Jennifer Silverman

WASHINGTON — Patients may find it easier to appeal denials of payment for medications under Medicare's new Part D prescription drug benefit than they do under other health programs, an analyst said during a meeting of the Medicare Payment Advisory Commission.

Specifically, the new benefit offers quicker alternatives to getting formulary exceptions for nonpreferred drugs than private plans or Medicaid, Joan Sokolovsky, Ph.D., a MedPAC senior analyst indicated. The new prescription drug benefit, a part of the Medicare Modernization Act of 2003, goes into effect in January.

MedPAC analysts reviewed the appeals processes in several private plans and in Medicaid to see how they compare with the upcoming Part D prescription drug benefit. The commission queried a number of stakeholders in these markets, including physicians, pharmacists, consumer advocates, health plan representatives, and pharmacy benefit manager representatives.

While Medicare's regulations on appeals generally support the processes of Medicaid and private health plans, MedPAC did find some fundamental differences, Dr. Sokolovsky said.

More situations are considered "coverage determinations" under the Part D benefit and may be appealed, she said. For example, Medicare beneficiaries will be able to appeal an increased copayment if they are prescribed a nonpreferred drug as opposed to a preferred drug. Dr. Sokolovsky said that private plans reported having little experience with this kind of adjustment.

The time frame for handling exception requests is also shorter under Part D, Dr. Sokolovsky continued. "If under an urgent request for an exception, a [Medicare Part D] plan must handle these determinations within 24 hours. That's typically faster than required for most [private insurers] now."

Shorter, expedited time frames and the ability to appeal copays, however, may lead to an increased volume of appeals, and possibly higher premiums, she said.

To minimize appeals, Part D plans may put fewer restrictions on separate, tiered cost sharing on nonpreferred drugs.

In some cases, physicians under Part D must get prior approval or authorization before nonpreferred drugs are covered.

From interviews with stakeholders, MedPAC learned prior authorization often creates burdens for beneficiaries and providers in commercial and Medicaid plans.

Prior authorization should ideally take place before the prescription is written—but often doesn't, Dr. Sokolovsky said.

"Physicians frequently don't know what the drugs are on their patients' formularies, or which ones require prior authorization." Patients often become aware of the need for prior authorization when the pharmacist tries to process the prescription and gets a notice the drug is not covered, but lists others that would be covered.

Private plans tend to keep detailed information on the disposition of exception requests; however, some information never comes back to a plan, she said.

WASHINGTON — Patients may find it easier to appeal denials of payment for medications under Medicare's new Part D prescription drug benefit than they do under other health programs, an analyst said during a meeting of the Medicare Payment Advisory Commission.

Specifically, the new benefit offers quicker alternatives to getting formulary exceptions for nonpreferred drugs than private plans or Medicaid, Joan Sokolovsky, Ph.D., a MedPAC senior analyst indicated. The new prescription drug benefit, a part of the Medicare Modernization Act of 2003, goes into effect in January.

MedPAC analysts reviewed the appeals processes in several private plans and in Medicaid to see how they compare with the upcoming Part D prescription drug benefit. The commission queried a number of stakeholders in these markets, including physicians, pharmacists, consumer advocates, health plan representatives, and pharmacy benefit manager representatives.

While Medicare's regulations on appeals generally support the processes of Medicaid and private health plans, MedPAC did find some fundamental differences, Dr. Sokolovsky said.

More situations are considered "coverage determinations" under the Part D benefit and may be appealed, she said. For example, Medicare beneficiaries will be able to appeal an increased copayment if they are prescribed a nonpreferred drug as opposed to a preferred drug. Dr. Sokolovsky said that private plans reported having little experience with this kind of adjustment.

The time frame for handling exception requests is also shorter under Part D, Dr. Sokolovsky continued. "If under an urgent request for an exception, a [Medicare Part D] plan must handle these determinations within 24 hours. That's typically faster than required for most [private insurers] now."

Shorter, expedited time frames and the ability to appeal copays, however, may lead to an increased volume of appeals, and possibly higher premiums, she said.

To minimize appeals, Part D plans may put fewer restrictions on separate, tiered cost sharing on nonpreferred drugs.

In some cases, physicians under Part D must get prior approval or authorization before nonpreferred drugs are covered.

From interviews with stakeholders, MedPAC learned prior authorization often creates burdens for beneficiaries and providers in commercial and Medicaid plans.

Prior authorization should ideally take place before the prescription is written—but often doesn't, Dr. Sokolovsky said.

"Physicians frequently don't know what the drugs are on their patients' formularies, or which ones require prior authorization." Patients often become aware of the need for prior authorization when the pharmacist tries to process the prescription and gets a notice the drug is not covered, but lists others that would be covered.

Private plans tend to keep detailed information on the disposition of exception requests; however, some information never comes back to a plan, she said.

WASHINGTON — Patients may find it easier to appeal denials of payment for medications under Medicare's new Part D prescription drug benefit than they do under other health programs, an analyst said during a meeting of the Medicare Payment Advisory Commission.

Specifically, the new benefit offers quicker alternatives to getting formulary exceptions for nonpreferred drugs than private plans or Medicaid, Joan Sokolovsky, Ph.D., a MedPAC senior analyst indicated. The new prescription drug benefit, a part of the Medicare Modernization Act of 2003, goes into effect in January.

MedPAC analysts reviewed the appeals processes in several private plans and in Medicaid to see how they compare with the upcoming Part D prescription drug benefit. The commission queried a number of stakeholders in these markets, including physicians, pharmacists, consumer advocates, health plan representatives, and pharmacy benefit manager representatives.

While Medicare's regulations on appeals generally support the processes of Medicaid and private health plans, MedPAC did find some fundamental differences, Dr. Sokolovsky said.

More situations are considered "coverage determinations" under the Part D benefit and may be appealed, she said. For example, Medicare beneficiaries will be able to appeal an increased copayment if they are prescribed a nonpreferred drug as opposed to a preferred drug. Dr. Sokolovsky said that private plans reported having little experience with this kind of adjustment.

The time frame for handling exception requests is also shorter under Part D, Dr. Sokolovsky continued. "If under an urgent request for an exception, a [Medicare Part D] plan must handle these determinations within 24 hours. That's typically faster than required for most [private insurers] now."

Shorter, expedited time frames and the ability to appeal copays, however, may lead to an increased volume of appeals, and possibly higher premiums, she said.

To minimize appeals, Part D plans may put fewer restrictions on separate, tiered cost sharing on nonpreferred drugs.

In some cases, physicians under Part D must get prior approval or authorization before nonpreferred drugs are covered.

From interviews with stakeholders, MedPAC learned prior authorization often creates burdens for beneficiaries and providers in commercial and Medicaid plans.

Prior authorization should ideally take place before the prescription is written—but often doesn't, Dr. Sokolovsky said.

"Physicians frequently don't know what the drugs are on their patients' formularies, or which ones require prior authorization." Patients often become aware of the need for prior authorization when the pharmacist tries to process the prescription and gets a notice the drug is not covered, but lists others that would be covered.

Private plans tend to keep detailed information on the disposition of exception requests; however, some information never comes back to a plan, she said.

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

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

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

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

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

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

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

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

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

In medicine, salary offers are going up. The Merritt, Hawkins & Associates 2005 survey on recruitment trends showed steady increases for all of the top 15 recruited specialties in 2005. For example, the average income offered to recruit cardiologists rose from $292,000 in 2003–2004 to $320,000 in 2004–2005, whereas the average offer to orthopedic surgeons increased from $330,000 in 2003–2004 to $361,000 in 2004–2005.

In primary care, the average income offered to recruit internists rose from $148,000 in 2001–2002 to $152,000 in 2003–2004 and crept up to $161,000 in 2004–2005. For the same years, average income offers for family physicians increased from $144,000 to $146,000 to $150,000.

Geographically, salaries were often lower in the Northeast than in other regions. For internists, the average offering there was $155,000 but was $164,000 in all other regions of the country. This trend also was seen in psychiatry, neurosurgery, general surgery, and cardiology. Salary offers for family physicians were slightly higher in the Southeast and Midwest ($151,000-$152,000) than in the Northeast and West, where income offers were $144,000–$145,000.

There are several reasons for the disparity, Mr. Miller said. "There's a higher rate of physicians per population [in the West and Northeast], so in general, production goals based on volume of patients seen are harder to reach. Also, managed care is minimal in many places in the high-earning states, such as Texas, where HMOs like Kaiser tried but failed to catch on, and where the old fee-for-service model still lives."

In medicine, salary offers are going up. The Merritt, Hawkins & Associates 2005 survey on recruitment trends showed steady increases for all of the top 15 recruited specialties in 2005. For example, the average income offered to recruit cardiologists rose from $292,000 in 2003–2004 to $320,000 in 2004–2005, whereas the average offer to orthopedic surgeons increased from $330,000 in 2003–2004 to $361,000 in 2004–2005.

In primary care, the average income offered to recruit internists rose from $148,000 in 2001–2002 to $152,000 in 2003–2004 and crept up to $161,000 in 2004–2005. For the same years, average income offers for family physicians increased from $144,000 to $146,000 to $150,000.

Geographically, salaries were often lower in the Northeast than in other regions. For internists, the average offering there was $155,000 but was $164,000 in all other regions of the country. This trend also was seen in psychiatry, neurosurgery, general surgery, and cardiology. Salary offers for family physicians were slightly higher in the Southeast and Midwest ($151,000-$152,000) than in the Northeast and West, where income offers were $144,000–$145,000.

There are several reasons for the disparity, Mr. Miller said. "There's a higher rate of physicians per population [in the West and Northeast], so in general, production goals based on volume of patients seen are harder to reach. Also, managed care is minimal in many places in the high-earning states, such as Texas, where HMOs like Kaiser tried but failed to catch on, and where the old fee-for-service model still lives."

In medicine, salary offers are going up. The Merritt, Hawkins & Associates 2005 survey on recruitment trends showed steady increases for all of the top 15 recruited specialties in 2005. For example, the average income offered to recruit cardiologists rose from $292,000 in 2003–2004 to $320,000 in 2004–2005, whereas the average offer to orthopedic surgeons increased from $330,000 in 2003–2004 to $361,000 in 2004–2005.

In primary care, the average income offered to recruit internists rose from $148,000 in 2001–2002 to $152,000 in 2003–2004 and crept up to $161,000 in 2004–2005. For the same years, average income offers for family physicians increased from $144,000 to $146,000 to $150,000.

Geographically, salaries were often lower in the Northeast than in other regions. For internists, the average offering there was $155,000 but was $164,000 in all other regions of the country. This trend also was seen in psychiatry, neurosurgery, general surgery, and cardiology. Salary offers for family physicians were slightly higher in the Southeast and Midwest ($151,000-$152,000) than in the Northeast and West, where income offers were $144,000–$145,000.

There are several reasons for the disparity, Mr. Miller said. "There's a higher rate of physicians per population [in the West and Northeast], so in general, production goals based on volume of patients seen are harder to reach. Also, managed care is minimal in many places in the high-earning states, such as Texas, where HMOs like Kaiser tried but failed to catch on, and where the old fee-for-service model still lives."

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

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

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

That's one reason physician groups need a data-based approach to help reduce errors and improve care, he continued.

A new program in California has yielded positive results, and is "certainly one way to pay for quality," Dr. Bangasser said.

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

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

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

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

The measures had to be valid and accurate, meaningful to consumers and physicians, and important to public health in California.

"They also had to get harder over time," Dr. Bangasser said.

In the IHA program, physicians get paid not just for performance, but also for performance improvement. "We actually have a calculator [that determines whether] people are improving," he pointed out.

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

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

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

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

Variations occurred in the clinical measures because not all of the groups used a registry-type system—a list that details the specific diagnoses of each patient.

Physicians using a registry can find out if a patient got a certain test or if they need one, Dr. Bangasser said. To date, groups that use registries "are doing much better on these measures than groups that don't."

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

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

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

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said.

There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be.

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

Applying the right types of incentives is key, he said.

"If a physician thinks the measure is a good idea, putting a little money behind it will speed quality improvement. However, if the physician thinks the measure is not going to improve quality, $1 million will not change behavior," Dr. Bangasser said.

Sometimes, the simplest incentives can produce good results.

Dr. Bangasser mentioned a particularly bad influenza season in 1998, when patients had to wait in long lines to see physicians in his group practice. "I asked all of the doctors if they'd take on two more patients a day. That's a long day, but I gave them two tickets to a movie theater for Christmas."

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

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

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

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

That's one reason physician groups need a data-based approach to help reduce errors and improve care, he continued.

A new program in California has yielded positive results, and is "certainly one way to pay for quality," Dr. Bangasser said.

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

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

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

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

The measures had to be valid and accurate, meaningful to consumers and physicians, and important to public health in California.

"They also had to get harder over time," Dr. Bangasser said.

In the IHA program, physicians get paid not just for performance, but also for performance improvement. "We actually have a calculator [that determines whether] people are improving," he pointed out.

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

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

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

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

Variations occurred in the clinical measures because not all of the groups used a registry-type system—a list that details the specific diagnoses of each patient.

Physicians using a registry can find out if a patient got a certain test or if they need one, Dr. Bangasser said. To date, groups that use registries "are doing much better on these measures than groups that don't."

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

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

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

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said.

There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be.

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

Applying the right types of incentives is key, he said.

"If a physician thinks the measure is a good idea, putting a little money behind it will speed quality improvement. However, if the physician thinks the measure is not going to improve quality, $1 million will not change behavior," Dr. Bangasser said.

Sometimes, the simplest incentives can produce good results.

Dr. Bangasser mentioned a particularly bad influenza season in 1998, when patients had to wait in long lines to see physicians in his group practice. "I asked all of the doctors if they'd take on two more patients a day. That's a long day, but I gave them two tickets to a movie theater for Christmas."

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

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

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

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

That's one reason physician groups need a data-based approach to help reduce errors and improve care, he continued.

A new program in California has yielded positive results, and is "certainly one way to pay for quality," Dr. Bangasser said.

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

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

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

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

The measures had to be valid and accurate, meaningful to consumers and physicians, and important to public health in California.

"They also had to get harder over time," Dr. Bangasser said.

In the IHA program, physicians get paid not just for performance, but also for performance improvement. "We actually have a calculator [that determines whether] people are improving," he pointed out.

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

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

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

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

Variations occurred in the clinical measures because not all of the groups used a registry-type system—a list that details the specific diagnoses of each patient.

Physicians using a registry can find out if a patient got a certain test or if they need one, Dr. Bangasser said. To date, groups that use registries "are doing much better on these measures than groups that don't."

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

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

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

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said.

There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be.

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

Applying the right types of incentives is key, he said.

"If a physician thinks the measure is a good idea, putting a little money behind it will speed quality improvement. However, if the physician thinks the measure is not going to improve quality, $1 million will not change behavior," Dr. Bangasser said.

Sometimes, the simplest incentives can produce good results.

Dr. Bangasser mentioned a particularly bad influenza season in 1998, when patients had to wait in long lines to see physicians in his group practice. "I asked all of the doctors if they'd take on two more patients a day. That's a long day, but I gave them two tickets to a movie theater for Christmas."

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

DALLAS — Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, "the number of Medicaid patients in retainer practices is much smaller—6% vs. 15% in traditional practice," Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practices—also known as concierge or boutique medicine practices—and received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

"We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered," Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent said working fewer hours was one benefit of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people "look down their noses at you," Dr. Wynia said. In a surprising statistic, "5% of people in retainer practices thought they should be discouraged" from this approach, he added.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. "Only 25%–30% of nonretainer physicians thought they should be discouraged or illegal," Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patients—about 88%—didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are considered, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, Dr. Wynia said. In addition, physicians on average would continue to see 140 patients who did not pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care averaged 9.14 hours per months vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were common services provided by the retainer physicians.

The survey did not ask about salary or fees charged to patients, but Dr. Wynia estimated retainer fees ranged from "several hundred to thousands of dollars per year."

He clarified that his presentation reflected the results of a research project and did not represent a policy statement of the AMA. The data are still unpublished and have been in review the past 6 months.

DALLAS — Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, "the number of Medicaid patients in retainer practices is much smaller—6% vs. 15% in traditional practice," Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practices—also known as concierge or boutique medicine practices—and received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

"We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered," Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent said working fewer hours was one benefit of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people "look down their noses at you," Dr. Wynia said. In a surprising statistic, "5% of people in retainer practices thought they should be discouraged" from this approach, he added.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. "Only 25%–30% of nonretainer physicians thought they should be discouraged or illegal," Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patients—about 88%—didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are considered, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, Dr. Wynia said. In addition, physicians on average would continue to see 140 patients who did not pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care averaged 9.14 hours per months vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were common services provided by the retainer physicians.

The survey did not ask about salary or fees charged to patients, but Dr. Wynia estimated retainer fees ranged from "several hundred to thousands of dollars per year."

He clarified that his presentation reflected the results of a research project and did not represent a policy statement of the AMA. The data are still unpublished and have been in review the past 6 months.

DALLAS — Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, "the number of Medicaid patients in retainer practices is much smaller—6% vs. 15% in traditional practice," Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practices—also known as concierge or boutique medicine practices—and received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

"We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered," Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent said working fewer hours was one benefit of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people "look down their noses at you," Dr. Wynia said. In a surprising statistic, "5% of people in retainer practices thought they should be discouraged" from this approach, he added.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. "Only 25%–30% of nonretainer physicians thought they should be discouraged or illegal," Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patients—about 88%—didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are considered, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, Dr. Wynia said. In addition, physicians on average would continue to see 140 patients who did not pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care averaged 9.14 hours per months vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were common services provided by the retainer physicians.

The survey did not ask about salary or fees charged to patients, but Dr. Wynia estimated retainer fees ranged from "several hundred to thousands of dollars per year."

He clarified that his presentation reflected the results of a research project and did not represent a policy statement of the AMA. The data are still unpublished and have been in review the past 6 months.

Bill to Thwart Medicare Cuts

A bipartisan bill (H.R. 2356) introduced by Rep. Clay Shaw (R-Fla.) and Rep. Ben Cardin (D-Md.) seeks to halt impending cuts to Medicare physician payments and replace the flawed formula that determines those payments. Following up on a recommendation of the Medicare Payment Advisory Commission, the bill would increase payments by no less than 2.7% in 2006. It would also repeal the sustainable growth rate adjustment, replacing it “with a methodology that assures adequate and appropriate payments as well as stable updates for Medicare providers,” Rep. Cardin said in a statement. Physicians face a 4.3% cut in Medicare payments in 2006 and subsequent cuts totaling 30% from 2007 and 2012, if the formula isn't fixed. The bill was referred to the House Ways and Means and Energy and Commerce committees. A similar bill introduced in the Senate (S. 1081) would provide a positive update to Medicare payments for 2 years.

Few Seeking Quality Improvement

A majority of physicians are not actively engaged in quality improvement practices and are reluctant to share information about the quality of care they provide with the general public, a survey of more than 1,800 physicians revealed. Only one-fourth of the respondents said they were using an electronic medical record routinely or occasionally, and one-third said they were redesigning their systems to improve care. In addition, just one-third said they had access to any data about the quality of their own clinical performance. Although 7 out of 10 thought physicians' clinical information should be shared with leaders of the health care systems at which they work, fewer respondents (55%) thought patients should have access to quality data about their own doctors, and only 29% thought the general public should have access to such data. The survey was conducted by the Commonwealth Fund between March and May 2003 and published in the journal Health Affairs.

Medicaid Patients and Drug Access

Medicaid patients are finding it just as difficult as the uninsured to get access to prescription drugs. Researchers from the Center for Studying Health System Change found that 22% of Medicaid beneficiaries aged 18 and older could not afford to get at least one prescription filled in the previous year. Although access problems experienced by Medicaid beneficiaries were comparable with those experienced by the uninsured, only 9% of adults with employer-sponsored health coverage said they could not afford a prescribed drug in the previous year. The findings were drawn from HSC's Community Tracking Study Household Survey, a national survey involving 46,600 people in 2003 and 60,000 people in 2001.

Vaccine Underinsurance

Just because you have insurance does not mean you're covered for immunizations, a survey of 995 Americans conducted by researchers at the University of Michigan, Ann Arbor, indicated. As many as 36 million privately insured adults and 5 million privately insured children are not covered for immunizations, a factor that may be contributing to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead study author Matthew Davis. “This means that new vaccines of the future may be available to many people only if they can pay out of pocket.” A majority of the respondents said they'd be willing to pay higher premiums for vaccine coverage, and most strongly believed that vaccines were effective and generally safe (Health Affairs 2005;24:770–9).

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office for National Drug Control Policy. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP Director John Walters said at a Washington press conference. “Now would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.” The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 were twice as likely to have serious mental illness in the last year as those who first used marijuana at age 18 or older.

AMA: Ban Booze Ads at NCAA Events

The American Medical Association has asked the National Collegiate Athletic Association to eliminate alcohol advertising associated with NCAA events. “The prevalence of alcohol advertising in college sports sends a damaging message about the core values of the NCAA and higher education,” AMA President-elect J. Edward Hill, M.D., said in a statement. In a national poll sponsored by the AMA, 62% of adults said the NCAA should reverse its policy and not allow beer companies to advertise during college sporting events. NCAA spokesman Erik Christianson said the association already limits alcohol ads to 60 seconds per hour of any broadcast NCAA event, and he noted that the NCAA executive committee was already planning to discuss, at an upcoming meeting, the idea of banning the ads completely, in response to a request from one of its divisions.

Bill to Thwart Medicare Cuts

A bipartisan bill (H.R. 2356) introduced by Rep. Clay Shaw (R-Fla.) and Rep. Ben Cardin (D-Md.) seeks to halt impending cuts to Medicare physician payments and replace the flawed formula that determines those payments. Following up on a recommendation of the Medicare Payment Advisory Commission, the bill would increase payments by no less than 2.7% in 2006. It would also repeal the sustainable growth rate adjustment, replacing it “with a methodology that assures adequate and appropriate payments as well as stable updates for Medicare providers,” Rep. Cardin said in a statement. Physicians face a 4.3% cut in Medicare payments in 2006 and subsequent cuts totaling 30% from 2007 and 2012, if the formula isn't fixed. The bill was referred to the House Ways and Means and Energy and Commerce committees. A similar bill introduced in the Senate (S. 1081) would provide a positive update to Medicare payments for 2 years.

Few Seeking Quality Improvement

A majority of physicians are not actively engaged in quality improvement practices and are reluctant to share information about the quality of care they provide with the general public, a survey of more than 1,800 physicians revealed. Only one-fourth of the respondents said they were using an electronic medical record routinely or occasionally, and one-third said they were redesigning their systems to improve care. In addition, just one-third said they had access to any data about the quality of their own clinical performance. Although 7 out of 10 thought physicians' clinical information should be shared with leaders of the health care systems at which they work, fewer respondents (55%) thought patients should have access to quality data about their own doctors, and only 29% thought the general public should have access to such data. The survey was conducted by the Commonwealth Fund between March and May 2003 and published in the journal Health Affairs.

Medicaid Patients and Drug Access

Medicaid patients are finding it just as difficult as the uninsured to get access to prescription drugs. Researchers from the Center for Studying Health System Change found that 22% of Medicaid beneficiaries aged 18 and older could not afford to get at least one prescription filled in the previous year. Although access problems experienced by Medicaid beneficiaries were comparable with those experienced by the uninsured, only 9% of adults with employer-sponsored health coverage said they could not afford a prescribed drug in the previous year. The findings were drawn from HSC's Community Tracking Study Household Survey, a national survey involving 46,600 people in 2003 and 60,000 people in 2001.

Vaccine Underinsurance

Just because you have insurance does not mean you're covered for immunizations, a survey of 995 Americans conducted by researchers at the University of Michigan, Ann Arbor, indicated. As many as 36 million privately insured adults and 5 million privately insured children are not covered for immunizations, a factor that may be contributing to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead study author Matthew Davis. “This means that new vaccines of the future may be available to many people only if they can pay out of pocket.” A majority of the respondents said they'd be willing to pay higher premiums for vaccine coverage, and most strongly believed that vaccines were effective and generally safe (Health Affairs 2005;24:770–9).

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office for National Drug Control Policy. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP Director John Walters said at a Washington press conference. “Now would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.” The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 were twice as likely to have serious mental illness in the last year as those who first used marijuana at age 18 or older.

AMA: Ban Booze Ads at NCAA Events

The American Medical Association has asked the National Collegiate Athletic Association to eliminate alcohol advertising associated with NCAA events. “The prevalence of alcohol advertising in college sports sends a damaging message about the core values of the NCAA and higher education,” AMA President-elect J. Edward Hill, M.D., said in a statement. In a national poll sponsored by the AMA, 62% of adults said the NCAA should reverse its policy and not allow beer companies to advertise during college sporting events. NCAA spokesman Erik Christianson said the association already limits alcohol ads to 60 seconds per hour of any broadcast NCAA event, and he noted that the NCAA executive committee was already planning to discuss, at an upcoming meeting, the idea of banning the ads completely, in response to a request from one of its divisions.

Bill to Thwart Medicare Cuts

A bipartisan bill (H.R. 2356) introduced by Rep. Clay Shaw (R-Fla.) and Rep. Ben Cardin (D-Md.) seeks to halt impending cuts to Medicare physician payments and replace the flawed formula that determines those payments. Following up on a recommendation of the Medicare Payment Advisory Commission, the bill would increase payments by no less than 2.7% in 2006. It would also repeal the sustainable growth rate adjustment, replacing it “with a methodology that assures adequate and appropriate payments as well as stable updates for Medicare providers,” Rep. Cardin said in a statement. Physicians face a 4.3% cut in Medicare payments in 2006 and subsequent cuts totaling 30% from 2007 and 2012, if the formula isn't fixed. The bill was referred to the House Ways and Means and Energy and Commerce committees. A similar bill introduced in the Senate (S. 1081) would provide a positive update to Medicare payments for 2 years.

Few Seeking Quality Improvement

A majority of physicians are not actively engaged in quality improvement practices and are reluctant to share information about the quality of care they provide with the general public, a survey of more than 1,800 physicians revealed. Only one-fourth of the respondents said they were using an electronic medical record routinely or occasionally, and one-third said they were redesigning their systems to improve care. In addition, just one-third said they had access to any data about the quality of their own clinical performance. Although 7 out of 10 thought physicians' clinical information should be shared with leaders of the health care systems at which they work, fewer respondents (55%) thought patients should have access to quality data about their own doctors, and only 29% thought the general public should have access to such data. The survey was conducted by the Commonwealth Fund between March and May 2003 and published in the journal Health Affairs.

Medicaid Patients and Drug Access

Medicaid patients are finding it just as difficult as the uninsured to get access to prescription drugs. Researchers from the Center for Studying Health System Change found that 22% of Medicaid beneficiaries aged 18 and older could not afford to get at least one prescription filled in the previous year. Although access problems experienced by Medicaid beneficiaries were comparable with those experienced by the uninsured, only 9% of adults with employer-sponsored health coverage said they could not afford a prescribed drug in the previous year. The findings were drawn from HSC's Community Tracking Study Household Survey, a national survey involving 46,600 people in 2003 and 60,000 people in 2001.

Vaccine Underinsurance

Just because you have insurance does not mean you're covered for immunizations, a survey of 995 Americans conducted by researchers at the University of Michigan, Ann Arbor, indicated. As many as 36 million privately insured adults and 5 million privately insured children are not covered for immunizations, a factor that may be contributing to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead study author Matthew Davis. “This means that new vaccines of the future may be available to many people only if they can pay out of pocket.” A majority of the respondents said they'd be willing to pay higher premiums for vaccine coverage, and most strongly believed that vaccines were effective and generally safe (Health Affairs 2005;24:770–9).

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office for National Drug Control Policy. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP Director John Walters said at a Washington press conference. “Now would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.” The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 were twice as likely to have serious mental illness in the last year as those who first used marijuana at age 18 or older.

AMA: Ban Booze Ads at NCAA Events

The American Medical Association has asked the National Collegiate Athletic Association to eliminate alcohol advertising associated with NCAA events. “The prevalence of alcohol advertising in college sports sends a damaging message about the core values of the NCAA and higher education,” AMA President-elect J. Edward Hill, M.D., said in a statement. In a national poll sponsored by the AMA, 62% of adults said the NCAA should reverse its policy and not allow beer companies to advertise during college sporting events. NCAA spokesman Erik Christianson said the association already limits alcohol ads to 60 seconds per hour of any broadcast NCAA event, and he noted that the NCAA executive committee was already planning to discuss, at an upcoming meeting, the idea of banning the ads completely, in response to a request from one of its divisions.

Bill Would Address Medicare Cuts

A bipartisan bill (H.R. 2356) introduced by Rep. Clay Shaw (R-Fla.) and Rep. Ben Cardin (D-Md.) seeks to halt cuts to Medicare physician payments and replace the flawed formula that sets those payments. Following up on a recommendation of the Medicare Payment Advisory Commission, the bill would increase payments by no less than 2.7% in 2006. It would also repeal the sustainable growth rate adjustment, replacing it “with a methodology that assures adequate and appropriate payments as well as stable updates for Medicare providers,” Rep. Cardin said in a statement. If the formula isn't fixed, physicians face a 4.3% cut in Medicare payments in 2006 and later cuts totaling 30% from 2007 and 2012. The bill was referred to the House Ways and Means and Energy and Commerce committees. A similar bill introduced in the Senate (S. 1081) would boost Medicare payments for 2 years.

Medicaid Patients and Drug Access

Medicaid patients are finding it just as difficult as the uninsured to get access to prescription drugs. Researchers from the Center for Studying Health System Change found that 22% of adult Medicaid beneficiaries couldn't afford to get at least one prescription filled in the previous year. Medicaid beneficiaries and the uninsured has similar access problems, but only 9% of adults with employer-sponsored health coverage said they couldn't afford a prescribed drug in the previous year. The findings were drawn from HSC's Community Tracking Study Household Survey, a national survey involving 46,600 people in 2003 and 60,000 people in 2001. States have been intensifying efforts to control rising Medicaid drug spending, but the proportion of Medicaid beneficiaries reporting they couldn't afford prescription drugs remained unchanged from 2001 to 2003.

Vaccine Underinsurance

Having insurance doesn't mean you're covered for immunizations, according to a survey of 995 Americans conducted by researchers at the University of Michigan, Ann Arbor. As many as 36 million privately insured adults and 5 million privately insured children are not covered for immunizations, a factor that may be contributing to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead study author Matthew Davis. “New vaccines of the future may be available to many people only if they can pay out of pocket.” Most respondents said they'd be willing to pay higher premiums for vaccine coverage, and most strongly believed that vaccines were effective and generally safe (Health Affairs 2005;24:770–9).

Limits to Quality Improvement

Most physicians are not using quality improvement measures and are reluctant to make public any information about the quality of care they provide, a survey of more than 1,800 physicians revealed. Only one-fourth of the respondents said they were using an electronic medical record routinely or occasionally, and one-third said they were redesigning their systems to improve care. Just one-third said they had access to any data about the quality of their own clinical performance. Although 7 out of 10 thought physicians' clinical information should be shared with leaders of the health care systems at which they work, only 55% thought patients should have access to quality-related data about their own doctors, and only 29% thought the general public should have access to such data. The survey, conducted by the Commonwealth Fund between March and May 2003, was published in the journal Health Affairs.

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office for National Drug Control Policy. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP Director John Walters said at a Washington press briefing. “Now would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.” The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 were twice as likely to have serious mental illness in the past year as those who first used marijuana at age 18 or older.

AMA: Ban Booze Ads at NCAA Events

The American Medical Association has asked the National Collegiate Athletic Association to eliminate alcohol advertising associated with NCAA events. “The prevalence of alcohol advertising in college sports sends a damaging message about the core values of the NCAA and higher education,” AMA President-elect J. Edward Hill, M.D., said in a statement. “Allowing aggressive alcohol advertising during its events only encourages underage consumption of alcohol.” In a national poll sponsored by the AMA, 62% of adults said the NCAA should reverse its policy and not let beer companies advertise during college sporting events. NCAA spokesman Erik Christianson said the association already limits alcohol ads to 60 seconds per hour of any broadcast NCAA event, and noted that the NCAA executive committee was already planning to discuss, at an upcoming meeting, the idea of banning the ads completely, in response to a request from one of its divisions.

Bill Would Address Medicare Cuts

A bipartisan bill (H.R. 2356) introduced by Rep. Clay Shaw (R-Fla.) and Rep. Ben Cardin (D-Md.) seeks to halt cuts to Medicare physician payments and replace the flawed formula that sets those payments. Following up on a recommendation of the Medicare Payment Advisory Commission, the bill would increase payments by no less than 2.7% in 2006. It would also repeal the sustainable growth rate adjustment, replacing it “with a methodology that assures adequate and appropriate payments as well as stable updates for Medicare providers,” Rep. Cardin said in a statement. If the formula isn't fixed, physicians face a 4.3% cut in Medicare payments in 2006 and later cuts totaling 30% from 2007 and 2012. The bill was referred to the House Ways and Means and Energy and Commerce committees. A similar bill introduced in the Senate (S. 1081) would boost Medicare payments for 2 years.

Medicaid Patients and Drug Access

Medicaid patients are finding it just as difficult as the uninsured to get access to prescription drugs. Researchers from the Center for Studying Health System Change found that 22% of adult Medicaid beneficiaries couldn't afford to get at least one prescription filled in the previous year. Medicaid beneficiaries and the uninsured has similar access problems, but only 9% of adults with employer-sponsored health coverage said they couldn't afford a prescribed drug in the previous year. The findings were drawn from HSC's Community Tracking Study Household Survey, a national survey involving 46,600 people in 2003 and 60,000 people in 2001. States have been intensifying efforts to control rising Medicaid drug spending, but the proportion of Medicaid beneficiaries reporting they couldn't afford prescription drugs remained unchanged from 2001 to 2003.

Vaccine Underinsurance

Having insurance doesn't mean you're covered for immunizations, according to a survey of 995 Americans conducted by researchers at the University of Michigan, Ann Arbor. As many as 36 million privately insured adults and 5 million privately insured children are not covered for immunizations, a factor that may be contributing to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead study author Matthew Davis. “New vaccines of the future may be available to many people only if they can pay out of pocket.” Most respondents said they'd be willing to pay higher premiums for vaccine coverage, and most strongly believed that vaccines were effective and generally safe (Health Affairs 2005;24:770–9).

Limits to Quality Improvement

Most physicians are not using quality improvement measures and are reluctant to make public any information about the quality of care they provide, a survey of more than 1,800 physicians revealed. Only one-fourth of the respondents said they were using an electronic medical record routinely or occasionally, and one-third said they were redesigning their systems to improve care. Just one-third said they had access to any data about the quality of their own clinical performance. Although 7 out of 10 thought physicians' clinical information should be shared with leaders of the health care systems at which they work, only 55% thought patients should have access to quality-related data about their own doctors, and only 29% thought the general public should have access to such data. The survey, conducted by the Commonwealth Fund between March and May 2003, was published in the journal Health Affairs.

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office for National Drug Control Policy. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP Director John Walters said at a Washington press briefing. “Now would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.” The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 were twice as likely to have serious mental illness in the past year as those who first used marijuana at age 18 or older.

AMA: Ban Booze Ads at NCAA Events

The American Medical Association has asked the National Collegiate Athletic Association to eliminate alcohol advertising associated with NCAA events. “The prevalence of alcohol advertising in college sports sends a damaging message about the core values of the NCAA and higher education,” AMA President-elect J. Edward Hill, M.D., said in a statement. “Allowing aggressive alcohol advertising during its events only encourages underage consumption of alcohol.” In a national poll sponsored by the AMA, 62% of adults said the NCAA should reverse its policy and not let beer companies advertise during college sporting events. NCAA spokesman Erik Christianson said the association already limits alcohol ads to 60 seconds per hour of any broadcast NCAA event, and noted that the NCAA executive committee was already planning to discuss, at an upcoming meeting, the idea of banning the ads completely, in response to a request from one of its divisions.

Bill Would Address Medicare Cuts

A bipartisan bill (H.R. 2356) introduced by Rep. Clay Shaw (R-Fla.) and Rep. Ben Cardin (D-Md.) seeks to halt cuts to Medicare physician payments and replace the flawed formula that sets those payments. Following up on a recommendation of the Medicare Payment Advisory Commission, the bill would increase payments by no less than 2.7% in 2006. It would also repeal the sustainable growth rate adjustment, replacing it “with a methodology that assures adequate and appropriate payments as well as stable updates for Medicare providers,” Rep. Cardin said in a statement. If the formula isn't fixed, physicians face a 4.3% cut in Medicare payments in 2006 and later cuts totaling 30% from 2007 and 2012. The bill was referred to the House Ways and Means and Energy and Commerce committees. A similar bill introduced in the Senate (S. 1081) would boost Medicare payments for 2 years.

Medicaid Patients and Drug Access

Medicaid patients are finding it just as difficult as the uninsured to get access to prescription drugs. Researchers from the Center for Studying Health System Change found that 22% of adult Medicaid beneficiaries couldn't afford to get at least one prescription filled in the previous year. Medicaid beneficiaries and the uninsured has similar access problems, but only 9% of adults with employer-sponsored health coverage said they couldn't afford a prescribed drug in the previous year. The findings were drawn from HSC's Community Tracking Study Household Survey, a national survey involving 46,600 people in 2003 and 60,000 people in 2001. States have been intensifying efforts to control rising Medicaid drug spending, but the proportion of Medicaid beneficiaries reporting they couldn't afford prescription drugs remained unchanged from 2001 to 2003.

Vaccine Underinsurance

Having insurance doesn't mean you're covered for immunizations, according to a survey of 995 Americans conducted by researchers at the University of Michigan, Ann Arbor. As many as 36 million privately insured adults and 5 million privately insured children are not covered for immunizations, a factor that may be contributing to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead study author Matthew Davis. “New vaccines of the future may be available to many people only if they can pay out of pocket.” Most respondents said they'd be willing to pay higher premiums for vaccine coverage, and most strongly believed that vaccines were effective and generally safe (Health Affairs 2005;24:770–9).

Limits to Quality Improvement

Most physicians are not using quality improvement measures and are reluctant to make public any information about the quality of care they provide, a survey of more than 1,800 physicians revealed. Only one-fourth of the respondents said they were using an electronic medical record routinely or occasionally, and one-third said they were redesigning their systems to improve care. Just one-third said they had access to any data about the quality of their own clinical performance. Although 7 out of 10 thought physicians' clinical information should be shared with leaders of the health care systems at which they work, only 55% thought patients should have access to quality-related data about their own doctors, and only 29% thought the general public should have access to such data. The survey, conducted by the Commonwealth Fund between March and May 2003, was published in the journal Health Affairs.

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office for National Drug Control Policy. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP Director John Walters said at a Washington press briefing. “Now would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.” The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 were twice as likely to have serious mental illness in the past year as those who first used marijuana at age 18 or older.

AMA: Ban Booze Ads at NCAA Events

The American Medical Association has asked the National Collegiate Athletic Association to eliminate alcohol advertising associated with NCAA events. “The prevalence of alcohol advertising in college sports sends a damaging message about the core values of the NCAA and higher education,” AMA President-elect J. Edward Hill, M.D., said in a statement. “Allowing aggressive alcohol advertising during its events only encourages underage consumption of alcohol.” In a national poll sponsored by the AMA, 62% of adults said the NCAA should reverse its policy and not let beer companies advertise during college sporting events. NCAA spokesman Erik Christianson said the association already limits alcohol ads to 60 seconds per hour of any broadcast NCAA event, and noted that the NCAA executive committee was already planning to discuss, at an upcoming meeting, the idea of banning the ads completely, in response to a request from one of its divisions.

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

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a manner that “best meets the needs” of the hospital's patients. The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

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

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

Hospitals testified that their emergency care was suffering due to physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals. “There no longer is any certainty that an on-call physician will report for duty when called,” he said.

Physicians say that economic, practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

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

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said.

To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process—before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

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

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

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

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

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

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

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

The group will be advising HHS on issues related to EMTALA. It includes hospital, physician, and patient representatives, in addition to CMS and state officials and one representative from a Quality Improvement Organization.

No recommendations were issued at the meeting, although a subcommittee was formed to address on-call concerns.

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

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a manner that “best meets the needs” of the hospital's patients. The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

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

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

Hospitals testified that their emergency care was suffering due to physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals. “There no longer is any certainty that an on-call physician will report for duty when called,” he said.

Physicians say that economic, practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

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

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said.

To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process—before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

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

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

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

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

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

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

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

The group will be advising HHS on issues related to EMTALA. It includes hospital, physician, and patient representatives, in addition to CMS and state officials and one representative from a Quality Improvement Organization.

No recommendations were issued at the meeting, although a subcommittee was formed to address on-call concerns.

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

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a manner that “best meets the needs” of the hospital's patients. The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

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

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

Hospitals testified that their emergency care was suffering due to physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals. “There no longer is any certainty that an on-call physician will report for duty when called,” he said.

Physicians say that economic, practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

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

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said.

To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process—before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

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

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

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

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

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

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

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

The group will be advising HHS on issues related to EMTALA. It includes hospital, physician, and patient representatives, in addition to CMS and state officials and one representative from a Quality Improvement Organization.

No recommendations were issued at the meeting, although a subcommittee was formed to address on-call concerns.

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

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

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

MedPAC commissioners recommended that the Department of Health and Human Services establish a process for the timely delivery of these data to interested parties.

Individuals, employers, and government agencies currently use performance measures to evaluate how well health plans and pharmacy benefit managers manage drug benefits, Ms. Boccuti said.

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

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

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

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

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

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

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

CMS plans on conducting its own consumer satisfaction surveys to provide comparative plan information to beneficiaries when they're making enrollment decisions, she said.

In addition, plans will submit data on grievances filed, and call center performance measures, such as abandonment rates and hold times.

MedPAC commissioner Nancy-Ann DeParle, a health care consultant in Washington and former head of CMs' predecessor agency (the Health Care Financing Administration), asked whether CMS would be looking at this data at a physician level, in terms of who did the prescribing. “In our pay-for-performance discussions around physicians, [MedPAC indicated that] it would be useful to have this.”

Ms. Boccuti noted that there is a prescriber code associated with each drug.

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

The agency is preparing to collect data on actual drugs and the spending associated with those specific drugs, “so there will be the ability to track how much was paid at the point of sale,” Ms. Boccuti said.

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

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

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

MedPAC commissioners recommended that the Department of Health and Human Services establish a process for the timely delivery of these data to interested parties.

Individuals, employers, and government agencies currently use performance measures to evaluate how well health plans and pharmacy benefit managers manage drug benefits, Ms. Boccuti said.

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

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

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

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

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

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

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

CMS plans on conducting its own consumer satisfaction surveys to provide comparative plan information to beneficiaries when they're making enrollment decisions, she said.

In addition, plans will submit data on grievances filed, and call center performance measures, such as abandonment rates and hold times.

MedPAC commissioner Nancy-Ann DeParle, a health care consultant in Washington and former head of CMs' predecessor agency (the Health Care Financing Administration), asked whether CMS would be looking at this data at a physician level, in terms of who did the prescribing. “In our pay-for-performance discussions around physicians, [MedPAC indicated that] it would be useful to have this.”

Ms. Boccuti noted that there is a prescriber code associated with each drug.

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

The agency is preparing to collect data on actual drugs and the spending associated with those specific drugs, “so there will be the ability to track how much was paid at the point of sale,” Ms. Boccuti said.

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

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

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

MedPAC commissioners recommended that the Department of Health and Human Services establish a process for the timely delivery of these data to interested parties.

Individuals, employers, and government agencies currently use performance measures to evaluate how well health plans and pharmacy benefit managers manage drug benefits, Ms. Boccuti said.

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

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

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

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

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

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

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

CMS plans on conducting its own consumer satisfaction surveys to provide comparative plan information to beneficiaries when they're making enrollment decisions, she said.

In addition, plans will submit data on grievances filed, and call center performance measures, such as abandonment rates and hold times.

MedPAC commissioner Nancy-Ann DeParle, a health care consultant in Washington and former head of CMs' predecessor agency (the Health Care Financing Administration), asked whether CMS would be looking at this data at a physician level, in terms of who did the prescribing. “In our pay-for-performance discussions around physicians, [MedPAC indicated that] it would be useful to have this.”

Ms. Boccuti noted that there is a prescriber code associated with each drug.

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

The agency is preparing to collect data on actual drugs and the spending associated with those specific drugs, “so there will be the ability to track how much was paid at the point of sale,” Ms. Boccuti said.

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

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

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

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package. Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

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

When considering software vendors, it's important to visit practice sites that are using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

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

Training should ideally take place during the slow season, from the end of June through early September. Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system. Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use system,” he advised.

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

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

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

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

Online Scheduling Increases Patients' Options for Booking Appointments

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

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

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

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

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

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

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

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

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

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

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package. Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

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

When considering software vendors, it's important to visit practice sites that are using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

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

Training should ideally take place during the slow season, from the end of June through early September. Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system. Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use system,” he advised.

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

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

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

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

Online Scheduling Increases Patients' Options for Booking Appointments

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

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

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

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

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

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

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

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

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

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

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package. Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

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

When considering software vendors, it's important to visit practice sites that are using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

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

Training should ideally take place during the slow season, from the end of June through early September. Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system. Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use system,” he advised.

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

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

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

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

Online Scheduling Increases Patients' Options for Booking Appointments

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

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

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

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

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

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

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