Jennifer Silverman

WASHINGTON — On-call services should not be a condition for participating in Medicare, a federal advisory panel on the Emergency Medical Treatment and Labor Act has recommended.

While most panel members panned the idea of an on-call/Medicare link, they were divided over whether to turn their disapproval into a formal recommendation to the Centers for Medicare and Medicaid Services.

Ultimately, the measure to recommend that CMS not link on-call participation with Medicare participation was approved in a close vote (7–6 with one abstention).

The technical advisory group advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to the Emergency Medical Treatment and Labor Act (EMTALA).

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition of privileges. To address the shortage of on-call physicians, hospital associations had floated a proposal to the technical advisory group to link on-call participation to Medicare participation or hospital privileges.

Technical advisory group members who voted against making a formal recommendation to CMS at this point said they “were concerned about angering or offending the hospital associations who brought the idea to begin with,” said Carol Bayer, M.D., a panel member and vice president for medical affairs at East Jefferson General Hospital in Metairie, La.

If such a link were enacted, however, “physicians would quit Medicare in droves,” Dr. Bayer told this newspaper. Participating in Medicare means “you abide by the rules and have to accept the payments, but it has never been linked to anything like this before.”

Some panel members, such as Charlotte Yeh, M.D., an emergency physician and CMS regional administrator for Region I in Boston, thought the issue deserved further review by the technical advisory group's on-call subcommittee before making a recommendation to CMS.

“Given the multiple factors affecting availability of on call, and the importance of solutions that both meet patient care needs and yet are practical enough for both hospitals and physicians, taking the time for analysis will result in a stronger position,” she said.

But James Nepola, M.D., an orthopedic trauma surgeon in Iowa City, and author of the recommendation, thought there was enough evidence to oppose a link between Medicare and on call. “We've had testimony, we've had studies, and we've had surveys on both sides of this issue. Cultural changes are taking place in medicine right now that don't bode well for emergency medicine, Dr. Nepola said. “Young physicians are moving as quickly as they can to study fields that do not require emergency work at all. They are moving toward boutique practices, which I abhor.”

For that reason, the technical advisory group should take affirmative actions “so that physicians can go in without this problem before them,” Dr. Nepola said. The panel should also be addressing physician concerns such as liability reform and adequate resources and compensation for on-call services. “We need to move toward solutions like warnings for hospitals, not big penalties, and get rid of things that are not going to work.”

Physician and hospitals groups offered their own views about the Medicare/on-call link at the technical advisory group's June meeting. Requiring on-call services as a condition of participating in Medicare “would far exceed the scope of the EMTALA statute,” the American College of Surgeons argued in written testimony.

It is also contrary to the regulations and the interpretive guidelines, which state that each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients, the ACS stated.

Many neurosurgeons are already being required to provide continuous call 24 hours a day, 7 days a week, 365 days per year, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons testified, reporting from a survey of more than 1,000 members.

“Despite the fact that EMTALA does not mandate continuous emergency call, hospitals are nevertheless imposing this requirement on nearly one-third of neurosurgeons,” the groups testified.

Going beyond Medicare, the neurosurgeons requested that CMS adopt a rule that would prohibit hospitals from requiring around-the-clock call of physicians.

In its own surveys, the American Hospital Association illustrated a continued struggle to recruit specialists for on-call services. Nearly one-third of the hospitals surveyed reported paying physicians for specialty coverage, and 40% of the community hospitals had to place their emergency departments on diversion for some period of time, said Kathleen DeVine, chief executive officer of Saint Anthony Hospital in Chicago, who testified on behalf of the AHA.

“If CMS wants to deal with any more specificity around on-call coverage, then physicians, those whom hospitals rely on to provide on-call care, must be brought to the table,” she said. “Hospitals cannot do it alone.”

WASHINGTON — On-call services should not be a condition for participating in Medicare, a federal advisory panel on the Emergency Medical Treatment and Labor Act has recommended.

While most panel members panned the idea of an on-call/Medicare link, they were divided over whether to turn their disapproval into a formal recommendation to the Centers for Medicare and Medicaid Services.

Ultimately, the measure to recommend that CMS not link on-call participation with Medicare participation was approved in a close vote (7–6 with one abstention).

The technical advisory group advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to the Emergency Medical Treatment and Labor Act (EMTALA).

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition of privileges. To address the shortage of on-call physicians, hospital associations had floated a proposal to the technical advisory group to link on-call participation to Medicare participation or hospital privileges.

Technical advisory group members who voted against making a formal recommendation to CMS at this point said they “were concerned about angering or offending the hospital associations who brought the idea to begin with,” said Carol Bayer, M.D., a panel member and vice president for medical affairs at East Jefferson General Hospital in Metairie, La.

If such a link were enacted, however, “physicians would quit Medicare in droves,” Dr. Bayer told this newspaper. Participating in Medicare means “you abide by the rules and have to accept the payments, but it has never been linked to anything like this before.”

Some panel members, such as Charlotte Yeh, M.D., an emergency physician and CMS regional administrator for Region I in Boston, thought the issue deserved further review by the technical advisory group's on-call subcommittee before making a recommendation to CMS.

“Given the multiple factors affecting availability of on call, and the importance of solutions that both meet patient care needs and yet are practical enough for both hospitals and physicians, taking the time for analysis will result in a stronger position,” she said.

But James Nepola, M.D., an orthopedic trauma surgeon in Iowa City, and author of the recommendation, thought there was enough evidence to oppose a link between Medicare and on call. “We've had testimony, we've had studies, and we've had surveys on both sides of this issue. Cultural changes are taking place in medicine right now that don't bode well for emergency medicine, Dr. Nepola said. “Young physicians are moving as quickly as they can to study fields that do not require emergency work at all. They are moving toward boutique practices, which I abhor.”

For that reason, the technical advisory group should take affirmative actions “so that physicians can go in without this problem before them,” Dr. Nepola said. The panel should also be addressing physician concerns such as liability reform and adequate resources and compensation for on-call services. “We need to move toward solutions like warnings for hospitals, not big penalties, and get rid of things that are not going to work.”

Physician and hospitals groups offered their own views about the Medicare/on-call link at the technical advisory group's June meeting. Requiring on-call services as a condition of participating in Medicare “would far exceed the scope of the EMTALA statute,” the American College of Surgeons argued in written testimony.

It is also contrary to the regulations and the interpretive guidelines, which state that each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients, the ACS stated.

Many neurosurgeons are already being required to provide continuous call 24 hours a day, 7 days a week, 365 days per year, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons testified, reporting from a survey of more than 1,000 members.

“Despite the fact that EMTALA does not mandate continuous emergency call, hospitals are nevertheless imposing this requirement on nearly one-third of neurosurgeons,” the groups testified.

Going beyond Medicare, the neurosurgeons requested that CMS adopt a rule that would prohibit hospitals from requiring around-the-clock call of physicians.

In its own surveys, the American Hospital Association illustrated a continued struggle to recruit specialists for on-call services. Nearly one-third of the hospitals surveyed reported paying physicians for specialty coverage, and 40% of the community hospitals had to place their emergency departments on diversion for some period of time, said Kathleen DeVine, chief executive officer of Saint Anthony Hospital in Chicago, who testified on behalf of the AHA.

“If CMS wants to deal with any more specificity around on-call coverage, then physicians, those whom hospitals rely on to provide on-call care, must be brought to the table,” she said. “Hospitals cannot do it alone.”

WASHINGTON — On-call services should not be a condition for participating in Medicare, a federal advisory panel on the Emergency Medical Treatment and Labor Act has recommended.

While most panel members panned the idea of an on-call/Medicare link, they were divided over whether to turn their disapproval into a formal recommendation to the Centers for Medicare and Medicaid Services.

Ultimately, the measure to recommend that CMS not link on-call participation with Medicare participation was approved in a close vote (7–6 with one abstention).

The technical advisory group advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services on issues related to the Emergency Medical Treatment and Labor Act (EMTALA).

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition of privileges. To address the shortage of on-call physicians, hospital associations had floated a proposal to the technical advisory group to link on-call participation to Medicare participation or hospital privileges.

Technical advisory group members who voted against making a formal recommendation to CMS at this point said they “were concerned about angering or offending the hospital associations who brought the idea to begin with,” said Carol Bayer, M.D., a panel member and vice president for medical affairs at East Jefferson General Hospital in Metairie, La.

If such a link were enacted, however, “physicians would quit Medicare in droves,” Dr. Bayer told this newspaper. Participating in Medicare means “you abide by the rules and have to accept the payments, but it has never been linked to anything like this before.”

Some panel members, such as Charlotte Yeh, M.D., an emergency physician and CMS regional administrator for Region I in Boston, thought the issue deserved further review by the technical advisory group's on-call subcommittee before making a recommendation to CMS.

“Given the multiple factors affecting availability of on call, and the importance of solutions that both meet patient care needs and yet are practical enough for both hospitals and physicians, taking the time for analysis will result in a stronger position,” she said.

But James Nepola, M.D., an orthopedic trauma surgeon in Iowa City, and author of the recommendation, thought there was enough evidence to oppose a link between Medicare and on call. “We've had testimony, we've had studies, and we've had surveys on both sides of this issue. Cultural changes are taking place in medicine right now that don't bode well for emergency medicine, Dr. Nepola said. “Young physicians are moving as quickly as they can to study fields that do not require emergency work at all. They are moving toward boutique practices, which I abhor.”

For that reason, the technical advisory group should take affirmative actions “so that physicians can go in without this problem before them,” Dr. Nepola said. The panel should also be addressing physician concerns such as liability reform and adequate resources and compensation for on-call services. “We need to move toward solutions like warnings for hospitals, not big penalties, and get rid of things that are not going to work.”

Physician and hospitals groups offered their own views about the Medicare/on-call link at the technical advisory group's June meeting. Requiring on-call services as a condition of participating in Medicare “would far exceed the scope of the EMTALA statute,” the American College of Surgeons argued in written testimony.

It is also contrary to the regulations and the interpretive guidelines, which state that each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital's patients, the ACS stated.

Many neurosurgeons are already being required to provide continuous call 24 hours a day, 7 days a week, 365 days per year, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons testified, reporting from a survey of more than 1,000 members.

“Despite the fact that EMTALA does not mandate continuous emergency call, hospitals are nevertheless imposing this requirement on nearly one-third of neurosurgeons,” the groups testified.

Going beyond Medicare, the neurosurgeons requested that CMS adopt a rule that would prohibit hospitals from requiring around-the-clock call of physicians.

In its own surveys, the American Hospital Association illustrated a continued struggle to recruit specialists for on-call services. Nearly one-third of the hospitals surveyed reported paying physicians for specialty coverage, and 40% of the community hospitals had to place their emergency departments on diversion for some period of time, said Kathleen DeVine, chief executive officer of Saint Anthony Hospital in Chicago, who testified on behalf of the AHA.

“If CMS wants to deal with any more specificity around on-call coverage, then physicians, those whom hospitals rely on to provide on-call care, must be brought to the table,” she said. “Hospitals cannot do it alone.”

WASHINGTON — Local laws and practice patterns should dictate which health care providers can certify false labor cases, according to a preliminary recommendation from the Emergency Medical Treatment and Labor Act Technical Advisory Group.

Currently, the EMTALA, which is now law, recognizes only physicians as qualified to certify false-labor cases. Agreeing with the recommendations of one of its subcommittees, the technical advisory group determined at its recent meeting that this requirement was “inconsistent with the scope of practice for nurse-midwives and other practitioners under state laws,” and should therefore be eliminated.

Instead, hospital policies and procedures should dictate which personnel are capable of making such an assessment, said the panel, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services (CMS) on issues related to EMTALA.

The changes proposed by the technical advisory group's subcommittee “would allow a hospital to take into account state law, federal law, local practice patterns, and scope of practice and make a decision that works for that hospital and its patients,” Charlotte Yeh, M.D., a member of the technical advisory group, an emergency physician, and the CMS regional administrator for Region I in Boston, told this newspaper.

Deanne Williams, a certified nurse-midwife and executive director of the American College of Nurse-Midwives, called the action “a very important step towards eliminating a significant barrier to care that was mistakenly created by the EMTALA regulations.”

Laws in every state permit nurse-midwives to determine if a woman is in false labor, she said. “We are very hopeful that this problem will be fixed quickly. As more hospitals create labor triage units, they will need teams of nurse-midwives and physicians to assure that pregnant women do not wait for hours to be discharged,” she said.

Dr. Yeh noted that nurse-midwives would still have to contend with the individual hospitals and their definitions of qualified personnel, even if the physician requirement for false labor was eliminated.

“The [advisory group] also recognizes that a woman in labor could have emergency medical conditions other than labor that would not be within the scope of practice of a nurse-midwife,” she said. “We would expect that a hospital, as part of its credentialing process, would take that into account when identifying who can perform medical screening examinations.”

“One of the most common conditions treated by a certified nurse-midwife/certified midwife is the assessment of labor,” Ms. Williams testified at a recent meeting of the technical advisory group. “Restricting a midwife's ability to discharge a patient who they have determined is not in labor merely takes physicians away from medical matters.”

While the full advisory group ultimately voted to support the subcommittee's recommendation, it does not represent a final action, David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, said in an interview. The recommendation will be part of a larger package that the technical advisory group's new “action subcommittee” will deliver to the group and, subsequently, to CMS.

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

WASHINGTON — Local laws and practice patterns should dictate which health care providers can certify false labor cases, according to a preliminary recommendation from the Emergency Medical Treatment and Labor Act Technical Advisory Group.

Currently, the EMTALA, which is now law, recognizes only physicians as qualified to certify false-labor cases. Agreeing with the recommendations of one of its subcommittees, the technical advisory group determined at its recent meeting that this requirement was “inconsistent with the scope of practice for nurse-midwives and other practitioners under state laws,” and should therefore be eliminated.

Instead, hospital policies and procedures should dictate which personnel are capable of making such an assessment, said the panel, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services (CMS) on issues related to EMTALA.

The changes proposed by the technical advisory group's subcommittee “would allow a hospital to take into account state law, federal law, local practice patterns, and scope of practice and make a decision that works for that hospital and its patients,” Charlotte Yeh, M.D., a member of the technical advisory group, an emergency physician, and the CMS regional administrator for Region I in Boston, told this newspaper.

Deanne Williams, a certified nurse-midwife and executive director of the American College of Nurse-Midwives, called the action “a very important step towards eliminating a significant barrier to care that was mistakenly created by the EMTALA regulations.”

Laws in every state permit nurse-midwives to determine if a woman is in false labor, she said. “We are very hopeful that this problem will be fixed quickly. As more hospitals create labor triage units, they will need teams of nurse-midwives and physicians to assure that pregnant women do not wait for hours to be discharged,” she said.

Dr. Yeh noted that nurse-midwives would still have to contend with the individual hospitals and their definitions of qualified personnel, even if the physician requirement for false labor was eliminated.

“The [advisory group] also recognizes that a woman in labor could have emergency medical conditions other than labor that would not be within the scope of practice of a nurse-midwife,” she said. “We would expect that a hospital, as part of its credentialing process, would take that into account when identifying who can perform medical screening examinations.”

“One of the most common conditions treated by a certified nurse-midwife/certified midwife is the assessment of labor,” Ms. Williams testified at a recent meeting of the technical advisory group. “Restricting a midwife's ability to discharge a patient who they have determined is not in labor merely takes physicians away from medical matters.”

While the full advisory group ultimately voted to support the subcommittee's recommendation, it does not represent a final action, David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, said in an interview. The recommendation will be part of a larger package that the technical advisory group's new “action subcommittee” will deliver to the group and, subsequently, to CMS.

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

WASHINGTON — Local laws and practice patterns should dictate which health care providers can certify false labor cases, according to a preliminary recommendation from the Emergency Medical Treatment and Labor Act Technical Advisory Group.

Currently, the EMTALA, which is now law, recognizes only physicians as qualified to certify false-labor cases. Agreeing with the recommendations of one of its subcommittees, the technical advisory group determined at its recent meeting that this requirement was “inconsistent with the scope of practice for nurse-midwives and other practitioners under state laws,” and should therefore be eliminated.

Instead, hospital policies and procedures should dictate which personnel are capable of making such an assessment, said the panel, which advises the Department of Health and Human Services and the administrator of the Centers for Medicare and Medicaid Services (CMS) on issues related to EMTALA.

The changes proposed by the technical advisory group's subcommittee “would allow a hospital to take into account state law, federal law, local practice patterns, and scope of practice and make a decision that works for that hospital and its patients,” Charlotte Yeh, M.D., a member of the technical advisory group, an emergency physician, and the CMS regional administrator for Region I in Boston, told this newspaper.

Deanne Williams, a certified nurse-midwife and executive director of the American College of Nurse-Midwives, called the action “a very important step towards eliminating a significant barrier to care that was mistakenly created by the EMTALA regulations.”

Laws in every state permit nurse-midwives to determine if a woman is in false labor, she said. “We are very hopeful that this problem will be fixed quickly. As more hospitals create labor triage units, they will need teams of nurse-midwives and physicians to assure that pregnant women do not wait for hours to be discharged,” she said.

Dr. Yeh noted that nurse-midwives would still have to contend with the individual hospitals and their definitions of qualified personnel, even if the physician requirement for false labor was eliminated.

“The [advisory group] also recognizes that a woman in labor could have emergency medical conditions other than labor that would not be within the scope of practice of a nurse-midwife,” she said. “We would expect that a hospital, as part of its credentialing process, would take that into account when identifying who can perform medical screening examinations.”

“One of the most common conditions treated by a certified nurse-midwife/certified midwife is the assessment of labor,” Ms. Williams testified at a recent meeting of the technical advisory group. “Restricting a midwife's ability to discharge a patient who they have determined is not in labor merely takes physicians away from medical matters.”

While the full advisory group ultimately voted to support the subcommittee's recommendation, it does not represent a final action, David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, said in an interview. The recommendation will be part of a larger package that the technical advisory group's new “action subcommittee” will deliver to the group and, subsequently, to CMS.

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

Any legislative approach to fixing Medicare's sustainable growth rate system “would be prohibitively expensive,” according to House Ways and Means Chair Bill Thomas (R-Calif.).

Attaining a permanent fix is possible, however, provided that Congress and the Bush administration work on efforts to combine administrative and legislative actions, Rep. Thomas and Nancy L. Johnson (R-Conn.), health subcommittee chair, wrote in a letter to Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services.

The proposal is one of several ideas floating in Congress that seek to fix the Medicare physician fee schedule, as physicians face a looming 4.3% cut to their reimbursement in 2006. CMS actuaries project negative payment updates of minus 5% annually for 7 years, beginning in 2006, if the flawed sustainable growth rate (SGR) is not corrected.

CMS could do its part by removing prescription drug expenditures from the baseline of the SGR, something it should have the authority to do, the letter suggested. Because drugs aren't reimbursed under the fee schedule, it's illogical to include them in the expenditure total when calculating the schedule's update.

The agency should also account for the costs of new and expanded Medicare benefits, which are included in the SGR calculation, the letter stated.

On a legislative fix, Rep. Thomas wrote that “the time is ripe” to tie physician payments to quality performance. CMS demonstration projects on performance-based payments in Medicare “will provide us with the experience we need to design appropriate rewards for delivering quality care,” he wrote.

At press time, Rep. Johnson was prepping to introduce a pay-for-performance bill that would repeal the SGR and base future updates for physician payments on the Medicare Economic Index (MEI).

At a recent hearing, Dr. McClellan informed Rep. Johnson that such a measure could come at a high cost: specifically, that MEI-based increases would be $183 billion over 10 years.

CMS in the meantime is working hard to remove Part B drugs from the formula, although the procedure “presents difficult legal issues that we haven't yet been able to solve.” It also would not solve the entire problem, as positive updates would not take place for several years, regardless of whether CMS removed drugs prospectively or retrospectively, his testimony indicated.

In addition, he cautioned Rep. Johnson's subcommittee that removal of drugs would increase beneficiary premiums.

Physicians' groups offered support for this legislative approach at the hearing. “We're committed to improving quality of care, but to make further quality improvements, physicians must be adequately reimbursed for treating Medicare patients,” John H. Armstrong, trustee to the American Medical Association, testified.

Leaders on the Senate Finance Committee have since introduced a pay-for-performance bill, although it may not get the same kind of support from physicians' groups as the forthcoming Johnson bill.

Applying the notion that Medicare should attain better “value” for its money, the bill from Sen. Chuck Grassley (R-Iowa) and Sen. Max Baucus (D-Mont.) proposes to link a small portion of physician Medicare payments to reporting of quality data and demonstrated progress against quality and efficiency measures. The measures would focus on health care processes, structures, outcomes, patient experience of care, efficiency, and use of health information technology.

Participation in the program would be voluntary. However, those choosing not to report quality data would receive a reduced payment update.

Unlike the Johnson proposal, however, the Senate bill fails to include a fix to the SGR, Mary Frank, M.D., president of the American Academy of Family Physicians, said in a statement. Instead, the legislation “attempts to improve the payment system to physicians without attempting to stem the declining Medicare reimbursement rate.”

Physicians could face lower Medicare payments and additional costs under such requirements, Dr. Frank said. While it might increase doctors' costs in order to meet and report specific care standards, the bill “doesn't help them obtain the technology to do so,” she said. Without the technology to participate in the bill's proposed reporting system, physicians' reimbursement will be cut even further, hindering their ability to afford the technology. “Sound like a vicious cycle? It is,” she said.

The outcome is family physicians may be forced to close their doors to Medicare beneficiaries, Dr. Frank said.

In addition, “tons of implementation questions” aren't broached in this bill, Michele Johnson, senior governmental relations representative of the Medical Group Management Association, told this newspaper.

“Right now, there are no evidence-based, valid scientific measures of efficiency, unless you're talking about clinical measures,” Ms. Johnson said. It's unclear how such measures would be developed under the legislation, and how people would physically report these quality measures.

In a summary of the bill, the authors explained that they didn't address the sustainable growth rate because they wanted to limit provisions to quality improvement, value-based purchasing, and health information technology. However, “sense of the Senate” language (nonbinding language that accompanied the bill) did acknowledge that the negative physician update needed to be addressed, based on the “unsustainable” nature of the SGR.

Primary care groups in June had lobbied Senate Majority Leader Bill Frist (R-Tenn.) for a pay-for-performance bill that would provide positive updates to Medicare's physician fee schedule, as well as reverse cuts that would otherwise occur under the SGR.

If any language from Grassley-Baucus is approved, “it will probably be inserted into 'end of the year must pass legislation,' along with an SGR fix,” Ms. Johnson stated. Standing alone, the bill is too risky on the Senate floor because it would provide Democrats with the opportunity to reopen the Medicare Modernization Act.

“They could introduce amendments stating that the government could negotiate prices with the pharmaceutical companies. The Republicans don't want that,” she said.

Any legislative approach to fixing Medicare's sustainable growth rate system “would be prohibitively expensive,” according to House Ways and Means Chair Bill Thomas (R-Calif.).

Attaining a permanent fix is possible, however, provided that Congress and the Bush administration work on efforts to combine administrative and legislative actions, Rep. Thomas and Nancy L. Johnson (R-Conn.), health subcommittee chair, wrote in a letter to Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services.

The proposal is one of several ideas floating in Congress that seek to fix the Medicare physician fee schedule, as physicians face a looming 4.3% cut to their reimbursement in 2006. CMS actuaries project negative payment updates of minus 5% annually for 7 years, beginning in 2006, if the flawed sustainable growth rate (SGR) is not corrected.

CMS could do its part by removing prescription drug expenditures from the baseline of the SGR, something it should have the authority to do, the letter suggested. Because drugs aren't reimbursed under the fee schedule, it's illogical to include them in the expenditure total when calculating the schedule's update.

The agency should also account for the costs of new and expanded Medicare benefits, which are included in the SGR calculation, the letter stated.

On a legislative fix, Rep. Thomas wrote that “the time is ripe” to tie physician payments to quality performance. CMS demonstration projects on performance-based payments in Medicare “will provide us with the experience we need to design appropriate rewards for delivering quality care,” he wrote.

At press time, Rep. Johnson was prepping to introduce a pay-for-performance bill that would repeal the SGR and base future updates for physician payments on the Medicare Economic Index (MEI).

At a recent hearing, Dr. McClellan informed Rep. Johnson that such a measure could come at a high cost: specifically, that MEI-based increases would be $183 billion over 10 years.

CMS in the meantime is working hard to remove Part B drugs from the formula, although the procedure “presents difficult legal issues that we haven't yet been able to solve.” It also would not solve the entire problem, as positive updates would not take place for several years, regardless of whether CMS removed drugs prospectively or retrospectively, his testimony indicated.

In addition, he cautioned Rep. Johnson's subcommittee that removal of drugs would increase beneficiary premiums.

Physicians' groups offered support for this legislative approach at the hearing. “We're committed to improving quality of care, but to make further quality improvements, physicians must be adequately reimbursed for treating Medicare patients,” John H. Armstrong, trustee to the American Medical Association, testified.

Leaders on the Senate Finance Committee have since introduced a pay-for-performance bill, although it may not get the same kind of support from physicians' groups as the forthcoming Johnson bill.

Applying the notion that Medicare should attain better “value” for its money, the bill from Sen. Chuck Grassley (R-Iowa) and Sen. Max Baucus (D-Mont.) proposes to link a small portion of physician Medicare payments to reporting of quality data and demonstrated progress against quality and efficiency measures. The measures would focus on health care processes, structures, outcomes, patient experience of care, efficiency, and use of health information technology.

Participation in the program would be voluntary. However, those choosing not to report quality data would receive a reduced payment update.

Unlike the Johnson proposal, however, the Senate bill fails to include a fix to the SGR, Mary Frank, M.D., president of the American Academy of Family Physicians, said in a statement. Instead, the legislation “attempts to improve the payment system to physicians without attempting to stem the declining Medicare reimbursement rate.”

Physicians could face lower Medicare payments and additional costs under such requirements, Dr. Frank said. While it might increase doctors' costs in order to meet and report specific care standards, the bill “doesn't help them obtain the technology to do so,” she said. Without the technology to participate in the bill's proposed reporting system, physicians' reimbursement will be cut even further, hindering their ability to afford the technology. “Sound like a vicious cycle? It is,” she said.

The outcome is family physicians may be forced to close their doors to Medicare beneficiaries, Dr. Frank said.

In addition, “tons of implementation questions” aren't broached in this bill, Michele Johnson, senior governmental relations representative of the Medical Group Management Association, told this newspaper.

“Right now, there are no evidence-based, valid scientific measures of efficiency, unless you're talking about clinical measures,” Ms. Johnson said. It's unclear how such measures would be developed under the legislation, and how people would physically report these quality measures.

In a summary of the bill, the authors explained that they didn't address the sustainable growth rate because they wanted to limit provisions to quality improvement, value-based purchasing, and health information technology. However, “sense of the Senate” language (nonbinding language that accompanied the bill) did acknowledge that the negative physician update needed to be addressed, based on the “unsustainable” nature of the SGR.

Primary care groups in June had lobbied Senate Majority Leader Bill Frist (R-Tenn.) for a pay-for-performance bill that would provide positive updates to Medicare's physician fee schedule, as well as reverse cuts that would otherwise occur under the SGR.

If any language from Grassley-Baucus is approved, “it will probably be inserted into 'end of the year must pass legislation,' along with an SGR fix,” Ms. Johnson stated. Standing alone, the bill is too risky on the Senate floor because it would provide Democrats with the opportunity to reopen the Medicare Modernization Act.

“They could introduce amendments stating that the government could negotiate prices with the pharmaceutical companies. The Republicans don't want that,” she said.

Any legislative approach to fixing Medicare's sustainable growth rate system “would be prohibitively expensive,” according to House Ways and Means Chair Bill Thomas (R-Calif.).

Attaining a permanent fix is possible, however, provided that Congress and the Bush administration work on efforts to combine administrative and legislative actions, Rep. Thomas and Nancy L. Johnson (R-Conn.), health subcommittee chair, wrote in a letter to Mark McClellan, M.D., administrator of the Centers for Medicare and Medicaid Services.

The proposal is one of several ideas floating in Congress that seek to fix the Medicare physician fee schedule, as physicians face a looming 4.3% cut to their reimbursement in 2006. CMS actuaries project negative payment updates of minus 5% annually for 7 years, beginning in 2006, if the flawed sustainable growth rate (SGR) is not corrected.

CMS could do its part by removing prescription drug expenditures from the baseline of the SGR, something it should have the authority to do, the letter suggested. Because drugs aren't reimbursed under the fee schedule, it's illogical to include them in the expenditure total when calculating the schedule's update.

The agency should also account for the costs of new and expanded Medicare benefits, which are included in the SGR calculation, the letter stated.

On a legislative fix, Rep. Thomas wrote that “the time is ripe” to tie physician payments to quality performance. CMS demonstration projects on performance-based payments in Medicare “will provide us with the experience we need to design appropriate rewards for delivering quality care,” he wrote.

At press time, Rep. Johnson was prepping to introduce a pay-for-performance bill that would repeal the SGR and base future updates for physician payments on the Medicare Economic Index (MEI).

At a recent hearing, Dr. McClellan informed Rep. Johnson that such a measure could come at a high cost: specifically, that MEI-based increases would be $183 billion over 10 years.

CMS in the meantime is working hard to remove Part B drugs from the formula, although the procedure “presents difficult legal issues that we haven't yet been able to solve.” It also would not solve the entire problem, as positive updates would not take place for several years, regardless of whether CMS removed drugs prospectively or retrospectively, his testimony indicated.

In addition, he cautioned Rep. Johnson's subcommittee that removal of drugs would increase beneficiary premiums.

Physicians' groups offered support for this legislative approach at the hearing. “We're committed to improving quality of care, but to make further quality improvements, physicians must be adequately reimbursed for treating Medicare patients,” John H. Armstrong, trustee to the American Medical Association, testified.

Leaders on the Senate Finance Committee have since introduced a pay-for-performance bill, although it may not get the same kind of support from physicians' groups as the forthcoming Johnson bill.

Applying the notion that Medicare should attain better “value” for its money, the bill from Sen. Chuck Grassley (R-Iowa) and Sen. Max Baucus (D-Mont.) proposes to link a small portion of physician Medicare payments to reporting of quality data and demonstrated progress against quality and efficiency measures. The measures would focus on health care processes, structures, outcomes, patient experience of care, efficiency, and use of health information technology.

Participation in the program would be voluntary. However, those choosing not to report quality data would receive a reduced payment update.

Unlike the Johnson proposal, however, the Senate bill fails to include a fix to the SGR, Mary Frank, M.D., president of the American Academy of Family Physicians, said in a statement. Instead, the legislation “attempts to improve the payment system to physicians without attempting to stem the declining Medicare reimbursement rate.”

Physicians could face lower Medicare payments and additional costs under such requirements, Dr. Frank said. While it might increase doctors' costs in order to meet and report specific care standards, the bill “doesn't help them obtain the technology to do so,” she said. Without the technology to participate in the bill's proposed reporting system, physicians' reimbursement will be cut even further, hindering their ability to afford the technology. “Sound like a vicious cycle? It is,” she said.

The outcome is family physicians may be forced to close their doors to Medicare beneficiaries, Dr. Frank said.

In addition, “tons of implementation questions” aren't broached in this bill, Michele Johnson, senior governmental relations representative of the Medical Group Management Association, told this newspaper.

“Right now, there are no evidence-based, valid scientific measures of efficiency, unless you're talking about clinical measures,” Ms. Johnson said. It's unclear how such measures would be developed under the legislation, and how people would physically report these quality measures.

In a summary of the bill, the authors explained that they didn't address the sustainable growth rate because they wanted to limit provisions to quality improvement, value-based purchasing, and health information technology. However, “sense of the Senate” language (nonbinding language that accompanied the bill) did acknowledge that the negative physician update needed to be addressed, based on the “unsustainable” nature of the SGR.

Primary care groups in June had lobbied Senate Majority Leader Bill Frist (R-Tenn.) for a pay-for-performance bill that would provide positive updates to Medicare's physician fee schedule, as well as reverse cuts that would otherwise occur under the SGR.

If any language from Grassley-Baucus is approved, “it will probably be inserted into 'end of the year must pass legislation,' along with an SGR fix,” Ms. Johnson stated. Standing alone, the bill is too risky on the Senate floor because it would provide Democrats with the opportunity to reopen the Medicare Modernization Act.

“They could introduce amendments stating that the government could negotiate prices with the pharmaceutical companies. The Republicans don't want that,” she said.

CHICAGO — A pharmacist's philosophy shouldn't get in the way of prescribing needed drugs to patients. That was one of the conclusions that physicians reached while addressing controversial topics at the annual meeting of the American Medical Association's House of Delegates.

American Pharmaceutical Association (APhA) policy recognizes an individual pharmacist's right to exercise conscientious refusal to fill prescriptions. In committee debate and in full congress, physicians at the House of Delegates meeting expressed concern that pharmacists were exercising this provision to impede access to certain medications, including emergency contraceptives and psychotropic agents.

“What happens between the doctor and the patient is between doctor and patient,” Mary Frank, M.D., president of the American Academy of Family Physicians, told this newspaper. “What they decide has to have priority over the pharmacist's objections.”

Although the delegates didn't outwardly oppose the use of conscience clauses, they did call for legislation that would require individual pharmacists or pharmacy chains to either fill legally valid prescriptions or refer patients to an alternative dispensing pharmacy.

AMA Trustee Peter W. Carmel, M.D., promised that the AMA would work with the pharmacists' associations and state legislators “so that neither patients' health nor the patient-physician relationship is harmed by pharmacists' refusal to fill prescribed medications.”

The House also agreed that the AMA should lobby for state legislation that would allow physicians to dispense medication to their own patients if no pharmacist within a 30-mile radius is able and willing to dispense the medication. The APhA did not respond to requests for comment from this newspaper.

In other business, delegates addressed the challenges physicians face in balancing the increasing value of imaging tests with payers' efforts to restrict reimbursement. Several resolutions were approved that directed the AMA to oppose any attempts to restrict such reimbursement based on physician specialty.

Some payers propose to reimburse only radiologists for imaging, a practice that other specialists believe is unfair, Bruce Scott, M.D., an otolaryngologist, told this newspaper. The bottom line is physicians should have the right to bill for a service they provide and are qualified to perform, he said.

Balance billing was another topic addressed and measures were approved asking that the AMA prepare legislation that would allow physicians to balance bill regardless of the payer. In the wake of pay-for-performance initiatives, “which are nothing but third-party managers taking over,” balance billing would place patients back in control, enabling them to negotiate their own bills with their individual physicians, Jay Gregory, M.D., of the Oklahoma delegation, said during committee debate.

To address the Medicare physician fee schedule, delegates recommended that savings under Medicare Part A that could be attributed to better Part B care (for example, fewer inpatient complications, shorter lengths of stay, and fewer hospital readmissions) should be “credited” and flow to the Part B physician payment pool.

On another contentious issue—malpractice—delegates called on the AMA to explore federal legislation that would correct inadequate state medical liability laws while preserving state medical liability reforms that have proven effective.

Addressing general policies on obesity, the AMA urged physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in routine adult examinations and BMI percentiles in children. In addition, the resolution called on the AMA to develop a school health advocacy agenda that includes funding for physical activity programs.

CHICAGO — A pharmacist's philosophy shouldn't get in the way of prescribing needed drugs to patients. That was one of the conclusions that physicians reached while addressing controversial topics at the annual meeting of the American Medical Association's House of Delegates.

American Pharmaceutical Association (APhA) policy recognizes an individual pharmacist's right to exercise conscientious refusal to fill prescriptions. In committee debate and in full congress, physicians at the House of Delegates meeting expressed concern that pharmacists were exercising this provision to impede access to certain medications, including emergency contraceptives and psychotropic agents.

“What happens between the doctor and the patient is between doctor and patient,” Mary Frank, M.D., president of the American Academy of Family Physicians, told this newspaper. “What they decide has to have priority over the pharmacist's objections.”

Although the delegates didn't outwardly oppose the use of conscience clauses, they did call for legislation that would require individual pharmacists or pharmacy chains to either fill legally valid prescriptions or refer patients to an alternative dispensing pharmacy.

AMA Trustee Peter W. Carmel, M.D., promised that the AMA would work with the pharmacists' associations and state legislators “so that neither patients' health nor the patient-physician relationship is harmed by pharmacists' refusal to fill prescribed medications.”

The House also agreed that the AMA should lobby for state legislation that would allow physicians to dispense medication to their own patients if no pharmacist within a 30-mile radius is able and willing to dispense the medication. The APhA did not respond to requests for comment from this newspaper.

In other business, delegates addressed the challenges physicians face in balancing the increasing value of imaging tests with payers' efforts to restrict reimbursement. Several resolutions were approved that directed the AMA to oppose any attempts to restrict such reimbursement based on physician specialty.

Some payers propose to reimburse only radiologists for imaging, a practice that other specialists believe is unfair, Bruce Scott, M.D., an otolaryngologist, told this newspaper. The bottom line is physicians should have the right to bill for a service they provide and are qualified to perform, he said.

Balance billing was another topic addressed and measures were approved asking that the AMA prepare legislation that would allow physicians to balance bill regardless of the payer. In the wake of pay-for-performance initiatives, “which are nothing but third-party managers taking over,” balance billing would place patients back in control, enabling them to negotiate their own bills with their individual physicians, Jay Gregory, M.D., of the Oklahoma delegation, said during committee debate.

To address the Medicare physician fee schedule, delegates recommended that savings under Medicare Part A that could be attributed to better Part B care (for example, fewer inpatient complications, shorter lengths of stay, and fewer hospital readmissions) should be “credited” and flow to the Part B physician payment pool.

On another contentious issue—malpractice—delegates called on the AMA to explore federal legislation that would correct inadequate state medical liability laws while preserving state medical liability reforms that have proven effective.

Addressing general policies on obesity, the AMA urged physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in routine adult examinations and BMI percentiles in children. In addition, the resolution called on the AMA to develop a school health advocacy agenda that includes funding for physical activity programs.

CHICAGO — A pharmacist's philosophy shouldn't get in the way of prescribing needed drugs to patients. That was one of the conclusions that physicians reached while addressing controversial topics at the annual meeting of the American Medical Association's House of Delegates.

American Pharmaceutical Association (APhA) policy recognizes an individual pharmacist's right to exercise conscientious refusal to fill prescriptions. In committee debate and in full congress, physicians at the House of Delegates meeting expressed concern that pharmacists were exercising this provision to impede access to certain medications, including emergency contraceptives and psychotropic agents.

“What happens between the doctor and the patient is between doctor and patient,” Mary Frank, M.D., president of the American Academy of Family Physicians, told this newspaper. “What they decide has to have priority over the pharmacist's objections.”

Although the delegates didn't outwardly oppose the use of conscience clauses, they did call for legislation that would require individual pharmacists or pharmacy chains to either fill legally valid prescriptions or refer patients to an alternative dispensing pharmacy.

AMA Trustee Peter W. Carmel, M.D., promised that the AMA would work with the pharmacists' associations and state legislators “so that neither patients' health nor the patient-physician relationship is harmed by pharmacists' refusal to fill prescribed medications.”

The House also agreed that the AMA should lobby for state legislation that would allow physicians to dispense medication to their own patients if no pharmacist within a 30-mile radius is able and willing to dispense the medication. The APhA did not respond to requests for comment from this newspaper.

In other business, delegates addressed the challenges physicians face in balancing the increasing value of imaging tests with payers' efforts to restrict reimbursement. Several resolutions were approved that directed the AMA to oppose any attempts to restrict such reimbursement based on physician specialty.

Some payers propose to reimburse only radiologists for imaging, a practice that other specialists believe is unfair, Bruce Scott, M.D., an otolaryngologist, told this newspaper. The bottom line is physicians should have the right to bill for a service they provide and are qualified to perform, he said.

Balance billing was another topic addressed and measures were approved asking that the AMA prepare legislation that would allow physicians to balance bill regardless of the payer. In the wake of pay-for-performance initiatives, “which are nothing but third-party managers taking over,” balance billing would place patients back in control, enabling them to negotiate their own bills with their individual physicians, Jay Gregory, M.D., of the Oklahoma delegation, said during committee debate.

To address the Medicare physician fee schedule, delegates recommended that savings under Medicare Part A that could be attributed to better Part B care (for example, fewer inpatient complications, shorter lengths of stay, and fewer hospital readmissions) should be “credited” and flow to the Part B physician payment pool.

On another contentious issue—malpractice—delegates called on the AMA to explore federal legislation that would correct inadequate state medical liability laws while preserving state medical liability reforms that have proven effective.

Addressing general policies on obesity, the AMA urged physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in routine adult examinations and BMI percentiles in children. In addition, the resolution called on the AMA to develop a school health advocacy agenda that includes funding for physical activity programs.

CHICAGO — Congress, state legislatures, government payers, and private payers should not be allowed to restrict imaging services based on physician specialty.

That was one of the conclusions physicians reached while addressing controversial topics at the annual meeting of the American Medical Association's House of Delegates.

The delegates addressed the challenges physicians face in balancing the increasing value of imaging tests with payers' efforts to restrict reimbursement. The “Freedom of Practice in Medical Imaging” resolution, directing the AMA to oppose any attempts to restrict such reimbursement based on physician specialty, was approved nearly unanimously.

Some payers propose to reimburse only radiologists for imaging, a practice that other specialists believe is unfair, Bruce Scott, M.D., an otolaryngologist, told this newspaper.

“The ob.gyns. are going to want to bill for ultrasound, and the cardiologists want to bill for their interpretation of slides,” he said, adding that the bottom line is physicians should have the right to bill for a service they provide and are qualified to perform.

Only the American College of Radiology opposed the measure, according to a statement from the American College of Cardiology. “The resolution's passage sends a clear message that efforts by policy makers and payers to impede the ability of patients to safely and conveniently receive imaging services in their physician's office will be vigorously opposed by the AMA and the physician specialty community,” wrote the ACC.

In other business, the house agreed that a pharmacist's philosophy shouldn't get in the way of prescribing needed drugs to patients.

American Pharmaceutical Association (APhA) policy recognizes an individual pharmacist's right to exercise conscientious refusal to fill prescriptions. In committee debate and in full congress, physicians at the House of Delegates meeting expressed concern that pharmacists were exercising this provision to impede access to certain medications, including emergency contraceptives and psychotropic agents.

“What happens between the doctor and the patient is between doctor and patient,” Mary Frank, M.D., president of the American Academy of Family Physicians, told this newspaper. “What they decide has to have priority over the pharmacist's objections.”

Although the delegates didn't outwardly oppose the use of conscience clauses, they did call for legislation that would require individual pharmacists or pharmacy chains to either fill legally valid prescriptions or refer patients to an alternative dispensing pharmacy.

AMA Trustee Peter W. Carmel, M.D., promised that the AMA would work with the pharmacists' associations and state legislators “so that neither patients' health nor the patient-physician relationship is harmed by pharmacists' refusal to fill prescribed medications.”

Balance billing was another topic addressed and measures were approved asking that the AMA prepare legislation that would allow physicians to balance bill regardless of the payer. In the wake of pay-for-performance initiatives, “which are nothing but third party managers taking over,” balance billing would place patients back in control, enabling them to negotiate their own bills with their individual physicians, Jay Gregory, M.D., of the Oklahoma delegation, said during committee debate.

To address the Medicare physician fee schedule, delegates recommended that savings under Medicare Part A that could be attributed to better Part B care (for example, fewer inpatient complications, shorter lengths of stay, and fewer hospital readmissions) should be “credited” and flow to the Part B physician payment pool.

On another contentious issue—malpractice—delegates called on the AMA to explore federal legislation that would correct inadequate state medical liability laws while preserving state medical liability reforms that have proven effective.

The House of Delegates also commented on the aftermath of the Terry Schiavo case, voting to oppose legislation that would “presume to prescribe a patient's preferences for artificial hydration and nutrition in situations where the patient lacks decision-making capacity and an advance directive or living will.”

A number of resolutions called on schools to develop children's health programs, such as sun-protection policies in elementary schools. Most delegates were in agreement with this resolution, although some concerns were raised that this might place undue burdens on teachers. Parents should be the adults in charge of applying sunscreen to their children, Peter Lavine, M.D., delegate to the Medical Society of the District of Columbia, said in committee proceedings.

Delegates rejected a provision to impose taxes on sugar-sweetened soft drinks. Instead, they approved policy urging public schools to promote the consumption and availability of nutritious beverages.

Reducing television watching would do more to curtail obesity in children than taxing soft drinks, Holly Wyatt, M.D., delegate to the Young Physicians Section for the Endocrine Society, said during committee debate.

Addressing general policies on obesity, the AMA urged physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in routine adult examinations and BMI percentiles in children. In addition, the resolution called on the AMA to develop a school health advocacy agenda that includes funding for physical activity programs.

CHICAGO — Congress, state legislatures, government payers, and private payers should not be allowed to restrict imaging services based on physician specialty.

That was one of the conclusions physicians reached while addressing controversial topics at the annual meeting of the American Medical Association's House of Delegates.

The delegates addressed the challenges physicians face in balancing the increasing value of imaging tests with payers' efforts to restrict reimbursement. The “Freedom of Practice in Medical Imaging” resolution, directing the AMA to oppose any attempts to restrict such reimbursement based on physician specialty, was approved nearly unanimously.

Some payers propose to reimburse only radiologists for imaging, a practice that other specialists believe is unfair, Bruce Scott, M.D., an otolaryngologist, told this newspaper.

“The ob.gyns. are going to want to bill for ultrasound, and the cardiologists want to bill for their interpretation of slides,” he said, adding that the bottom line is physicians should have the right to bill for a service they provide and are qualified to perform.

Only the American College of Radiology opposed the measure, according to a statement from the American College of Cardiology. “The resolution's passage sends a clear message that efforts by policy makers and payers to impede the ability of patients to safely and conveniently receive imaging services in their physician's office will be vigorously opposed by the AMA and the physician specialty community,” wrote the ACC.

In other business, the house agreed that a pharmacist's philosophy shouldn't get in the way of prescribing needed drugs to patients.

American Pharmaceutical Association (APhA) policy recognizes an individual pharmacist's right to exercise conscientious refusal to fill prescriptions. In committee debate and in full congress, physicians at the House of Delegates meeting expressed concern that pharmacists were exercising this provision to impede access to certain medications, including emergency contraceptives and psychotropic agents.

“What happens between the doctor and the patient is between doctor and patient,” Mary Frank, M.D., president of the American Academy of Family Physicians, told this newspaper. “What they decide has to have priority over the pharmacist's objections.”

Although the delegates didn't outwardly oppose the use of conscience clauses, they did call for legislation that would require individual pharmacists or pharmacy chains to either fill legally valid prescriptions or refer patients to an alternative dispensing pharmacy.

AMA Trustee Peter W. Carmel, M.D., promised that the AMA would work with the pharmacists' associations and state legislators “so that neither patients' health nor the patient-physician relationship is harmed by pharmacists' refusal to fill prescribed medications.”

Balance billing was another topic addressed and measures were approved asking that the AMA prepare legislation that would allow physicians to balance bill regardless of the payer. In the wake of pay-for-performance initiatives, “which are nothing but third party managers taking over,” balance billing would place patients back in control, enabling them to negotiate their own bills with their individual physicians, Jay Gregory, M.D., of the Oklahoma delegation, said during committee debate.

To address the Medicare physician fee schedule, delegates recommended that savings under Medicare Part A that could be attributed to better Part B care (for example, fewer inpatient complications, shorter lengths of stay, and fewer hospital readmissions) should be “credited” and flow to the Part B physician payment pool.

On another contentious issue—malpractice—delegates called on the AMA to explore federal legislation that would correct inadequate state medical liability laws while preserving state medical liability reforms that have proven effective.

The House of Delegates also commented on the aftermath of the Terry Schiavo case, voting to oppose legislation that would “presume to prescribe a patient's preferences for artificial hydration and nutrition in situations where the patient lacks decision-making capacity and an advance directive or living will.”

A number of resolutions called on schools to develop children's health programs, such as sun-protection policies in elementary schools. Most delegates were in agreement with this resolution, although some concerns were raised that this might place undue burdens on teachers. Parents should be the adults in charge of applying sunscreen to their children, Peter Lavine, M.D., delegate to the Medical Society of the District of Columbia, said in committee proceedings.

Delegates rejected a provision to impose taxes on sugar-sweetened soft drinks. Instead, they approved policy urging public schools to promote the consumption and availability of nutritious beverages.

Reducing television watching would do more to curtail obesity in children than taxing soft drinks, Holly Wyatt, M.D., delegate to the Young Physicians Section for the Endocrine Society, said during committee debate.

Addressing general policies on obesity, the AMA urged physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in routine adult examinations and BMI percentiles in children. In addition, the resolution called on the AMA to develop a school health advocacy agenda that includes funding for physical activity programs.

CHICAGO — Congress, state legislatures, government payers, and private payers should not be allowed to restrict imaging services based on physician specialty.

That was one of the conclusions physicians reached while addressing controversial topics at the annual meeting of the American Medical Association's House of Delegates.

The delegates addressed the challenges physicians face in balancing the increasing value of imaging tests with payers' efforts to restrict reimbursement. The “Freedom of Practice in Medical Imaging” resolution, directing the AMA to oppose any attempts to restrict such reimbursement based on physician specialty, was approved nearly unanimously.

Some payers propose to reimburse only radiologists for imaging, a practice that other specialists believe is unfair, Bruce Scott, M.D., an otolaryngologist, told this newspaper.

“The ob.gyns. are going to want to bill for ultrasound, and the cardiologists want to bill for their interpretation of slides,” he said, adding that the bottom line is physicians should have the right to bill for a service they provide and are qualified to perform.

Only the American College of Radiology opposed the measure, according to a statement from the American College of Cardiology. “The resolution's passage sends a clear message that efforts by policy makers and payers to impede the ability of patients to safely and conveniently receive imaging services in their physician's office will be vigorously opposed by the AMA and the physician specialty community,” wrote the ACC.

In other business, the house agreed that a pharmacist's philosophy shouldn't get in the way of prescribing needed drugs to patients.

American Pharmaceutical Association (APhA) policy recognizes an individual pharmacist's right to exercise conscientious refusal to fill prescriptions. In committee debate and in full congress, physicians at the House of Delegates meeting expressed concern that pharmacists were exercising this provision to impede access to certain medications, including emergency contraceptives and psychotropic agents.

“What happens between the doctor and the patient is between doctor and patient,” Mary Frank, M.D., president of the American Academy of Family Physicians, told this newspaper. “What they decide has to have priority over the pharmacist's objections.”

Although the delegates didn't outwardly oppose the use of conscience clauses, they did call for legislation that would require individual pharmacists or pharmacy chains to either fill legally valid prescriptions or refer patients to an alternative dispensing pharmacy.

AMA Trustee Peter W. Carmel, M.D., promised that the AMA would work with the pharmacists' associations and state legislators “so that neither patients' health nor the patient-physician relationship is harmed by pharmacists' refusal to fill prescribed medications.”

Balance billing was another topic addressed and measures were approved asking that the AMA prepare legislation that would allow physicians to balance bill regardless of the payer. In the wake of pay-for-performance initiatives, “which are nothing but third party managers taking over,” balance billing would place patients back in control, enabling them to negotiate their own bills with their individual physicians, Jay Gregory, M.D., of the Oklahoma delegation, said during committee debate.

To address the Medicare physician fee schedule, delegates recommended that savings under Medicare Part A that could be attributed to better Part B care (for example, fewer inpatient complications, shorter lengths of stay, and fewer hospital readmissions) should be “credited” and flow to the Part B physician payment pool.

On another contentious issue—malpractice—delegates called on the AMA to explore federal legislation that would correct inadequate state medical liability laws while preserving state medical liability reforms that have proven effective.

The House of Delegates also commented on the aftermath of the Terry Schiavo case, voting to oppose legislation that would “presume to prescribe a patient's preferences for artificial hydration and nutrition in situations where the patient lacks decision-making capacity and an advance directive or living will.”

A number of resolutions called on schools to develop children's health programs, such as sun-protection policies in elementary schools. Most delegates were in agreement with this resolution, although some concerns were raised that this might place undue burdens on teachers. Parents should be the adults in charge of applying sunscreen to their children, Peter Lavine, M.D., delegate to the Medical Society of the District of Columbia, said in committee proceedings.

Delegates rejected a provision to impose taxes on sugar-sweetened soft drinks. Instead, they approved policy urging public schools to promote the consumption and availability of nutritious beverages.

Reducing television watching would do more to curtail obesity in children than taxing soft drinks, Holly Wyatt, M.D., delegate to the Young Physicians Section for the Endocrine Society, said during committee debate.

Addressing general policies on obesity, the AMA urged physicians to incorporate body mass index (BMI) and waist circumference as a component measurement in routine adult examinations and BMI percentiles in children. In addition, the resolution called on the AMA to develop a school health advocacy agenda that includes funding for physical activity programs.

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 areas, Dr. Bangasser said. Fewer groups participated in IT measures than in the other measures, and of those who tried, only two-thirds got full credit for it.

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 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 surveys.

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.”

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 areas, Dr. Bangasser said. Fewer groups participated in IT measures than in the other measures, and of those who tried, only two-thirds got full credit for it.

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 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 surveys.

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.”

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 areas, Dr. Bangasser said. Fewer groups participated in IT measures than in the other measures, and of those who tried, only two-thirds got full credit for it.

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 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 surveys.

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.”

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

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, according to Dr. Friedman.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package.

Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system.

The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice.

“Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

For selection of software vendors, it is important to visit practice sites that are already using installed systems.

He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted.

The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.”

The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September.

Murray Hill physicians went through 3 months of formal training during such a period.

The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system, Dr. Friedman said.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” he said.

Still, a practice should gradually convert to an EMR system, Dr. Friedman cautioned.

A staff of two physicians, for example, should take turns going online.

“You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” Dr. Friedman advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see related story below), the system helps to automate prescription refills.

“The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said.

With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations. Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what actually needs to be done for each patient. “And any work you do provides income,” Dr. Friedman said.

An EMR also can point out errors in coding.

“A lot of times, we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Some Practices Order Online Scheduling

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said.

The practice estimates 35%–45% of all of its appointments are made electronically, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, some physicians “think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services. A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, according to Dr. Friedman.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package.

Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system.

The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice.

“Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

For selection of software vendors, it is important to visit practice sites that are already using installed systems.

He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted.

The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.”

The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September.

Murray Hill physicians went through 3 months of formal training during such a period.

The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system, Dr. Friedman said.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” he said.

Still, a practice should gradually convert to an EMR system, Dr. Friedman cautioned.

A staff of two physicians, for example, should take turns going online.

“You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” Dr. Friedman advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see related story below), the system helps to automate prescription refills.

“The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said.

With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations. Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what actually needs to be done for each patient. “And any work you do provides income,” Dr. Friedman said.

An EMR also can point out errors in coding.

“A lot of times, we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Some Practices Order Online Scheduling

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said.

The practice estimates 35%–45% of all of its appointments are made electronically, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, some physicians “think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services. A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, according to Dr. Friedman.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package.

Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system.

The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice.

“Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

For selection of software vendors, it is important to visit practice sites that are already using installed systems.

He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted.

The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.”

The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September.

Murray Hill physicians went through 3 months of formal training during such a period.

The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system, Dr. Friedman said.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” he said.

Still, a practice should gradually convert to an EMR system, Dr. Friedman cautioned.

A staff of two physicians, for example, should take turns going online.

“You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” Dr. Friedman advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see related story below), the system helps to automate prescription refills.

“The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said.

With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations. Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what actually needs to be done for each patient. “And any work you do provides income,” Dr. Friedman said.

An EMR also can point out errors in coding.

“A lot of times, we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Some Practices Order Online Scheduling

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said.

The practice estimates 35%–45% of all of its appointments are made electronically, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, some physicians “think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services. A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

Increase in Pediatric Labeling

Incentives to encourage pediatric studies and subsequent labeling are working, according to a report from the Tufts Center for the Study of Drug Development. Nearly 100 medicines for sale in the United States have received pediatric labeling since the late 1990s, based on new clinical studies to determine appropriate dosages, safety, efficacy, and formulations for children, the report said. “The increase in pediatric labeling signals a major advance in pediatric medicine,” said Christopher Milne, assistant director of the center and author of the study. The federal Best Pharmaceuticals for Children Act of 2001 seems responsible for this increase. The law granted extended patent exclusivity to drug companies willing to conduct pediatric studies on new or already approved drugs, and established time frames to expedite label changes. Prior to the law's enactment, 70% of drugs used in children had been dispensed without adequate pediatric dosing information, according to the Tufts analysis. Limited return on investment, difficulty enrolling and studying pediatric patients, and liability concerns previously discouraged drugmakers from conducting pediatric studies.

AAP Urges Sex Education

Pediatricians should encourage adolescents to postpone early sexual activity and encourage parents to educate their children and adolescents about sexual development, responsible sexuality, decision making, and values, the American Academy of Pediatrics stated in a clinical report that updates its policy on unintended teen pregnancy. While adolescent pregnancy and birth rates have steadily declined in the past 13 years, many teens still become pregnant, the report stated. Teaching young people about contraceptives does not increase sexual activity and improves teens' knowledge about access to reproductive health, the report emphasized. However, the conservative advocacy group Focus on the Family thought the report didn't go far enough to encourage abstinence. “It is inappropriate that the AAP leadership should advise policies that promote anything less than the most healthy, responsible behavior for our children,” said Marilyn A. Maxwell, M.D., a member of the AAP and of Focus on the Family's Physicians Resource Council.

Soft Drink Wars Focus on Sugar

The Center for Science in the Public Interest is targeting the public's consumption of soft drinks, something the group labels as “liquid candy.” Data show teenagers are drinking more high-calorie soft drinks than ever before, and less diet soda than in years past, the group stated. In a petition, the CSPI called on the Food and Drug Administration to require a series of rotating health notices on containers of all nondiet soft drinks (carbonated and noncarbonated) that contain more than 13 grams of refined sugars per 12 ounces. In a statement, Susan Neely, president and chief executive officer of the American Beverage Association, said she thought the CSPI's proposed warning labels on soft drinks patronized consumers and lacked common sense. “Even skim milk and thousands of other food products could potentially fit into a CSPI labeling scheme because of the sugars in those products,” she said.

Youth Concerned About Health

Most young people believe it's important to pay attention to their health. A survey of 1,278 youth aged 10–17 years conducted by Harris Interactive found that 92% cared about this issue, although many acknowledged that they might not be leading the healthiest lifestyles and that daily stress was a major contributor. More than half of those surveyed admitted that there were a lot of things they did that weren't healthy and 84% confessed to eating junk food after school. Only 19% didn't think they needed to worry about their health because they were young. The poll was taken on behalf of America's Promise- The Alliance for Youth, an advocacy group whose members work to ensure that young people meet their potential.

Health Insurance Statistics

Health insurance coverage for children continues to improve: Seven million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997, according to a survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Among poor and near-poor children, lack of coverage dropped by about a third from 1997. For near-poor children, public coverage almost doubled from 24% to 43% between 1997 and 2004. In general, the ranks of the uninsured appear to be leveling off. In 2004, 42 million Americans of all ages were without health insurance, about the same level as in 1997, the first year this survey began tracking these statistics. In addition, one in five adults aged 18–64 years were without health insurance last year, a number that had been steadily rising in recent years, but also leveled off in 2004.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, a poll of more than 1,200 adults conducted by the Kaiser Family Foundation showed. In fact, the majority thought the federal government should maintain (44%) or increase (36%) federal spending on Medicaid, with only 12% favoring cuts. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's director of public opinion and media research. The fact that many of the respondents (56%) reported having some interaction with Medicaid could explain why the program ranked closely with such other popular programs as Medicare and Social Security, she said.

Kids Miss Smoking/Addiction Link

Nearly one-third of children aged 10–12 years believe that they can smoke without becoming addicted, according to a survey of 418 families by the Group Health Cooperative's Center for Health Studies, Seattle. Terry Bush, Ph.D., and colleagues surveyed the preteens on their attitudes and beliefs about smoking over a 20-month period and found that the percentage agreeing with the statement “people can smoke a few cigarettes without becoming addicted” rose from 27% at the beginning of the study to 31% at the end. However, the percentage agreeing that “if you smoked, you could stop anytime you wanted to” dropped from 27% to 20% during that same period. The researchers found that two factors associated with positive attitudes toward smoking were lack of family cohesiveness and having a parent who smoked.

Florida's Parental Notification Law

After a court battle and a state constitutional amendment, the requirement for parental notification when a minor seeks an abortion is now the law in Florida. The “Parental Notice of Abortion Act” was signed by Gov. Jeb Bush (R). The legislation requires a physician to notify the parent or guardian of a minor at least 48 hours before the termination of a pregnancy. The law allows for the courts to waive the notification process in cases of medical emergency. The physician can also determine that a medical emergency exists, and there is insufficient time to comply with notification requirements; however, he or she must document the reason for the medical necessity in the patient's medical record.

Increase in Pediatric Labeling

Incentives to encourage pediatric studies and subsequent labeling are working, according to a report from the Tufts Center for the Study of Drug Development. Nearly 100 medicines for sale in the United States have received pediatric labeling since the late 1990s, based on new clinical studies to determine appropriate dosages, safety, efficacy, and formulations for children, the report said. “The increase in pediatric labeling signals a major advance in pediatric medicine,” said Christopher Milne, assistant director of the center and author of the study. The federal Best Pharmaceuticals for Children Act of 2001 seems responsible for this increase. The law granted extended patent exclusivity to drug companies willing to conduct pediatric studies on new or already approved drugs, and established time frames to expedite label changes. Prior to the law's enactment, 70% of drugs used in children had been dispensed without adequate pediatric dosing information, according to the Tufts analysis. Limited return on investment, difficulty enrolling and studying pediatric patients, and liability concerns previously discouraged drugmakers from conducting pediatric studies.

AAP Urges Sex Education

Pediatricians should encourage adolescents to postpone early sexual activity and encourage parents to educate their children and adolescents about sexual development, responsible sexuality, decision making, and values, the American Academy of Pediatrics stated in a clinical report that updates its policy on unintended teen pregnancy. While adolescent pregnancy and birth rates have steadily declined in the past 13 years, many teens still become pregnant, the report stated. Teaching young people about contraceptives does not increase sexual activity and improves teens' knowledge about access to reproductive health, the report emphasized. However, the conservative advocacy group Focus on the Family thought the report didn't go far enough to encourage abstinence. “It is inappropriate that the AAP leadership should advise policies that promote anything less than the most healthy, responsible behavior for our children,” said Marilyn A. Maxwell, M.D., a member of the AAP and of Focus on the Family's Physicians Resource Council.

Soft Drink Wars Focus on Sugar

The Center for Science in the Public Interest is targeting the public's consumption of soft drinks, something the group labels as “liquid candy.” Data show teenagers are drinking more high-calorie soft drinks than ever before, and less diet soda than in years past, the group stated. In a petition, the CSPI called on the Food and Drug Administration to require a series of rotating health notices on containers of all nondiet soft drinks (carbonated and noncarbonated) that contain more than 13 grams of refined sugars per 12 ounces. In a statement, Susan Neely, president and chief executive officer of the American Beverage Association, said she thought the CSPI's proposed warning labels on soft drinks patronized consumers and lacked common sense. “Even skim milk and thousands of other food products could potentially fit into a CSPI labeling scheme because of the sugars in those products,” she said.

Youth Concerned About Health

Most young people believe it's important to pay attention to their health. A survey of 1,278 youth aged 10–17 years conducted by Harris Interactive found that 92% cared about this issue, although many acknowledged that they might not be leading the healthiest lifestyles and that daily stress was a major contributor. More than half of those surveyed admitted that there were a lot of things they did that weren't healthy and 84% confessed to eating junk food after school. Only 19% didn't think they needed to worry about their health because they were young. The poll was taken on behalf of America's Promise- The Alliance for Youth, an advocacy group whose members work to ensure that young people meet their potential.

Health Insurance Statistics

Health insurance coverage for children continues to improve: Seven million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997, according to a survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Among poor and near-poor children, lack of coverage dropped by about a third from 1997. For near-poor children, public coverage almost doubled from 24% to 43% between 1997 and 2004. In general, the ranks of the uninsured appear to be leveling off. In 2004, 42 million Americans of all ages were without health insurance, about the same level as in 1997, the first year this survey began tracking these statistics. In addition, one in five adults aged 18–64 years were without health insurance last year, a number that had been steadily rising in recent years, but also leveled off in 2004.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, a poll of more than 1,200 adults conducted by the Kaiser Family Foundation showed. In fact, the majority thought the federal government should maintain (44%) or increase (36%) federal spending on Medicaid, with only 12% favoring cuts. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's director of public opinion and media research. The fact that many of the respondents (56%) reported having some interaction with Medicaid could explain why the program ranked closely with such other popular programs as Medicare and Social Security, she said.

Kids Miss Smoking/Addiction Link

Nearly one-third of children aged 10–12 years believe that they can smoke without becoming addicted, according to a survey of 418 families by the Group Health Cooperative's Center for Health Studies, Seattle. Terry Bush, Ph.D., and colleagues surveyed the preteens on their attitudes and beliefs about smoking over a 20-month period and found that the percentage agreeing with the statement “people can smoke a few cigarettes without becoming addicted” rose from 27% at the beginning of the study to 31% at the end. However, the percentage agreeing that “if you smoked, you could stop anytime you wanted to” dropped from 27% to 20% during that same period. The researchers found that two factors associated with positive attitudes toward smoking were lack of family cohesiveness and having a parent who smoked.

Florida's Parental Notification Law

After a court battle and a state constitutional amendment, the requirement for parental notification when a minor seeks an abortion is now the law in Florida. The “Parental Notice of Abortion Act” was signed by Gov. Jeb Bush (R). The legislation requires a physician to notify the parent or guardian of a minor at least 48 hours before the termination of a pregnancy. The law allows for the courts to waive the notification process in cases of medical emergency. The physician can also determine that a medical emergency exists, and there is insufficient time to comply with notification requirements; however, he or she must document the reason for the medical necessity in the patient's medical record.

Increase in Pediatric Labeling

Incentives to encourage pediatric studies and subsequent labeling are working, according to a report from the Tufts Center for the Study of Drug Development. Nearly 100 medicines for sale in the United States have received pediatric labeling since the late 1990s, based on new clinical studies to determine appropriate dosages, safety, efficacy, and formulations for children, the report said. “The increase in pediatric labeling signals a major advance in pediatric medicine,” said Christopher Milne, assistant director of the center and author of the study. The federal Best Pharmaceuticals for Children Act of 2001 seems responsible for this increase. The law granted extended patent exclusivity to drug companies willing to conduct pediatric studies on new or already approved drugs, and established time frames to expedite label changes. Prior to the law's enactment, 70% of drugs used in children had been dispensed without adequate pediatric dosing information, according to the Tufts analysis. Limited return on investment, difficulty enrolling and studying pediatric patients, and liability concerns previously discouraged drugmakers from conducting pediatric studies.

AAP Urges Sex Education

Pediatricians should encourage adolescents to postpone early sexual activity and encourage parents to educate their children and adolescents about sexual development, responsible sexuality, decision making, and values, the American Academy of Pediatrics stated in a clinical report that updates its policy on unintended teen pregnancy. While adolescent pregnancy and birth rates have steadily declined in the past 13 years, many teens still become pregnant, the report stated. Teaching young people about contraceptives does not increase sexual activity and improves teens' knowledge about access to reproductive health, the report emphasized. However, the conservative advocacy group Focus on the Family thought the report didn't go far enough to encourage abstinence. “It is inappropriate that the AAP leadership should advise policies that promote anything less than the most healthy, responsible behavior for our children,” said Marilyn A. Maxwell, M.D., a member of the AAP and of Focus on the Family's Physicians Resource Council.

Soft Drink Wars Focus on Sugar

The Center for Science in the Public Interest is targeting the public's consumption of soft drinks, something the group labels as “liquid candy.” Data show teenagers are drinking more high-calorie soft drinks than ever before, and less diet soda than in years past, the group stated. In a petition, the CSPI called on the Food and Drug Administration to require a series of rotating health notices on containers of all nondiet soft drinks (carbonated and noncarbonated) that contain more than 13 grams of refined sugars per 12 ounces. In a statement, Susan Neely, president and chief executive officer of the American Beverage Association, said she thought the CSPI's proposed warning labels on soft drinks patronized consumers and lacked common sense. “Even skim milk and thousands of other food products could potentially fit into a CSPI labeling scheme because of the sugars in those products,” she said.

Youth Concerned About Health

Most young people believe it's important to pay attention to their health. A survey of 1,278 youth aged 10–17 years conducted by Harris Interactive found that 92% cared about this issue, although many acknowledged that they might not be leading the healthiest lifestyles and that daily stress was a major contributor. More than half of those surveyed admitted that there were a lot of things they did that weren't healthy and 84% confessed to eating junk food after school. Only 19% didn't think they needed to worry about their health because they were young. The poll was taken on behalf of America's Promise- The Alliance for Youth, an advocacy group whose members work to ensure that young people meet their potential.

Health Insurance Statistics

Health insurance coverage for children continues to improve: Seven million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997, according to a survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics. Among poor and near-poor children, lack of coverage dropped by about a third from 1997. For near-poor children, public coverage almost doubled from 24% to 43% between 1997 and 2004. In general, the ranks of the uninsured appear to be leveling off. In 2004, 42 million Americans of all ages were without health insurance, about the same level as in 1997, the first year this survey began tracking these statistics. In addition, one in five adults aged 18–64 years were without health insurance last year, a number that had been steadily rising in recent years, but also leveled off in 2004.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, a poll of more than 1,200 adults conducted by the Kaiser Family Foundation showed. In fact, the majority thought the federal government should maintain (44%) or increase (36%) federal spending on Medicaid, with only 12% favoring cuts. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's director of public opinion and media research. The fact that many of the respondents (56%) reported having some interaction with Medicaid could explain why the program ranked closely with such other popular programs as Medicare and Social Security, she said.

Kids Miss Smoking/Addiction Link

Nearly one-third of children aged 10–12 years believe that they can smoke without becoming addicted, according to a survey of 418 families by the Group Health Cooperative's Center for Health Studies, Seattle. Terry Bush, Ph.D., and colleagues surveyed the preteens on their attitudes and beliefs about smoking over a 20-month period and found that the percentage agreeing with the statement “people can smoke a few cigarettes without becoming addicted” rose from 27% at the beginning of the study to 31% at the end. However, the percentage agreeing that “if you smoked, you could stop anytime you wanted to” dropped from 27% to 20% during that same period. The researchers found that two factors associated with positive attitudes toward smoking were lack of family cohesiveness and having a parent who smoked.

Florida's Parental Notification Law

After a court battle and a state constitutional amendment, the requirement for parental notification when a minor seeks an abortion is now the law in Florida. The “Parental Notice of Abortion Act” was signed by Gov. Jeb Bush (R). The legislation requires a physician to notify the parent or guardian of a minor at least 48 hours before the termination of a pregnancy. The law allows for the courts to waive the notification process in cases of medical emergency. The physician can also determine that a medical emergency exists, and there is insufficient time to comply with notification requirements; however, he or she must document the reason for the medical necessity in the patient's medical record.

WASHINGTON — The much talked about “pay-for-performance” style of reimbursement system is still largely untested and is not designed to reap cost savings, “particularly since most of the quality measures it targets are measures of underuse,” Meredith B. Rosenthal, Ph.D., of Harvard School of Public Health, Boston, said during testimony before a subcommittee of the House Committee on Education and the Workforce.

In addition, there is little guidance in the literature for purchasers and health plans to reference when they set out to design pay-for-performance programs.

Coordination among payers in using these measures is needed, she said. “If only a few of the many payers that a provider contracts with are paying for performance, or if each payer focuses on a different measure set, the effects of pay for performance may be dulled.” She suggested that Congress fund more research by the Agency for Healthcare Research and Quality to identify approaches that would improve this method's cost-effectiveness and increase the likely gains in quality of care.

WASHINGTON — The much talked about “pay-for-performance” style of reimbursement system is still largely untested and is not designed to reap cost savings, “particularly since most of the quality measures it targets are measures of underuse,” Meredith B. Rosenthal, Ph.D., of Harvard School of Public Health, Boston, said during testimony before a subcommittee of the House Committee on Education and the Workforce.

In addition, there is little guidance in the literature for purchasers and health plans to reference when they set out to design pay-for-performance programs.

Coordination among payers in using these measures is needed, she said. “If only a few of the many payers that a provider contracts with are paying for performance, or if each payer focuses on a different measure set, the effects of pay for performance may be dulled.” She suggested that Congress fund more research by the Agency for Healthcare Research and Quality to identify approaches that would improve this method's cost-effectiveness and increase the likely gains in quality of care.

WASHINGTON — The much talked about “pay-for-performance” style of reimbursement system is still largely untested and is not designed to reap cost savings, “particularly since most of the quality measures it targets are measures of underuse,” Meredith B. Rosenthal, Ph.D., of Harvard School of Public Health, Boston, said during testimony before a subcommittee of the House Committee on Education and the Workforce.

In addition, there is little guidance in the literature for purchasers and health plans to reference when they set out to design pay-for-performance programs.

Coordination among payers in using these measures is needed, she said. “If only a few of the many payers that a provider contracts with are paying for performance, or if each payer focuses on a different measure set, the effects of pay for performance may be dulled.” She suggested that Congress fund more research by the Agency for Healthcare Research and Quality to identify approaches that would improve this method's cost-effectiveness and increase the likely gains in quality of care.

WASHINGTON — Medicare intends to use performance measures to monitor cost, quality, and access issues related to the new prescription drug benefit, a research analyst said during a meeting of the Medicare Payment Advisory Commission.

However, Medicare has not yet “determined what those measures will be and how they will be used,” said MedPAC analyst Cristina Boccuti. MedPAC makes recommendations to Congress on Medicare payment issues.

The Centers for Medicare and Medicaid Services will be collecting a large amount of data on the new drug benefit—or Medicare Part D—including drug utilization and plan benefit information, to construct these performance measures, Ms. Boccuti said. In addition to the agency's need for the data, “congressional agencies will need Part D data to report to the Congress on the impact of the drug benefit on cost, quality, and access,” she added.

MedPAC commissioners recommended that the Health and Human Services department establish a process for the timely delivery of these data to interested parties. Individuals, employers, and government agencies currently use performance measures to evaluate how well health plans and pharmacy benefit managers manage drug benefits, Ms. Boccuti said.

To identify how policy makers could use these measures to monitor the Part D program, MedPAC convened a panel of 11 experts representing health plans, pharmacy benefits managers (PBMs), employers, pharmacies, consumers, quality assurance organizations, and researchers. The panel analyzed measures such as cost control, access and quality assurance, benefit administration and management, and enrollee satisfaction.

Based on the panel's findings, CMS plans to collect data on the following:

▸ Dispensing fees, generic dispensing rates, aggregate rebates, drug claims, and drug spending by plans and beneficiaries.

▸ Pharmacy networks, formularies (including prior authorization and exceptions), appeals rates, and drug utilization.

▸ Claims processing, including plans' out-of-pocket calculations.

▸ Beneficiary satisfaction, grievances, call center operations, and disenrollment rates.

Measures to track beneficiary satisfaction—such as member satisfaction surveys and performance of customer service call centers—are common types of performance guarantees that health plans and PBMs offer to their clients, Ms. Boccuti said.

CMS plans on conducting its own consumer satisfaction surveys to provide comparative plan information to beneficiaries when they're making enrollment decisions, she said. In addition, plans will submit data on grievances filed, and call center performance measures, such as abandonment rates and hold times.

MedPAC commissioner Nancy-Ann DeParle, a health care consultant in Washington and former head of CMs' predecessor agency (the Health Care Financing Administration), asked whether CMS would be looking at these data at a physician level, in terms of who did the prescribing.

“In our pay-for-performance discussions around physicians, [MedPAC indicated that] it would be useful to have this,” she said.

On the issue of collecting data on cost, Ms. DeParle said that she wondered whether CMS would be able to assess whether particular plans were getting a “good deal” on the drugs they purchased. “Will they know by drug?” she asked.

WASHINGTON — Medicare intends to use performance measures to monitor cost, quality, and access issues related to the new prescription drug benefit, a research analyst said during a meeting of the Medicare Payment Advisory Commission.

However, Medicare has not yet “determined what those measures will be and how they will be used,” said MedPAC analyst Cristina Boccuti. MedPAC makes recommendations to Congress on Medicare payment issues.

The Centers for Medicare and Medicaid Services will be collecting a large amount of data on the new drug benefit—or Medicare Part D—including drug utilization and plan benefit information, to construct these performance measures, Ms. Boccuti said. In addition to the agency's need for the data, “congressional agencies will need Part D data to report to the Congress on the impact of the drug benefit on cost, quality, and access,” she added.

MedPAC commissioners recommended that the Health and Human Services department establish a process for the timely delivery of these data to interested parties. Individuals, employers, and government agencies currently use performance measures to evaluate how well health plans and pharmacy benefit managers manage drug benefits, Ms. Boccuti said.

To identify how policy makers could use these measures to monitor the Part D program, MedPAC convened a panel of 11 experts representing health plans, pharmacy benefits managers (PBMs), employers, pharmacies, consumers, quality assurance organizations, and researchers. The panel analyzed measures such as cost control, access and quality assurance, benefit administration and management, and enrollee satisfaction.

Based on the panel's findings, CMS plans to collect data on the following:

▸ Dispensing fees, generic dispensing rates, aggregate rebates, drug claims, and drug spending by plans and beneficiaries.

▸ Pharmacy networks, formularies (including prior authorization and exceptions), appeals rates, and drug utilization.

▸ Claims processing, including plans' out-of-pocket calculations.

▸ Beneficiary satisfaction, grievances, call center operations, and disenrollment rates.

Measures to track beneficiary satisfaction—such as member satisfaction surveys and performance of customer service call centers—are common types of performance guarantees that health plans and PBMs offer to their clients, Ms. Boccuti said.

CMS plans on conducting its own consumer satisfaction surveys to provide comparative plan information to beneficiaries when they're making enrollment decisions, she said. In addition, plans will submit data on grievances filed, and call center performance measures, such as abandonment rates and hold times.

MedPAC commissioner Nancy-Ann DeParle, a health care consultant in Washington and former head of CMs' predecessor agency (the Health Care Financing Administration), asked whether CMS would be looking at these data at a physician level, in terms of who did the prescribing.

“In our pay-for-performance discussions around physicians, [MedPAC indicated that] it would be useful to have this,” she said.

On the issue of collecting data on cost, Ms. DeParle said that she wondered whether CMS would be able to assess whether particular plans were getting a “good deal” on the drugs they purchased. “Will they know by drug?” she asked.

WASHINGTON — Medicare intends to use performance measures to monitor cost, quality, and access issues related to the new prescription drug benefit, a research analyst said during a meeting of the Medicare Payment Advisory Commission.

However, Medicare has not yet “determined what those measures will be and how they will be used,” said MedPAC analyst Cristina Boccuti. MedPAC makes recommendations to Congress on Medicare payment issues.

The Centers for Medicare and Medicaid Services will be collecting a large amount of data on the new drug benefit—or Medicare Part D—including drug utilization and plan benefit information, to construct these performance measures, Ms. Boccuti said. In addition to the agency's need for the data, “congressional agencies will need Part D data to report to the Congress on the impact of the drug benefit on cost, quality, and access,” she added.

MedPAC commissioners recommended that the Health and Human Services department establish a process for the timely delivery of these data to interested parties. Individuals, employers, and government agencies currently use performance measures to evaluate how well health plans and pharmacy benefit managers manage drug benefits, Ms. Boccuti said.

To identify how policy makers could use these measures to monitor the Part D program, MedPAC convened a panel of 11 experts representing health plans, pharmacy benefits managers (PBMs), employers, pharmacies, consumers, quality assurance organizations, and researchers. The panel analyzed measures such as cost control, access and quality assurance, benefit administration and management, and enrollee satisfaction.

Based on the panel's findings, CMS plans to collect data on the following:

▸ Dispensing fees, generic dispensing rates, aggregate rebates, drug claims, and drug spending by plans and beneficiaries.

▸ Pharmacy networks, formularies (including prior authorization and exceptions), appeals rates, and drug utilization.

▸ Claims processing, including plans' out-of-pocket calculations.

▸ Beneficiary satisfaction, grievances, call center operations, and disenrollment rates.

Measures to track beneficiary satisfaction—such as member satisfaction surveys and performance of customer service call centers—are common types of performance guarantees that health plans and PBMs offer to their clients, Ms. Boccuti said.

CMS plans on conducting its own consumer satisfaction surveys to provide comparative plan information to beneficiaries when they're making enrollment decisions, she said. In addition, plans will submit data on grievances filed, and call center performance measures, such as abandonment rates and hold times.

MedPAC commissioner Nancy-Ann DeParle, a health care consultant in Washington and former head of CMs' predecessor agency (the Health Care Financing Administration), asked whether CMS would be looking at these data at a physician level, in terms of who did the prescribing.

“In our pay-for-performance discussions around physicians, [MedPAC indicated that] it would be useful to have this,” she said.

On the issue of collecting data on cost, Ms. DeParle said that she wondered whether CMS would be able to assess whether particular plans were getting a “good deal” on the drugs they purchased. “Will they know by drug?” she asked.