Jennifer Silverman

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 Active 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 medical 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 toward 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 ensure that pregnant women do not wait for hours to be discharged,” she added.

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 [technical 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,” Dr. Yeh added.

“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,” she added.

While the full advisory group ultimately voted to support the subcommittee's recommendation, it does not represent a final action of the panel, David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, clarified 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 Active 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 medical 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 toward 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 ensure that pregnant women do not wait for hours to be discharged,” she added.

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 [technical 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,” Dr. Yeh added.

“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,” she added.

While the full advisory group ultimately voted to support the subcommittee's recommendation, it does not represent a final action of the panel, David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, clarified 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 Active 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 medical 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 toward 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 ensure that pregnant women do not wait for hours to be discharged,” she added.

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 [technical 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,” Dr. Yeh added.

“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,” she added.

While the full advisory group ultimately voted to support the subcommittee's recommendation, it does not represent a final action of the panel, David Siegel, M.D., an emergency and internal medicine physician in Tampa, Fla., and the panel's chairman, clarified 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 — 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.

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.

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.”

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay.

The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — 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.

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.

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.”

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay.

The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

WASHINGTON — 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.

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.

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.”

EMTALA was enacted in 1986 to ensure public access to emergency services regardless of ability to pay.

The Medicare Modernization Act of 2003 required that HHS establish a technical advisory group to review EMTALA regulations. It is required by law to meet at least twice a year.

Guidelines on Organ Donation

The American Medical Association at its annual meeting adopted new resolutions to guide physicians involved in transplanting organs from living donors. The resolutions recommend that living donors be assigned an “advocate” team whose primary concern will be the well-being of the donor. Physician support is also needed to develop and maintain a national database of living donor outcomes, the new language stated. “Over the past 10 years, the number of living organ donors has more than doubled, and these living donors, who give the gift of life, require special protection,” said AMA Trustee Peter Carmel, M.D. The AMA claims these are the first national guidelines to be developed on this issue. In another measure, the House of Delegates voted to encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.

The Cost of Smoking Deaths

Smoking deaths cost the nation $92 billion in lost productivity on an annual basis, from 1997 to 2001, the Centers for Disease Control and Prevention reported. This reflects an increase of about $10 billion from the annual mortality losses for the years 1995 through 1999. During the same period, an estimated 438,000 premature deaths occurred each year as a result of smoking and exposure to secondhand smoke. To reduce the toll, “we must provide the 32 million smokers who say they want to quit with the tools and support to do it successfully,” CDC Director Julie Gerberding, M.D., said in a statement. In an independent action, the AMA's House of Delegates took measures at its annual meeting to discourage tobacco use, voting to support increases in federal, state, and local excise taxes on tobacco. Such increases in the excise taxes should be used to fund the treatment of those with tobacco-related illness and to support counteradvertising efforts, the resolution stated.

Health Insurance Statistics

The ranks of the uninsured appear to be leveling off, according to a survey conducted by the CDC's National Center for Health Statistics. 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. The survey showed continued improvements in coverage for children: 7 million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997.

Uneasy Retirement

Baby boomers are concerned about their financial and health security—and would favor setting aside a portion of their earnings in a special account to save for future medical expenses, a report from the Commonwealth Fund stated. In a nationally representative sample of 2,000 adults aged 50–70, very few thought they would have enough income and savings for retirement, and three of five adults in this age group worry that they will not be able to afford medical care in the future. More than 50% of those working or with a working spouse said they would not have job-based retiree health benefits when they retire. These fears are somewhat warranted: 12 million older adults are currently uninsured or have had histories of unstable coverage. The survey reflected a strong interest among older adults in a Medicare health account that would allow people to add to savings as well as receive the traditional Medicare benefit.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, the results of 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. Only 12% thought cuts to Medicaid should take place. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's vice president and 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.

NIH Extends Disclosure Deadline

Officials at the Department of Health and Human Services are giving employees at the National Institutes of Health more time to report prohibited financial interests and to divest stock investments. In its announcement of the extension, HHS wrote that the department is considering issuing revisions to its current ethics regulations. In February, the agency issued regulations prohibiting NIH employees from engaging in consulting relationships with organizations that are substantially affected by NIH decisions. And NIH employees who are required to file financial disclosure statements are prohibited from acquiring or holding financial interests, such as stocks, in these affected organizations. NIH employees now have until Oct. 3, 2005, to file financial disclosure reports and until Jan. 2, 2006, to divest prohibited financial interests. This is the second extension offered to NIH employees. “There's no doubt in my mind that at the end of the day, the advice that NIH gives has to be completely untainted, completely unimpeachable, and completely trusted,” NIH Director Elias A. Zerhouni, M.D., said during a teleconference sponsored by the Kaiser Family Foundation.

Guidelines on Organ Donation

The American Medical Association at its annual meeting adopted new resolutions to guide physicians involved in transplanting organs from living donors. The resolutions recommend that living donors be assigned an “advocate” team whose primary concern will be the well-being of the donor. Physician support is also needed to develop and maintain a national database of living donor outcomes, the new language stated. “Over the past 10 years, the number of living organ donors has more than doubled, and these living donors, who give the gift of life, require special protection,” said AMA Trustee Peter Carmel, M.D. The AMA claims these are the first national guidelines to be developed on this issue. In another measure, the House of Delegates voted to encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.

The Cost of Smoking Deaths

Smoking deaths cost the nation $92 billion in lost productivity on an annual basis, from 1997 to 2001, the Centers for Disease Control and Prevention reported. This reflects an increase of about $10 billion from the annual mortality losses for the years 1995 through 1999. During the same period, an estimated 438,000 premature deaths occurred each year as a result of smoking and exposure to secondhand smoke. To reduce the toll, “we must provide the 32 million smokers who say they want to quit with the tools and support to do it successfully,” CDC Director Julie Gerberding, M.D., said in a statement. In an independent action, the AMA's House of Delegates took measures at its annual meeting to discourage tobacco use, voting to support increases in federal, state, and local excise taxes on tobacco. Such increases in the excise taxes should be used to fund the treatment of those with tobacco-related illness and to support counteradvertising efforts, the resolution stated.

Health Insurance Statistics

The ranks of the uninsured appear to be leveling off, according to a survey conducted by the CDC's National Center for Health Statistics. 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. The survey showed continued improvements in coverage for children: 7 million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997.

Uneasy Retirement

Baby boomers are concerned about their financial and health security—and would favor setting aside a portion of their earnings in a special account to save for future medical expenses, a report from the Commonwealth Fund stated. In a nationally representative sample of 2,000 adults aged 50–70, very few thought they would have enough income and savings for retirement, and three of five adults in this age group worry that they will not be able to afford medical care in the future. More than 50% of those working or with a working spouse said they would not have job-based retiree health benefits when they retire. These fears are somewhat warranted: 12 million older adults are currently uninsured or have had histories of unstable coverage. The survey reflected a strong interest among older adults in a Medicare health account that would allow people to add to savings as well as receive the traditional Medicare benefit.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, the results of 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. Only 12% thought cuts to Medicaid should take place. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's vice president and 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.

NIH Extends Disclosure Deadline

Officials at the Department of Health and Human Services are giving employees at the National Institutes of Health more time to report prohibited financial interests and to divest stock investments. In its announcement of the extension, HHS wrote that the department is considering issuing revisions to its current ethics regulations. In February, the agency issued regulations prohibiting NIH employees from engaging in consulting relationships with organizations that are substantially affected by NIH decisions. And NIH employees who are required to file financial disclosure statements are prohibited from acquiring or holding financial interests, such as stocks, in these affected organizations. NIH employees now have until Oct. 3, 2005, to file financial disclosure reports and until Jan. 2, 2006, to divest prohibited financial interests. This is the second extension offered to NIH employees. “There's no doubt in my mind that at the end of the day, the advice that NIH gives has to be completely untainted, completely unimpeachable, and completely trusted,” NIH Director Elias A. Zerhouni, M.D., said during a teleconference sponsored by the Kaiser Family Foundation.

Guidelines on Organ Donation

The American Medical Association at its annual meeting adopted new resolutions to guide physicians involved in transplanting organs from living donors. The resolutions recommend that living donors be assigned an “advocate” team whose primary concern will be the well-being of the donor. Physician support is also needed to develop and maintain a national database of living donor outcomes, the new language stated. “Over the past 10 years, the number of living organ donors has more than doubled, and these living donors, who give the gift of life, require special protection,” said AMA Trustee Peter Carmel, M.D. The AMA claims these are the first national guidelines to be developed on this issue. In another measure, the House of Delegates voted to encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.

The Cost of Smoking Deaths

Smoking deaths cost the nation $92 billion in lost productivity on an annual basis, from 1997 to 2001, the Centers for Disease Control and Prevention reported. This reflects an increase of about $10 billion from the annual mortality losses for the years 1995 through 1999. During the same period, an estimated 438,000 premature deaths occurred each year as a result of smoking and exposure to secondhand smoke. To reduce the toll, “we must provide the 32 million smokers who say they want to quit with the tools and support to do it successfully,” CDC Director Julie Gerberding, M.D., said in a statement. In an independent action, the AMA's House of Delegates took measures at its annual meeting to discourage tobacco use, voting to support increases in federal, state, and local excise taxes on tobacco. Such increases in the excise taxes should be used to fund the treatment of those with tobacco-related illness and to support counteradvertising efforts, the resolution stated.

Health Insurance Statistics

The ranks of the uninsured appear to be leveling off, according to a survey conducted by the CDC's National Center for Health Statistics. 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. The survey showed continued improvements in coverage for children: 7 million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997.

Uneasy Retirement

Baby boomers are concerned about their financial and health security—and would favor setting aside a portion of their earnings in a special account to save for future medical expenses, a report from the Commonwealth Fund stated. In a nationally representative sample of 2,000 adults aged 50–70, very few thought they would have enough income and savings for retirement, and three of five adults in this age group worry that they will not be able to afford medical care in the future. More than 50% of those working or with a working spouse said they would not have job-based retiree health benefits when they retire. These fears are somewhat warranted: 12 million older adults are currently uninsured or have had histories of unstable coverage. The survey reflected a strong interest among older adults in a Medicare health account that would allow people to add to savings as well as receive the traditional Medicare benefit.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, the results of 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. Only 12% thought cuts to Medicaid should take place. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's vice president and 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.

NIH Extends Disclosure Deadline

Officials at the Department of Health and Human Services are giving employees at the National Institutes of Health more time to report prohibited financial interests and to divest stock investments. In its announcement of the extension, HHS wrote that the department is considering issuing revisions to its current ethics regulations. In February, the agency issued regulations prohibiting NIH employees from engaging in consulting relationships with organizations that are substantially affected by NIH decisions. And NIH employees who are required to file financial disclosure statements are prohibited from acquiring or holding financial interests, such as stocks, in these affected organizations. NIH employees now have until Oct. 3, 2005, to file financial disclosure reports and until Jan. 2, 2006, to divest prohibited financial interests. This is the second extension offered to NIH employees. “There's no doubt in my mind that at the end of the day, the advice that NIH gives has to be completely untainted, completely unimpeachable, and completely trusted,” NIH Director Elias A. Zerhouni, M.D., said during a teleconference sponsored by the Kaiser Family Foundation.

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 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.

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.

Responding to the highly publicized alleged link between antidepressant use and suicidal tendencies in children and young adults, delegates adopted language to promote the education of physicians about the appropriate use of such medications in these age groups. In addition, the AMA should endorse efforts to train additional qualified clinical investigators in pediatrics, child psychiatry, and therapeutics to carry out studies related to the effects of psychotropic drugs in children, adolescents, and young adults.

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 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.

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.

Responding to the highly publicized alleged link between antidepressant use and suicidal tendencies in children and young adults, delegates adopted language to promote the education of physicians about the appropriate use of such medications in these age groups. In addition, the AMA should endorse efforts to train additional qualified clinical investigators in pediatrics, child psychiatry, and therapeutics to carry out studies related to the effects of psychotropic drugs in children, adolescents, and young adults.

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 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.

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.

Responding to the highly publicized alleged link between antidepressant use and suicidal tendencies in children and young adults, delegates adopted language to promote the education of physicians about the appropriate use of such medications in these age groups. In addition, the AMA should endorse efforts to train additional qualified clinical investigators in pediatrics, child psychiatry, and therapeutics to carry out studies related to the effects of psychotropic drugs in children, adolescents, and young adults.

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.

Such actions would “reduce the cost of permanently replacing the physician payment formula with one that accurately reflects the cost of patient care,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement supporting the proposal.

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. A spokeswoman for the agency said CMS was reviewing Rep. Thomas' recommendations, but declined to comment further.

Leaders on the Senate Finance Committee have since introduced a pay-for-performance bill, although it appears to fall short of some physicians' expectations.

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.

What the Senate bill fails to do is 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.

The American College of Physicians has yet to comment on the Grassley-Baucus bill. “We need to evaluate the final language against our policies and the joint letter we and the other primary care groups sent” to Sen. Frist, Robert B. Doherty, the ACP's senior vice president for governmental affairs and public policy, said in an interview.

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.

Such actions would “reduce the cost of permanently replacing the physician payment formula with one that accurately reflects the cost of patient care,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement supporting the proposal.

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. A spokeswoman for the agency said CMS was reviewing Rep. Thomas' recommendations, but declined to comment further.

Leaders on the Senate Finance Committee have since introduced a pay-for-performance bill, although it appears to fall short of some physicians' expectations.

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.

What the Senate bill fails to do is 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.

The American College of Physicians has yet to comment on the Grassley-Baucus bill. “We need to evaluate the final language against our policies and the joint letter we and the other primary care groups sent” to Sen. Frist, Robert B. Doherty, the ACP's senior vice president for governmental affairs and public policy, said in an interview.

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.

Such actions would “reduce the cost of permanently replacing the physician payment formula with one that accurately reflects the cost of patient care,” J. Edward Hill, M.D., president of the American Medical Association, said in a statement supporting the proposal.

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. A spokeswoman for the agency said CMS was reviewing Rep. Thomas' recommendations, but declined to comment further.

Leaders on the Senate Finance Committee have since introduced a pay-for-performance bill, although it appears to fall short of some physicians' expectations.

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.

What the Senate bill fails to do is 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.

The American College of Physicians has yet to comment on the Grassley-Baucus bill. “We need to evaluate the final language against our policies and the joint letter we and the other primary care groups sent” to Sen. Frist, Robert B. Doherty, the ACP's senior vice president for governmental affairs and public policy, said in an interview.

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.

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 & Medicaid Services.

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 CMS administrator 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 “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 the on-call/Medicare link. “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 hospital 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.”

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

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 & Medicaid Services.

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 CMS administrator 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 “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 the on-call/Medicare link. “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 hospital 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.”

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

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 & Medicaid Services.

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 CMS administrator 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 “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 the on-call/Medicare link. “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 hospital 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.”

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

Guidelines on Organ Donation

The American Medical Association at its annual meeting adopted new resolutions to guide physicians involved in transplanting organs from living donors. The resolutions recommend that living donors be assigned an “advocate” team whose primary concern will be the well-being of the donor. Physician support is also needed to develop and maintain a national database of living donor outcomes, the new language stated. “Over the past 10 years, the number of living organ donors has more than doubled, and these living donors, who give the gift of life, require special protection,” said AMA Trustee Peter Carmel, M.D. The AMA claims these are the first national guidelines to be developed on this issue. In another measure, the House of Delegates voted to encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.

The Cost of Smoking Deaths

Smoking deaths cost the nation $92 billion in lost productivity on an annual basis, from 1997 to 2001, the Centers for Disease Control and Prevention reported. This reflects an increase of about $10 billion from the annual mortality losses for the years 1995 through 1999. During the same period, an estimated 438,000 premature deaths occurred each year as a result of smoking and exposure to secondhand smoke. To reduce the toll, “we must provide the 32 million smokers who say they want to quit with the tools and support to do it successfully,” CDC Director Julie Gerberding, M.D., said in a statement. In an independent action, the AMA's House of Delegates took measures at its annual meeting to discourage tobacco use, voting to support increases in federal, state, and local excise taxes on tobacco. Such increases in the excise taxes should be used to fund the treatment of those with tobacco-related illness and to support counteradvertising efforts, the resolution stated.

Health Insurance Statistics

The ranks of the uninsured appear to be leveling off, according to a survey conducted by the CDC's National Center for Health Statistics. 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. 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. The survey showed continued improvements in coverage for children: 7 million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997.

Uneasy Retirement

Baby boomers are concerned about their financial and health security—and would favor setting aside a portion of their earnings in a special account to save for future medical expenses, a report from the Commonwealth Fund stated. In a nationally representative sample of 2,000 adults aged 50–70, very few thought they would have enough income and savings for retirement, and three of five adults in this age group worry that they will not be able to afford medical care in the future. More than 50% of those working or with a working spouse said they would not have job-based retiree health benefits when they retire. These fears are somewhat warranted: 12 million older adults are currently uninsured or have had histories of unstable coverage. The survey reflected a strong interest among older adults in a Medicare health account that would allow people to add to savings as well as receive the traditional Medicare benefit.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, the results of 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. Only 12% thought cuts to Medicaid should take place. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's vice president and 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.

NIH Extends Disclosure Deadline

Officials at the Department of Health and Human Services are giving employees at the National Institutes of Health more time to report prohibited financial interests and to divest stock investments. In its announcement of the extension, HHS wrote that the department is considering issuing revisions to its current ethics regulations. In February, the agency issued regulations prohibiting NIH employees from engaging in consulting relationships with organizations that are substantially affected by NIH decisions. And NIH employees who are required to file financial disclosure statements are prohibited from acquiring or holding financial interests, such as stocks, in these affected organizations. NIH employees now have until Oct. 3, 2005, to file financial disclosure reports and until Jan. 2, 2006, to divest prohibited financial interests. This is the second extension offered to NIH employees. “There's no doubt in my mind that at the end of the day, the advice that NIH gives has to be completely untainted, completely unimpeachable, and completely trusted,” NIH Director Elias A. Zerhouni, M.D., said during a teleconference sponsored by the Kaiser Family Foundation.

Guidelines on Organ Donation

The American Medical Association at its annual meeting adopted new resolutions to guide physicians involved in transplanting organs from living donors. The resolutions recommend that living donors be assigned an “advocate” team whose primary concern will be the well-being of the donor. Physician support is also needed to develop and maintain a national database of living donor outcomes, the new language stated. “Over the past 10 years, the number of living organ donors has more than doubled, and these living donors, who give the gift of life, require special protection,” said AMA Trustee Peter Carmel, M.D. The AMA claims these are the first national guidelines to be developed on this issue. In another measure, the House of Delegates voted to encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.

The Cost of Smoking Deaths

Smoking deaths cost the nation $92 billion in lost productivity on an annual basis, from 1997 to 2001, the Centers for Disease Control and Prevention reported. This reflects an increase of about $10 billion from the annual mortality losses for the years 1995 through 1999. During the same period, an estimated 438,000 premature deaths occurred each year as a result of smoking and exposure to secondhand smoke. To reduce the toll, “we must provide the 32 million smokers who say they want to quit with the tools and support to do it successfully,” CDC Director Julie Gerberding, M.D., said in a statement. In an independent action, the AMA's House of Delegates took measures at its annual meeting to discourage tobacco use, voting to support increases in federal, state, and local excise taxes on tobacco. Such increases in the excise taxes should be used to fund the treatment of those with tobacco-related illness and to support counteradvertising efforts, the resolution stated.

Health Insurance Statistics

The ranks of the uninsured appear to be leveling off, according to a survey conducted by the CDC's National Center for Health Statistics. 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. 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. The survey showed continued improvements in coverage for children: 7 million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997.

Uneasy Retirement

Baby boomers are concerned about their financial and health security—and would favor setting aside a portion of their earnings in a special account to save for future medical expenses, a report from the Commonwealth Fund stated. In a nationally representative sample of 2,000 adults aged 50–70, very few thought they would have enough income and savings for retirement, and three of five adults in this age group worry that they will not be able to afford medical care in the future. More than 50% of those working or with a working spouse said they would not have job-based retiree health benefits when they retire. These fears are somewhat warranted: 12 million older adults are currently uninsured or have had histories of unstable coverage. The survey reflected a strong interest among older adults in a Medicare health account that would allow people to add to savings as well as receive the traditional Medicare benefit.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, the results of 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. Only 12% thought cuts to Medicaid should take place. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's vice president and 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.

NIH Extends Disclosure Deadline

Officials at the Department of Health and Human Services are giving employees at the National Institutes of Health more time to report prohibited financial interests and to divest stock investments. In its announcement of the extension, HHS wrote that the department is considering issuing revisions to its current ethics regulations. In February, the agency issued regulations prohibiting NIH employees from engaging in consulting relationships with organizations that are substantially affected by NIH decisions. And NIH employees who are required to file financial disclosure statements are prohibited from acquiring or holding financial interests, such as stocks, in these affected organizations. NIH employees now have until Oct. 3, 2005, to file financial disclosure reports and until Jan. 2, 2006, to divest prohibited financial interests. This is the second extension offered to NIH employees. “There's no doubt in my mind that at the end of the day, the advice that NIH gives has to be completely untainted, completely unimpeachable, and completely trusted,” NIH Director Elias A. Zerhouni, M.D., said during a teleconference sponsored by the Kaiser Family Foundation.

Guidelines on Organ Donation

The American Medical Association at its annual meeting adopted new resolutions to guide physicians involved in transplanting organs from living donors. The resolutions recommend that living donors be assigned an “advocate” team whose primary concern will be the well-being of the donor. Physician support is also needed to develop and maintain a national database of living donor outcomes, the new language stated. “Over the past 10 years, the number of living organ donors has more than doubled, and these living donors, who give the gift of life, require special protection,” said AMA Trustee Peter Carmel, M.D. The AMA claims these are the first national guidelines to be developed on this issue. In another measure, the House of Delegates voted to encourage and support pilot studies that investigate the effectiveness of presumed consent and mandated choice for organ donation.

The Cost of Smoking Deaths

Smoking deaths cost the nation $92 billion in lost productivity on an annual basis, from 1997 to 2001, the Centers for Disease Control and Prevention reported. This reflects an increase of about $10 billion from the annual mortality losses for the years 1995 through 1999. During the same period, an estimated 438,000 premature deaths occurred each year as a result of smoking and exposure to secondhand smoke. To reduce the toll, “we must provide the 32 million smokers who say they want to quit with the tools and support to do it successfully,” CDC Director Julie Gerberding, M.D., said in a statement. In an independent action, the AMA's House of Delegates took measures at its annual meeting to discourage tobacco use, voting to support increases in federal, state, and local excise taxes on tobacco. Such increases in the excise taxes should be used to fund the treatment of those with tobacco-related illness and to support counteradvertising efforts, the resolution stated.

Health Insurance Statistics

The ranks of the uninsured appear to be leveling off, according to a survey conducted by the CDC's National Center for Health Statistics. 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. 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. The survey showed continued improvements in coverage for children: 7 million children under 18 years of age were without health insurance in 2004, compared with 10 million children in 1997.

Uneasy Retirement

Baby boomers are concerned about their financial and health security—and would favor setting aside a portion of their earnings in a special account to save for future medical expenses, a report from the Commonwealth Fund stated. In a nationally representative sample of 2,000 adults aged 50–70, very few thought they would have enough income and savings for retirement, and three of five adults in this age group worry that they will not be able to afford medical care in the future. More than 50% of those working or with a working spouse said they would not have job-based retiree health benefits when they retire. These fears are somewhat warranted: 12 million older adults are currently uninsured or have had histories of unstable coverage. The survey reflected a strong interest among older adults in a Medicare health account that would allow people to add to savings as well as receive the traditional Medicare benefit.

Medicaid's Public Support

Most people think Medicaid is a “very important program” and should not be cut to balance state budgets, the results of 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. Only 12% thought cuts to Medicaid should take place. “We expected Medicaid to be relatively unpopular with the public, much like welfare was,” said Mollyann Brodie, Ph.D., Kaiser's vice president and 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.

NIH Extends Disclosure Deadline

Officials at the Department of Health and Human Services are giving employees at the National Institutes of Health more time to report prohibited financial interests and to divest stock investments. In its announcement of the extension, HHS wrote that the department is considering issuing revisions to its current ethics regulations. In February, the agency issued regulations prohibiting NIH employees from engaging in consulting relationships with organizations that are substantially affected by NIH decisions. And NIH employees who are required to file financial disclosure statements are prohibited from acquiring or holding financial interests, such as stocks, in these affected organizations. NIH employees now have until Oct. 3, 2005, to file financial disclosure reports and until Jan. 2, 2006, to divest prohibited financial interests. This is the second extension offered to NIH employees. “There's no doubt in my mind that at the end of the day, the advice that NIH gives has to be completely untainted, completely unimpeachable, and completely trusted,” NIH Director Elias A. Zerhouni, M.D., said during a teleconference sponsored by the Kaiser Family Foundation.

DALLAS — Of the existing "concierge-care" models, practices that offer fees for non-covered services to patients who have insurance carry the highest legal risk, attorney John Marquis said at a national conference on concierge medicine.

In light of recent actions taken by Congress, state insurance commissioners, and federal agencies, it's clear that authorities are looking out for potential conflicts of interest with this particular care model, said Mr. Marquis, a partner with Warner, Norcross, & Judd, LLP, a Michigan law firm that specializes in concierge-care issues.

There are several models for concierge-care practices. Some opt out of Medicare and private insurance to offer a periodic fee for medical care. Others accept only cash for their services. What seems to attract most of the legal action is the "fee for non-covered services" or FNCS model. These practices accept patients with private insurance or Medicare but also charge a flat fee monthly, quarterly, or annually, he said at the conference, sponsored by the Society for Innovative Medical Practice Design.

In return, patients are promised a smaller patient base, greater access to the physician, and other amenities. For some time, this approach has aroused speculation on whether the physician might be double billing for Medicare patients.

Exactly what the periodic fee pays for is the gray area that incites legal action, Mr. Marquis said. The fact that certain FNCS practices offer preventive care is not a complete answer to the legal issues, given that Medicare covers certain preventive-care services, he said. Home visits are another problem; in many cases, they're also a covered service under Medicare.

Although Medicare is usually the 800-pound gorilla, it's private insurers that pose the biggest risks to these practices.

They can tell a practice, "We don't like what you're doing—boom, you're out," Mr. Marquis said. "I have had clients who've essentially decided to not [become an FNCS-style practice] out of fear of being terminated as a result of notifying the insurance companies of what was going on."

The rub is that insurance companies don't need any cause to terminate a plan, he said. "And there's really no clear legal recourse."

Health departments and insurance commissioners pose another credible risk to FNCS practices. In 2003, New Jersey's health department found that physicians who already had contracts with HMOs were requiring HMO patients to pay an annual fee to get into their practices.

The conflict was that many services these FNCS providers were offering were already required to be included in any health insurance plan offered in the state. "The department's main objection was not duplication of service but that these practices were making patients pay" for covered medical care.

In an edict that had the force of law, New Jersey asserted that this requirement was illegal, even though the fee in these practices was limited to services clearly not covered by the health plan. "They're stating, 'We don't care if the service is covered by the health plan or not. It's illegal if you charge that "poll tax" for a patient to get into the practice,'" Mr. Marquis said.

The New York Department of Health raised similar objections, except the state found FNCS-type practices to be illegal on more than one account.

Typically, insurance contracts in the state of New York require that physicians provide 24-hour case management and coordination of necessary referrals. Furthermore, the state has determined that expedited appointments discriminate against patients who don't have the money to pay the fee, he said.

Legislative efforts at the state and federal level to thwart FNCS practices have caused some commotion but so far haven't amounted to much, Mr. Marquis said.

Several years ago, Rep. Henry Waxman (D-Calif.) targeted an FNCS practice, MDVIP, in a letter to Tommy Thompson, then secretary of the Department of Health and Human Services.

"There could be a substantial overlap between services that were covered by Medicare and for which MDVIP was asking patients to pay," Rep. Waxman wrote. Moreover, MDVIP physicians were providing Medicare services to patients but charging them a "poll tax"— "a conditional payment that says, 'Either pay me $1,500, or I will not render Medicare services to you.'"

Secretary Thompson disposed of the conditional fee argument in a one-page statement. "Under current law, physicians have some discretion regarding the patients they choose to accept. While the limiting charge provisions govern physicians' charges for Medicare-covered services, these provisions do not directly affect charges for non-covered services," according to the statement.

Insofar as the retainer fee under such an agreement is truly for noncovered services, such fees would not appear to be in violation of Medicare law, Mr. Thompson continued.

An alert issued by HHs' Office of Inspector General in 2002 reminded physicians that they could "have a problem" if they proposed services to patients in exchange for a flat fee that would otherwise be covered by Medicare. The OIG's chief counsel later clarified that the alert did not specifically take a position on concierge medicine but only addressed fees for covered services and was consistent with the position previously taken by Secretary Thompson.

"At least now we know that the Thompson letter is being enforced—that there are such things as non-covered services, and if we charge for those, that should be okay," Mr. Marquis said.

Several bills have been introduced in Congress that would prohibit physicians from charging a membership fee to a Medicare beneficiary or would forbid physicians from requiring a Medicare beneficiary to purchase a non-covered item or service as a prerequisite for receiving a covered item or service. These bills "never got out of committee," Mr. Marquis said.

A bill in Massachusetts a few years back stated that any preferred-provider arrangement would have to contain a provision barring physicians from charging an access fee to a covered person. Although it didnot go anywhere, such legislation would deal a "devastating blow" to FNCS practices if it were ever approved, he said.

DALLAS — Of the existing "concierge-care" models, practices that offer fees for non-covered services to patients who have insurance carry the highest legal risk, attorney John Marquis said at a national conference on concierge medicine.

In light of recent actions taken by Congress, state insurance commissioners, and federal agencies, it's clear that authorities are looking out for potential conflicts of interest with this particular care model, said Mr. Marquis, a partner with Warner, Norcross, & Judd, LLP, a Michigan law firm that specializes in concierge-care issues.

There are several models for concierge-care practices. Some opt out of Medicare and private insurance to offer a periodic fee for medical care. Others accept only cash for their services. What seems to attract most of the legal action is the "fee for non-covered services" or FNCS model. These practices accept patients with private insurance or Medicare but also charge a flat fee monthly, quarterly, or annually, he said at the conference, sponsored by the Society for Innovative Medical Practice Design.

In return, patients are promised a smaller patient base, greater access to the physician, and other amenities. For some time, this approach has aroused speculation on whether the physician might be double billing for Medicare patients.

Exactly what the periodic fee pays for is the gray area that incites legal action, Mr. Marquis said. The fact that certain FNCS practices offer preventive care is not a complete answer to the legal issues, given that Medicare covers certain preventive-care services, he said. Home visits are another problem; in many cases, they're also a covered service under Medicare.

Although Medicare is usually the 800-pound gorilla, it's private insurers that pose the biggest risks to these practices.

They can tell a practice, "We don't like what you're doing—boom, you're out," Mr. Marquis said. "I have had clients who've essentially decided to not [become an FNCS-style practice] out of fear of being terminated as a result of notifying the insurance companies of what was going on."

The rub is that insurance companies don't need any cause to terminate a plan, he said. "And there's really no clear legal recourse."

Health departments and insurance commissioners pose another credible risk to FNCS practices. In 2003, New Jersey's health department found that physicians who already had contracts with HMOs were requiring HMO patients to pay an annual fee to get into their practices.

The conflict was that many services these FNCS providers were offering were already required to be included in any health insurance plan offered in the state. "The department's main objection was not duplication of service but that these practices were making patients pay" for covered medical care.

In an edict that had the force of law, New Jersey asserted that this requirement was illegal, even though the fee in these practices was limited to services clearly not covered by the health plan. "They're stating, 'We don't care if the service is covered by the health plan or not. It's illegal if you charge that "poll tax" for a patient to get into the practice,'" Mr. Marquis said.

The New York Department of Health raised similar objections, except the state found FNCS-type practices to be illegal on more than one account.

Typically, insurance contracts in the state of New York require that physicians provide 24-hour case management and coordination of necessary referrals. Furthermore, the state has determined that expedited appointments discriminate against patients who don't have the money to pay the fee, he said.

Legislative efforts at the state and federal level to thwart FNCS practices have caused some commotion but so far haven't amounted to much, Mr. Marquis said.

Several years ago, Rep. Henry Waxman (D-Calif.) targeted an FNCS practice, MDVIP, in a letter to Tommy Thompson, then secretary of the Department of Health and Human Services.

"There could be a substantial overlap between services that were covered by Medicare and for which MDVIP was asking patients to pay," Rep. Waxman wrote. Moreover, MDVIP physicians were providing Medicare services to patients but charging them a "poll tax"— "a conditional payment that says, 'Either pay me $1,500, or I will not render Medicare services to you.'"

Secretary Thompson disposed of the conditional fee argument in a one-page statement. "Under current law, physicians have some discretion regarding the patients they choose to accept. While the limiting charge provisions govern physicians' charges for Medicare-covered services, these provisions do not directly affect charges for non-covered services," according to the statement.

Insofar as the retainer fee under such an agreement is truly for noncovered services, such fees would not appear to be in violation of Medicare law, Mr. Thompson continued.

An alert issued by HHs' Office of Inspector General in 2002 reminded physicians that they could "have a problem" if they proposed services to patients in exchange for a flat fee that would otherwise be covered by Medicare. The OIG's chief counsel later clarified that the alert did not specifically take a position on concierge medicine but only addressed fees for covered services and was consistent with the position previously taken by Secretary Thompson.

"At least now we know that the Thompson letter is being enforced—that there are such things as non-covered services, and if we charge for those, that should be okay," Mr. Marquis said.

Several bills have been introduced in Congress that would prohibit physicians from charging a membership fee to a Medicare beneficiary or would forbid physicians from requiring a Medicare beneficiary to purchase a non-covered item or service as a prerequisite for receiving a covered item or service. These bills "never got out of committee," Mr. Marquis said.

A bill in Massachusetts a few years back stated that any preferred-provider arrangement would have to contain a provision barring physicians from charging an access fee to a covered person. Although it didnot go anywhere, such legislation would deal a "devastating blow" to FNCS practices if it were ever approved, he said.

DALLAS — Of the existing "concierge-care" models, practices that offer fees for non-covered services to patients who have insurance carry the highest legal risk, attorney John Marquis said at a national conference on concierge medicine.

In light of recent actions taken by Congress, state insurance commissioners, and federal agencies, it's clear that authorities are looking out for potential conflicts of interest with this particular care model, said Mr. Marquis, a partner with Warner, Norcross, & Judd, LLP, a Michigan law firm that specializes in concierge-care issues.

There are several models for concierge-care practices. Some opt out of Medicare and private insurance to offer a periodic fee for medical care. Others accept only cash for their services. What seems to attract most of the legal action is the "fee for non-covered services" or FNCS model. These practices accept patients with private insurance or Medicare but also charge a flat fee monthly, quarterly, or annually, he said at the conference, sponsored by the Society for Innovative Medical Practice Design.

In return, patients are promised a smaller patient base, greater access to the physician, and other amenities. For some time, this approach has aroused speculation on whether the physician might be double billing for Medicare patients.

Exactly what the periodic fee pays for is the gray area that incites legal action, Mr. Marquis said. The fact that certain FNCS practices offer preventive care is not a complete answer to the legal issues, given that Medicare covers certain preventive-care services, he said. Home visits are another problem; in many cases, they're also a covered service under Medicare.

Although Medicare is usually the 800-pound gorilla, it's private insurers that pose the biggest risks to these practices.

They can tell a practice, "We don't like what you're doing—boom, you're out," Mr. Marquis said. "I have had clients who've essentially decided to not [become an FNCS-style practice] out of fear of being terminated as a result of notifying the insurance companies of what was going on."

The rub is that insurance companies don't need any cause to terminate a plan, he said. "And there's really no clear legal recourse."

Health departments and insurance commissioners pose another credible risk to FNCS practices. In 2003, New Jersey's health department found that physicians who already had contracts with HMOs were requiring HMO patients to pay an annual fee to get into their practices.

The conflict was that many services these FNCS providers were offering were already required to be included in any health insurance plan offered in the state. "The department's main objection was not duplication of service but that these practices were making patients pay" for covered medical care.

In an edict that had the force of law, New Jersey asserted that this requirement was illegal, even though the fee in these practices was limited to services clearly not covered by the health plan. "They're stating, 'We don't care if the service is covered by the health plan or not. It's illegal if you charge that "poll tax" for a patient to get into the practice,'" Mr. Marquis said.

The New York Department of Health raised similar objections, except the state found FNCS-type practices to be illegal on more than one account.

Typically, insurance contracts in the state of New York require that physicians provide 24-hour case management and coordination of necessary referrals. Furthermore, the state has determined that expedited appointments discriminate against patients who don't have the money to pay the fee, he said.

Legislative efforts at the state and federal level to thwart FNCS practices have caused some commotion but so far haven't amounted to much, Mr. Marquis said.

Several years ago, Rep. Henry Waxman (D-Calif.) targeted an FNCS practice, MDVIP, in a letter to Tommy Thompson, then secretary of the Department of Health and Human Services.

"There could be a substantial overlap between services that were covered by Medicare and for which MDVIP was asking patients to pay," Rep. Waxman wrote. Moreover, MDVIP physicians were providing Medicare services to patients but charging them a "poll tax"— "a conditional payment that says, 'Either pay me $1,500, or I will not render Medicare services to you.'"

Secretary Thompson disposed of the conditional fee argument in a one-page statement. "Under current law, physicians have some discretion regarding the patients they choose to accept. While the limiting charge provisions govern physicians' charges for Medicare-covered services, these provisions do not directly affect charges for non-covered services," according to the statement.

Insofar as the retainer fee under such an agreement is truly for noncovered services, such fees would not appear to be in violation of Medicare law, Mr. Thompson continued.

An alert issued by HHs' Office of Inspector General in 2002 reminded physicians that they could "have a problem" if they proposed services to patients in exchange for a flat fee that would otherwise be covered by Medicare. The OIG's chief counsel later clarified that the alert did not specifically take a position on concierge medicine but only addressed fees for covered services and was consistent with the position previously taken by Secretary Thompson.

"At least now we know that the Thompson letter is being enforced—that there are such things as non-covered services, and if we charge for those, that should be okay," Mr. Marquis said.

Several bills have been introduced in Congress that would prohibit physicians from charging a membership fee to a Medicare beneficiary or would forbid physicians from requiring a Medicare beneficiary to purchase a non-covered item or service as a prerequisite for receiving a covered item or service. These bills "never got out of committee," Mr. Marquis said.

A bill in Massachusetts a few years back stated that any preferred-provider arrangement would have to contain a provision barring physicians from charging an access fee to a covered person. Although it didnot go anywhere, such legislation would deal a "devastating blow" to FNCS practices if it were ever approved, he 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 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.

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.

Responding to the highly publicized alleged link between antidepressant use and suicidal tendencies in children and young adults, delegates adopted language to promote the education of physicians about the appropriate use of such medications in these age groups. In addition, the AMA should endorse efforts to train additional qualified clinical investigators in pediatrics, child psychiatry, and therapeutics to carry out studies related to the effects of psychotropic drugs in children, adolescents, and young adults.

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 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.

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.

Responding to the highly publicized alleged link between antidepressant use and suicidal tendencies in children and young adults, delegates adopted language to promote the education of physicians about the appropriate use of such medications in these age groups. In addition, the AMA should endorse efforts to train additional qualified clinical investigators in pediatrics, child psychiatry, and therapeutics to carry out studies related to the effects of psychotropic drugs in children, adolescents, and young adults.

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 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.

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.

Responding to the highly publicized alleged link between antidepressant use and suicidal tendencies in children and young adults, delegates adopted language to promote the education of physicians about the appropriate use of such medications in these age groups. In addition, the AMA should endorse efforts to train additional qualified clinical investigators in pediatrics, child psychiatry, and therapeutics to carry out studies related to the effects of psychotropic drugs in children, adolescents, and young adults.

DALLAS — Of the existing “concierge” care models, practices that offer fees for noncovered services to patients who have insurance carry the highest legal risk, attorney John Marquis said at a national conference on concierge medicine.

In light of recent actions taken by Congress, state insurance commissioners, and federal agencies, it's clear that authorities are looking out for potential conflicts of interest with this particular care model, said Mr. Marquis, a partner with Warner, Norcross, & Judd, LLP, a Michigan law firm that specializes in concierge-care issues.

There are several models for concierge-care practices. Some opt out of Medicare and private insurance to offer a periodic fee for medical care. Others accept only cash for their services. What seems to attract most of the legal action is the “fee for noncovered services” or FNCS model. These practices accept patients with private insurance or Medicare but also charge a flat fee monthly, quarterly, or annually, he said at the conference, sponsored by the Society for Innovative Medical Practice Design.

In return, patients are promised a smaller patient base, greater access to the physician, and other amenities. For some time, this approach has aroused speculation on whether the physician might be double billing for Medicare patients.

Exactly what the periodic fee pays for is the gray area that incites legal action, Mr. Marquis said. The fact that certain FNCS practices offer preventive care is not a complete answer to the legal issues, given that Medicare covers certain preventive-care services, he said. Home visits are another problem; in many cases, they're also a covered service under Medicare.

Although Medicare is usually the 800-pound gorilla in these situations, it's private insurers that currently pose the biggest risks to these practices.

They can tell a practice, “We don't like what you're doing—boom, you're out,” Mr. Marquis said. For an FNCS-style practice counting on insurance reimbursement, “this could be devastating. I have had clients who've essentially decided to not [become a FNCS-style practice] out of fear of being terminated as a result of notifying the insurance companies of what was going on.”

The rub is that insurance companies don't need any cause to terminate a plan, he said. “It's a policy business decision that they apparently make, and there's really no clear legal recourse.”

Health departments and insurance commissioners pose another credible risk to FNCS practices. In 2003, New Jersey's health department found that physicians who already had contracts with HMOs were requiring HMO patients to pay an annual fee to get into their practices.

The conflict was that many services these FNCS providers were offering were already required to be included in any health insurance plan offered in the state. “The department's main objection was not duplication of service but that these practices were making patients pay” for covered medical care.

In an edict that had the force of law, New Jersey asserted that this requirement was illegal, even though the fee in these practices was limited to services clearly not covered by the health plan. “They're stating, 'We don't care if the service is covered by the health plan or not. It's illegal if you charge that “poll tax” for a patient to get into the practice,'” Mr. Marquis said.

The New York Department of Health raised similar objections, except the state found FNCS-type practices to be illegal on more than one account.

Typically, insurance contracts in the state of New York require that physicians provide 24-hour case management and coordination of necessary referrals. Furthermore, the state has determined that expedited appointments discriminate against patients who don't have the money to pay the fee, he said.

Legislative efforts at the state and federal level to thwart FNCS practices have caused some commotion but so far haven't amounted to much, Mr. Marquis said.

Several years ago, Rep. Henry Waxman (D-Calif.) targeted an FNCS practice, MDVIP, in a letter to Tommy Thompson, then secretary of the Department of Health and Human Services.

“There could be a substantial overlap between services that were covered by Medicare and for which MDVIP was asking patients to pay,” Rep. Waxman wrote. Moreover, MDVIP physicians were providing Medicare services to patients but charging them a “poll tax”—“a conditional payment that says, 'Either pay me $1,500, or I will not render Medicare services to you.'”

Secretary Thompson disposed of the conditional fee argument in a one-page statement. “Under current law, physicians have some discretion regarding the patients they choose to accept. While the limiting charge provisions govern physicians' charges for Medicare-covered services, these provisions do not directly affect charges for noncovered services,” according to the statement.

Insofar as the retainer fee under such an agreement is truly for noncovered services, such fees would not appear to be in violation of Medicare law, Mr. Thompson continued.

An alert issued by HHS' Office of Inspector General in 2002 reminded physicians that they could “have a problem” if they proposed services to patients in exchange for a flat fee that would otherwise be covered by Medicare. The OIG's chief counsel later clarified that the alert did not specifically take a position on concierge medicine but only addressed fees for covered services and was consistent with the position previously taken by Secretary Thompson.

“At least now we know that the Thompson letter is being enforced—that there are such things as noncovered services, and if we charge for those, that should be okay,” Mr. Marquis said.

Several bills have been introduced in Congress that would prohibit physicians from charging a membership fee to a Medicare beneficiary or would forbid physicians from requiring a Medicare beneficiary to purchase a noncovered item or service as a prerequisite for receiving a covered item or service. These bills “never got out of committee,” Mr. Marquis said.

DALLAS — Of the existing “concierge” care models, practices that offer fees for noncovered services to patients who have insurance carry the highest legal risk, attorney John Marquis said at a national conference on concierge medicine.

In light of recent actions taken by Congress, state insurance commissioners, and federal agencies, it's clear that authorities are looking out for potential conflicts of interest with this particular care model, said Mr. Marquis, a partner with Warner, Norcross, & Judd, LLP, a Michigan law firm that specializes in concierge-care issues.

There are several models for concierge-care practices. Some opt out of Medicare and private insurance to offer a periodic fee for medical care. Others accept only cash for their services. What seems to attract most of the legal action is the “fee for noncovered services” or FNCS model. These practices accept patients with private insurance or Medicare but also charge a flat fee monthly, quarterly, or annually, he said at the conference, sponsored by the Society for Innovative Medical Practice Design.

In return, patients are promised a smaller patient base, greater access to the physician, and other amenities. For some time, this approach has aroused speculation on whether the physician might be double billing for Medicare patients.

Exactly what the periodic fee pays for is the gray area that incites legal action, Mr. Marquis said. The fact that certain FNCS practices offer preventive care is not a complete answer to the legal issues, given that Medicare covers certain preventive-care services, he said. Home visits are another problem; in many cases, they're also a covered service under Medicare.

Although Medicare is usually the 800-pound gorilla in these situations, it's private insurers that currently pose the biggest risks to these practices.

They can tell a practice, “We don't like what you're doing—boom, you're out,” Mr. Marquis said. For an FNCS-style practice counting on insurance reimbursement, “this could be devastating. I have had clients who've essentially decided to not [become a FNCS-style practice] out of fear of being terminated as a result of notifying the insurance companies of what was going on.”

The rub is that insurance companies don't need any cause to terminate a plan, he said. “It's a policy business decision that they apparently make, and there's really no clear legal recourse.”

Health departments and insurance commissioners pose another credible risk to FNCS practices. In 2003, New Jersey's health department found that physicians who already had contracts with HMOs were requiring HMO patients to pay an annual fee to get into their practices.

The conflict was that many services these FNCS providers were offering were already required to be included in any health insurance plan offered in the state. “The department's main objection was not duplication of service but that these practices were making patients pay” for covered medical care.

In an edict that had the force of law, New Jersey asserted that this requirement was illegal, even though the fee in these practices was limited to services clearly not covered by the health plan. “They're stating, 'We don't care if the service is covered by the health plan or not. It's illegal if you charge that “poll tax” for a patient to get into the practice,'” Mr. Marquis said.

The New York Department of Health raised similar objections, except the state found FNCS-type practices to be illegal on more than one account.

Typically, insurance contracts in the state of New York require that physicians provide 24-hour case management and coordination of necessary referrals. Furthermore, the state has determined that expedited appointments discriminate against patients who don't have the money to pay the fee, he said.

Legislative efforts at the state and federal level to thwart FNCS practices have caused some commotion but so far haven't amounted to much, Mr. Marquis said.

Several years ago, Rep. Henry Waxman (D-Calif.) targeted an FNCS practice, MDVIP, in a letter to Tommy Thompson, then secretary of the Department of Health and Human Services.

“There could be a substantial overlap between services that were covered by Medicare and for which MDVIP was asking patients to pay,” Rep. Waxman wrote. Moreover, MDVIP physicians were providing Medicare services to patients but charging them a “poll tax”—“a conditional payment that says, 'Either pay me $1,500, or I will not render Medicare services to you.'”

Secretary Thompson disposed of the conditional fee argument in a one-page statement. “Under current law, physicians have some discretion regarding the patients they choose to accept. While the limiting charge provisions govern physicians' charges for Medicare-covered services, these provisions do not directly affect charges for noncovered services,” according to the statement.

Insofar as the retainer fee under such an agreement is truly for noncovered services, such fees would not appear to be in violation of Medicare law, Mr. Thompson continued.

An alert issued by HHS' Office of Inspector General in 2002 reminded physicians that they could “have a problem” if they proposed services to patients in exchange for a flat fee that would otherwise be covered by Medicare. The OIG's chief counsel later clarified that the alert did not specifically take a position on concierge medicine but only addressed fees for covered services and was consistent with the position previously taken by Secretary Thompson.

“At least now we know that the Thompson letter is being enforced—that there are such things as noncovered services, and if we charge for those, that should be okay,” Mr. Marquis said.

Several bills have been introduced in Congress that would prohibit physicians from charging a membership fee to a Medicare beneficiary or would forbid physicians from requiring a Medicare beneficiary to purchase a noncovered item or service as a prerequisite for receiving a covered item or service. These bills “never got out of committee,” Mr. Marquis said.

DALLAS — Of the existing “concierge” care models, practices that offer fees for noncovered services to patients who have insurance carry the highest legal risk, attorney John Marquis said at a national conference on concierge medicine.

In light of recent actions taken by Congress, state insurance commissioners, and federal agencies, it's clear that authorities are looking out for potential conflicts of interest with this particular care model, said Mr. Marquis, a partner with Warner, Norcross, & Judd, LLP, a Michigan law firm that specializes in concierge-care issues.

There are several models for concierge-care practices. Some opt out of Medicare and private insurance to offer a periodic fee for medical care. Others accept only cash for their services. What seems to attract most of the legal action is the “fee for noncovered services” or FNCS model. These practices accept patients with private insurance or Medicare but also charge a flat fee monthly, quarterly, or annually, he said at the conference, sponsored by the Society for Innovative Medical Practice Design.

In return, patients are promised a smaller patient base, greater access to the physician, and other amenities. For some time, this approach has aroused speculation on whether the physician might be double billing for Medicare patients.

Exactly what the periodic fee pays for is the gray area that incites legal action, Mr. Marquis said. The fact that certain FNCS practices offer preventive care is not a complete answer to the legal issues, given that Medicare covers certain preventive-care services, he said. Home visits are another problem; in many cases, they're also a covered service under Medicare.

Although Medicare is usually the 800-pound gorilla in these situations, it's private insurers that currently pose the biggest risks to these practices.

They can tell a practice, “We don't like what you're doing—boom, you're out,” Mr. Marquis said. For an FNCS-style practice counting on insurance reimbursement, “this could be devastating. I have had clients who've essentially decided to not [become a FNCS-style practice] out of fear of being terminated as a result of notifying the insurance companies of what was going on.”

The rub is that insurance companies don't need any cause to terminate a plan, he said. “It's a policy business decision that they apparently make, and there's really no clear legal recourse.”

Health departments and insurance commissioners pose another credible risk to FNCS practices. In 2003, New Jersey's health department found that physicians who already had contracts with HMOs were requiring HMO patients to pay an annual fee to get into their practices.

The conflict was that many services these FNCS providers were offering were already required to be included in any health insurance plan offered in the state. “The department's main objection was not duplication of service but that these practices were making patients pay” for covered medical care.

In an edict that had the force of law, New Jersey asserted that this requirement was illegal, even though the fee in these practices was limited to services clearly not covered by the health plan. “They're stating, 'We don't care if the service is covered by the health plan or not. It's illegal if you charge that “poll tax” for a patient to get into the practice,'” Mr. Marquis said.

The New York Department of Health raised similar objections, except the state found FNCS-type practices to be illegal on more than one account.

Typically, insurance contracts in the state of New York require that physicians provide 24-hour case management and coordination of necessary referrals. Furthermore, the state has determined that expedited appointments discriminate against patients who don't have the money to pay the fee, he said.

Legislative efforts at the state and federal level to thwart FNCS practices have caused some commotion but so far haven't amounted to much, Mr. Marquis said.

Several years ago, Rep. Henry Waxman (D-Calif.) targeted an FNCS practice, MDVIP, in a letter to Tommy Thompson, then secretary of the Department of Health and Human Services.

“There could be a substantial overlap between services that were covered by Medicare and for which MDVIP was asking patients to pay,” Rep. Waxman wrote. Moreover, MDVIP physicians were providing Medicare services to patients but charging them a “poll tax”—“a conditional payment that says, 'Either pay me $1,500, or I will not render Medicare services to you.'”

Secretary Thompson disposed of the conditional fee argument in a one-page statement. “Under current law, physicians have some discretion regarding the patients they choose to accept. While the limiting charge provisions govern physicians' charges for Medicare-covered services, these provisions do not directly affect charges for noncovered services,” according to the statement.

Insofar as the retainer fee under such an agreement is truly for noncovered services, such fees would not appear to be in violation of Medicare law, Mr. Thompson continued.

An alert issued by HHS' Office of Inspector General in 2002 reminded physicians that they could “have a problem” if they proposed services to patients in exchange for a flat fee that would otherwise be covered by Medicare. The OIG's chief counsel later clarified that the alert did not specifically take a position on concierge medicine but only addressed fees for covered services and was consistent with the position previously taken by Secretary Thompson.

“At least now we know that the Thompson letter is being enforced—that there are such things as noncovered services, and if we charge for those, that should be okay,” Mr. Marquis said.

Several bills have been introduced in Congress that would prohibit physicians from charging a membership fee to a Medicare beneficiary or would forbid physicians from requiring a Medicare beneficiary to purchase a noncovered item or service as a prerequisite for receiving a covered item or service. These bills “never got out of committee,” Mr. Marquis said.