Jennifer Silverman

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% versus 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 of the retainer physicians said working fewer hours was one of the benefits.

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 pursuing this approach.

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%).

Taking these factors into account, 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 for retainer physicians averaged 9.14 hours per months versus 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 specific fees charged, 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 for 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% versus 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 of the retainer physicians said working fewer hours was one of the benefits.

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 pursuing this approach.

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%).

Taking these factors into account, 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 for retainer physicians averaged 9.14 hours per months versus 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 specific fees charged, 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 for 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% versus 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 of the retainer physicians said working fewer hours was one of the benefits.

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 pursuing this approach.

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%).

Taking these factors into account, 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 for retainer physicians averaged 9.14 hours per months versus 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 specific fees charged, 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 for the past 6 months.

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, Medicare Part D plans may put fewer restrictions on separate, tiered cost sharing on nonpreferred drugs. “Good communication is important to prevent an excessive increase in appeals,” she said.

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

From its interviews with stakeholders, MedPAC learned that prior authorization often creates burdens for both 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 that the drug is not covered, but lists other drugs that would be covered.

Private health plans tend to keep detailed information on the disposition of exception requests; however, some information never comes back to a plan, she said. For example, the private plans MedPAC surveyed didn't seem to know how often a beneficiary paid out of pocket for a drug when the drug was not covered, how often pharmacists contact physicians or the plan member when a drug isn't covered, or if the physician even had time to respond to the situation.

One physician who MedPAC analysts surveyed reported that his practice spends several hours a day trying to resolve prior authorization matters.

Private plans have tried to minimize this burden by educating their members and physicians about their formularies.

“Some plans deal with the burden by simply placing fewer drugs on prior authorization,” 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, Medicare Part D plans may put fewer restrictions on separate, tiered cost sharing on nonpreferred drugs. “Good communication is important to prevent an excessive increase in appeals,” she said.

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

From its interviews with stakeholders, MedPAC learned that prior authorization often creates burdens for both 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 that the drug is not covered, but lists other drugs that would be covered.

Private health plans tend to keep detailed information on the disposition of exception requests; however, some information never comes back to a plan, she said. For example, the private plans MedPAC surveyed didn't seem to know how often a beneficiary paid out of pocket for a drug when the drug was not covered, how often pharmacists contact physicians or the plan member when a drug isn't covered, or if the physician even had time to respond to the situation.

One physician who MedPAC analysts surveyed reported that his practice spends several hours a day trying to resolve prior authorization matters.

Private plans have tried to minimize this burden by educating their members and physicians about their formularies.

“Some plans deal with the burden by simply placing fewer drugs on prior authorization,” 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, Medicare Part D plans may put fewer restrictions on separate, tiered cost sharing on nonpreferred drugs. “Good communication is important to prevent an excessive increase in appeals,” she said.

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

From its interviews with stakeholders, MedPAC learned that prior authorization often creates burdens for both 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 that the drug is not covered, but lists other drugs that would be covered.

Private health plans tend to keep detailed information on the disposition of exception requests; however, some information never comes back to a plan, she said. For example, the private plans MedPAC surveyed didn't seem to know how often a beneficiary paid out of pocket for a drug when the drug was not covered, how often pharmacists contact physicians or the plan member when a drug isn't covered, or if the physician even had time to respond to the situation.

One physician who MedPAC analysts surveyed reported that his practice spends several hours a day trying to resolve prior authorization matters.

Private plans have tried to minimize this burden by educating their members and physicians about their formularies.

“Some plans deal with the burden by simply placing fewer drugs on prior authorization,” she said.

U.S. medical schools need to improve their tuition- and fee-setting processes to help students pay off their debts, the Association of American Medical Colleges concluded in a new study.

The future affordability of a U.S. medical education may be in jeopardy unless significant changes are made, particularly for lower-income applicants and applicants from racial and ethnic groups underrepresented in medicine, said the study, conducted by an AAMC working group.

The median indebtedness of medical school graduates has increased dramatically during the last 20 years–from $20,000 for both public and private schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Although medical school tuition and fees have increased at rates far in excess of inflation, physician income at the same time has remained relatively flat, the study said.

To address rising tuition costs and student debt, the AAMC recommended medical schools offer:

▸ Greater predictability about the student costs of a medical education.

▸ Ongoing financial education for medical students.

▸ More financial aid, with an emphasis on need-based scholarships and on programs offering loan repayment and forgiveness in exchange for service in the military or to underserved populations.

▸ Periodic self-reviews of their attendance costs.

Medical schools should also reevaluate their funding of medical education and develop innovative methods to generate financial support at the local, state, and national levels for financial aid programs that would address the nation's current health care needs, the AAMC recommended.

“It's essential that we find more creative ways for students to pay off their educational debt by providing health care services to our uninsured and underserved citizens,” said Jordan J. Cohen, M.D., president of the AAMC.

The American Medical Association has offered some assistance in this area by awarding a total of $40,000 in grants to five medical schools to help medical students and patients care for patients in underserved communities.

The grants, part of the AMA's Reaching Equitable Access to Care for Health Program, will support health promotion and disease prevention projects in free clinics led by medical students. Grant recipients included schools in New York, Texas, Pennsylvania, and Chicago.

U.S. medical schools need to improve their tuition- and fee-setting processes to help students pay off their debts, the Association of American Medical Colleges concluded in a new study.

The future affordability of a U.S. medical education may be in jeopardy unless significant changes are made, particularly for lower-income applicants and applicants from racial and ethnic groups underrepresented in medicine, said the study, conducted by an AAMC working group.

The median indebtedness of medical school graduates has increased dramatically during the last 20 years–from $20,000 for both public and private schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Although medical school tuition and fees have increased at rates far in excess of inflation, physician income at the same time has remained relatively flat, the study said.

To address rising tuition costs and student debt, the AAMC recommended medical schools offer:

▸ Greater predictability about the student costs of a medical education.

▸ Ongoing financial education for medical students.

▸ More financial aid, with an emphasis on need-based scholarships and on programs offering loan repayment and forgiveness in exchange for service in the military or to underserved populations.

▸ Periodic self-reviews of their attendance costs.

Medical schools should also reevaluate their funding of medical education and develop innovative methods to generate financial support at the local, state, and national levels for financial aid programs that would address the nation's current health care needs, the AAMC recommended.

“It's essential that we find more creative ways for students to pay off their educational debt by providing health care services to our uninsured and underserved citizens,” said Jordan J. Cohen, M.D., president of the AAMC.

The American Medical Association has offered some assistance in this area by awarding a total of $40,000 in grants to five medical schools to help medical students and patients care for patients in underserved communities.

The grants, part of the AMA's Reaching Equitable Access to Care for Health Program, will support health promotion and disease prevention projects in free clinics led by medical students. Grant recipients included schools in New York, Texas, Pennsylvania, and Chicago.

U.S. medical schools need to improve their tuition- and fee-setting processes to help students pay off their debts, the Association of American Medical Colleges concluded in a new study.

The future affordability of a U.S. medical education may be in jeopardy unless significant changes are made, particularly for lower-income applicants and applicants from racial and ethnic groups underrepresented in medicine, said the study, conducted by an AAMC working group.

The median indebtedness of medical school graduates has increased dramatically during the last 20 years–from $20,000 for both public and private schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Although medical school tuition and fees have increased at rates far in excess of inflation, physician income at the same time has remained relatively flat, the study said.

To address rising tuition costs and student debt, the AAMC recommended medical schools offer:

▸ Greater predictability about the student costs of a medical education.

▸ Ongoing financial education for medical students.

▸ More financial aid, with an emphasis on need-based scholarships and on programs offering loan repayment and forgiveness in exchange for service in the military or to underserved populations.

▸ Periodic self-reviews of their attendance costs.

Medical schools should also reevaluate their funding of medical education and develop innovative methods to generate financial support at the local, state, and national levels for financial aid programs that would address the nation's current health care needs, the AAMC recommended.

“It's essential that we find more creative ways for students to pay off their educational debt by providing health care services to our uninsured and underserved citizens,” said Jordan J. Cohen, M.D., president of the AAMC.

The American Medical Association has offered some assistance in this area by awarding a total of $40,000 in grants to five medical schools to help medical students and patients care for patients in underserved communities.

The grants, part of the AMA's Reaching Equitable Access to Care for Health Program, will support health promotion and disease prevention projects in free clinics led by medical students. Grant recipients included schools in New York, Texas, Pennsylvania, and Chicago.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said. There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be. It was also determined that groups serving large Hispanic or Native American populations should get “extra credit” for having to deal with more diverse, culturally different populations.

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

Sometimes, the simplest incentives can produce good results.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said. There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be. It was also determined that groups serving large Hispanic or Native American populations should get “extra credit” for having to deal with more diverse, culturally different populations.

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

Sometimes, the simplest incentives can produce good results.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The estimated aggregate payment to physician groups in the IHA program in 2003 was between $40 million and $50 million, although some groups thought they didn't get paid properly, Dr. Bangasser said. There were some concerns about increased utilization and cost of services for groups participating in the program, and what the long-term returns on investment would be. It was also determined that groups serving large Hispanic or Native American populations should get “extra credit” for having to deal with more diverse, culturally different populations.

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

Sometimes, the simplest incentives can produce good results.

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

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

Ads Influence Prescribing

Direct-to-consumer advertisements appear to have an impact on physician prescribing practices, a study by Richard L. Kravitz, M.D., of the University of California, Davis, found. A total of 152 general internists and family physicians were recruited from solo and group practices and health maintenance organizations to participate in the study, which focused on advertising for prescription antidepressants (JAMA 2005;293:1995–2002). Standardized patients were randomly assigned to make 298 unannounced visits, presenting either with major depression or adjustment disorder with depressed mood. When the patients with depression made a general request for an antidepressant, only 3% of the physicians prescribed paroxetine (Paxil). However, when they asked for the prescription by name, 27% were given a prescription for Paxil. In addition, patients with adjustment disorder symptoms were more likely to receive a prescription for an antidepressant if they made a brand specific request (55%) versus a general request (39%).

E-Prescribing Standards

Medicare should adopt a program-wide system of uniform national electronic prescribing standards for its new prescription drug benefit, according to the Pharmaceutical Care Management Association (PCMA). A uniform national standard is key to maximizing the participation of private plans in the Part D benefit and in helping to reduce regional variations in health care delivery and outcomes, PCMA said in comments sent to the Centers for Medicare and Medicaid Services on its proposed rule for Medicare e-prescribing standards. “PCMA believes that Medicare e-prescribing holds the potential to transform the health care delivery system,” PCMA President Mark Merritt said in a statement. “Regrettably, a 50-state patchwork approach would increase costs, decrease efficiency, and severely undermine the promise of e-prescribing.” The organization also urged CMS officials to pre-empt duplicative and conflicting state laws that could result in increased costs.

CMS: Pay for Performance Works

Preliminary data indicate that pay-for-performance is improving quality of care in hospitals. A 3-year demonstration project sponsored by the Centers for Medicare and Medicaid Services is tracking hospital performance on a set of 34 measures of processes and outcomes of care for five common clinical conditions. Reports from more than 270 participating hospitals on their experiences during the project's first year show that median quality scores improved in all of the clinical areas. For example, scores increased from 90% to 93% for patients with acute myocardial infarction; from 64% to 76% for patients with heart failure; and from 70% to 80% for patients with pneumonia. These early findings demonstrate that using financial incentives works to promote delivery of better patient care and to avoid costly complications for patients, said CMS Administrator Mark B. McClellan, M.D.

New Medicare Wheelchair Policy

Ability to function is the primary criteria in the new national coverage policy issued by CMS for power wheelchairs and scooters. The criteria look at how well the beneficiary can accomplish activities of daily living such as toileting, grooming, and eating with and without using a wheelchair or other mobility device. The criteria are “part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” Dr. McClellan said in a statement. The coverage policy is one element in Medicare's year-old effort to improve the coverage, payment, and quality of suppliers for wheelchairs and scooters. That effort was launched after Medicare spending on mobility equipment rose to $1.2 billion annually.

Uninsured Rates Among the States

Minnesota has the lowest uninsured rate among employed adults (7%), followed by Hawaii, the District of Columbia, and Delaware, each with uninsured rates of 9%. The states with the highest rates of uninsured residents include Texas (27%), New Mexico (23%), and Florida (22%). The report was compiled by the Robert Wood Johnson Foundation, which analyzed 2003 data from the Centers for Disease Control and Prevention. Although some states fare better than others, the problem is pervasive among workers in every state. More than 20 million working adults do not have health insurance. In eight states, at least 1 in 5 working adults is uninsured, and in 39 other states at least 1 working adult in every 10 does not have health coverage.

Unhealthy Habits

Very few Americans are doing all they can to maintain a healthy life, according to a nationally representative survey of 153,805 adults (Arch. Intern. Med. 2005;165:854–7). Mathew Reeves, Ph.D., of Michigan State University, East Lansing, found that only 3% followed four steps that define a healthy lifestyle: not smoking, holding weight down, eating adequate amounts of fruits and vegetables, and exercising. Women tended to follow these steps more than men, as did whites compared with minority populations. But no one group came close to what is necessary to lead a healthy life, Dr. Reeves said. When assessed individually, these health statistics didn't look as grim: Of the respondents, 76% said they didn't smoke, 23% included at least five fruits and vegetables in their diets, and 40% maintained a healthy weight.

Ads Influence Prescribing

Direct-to-consumer advertisements appear to have an impact on physician prescribing practices, a study by Richard L. Kravitz, M.D., of the University of California, Davis, found. A total of 152 general internists and family physicians were recruited from solo and group practices and health maintenance organizations to participate in the study, which focused on advertising for prescription antidepressants (JAMA 2005;293:1995–2002). Standardized patients were randomly assigned to make 298 unannounced visits, presenting either with major depression or adjustment disorder with depressed mood. When the patients with depression made a general request for an antidepressant, only 3% of the physicians prescribed paroxetine (Paxil). However, when they asked for the prescription by name, 27% were given a prescription for Paxil. In addition, patients with adjustment disorder symptoms were more likely to receive a prescription for an antidepressant if they made a brand specific request (55%) versus a general request (39%).

E-Prescribing Standards

Medicare should adopt a program-wide system of uniform national electronic prescribing standards for its new prescription drug benefit, according to the Pharmaceutical Care Management Association (PCMA). A uniform national standard is key to maximizing the participation of private plans in the Part D benefit and in helping to reduce regional variations in health care delivery and outcomes, PCMA said in comments sent to the Centers for Medicare and Medicaid Services on its proposed rule for Medicare e-prescribing standards. “PCMA believes that Medicare e-prescribing holds the potential to transform the health care delivery system,” PCMA President Mark Merritt said in a statement. “Regrettably, a 50-state patchwork approach would increase costs, decrease efficiency, and severely undermine the promise of e-prescribing.” The organization also urged CMS officials to pre-empt duplicative and conflicting state laws that could result in increased costs.

CMS: Pay for Performance Works

Preliminary data indicate that pay-for-performance is improving quality of care in hospitals. A 3-year demonstration project sponsored by the Centers for Medicare and Medicaid Services is tracking hospital performance on a set of 34 measures of processes and outcomes of care for five common clinical conditions. Reports from more than 270 participating hospitals on their experiences during the project's first year show that median quality scores improved in all of the clinical areas. For example, scores increased from 90% to 93% for patients with acute myocardial infarction; from 64% to 76% for patients with heart failure; and from 70% to 80% for patients with pneumonia. These early findings demonstrate that using financial incentives works to promote delivery of better patient care and to avoid costly complications for patients, said CMS Administrator Mark B. McClellan, M.D.

New Medicare Wheelchair Policy

Ability to function is the primary criteria in the new national coverage policy issued by CMS for power wheelchairs and scooters. The criteria look at how well the beneficiary can accomplish activities of daily living such as toileting, grooming, and eating with and without using a wheelchair or other mobility device. The criteria are “part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” Dr. McClellan said in a statement. The coverage policy is one element in Medicare's year-old effort to improve the coverage, payment, and quality of suppliers for wheelchairs and scooters. That effort was launched after Medicare spending on mobility equipment rose to $1.2 billion annually.

Uninsured Rates Among the States

Minnesota has the lowest uninsured rate among employed adults (7%), followed by Hawaii, the District of Columbia, and Delaware, each with uninsured rates of 9%. The states with the highest rates of uninsured residents include Texas (27%), New Mexico (23%), and Florida (22%). The report was compiled by the Robert Wood Johnson Foundation, which analyzed 2003 data from the Centers for Disease Control and Prevention. Although some states fare better than others, the problem is pervasive among workers in every state. More than 20 million working adults do not have health insurance. In eight states, at least 1 in 5 working adults is uninsured, and in 39 other states at least 1 working adult in every 10 does not have health coverage.

Unhealthy Habits

Very few Americans are doing all they can to maintain a healthy life, according to a nationally representative survey of 153,805 adults (Arch. Intern. Med. 2005;165:854–7). Mathew Reeves, Ph.D., of Michigan State University, East Lansing, found that only 3% followed four steps that define a healthy lifestyle: not smoking, holding weight down, eating adequate amounts of fruits and vegetables, and exercising. Women tended to follow these steps more than men, as did whites compared with minority populations. But no one group came close to what is necessary to lead a healthy life, Dr. Reeves said. When assessed individually, these health statistics didn't look as grim: Of the respondents, 76% said they didn't smoke, 23% included at least five fruits and vegetables in their diets, and 40% maintained a healthy weight.

Ads Influence Prescribing

Direct-to-consumer advertisements appear to have an impact on physician prescribing practices, a study by Richard L. Kravitz, M.D., of the University of California, Davis, found. A total of 152 general internists and family physicians were recruited from solo and group practices and health maintenance organizations to participate in the study, which focused on advertising for prescription antidepressants (JAMA 2005;293:1995–2002). Standardized patients were randomly assigned to make 298 unannounced visits, presenting either with major depression or adjustment disorder with depressed mood. When the patients with depression made a general request for an antidepressant, only 3% of the physicians prescribed paroxetine (Paxil). However, when they asked for the prescription by name, 27% were given a prescription for Paxil. In addition, patients with adjustment disorder symptoms were more likely to receive a prescription for an antidepressant if they made a brand specific request (55%) versus a general request (39%).

E-Prescribing Standards

Medicare should adopt a program-wide system of uniform national electronic prescribing standards for its new prescription drug benefit, according to the Pharmaceutical Care Management Association (PCMA). A uniform national standard is key to maximizing the participation of private plans in the Part D benefit and in helping to reduce regional variations in health care delivery and outcomes, PCMA said in comments sent to the Centers for Medicare and Medicaid Services on its proposed rule for Medicare e-prescribing standards. “PCMA believes that Medicare e-prescribing holds the potential to transform the health care delivery system,” PCMA President Mark Merritt said in a statement. “Regrettably, a 50-state patchwork approach would increase costs, decrease efficiency, and severely undermine the promise of e-prescribing.” The organization also urged CMS officials to pre-empt duplicative and conflicting state laws that could result in increased costs.

CMS: Pay for Performance Works

Preliminary data indicate that pay-for-performance is improving quality of care in hospitals. A 3-year demonstration project sponsored by the Centers for Medicare and Medicaid Services is tracking hospital performance on a set of 34 measures of processes and outcomes of care for five common clinical conditions. Reports from more than 270 participating hospitals on their experiences during the project's first year show that median quality scores improved in all of the clinical areas. For example, scores increased from 90% to 93% for patients with acute myocardial infarction; from 64% to 76% for patients with heart failure; and from 70% to 80% for patients with pneumonia. These early findings demonstrate that using financial incentives works to promote delivery of better patient care and to avoid costly complications for patients, said CMS Administrator Mark B. McClellan, M.D.

New Medicare Wheelchair Policy

Ability to function is the primary criteria in the new national coverage policy issued by CMS for power wheelchairs and scooters. The criteria look at how well the beneficiary can accomplish activities of daily living such as toileting, grooming, and eating with and without using a wheelchair or other mobility device. The criteria are “part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” Dr. McClellan said in a statement. The coverage policy is one element in Medicare's year-old effort to improve the coverage, payment, and quality of suppliers for wheelchairs and scooters. That effort was launched after Medicare spending on mobility equipment rose to $1.2 billion annually.

Uninsured Rates Among the States

Minnesota has the lowest uninsured rate among employed adults (7%), followed by Hawaii, the District of Columbia, and Delaware, each with uninsured rates of 9%. The states with the highest rates of uninsured residents include Texas (27%), New Mexico (23%), and Florida (22%). The report was compiled by the Robert Wood Johnson Foundation, which analyzed 2003 data from the Centers for Disease Control and Prevention. Although some states fare better than others, the problem is pervasive among workers in every state. More than 20 million working adults do not have health insurance. In eight states, at least 1 in 5 working adults is uninsured, and in 39 other states at least 1 working adult in every 10 does not have health coverage.

Unhealthy Habits

Very few Americans are doing all they can to maintain a healthy life, according to a nationally representative survey of 153,805 adults (Arch. Intern. Med. 2005;165:854–7). Mathew Reeves, Ph.D., of Michigan State University, East Lansing, found that only 3% followed four steps that define a healthy lifestyle: not smoking, holding weight down, eating adequate amounts of fruits and vegetables, and exercising. Women tended to follow these steps more than men, as did whites compared with minority populations. But no one group came close to what is necessary to lead a healthy life, Dr. Reeves said. When assessed individually, these health statistics didn't look as grim: Of the respondents, 76% said they didn't smoke, 23% included at least five fruits and vegetables in their diets, and 40% maintained a healthy weight.

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.

When considering software vendors, it's important to visit practice sites that are using installed systems. He advised physicians to 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. In researching vendors, Dr. Friedman learned that the per-doctor cost to install an EMR system, "including the whistles and bells," was $30,000-$50,000, including training.

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.

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 the 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 or surpassed their usual level of efficiency.

Besides handling appointment scheduling (see box), the system helps automate prescription refills. Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. Also, online preventive notices can remind physicians of what needs to be done for each patient. "And any work you do provides income," Dr. Friedman said.

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

Go Online for Appointment Scheduling

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

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

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

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit instead of becoming a "no show," he said. The practice estimates that 35%-45% of all of its appointments are made online, and the no-show rate with those 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. A 2003 Harris poll found 80% of all patients go online to get 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.

When considering software vendors, it's important to visit practice sites that are using installed systems. He advised physicians to 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. In researching vendors, Dr. Friedman learned that the per-doctor cost to install an EMR system, "including the whistles and bells," was $30,000-$50,000, including training.

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.

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 the 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 or surpassed their usual level of efficiency.

Besides handling appointment scheduling (see box), the system helps automate prescription refills. Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. Also, online preventive notices can remind physicians of what needs to be done for each patient. "And any work you do provides income," Dr. Friedman said.

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

Go Online for Appointment Scheduling

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

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

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

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit instead of becoming a "no show," he said. The practice estimates that 35%-45% of all of its appointments are made online, and the no-show rate with those 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. A 2003 Harris poll found 80% of all patients go online to get 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.

When considering software vendors, it's important to visit practice sites that are using installed systems. He advised physicians to 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. In researching vendors, Dr. Friedman learned that the per-doctor cost to install an EMR system, "including the whistles and bells," was $30,000-$50,000, including training.

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.

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 the 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 or surpassed their usual level of efficiency.

Besides handling appointment scheduling (see box), the system helps automate prescription refills. Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. Also, online preventive notices can remind physicians of what needs to be done for each patient. "And any work you do provides income," Dr. Friedman said.

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

Go Online for Appointment Scheduling

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

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

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

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit instead of becoming a "no show," he said. The practice estimates that 35%-45% of all of its appointments are made online, and the no-show rate with those 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. A 2003 Harris poll found 80% of all patients go online to get information.

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

Following up on a trend that has already affected the physician community, Mr. Aaron proposed a "pay-for-performance" system, where states could receive federal grants based on their "actual measured progress of increasing the number and proportion of state residents covered by health insurance." The grants would be set to cover much or all of the costs of extending health insurance coverage.

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

The federal government should first define a standard for health insurance coverage, Mr. Aaron said.

Mr. Aaron suggested that the minimum standard for coverage should be "similar to the actuarial value of the Federal Employees Health Benefits Program."

In addition, Mr. Aaron's plan would include a "first do no harm" standard, which would prohibit states from materially eroding coverage for the current Medicaid population.

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

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

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

Within these broad guidelines, it is important that states be encouraged to pursue any approach that would lead to an increase in the proportion of state residents who possess health insurance coverage, he continued.

Depending on local conditions and political preferences, states could use refundable tax credits or vouchers as a means to promote individual insurance coverage.

States could also facilitate new insurance groups by allowing churches, unions, and other organizations to create association health plans; extend Medicaid or the State Children's Health Insurance Program; impose employer mandates; or try to create an intrastate single-payer plan.

None of these options would be mandatory, he said.

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

Under such an approach, states would be able to propose an initiative for preserving coverage, select certain elements from the toolbox, and negotiate with the U.S. Health and Human Services department on appropriate waivers that would be used to pull such an option together, Mr. Butler explained.

In an attempt to maintain and extend the functional equivalent of Medicaid during these very tight budget times, states could utilize an enhanced federal refundable tax credit from the policy toolbox. By this means, states would be able to use additional federal funds to create purchasing alliances or pools, he said.

The key is to make sure that Medicaid populations are protected, "encouraging innovations through the states [and] rewarding pay-for-performance successes by the states, to reach these goals," he said.

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

Following up on a trend that has already affected the physician community, Mr. Aaron proposed a "pay-for-performance" system, where states could receive federal grants based on their "actual measured progress of increasing the number and proportion of state residents covered by health insurance." The grants would be set to cover much or all of the costs of extending health insurance coverage.

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

The federal government should first define a standard for health insurance coverage, Mr. Aaron said.

Mr. Aaron suggested that the minimum standard for coverage should be "similar to the actuarial value of the Federal Employees Health Benefits Program."

In addition, Mr. Aaron's plan would include a "first do no harm" standard, which would prohibit states from materially eroding coverage for the current Medicaid population.

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

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

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

Within these broad guidelines, it is important that states be encouraged to pursue any approach that would lead to an increase in the proportion of state residents who possess health insurance coverage, he continued.

Depending on local conditions and political preferences, states could use refundable tax credits or vouchers as a means to promote individual insurance coverage.

States could also facilitate new insurance groups by allowing churches, unions, and other organizations to create association health plans; extend Medicaid or the State Children's Health Insurance Program; impose employer mandates; or try to create an intrastate single-payer plan.

None of these options would be mandatory, he said.

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

Under such an approach, states would be able to propose an initiative for preserving coverage, select certain elements from the toolbox, and negotiate with the U.S. Health and Human Services department on appropriate waivers that would be used to pull such an option together, Mr. Butler explained.

In an attempt to maintain and extend the functional equivalent of Medicaid during these very tight budget times, states could utilize an enhanced federal refundable tax credit from the policy toolbox. By this means, states would be able to use additional federal funds to create purchasing alliances or pools, he said.

The key is to make sure that Medicaid populations are protected, "encouraging innovations through the states [and] rewarding pay-for-performance successes by the states, to reach these goals," he said.

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

Following up on a trend that has already affected the physician community, Mr. Aaron proposed a "pay-for-performance" system, where states could receive federal grants based on their "actual measured progress of increasing the number and proportion of state residents covered by health insurance." The grants would be set to cover much or all of the costs of extending health insurance coverage.

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

The federal government should first define a standard for health insurance coverage, Mr. Aaron said.

Mr. Aaron suggested that the minimum standard for coverage should be "similar to the actuarial value of the Federal Employees Health Benefits Program."

In addition, Mr. Aaron's plan would include a "first do no harm" standard, which would prohibit states from materially eroding coverage for the current Medicaid population.

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

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

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

Within these broad guidelines, it is important that states be encouraged to pursue any approach that would lead to an increase in the proportion of state residents who possess health insurance coverage, he continued.

Depending on local conditions and political preferences, states could use refundable tax credits or vouchers as a means to promote individual insurance coverage.

States could also facilitate new insurance groups by allowing churches, unions, and other organizations to create association health plans; extend Medicaid or the State Children's Health Insurance Program; impose employer mandates; or try to create an intrastate single-payer plan.

None of these options would be mandatory, he said.

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

Under such an approach, states would be able to propose an initiative for preserving coverage, select certain elements from the toolbox, and negotiate with the U.S. Health and Human Services department on appropriate waivers that would be used to pull such an option together, Mr. Butler explained.

In an attempt to maintain and extend the functional equivalent of Medicaid during these very tight budget times, states could utilize an enhanced federal refundable tax credit from the policy toolbox. By this means, states would be able to use additional federal funds to create purchasing alliances or pools, he said.

The key is to make sure that Medicaid populations are protected, "encouraging innovations through the states [and] rewarding pay-for-performance successes by the states, to reach these goals," he 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 said during a meeting of the Medicare Payment Advisory Commission.

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

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

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

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

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

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

▸ Pharmacy networks, formularies (which include 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.

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.

The agency will be collecting data on actual drugs and the spending associated with those drugs, "so there will be the ability to track how much was paid at the point of sale," Ms. Boccuti commented.

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

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

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

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

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

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

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

▸ Pharmacy networks, formularies (which include 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.

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.

The agency will be collecting data on actual drugs and the spending associated with those drugs, "so there will be the ability to track how much was paid at the point of sale," Ms. Boccuti commented.

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

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

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

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

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

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

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

▸ Pharmacy networks, formularies (which include 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.

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.

The agency will be collecting data on actual drugs and the spending associated with those drugs, "so there will be the ability to track how much was paid at the point of sale," Ms. Boccuti commented.

U.S. medical schools need to improve tuition- and fee-setting processes to help students pay their debts, the Association of American Medical Colleges said in a study.

The median indebtedness of medical school graduates has swelled from $20,000 for both private and public schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Income is relatively flat, according to the study by an AAMC working group

To address rising tuition and debt, the AAMC advised that medical schools offer:

▸ Greater predictability about the student costs of a medical education.

▸ Ongoing financial education for students.

▸ More financial aid, with an emphasis on need-based scholarships, loan repayment plans, and forgiveness in exchange for military service or to underserved groups.

▸ Periodic self-reviews of attendance costs.

Schools should also reevaluate their funding of medical education and innovative methods to generate financial support for financial aid programs that would address current health care needs, the AAMC recommended.

U.S. medical schools need to improve tuition- and fee-setting processes to help students pay their debts, the Association of American Medical Colleges said in a study.

The median indebtedness of medical school graduates has swelled from $20,000 for both private and public schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Income is relatively flat, according to the study by an AAMC working group

To address rising tuition and debt, the AAMC advised that medical schools offer:

▸ Greater predictability about the student costs of a medical education.

▸ Ongoing financial education for students.

▸ More financial aid, with an emphasis on need-based scholarships, loan repayment plans, and forgiveness in exchange for military service or to underserved groups.

▸ Periodic self-reviews of attendance costs.

Schools should also reevaluate their funding of medical education and innovative methods to generate financial support for financial aid programs that would address current health care needs, the AAMC recommended.

U.S. medical schools need to improve tuition- and fee-setting processes to help students pay their debts, the Association of American Medical Colleges said in a study.

The median indebtedness of medical school graduates has swelled from $20,000 for both private and public schools in 1984, to almost $140,000 and $100,000 for private and public schools, respectively, last year. Income is relatively flat, according to the study by an AAMC working group

To address rising tuition and debt, the AAMC advised that medical schools offer:

▸ Greater predictability about the student costs of a medical education.

▸ Ongoing financial education for students.

▸ More financial aid, with an emphasis on need-based scholarships, loan repayment plans, and forgiveness in exchange for military service or to underserved groups.

▸ Periodic self-reviews of attendance costs.

Schools should also reevaluate their funding of medical education and innovative methods to generate financial support for financial aid programs that would address current health care needs, the AAMC recommended.

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

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

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

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

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.

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

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

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.

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

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

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.