients a day. That's a long day, but I gave them two tickets to a movie theater for Christmas,” Dr. Bangasser said.

All but two physicians took on the extra patients. “This meant that over 60 physicians saw an extra 120 patients per day,” he said.

WASHINGTON — Mix a little money with solid incentives physicians can relate to, and you've got a successful recipe for a pay-for-performance program, Ronald P. Bangasser, M.D., said at the annual National Managed Health Care Congress.

Physicians try to deliver the highest level of medical care they can, but most can't keep track of the needs of every patient, said Dr. Bangasser, a family physician and immediate past president of the California Medical Association.

Studies show that 50% of patients don't get what they need in quality of care, he said. “Most patients rate their doctor a four out of five, but they hate the health care system.”

That's one reason physician groups need a data-based approach to help reduce errors and improve care, he continued. A new program in California has yielded positive results, and is “certainly one way to pay for quality,” Dr. Bangasser said.

Backed by a state foundation grant, the statewide Integrated Healthcare Association (IHA) got together with medical groups, health plans, purchasers, and consumer groups several years ago to collaborate on a plan to reduce expenses for physician reporting.

The program was able to achieve this savings “by accumulating all of the health plans together, so physician groups only had one reporting mechanism instead of seven or eight,” said Dr. Bangasser, medical director of the wound care department of the Beaver Medical Group L.P., at Redlands (Calif.) Community Hospital. The group participates in the IHA program.

All of the health plans and medical groups had to agree on a common set of measures and a common way to report those measures. The IHA in turn acted as a “neutral convener,” in coming up with standards for reporting the data, he said.

Technical and steering committees were formed to work with technical experts on proposing measures.

The measures had to be valid and accurate, meaningful to consumers and physicians, and important to public health in California. “They also had to get harder over time,” Dr. Bangasser said. In the IHA program, physicians get paid not just for performance, but also for performance improvement. “We actually have a calculator [that determines whether] people are improving.”

The first payout took place in 2004, based on first-year data from 2003.

Physicians are assessed on three types of measures: clinical, patient experience, and information-technology investment.

First-year results saw little variation among the participating groups on patient experience, although variations were seen among clinical and IT measures.

There was room for improvement in both of these areas, Dr. Bangasser said. Fewer groups participated in IT measures than in the other measures, and of those who tried, “only two-thirds of them got full credit for it. It showed us that we had a huge IT deficit.”

Variations occurred in the clinical measures because not all of the groups used a registry-type system—a list that details the specific diagnoses of each patient. Physicians using a registry can find out if a patient got a certain test or if they need one, Dr. Bangasser said. To date, groups that use registries “are doing much better on these measures than groups that don't.”

One of the biggest improvement areas was in cervical cancer screening, he said. Based on data comparisons between 2002 and 2003—the year the program got started—nearly 150,000 more women were screened for cervical cancer, and 35,000 more women were screened for breast cancer.

An additional 10,000 children got two needed immunizations, and 180,000 more patients were tested for diabetes.

Although some groups scored fairly high, specialists didn't fare as well. Patients cited access problems to specialists as a specific complaint in the satisfaction surveys, Dr. Bangasser said.

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said. There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be.

It was also determined that groups serving large Hispanic or Native American populations should get “extra credit” for having to deal with more diverse, culturally different populations.

Applying the right types of incentives is key, he said. “If a physician thinks the measure is a good idea, putting a little money behind it will speed quality improvement. However, if the physician thinks the measure is not going to improve quality, $1 million will not change behavior.”

Sometimes, the simplest incentives can produce good results.

Dr. Bangasser mentioned a particularly bad influenza season in 1998, when patients had to wait in long lines to see physicians in his group practice.

“I asked all of the doctors if they'd take on two more patients a day. That's a long day, but I gave them two tickets to a movie theater for Christmas,” Dr. Bangasser said.

All but two physicians took on the extra patients. “This meant that over 60 physicians saw an extra 120 patients per day,” he said.

WASHINGTON — Federal regulations should recognize the expertise of nurse-midwives in certifying false-labor cases in the hospital, Deanne Williams, a certified nurse-midwife, testified at a meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

Under EMTALA, “only a physician is recognized to certify that a woman who presents to a hospital for evaluation is actually experiencing false labor,” said Ms. Williams, executive director of the American College of Nurse-Midwives (ACNM). In the college's view, the regulation fails to acknowledge the scope of practice under which certified nurse-midwives and certified midwives are authorized to treat patients, she said.

“Midwives have a very long history of working collaboratively with physicians to provide women's health care, with a particular focus on care during the maternity cycle,” Ms. Williams said, adding that midwives attend more than 10% of the vaginal births in the United States, and 98% of the births attended by midwives occur in hospitals.

EMTALA's requirement for physician certification “places unnecessary costs on the hospital, which is required to take physicians away from other matters to certify that the woman is in false labor, when a certified nurse-midwife or certified midwife is also licensed to make that decision,” Ms. Williams testified.

While EMTALA regulations require a signed certification that a woman is experiencing false labor and may be discharged, “there is no requirement in the regulations that a physician must personally examine the patient,” noted one advisory group member, Charlotte Yeh, M.D., an emergency physician and the CMS regional administrator for Region I in Boston.

The law's interpretive guidelines explain further that a physician must be contacted by the qualified medical professional—i.e., nurse-midwife—to ensure that the woman with contractions has false labor. The guidelines leave it up to the individual hospitals to determine whether physicians should personally examine the patient, she said.

The issue before the technical advisory group is whether the latitude provided by EMTALA's interpretive guidelines is sufficient to protect patients, yet recognizes the value that nurse-midwives bring to labor and delivery, Dr. Yeh told this newspaper. “Or, the [technical advisory group] could say that the regulations are too prescriptive, and that certification should be removed altogether, letting individual hospitals decide who's qualified to determine emergency medical conditions” in patients.

It's clear that ACNM's request “would necessitate a change,” David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, indicated. Dr. Siegel asked that the panel seek formal input from the American College of Obstetricians and Gynecologists and other appropriate medical specialty organizations on their policies regarding this issue.

Warren Jones, M.D., Medicaid director for the state of Mississippi and a past president of the American Academy of Family Physicians, emphasized that the panel should seek input from the AAFP on this issue. “There needs to be a recognition that ob.gyns. are not the only physicians who deliver babies and provide maternity care. Family physicians do a lot of that. Many of them work with nurse-midwives, and many of them provide it in rural areas where it's really needed,” he told this newspaper.

The advisory committee also will need to consider that in some states, nurse-midwives are already recognized as qualified to determine false labor, Dr. Yeh said. What the nurse-midwives want is for those qualifications to be recognized by CMS, she said.

Robert Bitterman, M.D., a representative of the American College of Emergency Physicians, and a participant at the meeting, noted that the regulations might not have to be changed at all.

“If you hearken back to the actual statute, the word 'labor' does not appear anywhere in the definition of an emergency medical physician in EMTALA. Therefore, whether someone is in actual labor or in false labor is entirely irrelevant,” he stated.

EMTALA is meant to be a limited law, Dr. Bitterman continued. “It asks: Is this pregnant woman having contractions, and if so, is it safe to go home, and if doing so would pose a hardship to the baby or the mother.” Therefore, it's perfectly appropriate under EMTALA for nurses, physicians, family physicians, or pathologists to perform the screening exam if they're the ones designated by the hospital to make those types of decisions, he said.

“It's a myth to think that physicians and hospitals don't send home patients if they have active labor. We do it every day because it's an early active labor, and because it's safe to do so—and it meets the elements of the statute,” Dr. Bitterman said.

Dr. Yeh clarified that the word “labor” did in fact appear in the EMTALA statute under the definition of a transfer, and that a false-labor discharge qualified as a transfer.

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 the department of Health and Human Services establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

The group will advise HHS and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA. It is composed of representatives of hospital, physician, and patient groups, plus CMS staff and state government officials.

WASHINGTON — Federal regulations should recognize the expertise of nurse-midwives in certifying false-labor cases in the hospital, Deanne Williams, a certified nurse-midwife, testified at a meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

Under EMTALA, “only a physician is recognized to certify that a woman who presents to a hospital for evaluation is actually experiencing false labor,” said Ms. Williams, executive director of the American College of Nurse-Midwives (ACNM). In the college's view, the regulation fails to acknowledge the scope of practice under which certified nurse-midwives and certified midwives are authorized to treat patients, she said.

“Midwives have a very long history of working collaboratively with physicians to provide women's health care, with a particular focus on care during the maternity cycle,” Ms. Williams said, adding that midwives attend more than 10% of the vaginal births in the United States, and 98% of the births attended by midwives occur in hospitals.

EMTALA's requirement for physician certification “places unnecessary costs on the hospital, which is required to take physicians away from other matters to certify that the woman is in false labor, when a certified nurse-midwife or certified midwife is also licensed to make that decision,” Ms. Williams testified.

While EMTALA regulations require a signed certification that a woman is experiencing false labor and may be discharged, “there is no requirement in the regulations that a physician must personally examine the patient,” noted one advisory group member, Charlotte Yeh, M.D., an emergency physician and the CMS regional administrator for Region I in Boston.

The law's interpretive guidelines explain further that a physician must be contacted by the qualified medical professional—i.e., nurse-midwife—to ensure that the woman with contractions has false labor. The guidelines leave it up to the individual hospitals to determine whether physicians should personally examine the patient, she said.

The issue before the technical advisory group is whether the latitude provided by EMTALA's interpretive guidelines is sufficient to protect patients, yet recognizes the value that nurse-midwives bring to labor and delivery, Dr. Yeh told this newspaper. “Or, the [technical advisory group] could say that the regulations are too prescriptive, and that certification should be removed altogether, letting individual hospitals decide who's qualified to determine emergency medical conditions” in patients.

It's clear that ACNM's request “would necessitate a change,” David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, indicated. Dr. Siegel asked that the panel seek formal input from the American College of Obstetricians and Gynecologists and other appropriate medical specialty organizations on their policies regarding this issue.

Warren Jones, M.D., Medicaid director for the state of Mississippi and a past president of the American Academy of Family Physicians, emphasized that the panel should seek input from the AAFP on this issue. “There needs to be a recognition that ob.gyns. are not the only physicians who deliver babies and provide maternity care. Family physicians do a lot of that. Many of them work with nurse-midwives, and many of them provide it in rural areas where it's really needed,” he told this newspaper.

The advisory committee also will need to consider that in some states, nurse-midwives are already recognized as qualified to determine false labor, Dr. Yeh said. What the nurse-midwives want is for those qualifications to be recognized by CMS, she said.

Robert Bitterman, M.D., a representative of the American College of Emergency Physicians, and a participant at the meeting, noted that the regulations might not have to be changed at all.

“If you hearken back to the actual statute, the word 'labor' does not appear anywhere in the definition of an emergency medical physician in EMTALA. Therefore, whether someone is in actual labor or in false labor is entirely irrelevant,” he stated.

EMTALA is meant to be a limited law, Dr. Bitterman continued. “It asks: Is this pregnant woman having contractions, and if so, is it safe to go home, and if doing so would pose a hardship to the baby or the mother.” Therefore, it's perfectly appropriate under EMTALA for nurses, physicians, family physicians, or pathologists to perform the screening exam if they're the ones designated by the hospital to make those types of decisions, he said.

“It's a myth to think that physicians and hospitals don't send home patients if they have active labor. We do it every day because it's an early active labor, and because it's safe to do so—and it meets the elements of the statute,” Dr. Bitterman said.

Dr. Yeh clarified that the word “labor” did in fact appear in the EMTALA statute under the definition of a transfer, and that a false-labor discharge qualified as a transfer.

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 the department of Health and Human Services establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

The group will advise HHS and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA. It is composed of representatives of hospital, physician, and patient groups, plus CMS staff and state government officials.

WASHINGTON — Federal regulations should recognize the expertise of nurse-midwives in certifying false-labor cases in the hospital, Deanne Williams, a certified nurse-midwife, testified at a meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

Under EMTALA, “only a physician is recognized to certify that a woman who presents to a hospital for evaluation is actually experiencing false labor,” said Ms. Williams, executive director of the American College of Nurse-Midwives (ACNM). In the college's view, the regulation fails to acknowledge the scope of practice under which certified nurse-midwives and certified midwives are authorized to treat patients, she said.

“Midwives have a very long history of working collaboratively with physicians to provide women's health care, with a particular focus on care during the maternity cycle,” Ms. Williams said, adding that midwives attend more than 10% of the vaginal births in the United States, and 98% of the births attended by midwives occur in hospitals.

EMTALA's requirement for physician certification “places unnecessary costs on the hospital, which is required to take physicians away from other matters to certify that the woman is in false labor, when a certified nurse-midwife or certified midwife is also licensed to make that decision,” Ms. Williams testified.

While EMTALA regulations require a signed certification that a woman is experiencing false labor and may be discharged, “there is no requirement in the regulations that a physician must personally examine the patient,” noted one advisory group member, Charlotte Yeh, M.D., an emergency physician and the CMS regional administrator for Region I in Boston.

The law's interpretive guidelines explain further that a physician must be contacted by the qualified medical professional—i.e., nurse-midwife—to ensure that the woman with contractions has false labor. The guidelines leave it up to the individual hospitals to determine whether physicians should personally examine the patient, she said.

The issue before the technical advisory group is whether the latitude provided by EMTALA's interpretive guidelines is sufficient to protect patients, yet recognizes the value that nurse-midwives bring to labor and delivery, Dr. Yeh told this newspaper. “Or, the [technical advisory group] could say that the regulations are too prescriptive, and that certification should be removed altogether, letting individual hospitals decide who's qualified to determine emergency medical conditions” in patients.

It's clear that ACNM's request “would necessitate a change,” David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, indicated. Dr. Siegel asked that the panel seek formal input from the American College of Obstetricians and Gynecologists and other appropriate medical specialty organizations on their policies regarding this issue.

Warren Jones, M.D., Medicaid director for the state of Mississippi and a past president of the American Academy of Family Physicians, emphasized that the panel should seek input from the AAFP on this issue. “There needs to be a recognition that ob.gyns. are not the only physicians who deliver babies and provide maternity care. Family physicians do a lot of that. Many of them work with nurse-midwives, and many of them provide it in rural areas where it's really needed,” he told this newspaper.

The advisory committee also will need to consider that in some states, nurse-midwives are already recognized as qualified to determine false labor, Dr. Yeh said. What the nurse-midwives want is for those qualifications to be recognized by CMS, she said.

Robert Bitterman, M.D., a representative of the American College of Emergency Physicians, and a participant at the meeting, noted that the regulations might not have to be changed at all.

“If you hearken back to the actual statute, the word 'labor' does not appear anywhere in the definition of an emergency medical physician in EMTALA. Therefore, whether someone is in actual labor or in false labor is entirely irrelevant,” he stated.

EMTALA is meant to be a limited law, Dr. Bitterman continued. “It asks: Is this pregnant woman having contractions, and if so, is it safe to go home, and if doing so would pose a hardship to the baby or the mother.” Therefore, it's perfectly appropriate under EMTALA for nurses, physicians, family physicians, or pathologists to perform the screening exam if they're the ones designated by the hospital to make those types of decisions, he said.

“It's a myth to think that physicians and hospitals don't send home patients if they have active labor. We do it every day because it's an early active labor, and because it's safe to do so—and it meets the elements of the statute,” Dr. Bitterman said.

Dr. Yeh clarified that the word “labor” did in fact appear in the EMTALA statute under the definition of a transfer, and that a false-labor discharge qualified as a transfer.

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 the department of Health and Human Services establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

The group will advise HHS and the administrator of the Centers for Medicare and Medicaid Services on issues related to EMTALA. It is composed of representatives of hospital, physician, and patient groups, plus CMS staff and state government officials.

WASHINGTON – Congress should fix Medicare's payment formula before taking on any new reforms to pay physicians on the basis of quality, medical organizations testified at a hearing of the House Ways and Means health subcommittee.

If impending cuts to the fee schedule go into effect, “physicians will be hard pressed to undertake quality initiatives such as information technology,” testified Nancy H. Nielsen, M.D., trustee to the American Medical Association.

President Bush's budget request for fiscal year 2006 includes a scheduled 5.2% payment cut for physician services under Medicare. Actuaries have estimated that physician payments could decline by more than 30% through 2012, unless modifications are made to the sustainable growth rate (SGR), a component in the physician pay formula that determines each year's update.

Although the AMA has engaged in its own evidence-based, quality improvement measures, “it is critical to replace the flawed physician payment formula to allow quality initiatives to flourish,” Dr. Nielsen said.

Other medical organizations offered similar pleas in testimony and in statements to the subcommittee.

Going ahead with pay-for-performance initiatives but not changing the formula to stave off the 5.2% cut “is unacceptable,” Jerome B. Connolly, senior government relations representative with the American Academy of Family Physicians, told this newspaper.

At the hearing, pay-for-performance proposals were heavily touted as a viable payment alternative by witnesses and panel members alike. “We fundamentally have to rethink how we pay our doctors,” said Subcommittee Chair Nancy L. Johnson (R-Conn.).

Some physicians perform better than others in the quality of care they deliver, Glenn M. Hackbarth, chairman of the Medicare Payment Advisory Commission (MedPAC), testified.

The SGR system “fails to create appropriate incentives to improve performance,” he said. MedPAC in its March report to Congress recommended a quality incentive payment system for physicians under Medicare, using various types of information technology to manage patients.

Such an approach would establish exclusive performance standards and award physicians accordingly, while establishing standards to improve quality, he said.

Rep. Pete Stark (D-Calif.), the panel's ranking member, countered that he was “reluctant to get into the quality issue.” As far as reforming payments, “I think it's up to the doctors to regulate themselves.”

Any type of payment system that rewards providers by improving patient care and outcomes must not be punitive or used as a control for physician volume, said William F. Gee, M.D., a urologist from Lexington, Ky., who testified on behalf of the Alliance for Specialty Medicine.

Measures should also be specialty specific, he continued. “In some areas, particularly surgery, it can be difficult to keep quality measures up to date enough to be perceived as relevant.”

In addition, the reporting of quality or efficiency indicators and health outcomes data could be administratively prohibitive to many physicians, especially those in small practices that don't have electronic health records, Dr. Gee testified.

There is some evidence that pay for performance can work, at least in the private sector. Since the implementation of three major pay-for-performance contracts with Partners Healthcare System in Boston, “we have steadily improved in targeted areas,” such as diabetes care, Thomas H. Lee, M.D., network president for the health care system, testified.

The rate of rise in pharmacy spending under these contracts averaged about 5% in 2004, which is lower than the national average of 9%.

The contracts cover the care of over 500,000 primary care patients and a number of patients referred to specialists.

WASHINGTON – Congress should fix Medicare's payment formula before taking on any new reforms to pay physicians on the basis of quality, medical organizations testified at a hearing of the House Ways and Means health subcommittee.

If impending cuts to the fee schedule go into effect, “physicians will be hard pressed to undertake quality initiatives such as information technology,” testified Nancy H. Nielsen, M.D., trustee to the American Medical Association.

President Bush's budget request for fiscal year 2006 includes a scheduled 5.2% payment cut for physician services under Medicare. Actuaries have estimated that physician payments could decline by more than 30% through 2012, unless modifications are made to the sustainable growth rate (SGR), a component in the physician pay formula that determines each year's update.

Although the AMA has engaged in its own evidence-based, quality improvement measures, “it is critical to replace the flawed physician payment formula to allow quality initiatives to flourish,” Dr. Nielsen said.

Other medical organizations offered similar pleas in testimony and in statements to the subcommittee.

Going ahead with pay-for-performance initiatives but not changing the formula to stave off the 5.2% cut “is unacceptable,” Jerome B. Connolly, senior government relations representative with the American Academy of Family Physicians, told this newspaper.

At the hearing, pay-for-performance proposals were heavily touted as a viable payment alternative by witnesses and panel members alike. “We fundamentally have to rethink how we pay our doctors,” said Subcommittee Chair Nancy L. Johnson (R-Conn.).

Some physicians perform better than others in the quality of care they deliver, Glenn M. Hackbarth, chairman of the Medicare Payment Advisory Commission (MedPAC), testified.

The SGR system “fails to create appropriate incentives to improve performance,” he said. MedPAC in its March report to Congress recommended a quality incentive payment system for physicians under Medicare, using various types of information technology to manage patients.

Such an approach would establish exclusive performance standards and award physicians accordingly, while establishing standards to improve quality, he said.

Rep. Pete Stark (D-Calif.), the panel's ranking member, countered that he was “reluctant to get into the quality issue.” As far as reforming payments, “I think it's up to the doctors to regulate themselves.”

Any type of payment system that rewards providers by improving patient care and outcomes must not be punitive or used as a control for physician volume, said William F. Gee, M.D., a urologist from Lexington, Ky., who testified on behalf of the Alliance for Specialty Medicine.

Measures should also be specialty specific, he continued. “In some areas, particularly surgery, it can be difficult to keep quality measures up to date enough to be perceived as relevant.”

In addition, the reporting of quality or efficiency indicators and health outcomes data could be administratively prohibitive to many physicians, especially those in small practices that don't have electronic health records, Dr. Gee testified.

There is some evidence that pay for performance can work, at least in the private sector. Since the implementation of three major pay-for-performance contracts with Partners Healthcare System in Boston, “we have steadily improved in targeted areas,” such as diabetes care, Thomas H. Lee, M.D., network president for the health care system, testified.

The rate of rise in pharmacy spending under these contracts averaged about 5% in 2004, which is lower than the national average of 9%.

The contracts cover the care of over 500,000 primary care patients and a number of patients referred to specialists.

WASHINGTON – Congress should fix Medicare's payment formula before taking on any new reforms to pay physicians on the basis of quality, medical organizations testified at a hearing of the House Ways and Means health subcommittee.

If impending cuts to the fee schedule go into effect, “physicians will be hard pressed to undertake quality initiatives such as information technology,” testified Nancy H. Nielsen, M.D., trustee to the American Medical Association.

President Bush's budget request for fiscal year 2006 includes a scheduled 5.2% payment cut for physician services under Medicare. Actuaries have estimated that physician payments could decline by more than 30% through 2012, unless modifications are made to the sustainable growth rate (SGR), a component in the physician pay formula that determines each year's update.

Although the AMA has engaged in its own evidence-based, quality improvement measures, “it is critical to replace the flawed physician payment formula to allow quality initiatives to flourish,” Dr. Nielsen said.

Other medical organizations offered similar pleas in testimony and in statements to the subcommittee.

Going ahead with pay-for-performance initiatives but not changing the formula to stave off the 5.2% cut “is unacceptable,” Jerome B. Connolly, senior government relations representative with the American Academy of Family Physicians, told this newspaper.

At the hearing, pay-for-performance proposals were heavily touted as a viable payment alternative by witnesses and panel members alike. “We fundamentally have to rethink how we pay our doctors,” said Subcommittee Chair Nancy L. Johnson (R-Conn.).

Some physicians perform better than others in the quality of care they deliver, Glenn M. Hackbarth, chairman of the Medicare Payment Advisory Commission (MedPAC), testified.

The SGR system “fails to create appropriate incentives to improve performance,” he said. MedPAC in its March report to Congress recommended a quality incentive payment system for physicians under Medicare, using various types of information technology to manage patients.

Such an approach would establish exclusive performance standards and award physicians accordingly, while establishing standards to improve quality, he said.

Rep. Pete Stark (D-Calif.), the panel's ranking member, countered that he was “reluctant to get into the quality issue.” As far as reforming payments, “I think it's up to the doctors to regulate themselves.”

Any type of payment system that rewards providers by improving patient care and outcomes must not be punitive or used as a control for physician volume, said William F. Gee, M.D., a urologist from Lexington, Ky., who testified on behalf of the Alliance for Specialty Medicine.

Measures should also be specialty specific, he continued. “In some areas, particularly surgery, it can be difficult to keep quality measures up to date enough to be perceived as relevant.”

In addition, the reporting of quality or efficiency indicators and health outcomes data could be administratively prohibitive to many physicians, especially those in small practices that don't have electronic health records, Dr. Gee testified.

There is some evidence that pay for performance can work, at least in the private sector. Since the implementation of three major pay-for-performance contracts with Partners Healthcare System in Boston, “we have steadily improved in targeted areas,” such as diabetes care, Thomas H. Lee, M.D., network president for the health care system, testified.

The rate of rise in pharmacy spending under these contracts averaged about 5% in 2004, which is lower than the national average of 9%.

The contracts cover the care of over 500,000 primary care patients and a number of patients referred to specialists.

WASHINGTON – On-call emergency care dominated the agenda at the inaugural meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a manner that “best meets the needs” of the hospital's patients.

The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

While the obligation to provide the on-call list falls on the hospital, physicians assume new liability and other obligations once they agree to take on-call responsibilities, Charlotte Yeh, M.D., an emergency physician and advisory group member, said in an interview.

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition for having privileges, she said. “Factor in issues such as reimbursement, and the physician is asking himself: Why should I do this? And that's how physicians get into the EMTALA debate.”

Hospital groups who testified before the advisory group said their emergency care was suffering because of physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals.

“Also, there no longer is any certainty that an on-call physician will report for duty when called,” he said. Physicians say that economic, medical practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

Physician-owned specialty hospitals, already a volatile issue, have exacerbated the on-call issue, said Mary Beth Savary Taylor, who spoke on behalf of the American Hospital Association. “Physicians who own limited-service hospitals often refuse to participate in emergency on-call duty at community hospitals, leaving them struggling to maintain [emergency department] specialty coverage.”

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said. To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process–before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

Leslie Norwalk, CMS deputy administrator, told advisory group members that the agency could issue guidelines to hospitals on how they could protect themselves from lawsuits. “We'd like to help so courts will not punish [hospitals] for doing the right thing,” she said.

Mr. Micklos asserted that the statute's obligations should apply equally to hospitals and physicians, noting that a hospital “can only can be as good as the physicians on its medical staff.”

EMTALA states that on-call coverage is a joint decision between hospital administrators and physicians who provide on-call coverage, said Jason W. Nascone, M.D., who testified on behalf of the American Association of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

“But it is unrealistic to expect physicians to work together with hospitals in developing and implementing on-call plans if physicians aren't included as equal partners with more authority, oversight and control, in the development and implementation of these plans,” Dr. Nascone said.

Interpretive guidelines developed to clarify hospitals' EMTALA responsibilities should be amended to further encourage true partnership arrangements between hospitals and physicians, Dr. Nascone said.

Physician groups urged CMS to adopt an affirmative rule prohibiting hospitals from requiring physicians to provide 24-7 emergency call coverage.

“We support the rule that physicians are not required to be on call at all times, but we fear that this provision doesn't go far enough to protect on-call physicians from nevertheless being required by hospitals to provide continuous emergency on-call coverage,” Alex B. Valadka, M.D., who spoke on behalf of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, testified.

Physicians also had concerns about a provision requiring response time to be stated in “minutes.” The advisory group should recommend modifications that such response times could be stated in a range of minutes, Dr. Valadka said. “Exceptions should be explicitly permitted in situations when the on-call physician cannot respond within the stated time frame because of circumstances beyond his or her control.”

WASHINGTON – On-call emergency care dominated the agenda at the inaugural meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a manner that “best meets the needs” of the hospital's patients.

The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

While the obligation to provide the on-call list falls on the hospital, physicians assume new liability and other obligations once they agree to take on-call responsibilities, Charlotte Yeh, M.D., an emergency physician and advisory group member, said in an interview.

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition for having privileges, she said. “Factor in issues such as reimbursement, and the physician is asking himself: Why should I do this? And that's how physicians get into the EMTALA debate.”

Hospital groups who testified before the advisory group said their emergency care was suffering because of physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals.

“Also, there no longer is any certainty that an on-call physician will report for duty when called,” he said. Physicians say that economic, medical practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

Physician-owned specialty hospitals, already a volatile issue, have exacerbated the on-call issue, said Mary Beth Savary Taylor, who spoke on behalf of the American Hospital Association. “Physicians who own limited-service hospitals often refuse to participate in emergency on-call duty at community hospitals, leaving them struggling to maintain [emergency department] specialty coverage.”

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said. To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process–before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

Leslie Norwalk, CMS deputy administrator, told advisory group members that the agency could issue guidelines to hospitals on how they could protect themselves from lawsuits. “We'd like to help so courts will not punish [hospitals] for doing the right thing,” she said.

Mr. Micklos asserted that the statute's obligations should apply equally to hospitals and physicians, noting that a hospital “can only can be as good as the physicians on its medical staff.”

EMTALA states that on-call coverage is a joint decision between hospital administrators and physicians who provide on-call coverage, said Jason W. Nascone, M.D., who testified on behalf of the American Association of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

“But it is unrealistic to expect physicians to work together with hospitals in developing and implementing on-call plans if physicians aren't included as equal partners with more authority, oversight and control, in the development and implementation of these plans,” Dr. Nascone said.

Interpretive guidelines developed to clarify hospitals' EMTALA responsibilities should be amended to further encourage true partnership arrangements between hospitals and physicians, Dr. Nascone said.

Physician groups urged CMS to adopt an affirmative rule prohibiting hospitals from requiring physicians to provide 24-7 emergency call coverage.

“We support the rule that physicians are not required to be on call at all times, but we fear that this provision doesn't go far enough to protect on-call physicians from nevertheless being required by hospitals to provide continuous emergency on-call coverage,” Alex B. Valadka, M.D., who spoke on behalf of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, testified.

Physicians also had concerns about a provision requiring response time to be stated in “minutes.” The advisory group should recommend modifications that such response times could be stated in a range of minutes, Dr. Valadka said. “Exceptions should be explicitly permitted in situations when the on-call physician cannot respond within the stated time frame because of circumstances beyond his or her control.”

WASHINGTON – On-call emergency care dominated the agenda at the inaugural meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a manner that “best meets the needs” of the hospital's patients.

The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

While the obligation to provide the on-call list falls on the hospital, physicians assume new liability and other obligations once they agree to take on-call responsibilities, Charlotte Yeh, M.D., an emergency physician and advisory group member, said in an interview.

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition for having privileges, she said. “Factor in issues such as reimbursement, and the physician is asking himself: Why should I do this? And that's how physicians get into the EMTALA debate.”

Hospital groups who testified before the advisory group said their emergency care was suffering because of physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals.

“Also, there no longer is any certainty that an on-call physician will report for duty when called,” he said. Physicians say that economic, medical practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

Physician-owned specialty hospitals, already a volatile issue, have exacerbated the on-call issue, said Mary Beth Savary Taylor, who spoke on behalf of the American Hospital Association. “Physicians who own limited-service hospitals often refuse to participate in emergency on-call duty at community hospitals, leaving them struggling to maintain [emergency department] specialty coverage.”

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said. To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process–before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

Leslie Norwalk, CMS deputy administrator, told advisory group members that the agency could issue guidelines to hospitals on how they could protect themselves from lawsuits. “We'd like to help so courts will not punish [hospitals] for doing the right thing,” she said.

Mr. Micklos asserted that the statute's obligations should apply equally to hospitals and physicians, noting that a hospital “can only can be as good as the physicians on its medical staff.”

EMTALA states that on-call coverage is a joint decision between hospital administrators and physicians who provide on-call coverage, said Jason W. Nascone, M.D., who testified on behalf of the American Association of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

“But it is unrealistic to expect physicians to work together with hospitals in developing and implementing on-call plans if physicians aren't included as equal partners with more authority, oversight and control, in the development and implementation of these plans,” Dr. Nascone said.

Interpretive guidelines developed to clarify hospitals' EMTALA responsibilities should be amended to further encourage true partnership arrangements between hospitals and physicians, Dr. Nascone said.

Physician groups urged CMS to adopt an affirmative rule prohibiting hospitals from requiring physicians to provide 24-7 emergency call coverage.

“We support the rule that physicians are not required to be on call at all times, but we fear that this provision doesn't go far enough to protect on-call physicians from nevertheless being required by hospitals to provide continuous emergency on-call coverage,” Alex B. Valadka, M.D., who spoke on behalf of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, testified.

Physicians also had concerns about a provision requiring response time to be stated in “minutes.” The advisory group should recommend modifications that such response times could be stated in a range of minutes, Dr. Valadka said. “Exceptions should be explicitly permitted in situations when the on-call physician cannot respond within the stated time frame because of circumstances beyond his or her control.”