Mary Ellen Schneider

Private insurers will no longer be allowed to charge patients copayments or coinsurance when they have polyps removed during a colonoscopy.

Under the Affordable Care Act, most insurers are prohibited from imposing cost-sharing on patients for several recommended preventive screening procedures, including colonoscopy.

However, some health plans had been charging copayments or coinsurance when polyps were removed during the procedure. In February, the Department of Labor clarified that polyp removal is "an integral part of colonoscopy" and plans cannot charge patients for that part of the procedure.

The move was praised by the American Gastroenterological Association (AGA), which along with other physician groups, had been pushing the government to make that policy clear.

However, the groups remain concerned because the policy does not apply to Medicare. The current Medicare policy covers screening colonoscopy with no coinsurance or deductible. But if polyps are removed, the screening is reclassified as therapeutic and patients are responsible for coinsurance equal to 20% of the Medicare-approved charge.

This "colonoscopy loophole" creates a financial barrier that could discourage patients from undergoing colonoscopy, according to the AGA. Currently, nearly 38% of U.S. adults age 50 years and older have never been screened for colorectal cancer.

Changing the Medicare policy requires action by Congress and would cost the government about $200 million in lost revenue over 10 years, according to the AGA.

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Private insurers will no longer be allowed to charge patients copayments or coinsurance when they have polyps removed during a colonoscopy.

Under the Affordable Care Act, most insurers are prohibited from imposing cost-sharing on patients for several recommended preventive screening procedures, including colonoscopy.

However, some health plans had been charging copayments or coinsurance when polyps were removed during the procedure. In February, the Department of Labor clarified that polyp removal is "an integral part of colonoscopy" and plans cannot charge patients for that part of the procedure.

The move was praised by the American Gastroenterological Association (AGA), which along with other physician groups, had been pushing the government to make that policy clear.

However, the groups remain concerned because the policy does not apply to Medicare. The current Medicare policy covers screening colonoscopy with no coinsurance or deductible. But if polyps are removed, the screening is reclassified as therapeutic and patients are responsible for coinsurance equal to 20% of the Medicare-approved charge.

This "colonoscopy loophole" creates a financial barrier that could discourage patients from undergoing colonoscopy, according to the AGA. Currently, nearly 38% of U.S. adults age 50 years and older have never been screened for colorectal cancer.

Changing the Medicare policy requires action by Congress and would cost the government about $200 million in lost revenue over 10 years, according to the AGA.

[email protected]

Private insurers will no longer be allowed to charge patients copayments or coinsurance when they have polyps removed during a colonoscopy.

Under the Affordable Care Act, most insurers are prohibited from imposing cost-sharing on patients for several recommended preventive screening procedures, including colonoscopy.

However, some health plans had been charging copayments or coinsurance when polyps were removed during the procedure. In February, the Department of Labor clarified that polyp removal is "an integral part of colonoscopy" and plans cannot charge patients for that part of the procedure.

The move was praised by the American Gastroenterological Association (AGA), which along with other physician groups, had been pushing the government to make that policy clear.

However, the groups remain concerned because the policy does not apply to Medicare. The current Medicare policy covers screening colonoscopy with no coinsurance or deductible. But if polyps are removed, the screening is reclassified as therapeutic and patients are responsible for coinsurance equal to 20% of the Medicare-approved charge.

This "colonoscopy loophole" creates a financial barrier that could discourage patients from undergoing colonoscopy, according to the AGA. Currently, nearly 38% of U.S. adults age 50 years and older have never been screened for colorectal cancer.

Changing the Medicare policy requires action by Congress and would cost the government about $200 million in lost revenue over 10 years, according to the AGA.

[email protected]

It’s no April Fool’s joke: Brace for a 2% Medicare pay cut starting April 1 now that Congress and the president have failed to reach a deficit-reduction agreement to avoid $85 billion in federal spending cuts known as the sequester.

The deadline for an agreement was March 1, but the pay cut won’t kick in for another month, according to the Centers for Medicare and Medicaid Services.

The Medicare cut will impact physicians, hospitals, other health care providers, health plans, and prescription drug plans but will not directly impact beneficiaries.

Although the 2% cut is lower than the reductions in other federal agencies, physicians said it will still have a significant impact. Dr. Jeremy Lazarus, president of the American Medical Association, said that the cut comes at an especially bad time because physician payment rates have risen only about 4% over the last decade or so while the cost of caring for patients has climbed by more than 20%.

"A 2% cut erases half of what’s been gained over the past 12 years and continues to widen that gap between what Medicare pays and what it actually costs to care for patients," Dr. Lazarus said. "This is on top of the yearly concerns about even larger cuts that we’ve been going through over the last decade."

The cuts, and the back-and-forth in Washington over sequestration, add to physicians’ general concerns about the instability of Medicare payments, Dr. Lazarus said. That could lead some physicians to stop accepting Medicare patients.

"It’s a very difficult time to plan your practice and plan hiring new employees because you don’t understand what you’re going to be getting paid and what you can afford," said Dr. David L. Bronson, president of the American College of Physicians.

Other federal health agencies also will be affected by the cuts. The sequester calls for across-the-board cuts of about 5% annually from nondefense discretionary programs, but since the cuts will spread over 7 months instead of 12, the real percentage reductions will be closer to 9% for nondefense programs, according to a spokesperson from the Health Resources and Services Administration, which handles physician training and loan repayment programs.

At the National Institutes of Health, for example, officials estimate that they will have to cut about $1.6 billion from their biomedical research portfolio. That means the agency will be unable to award hundreds of new grants that otherwise would have been funded. It also will slow the pace of research in areas like cancer, development of a universal influenza vaccine covering all flu strains, and Alzheimer’s research, according to NIH Director Francis Collins.

"We will slow down research as a result of this," Dr. Collins said on a press call on Feb. 25.

[email protected]

It’s no April Fool’s joke: Brace for a 2% Medicare pay cut starting April 1 now that Congress and the president have failed to reach a deficit-reduction agreement to avoid $85 billion in federal spending cuts known as the sequester.

The deadline for an agreement was March 1, but the pay cut won’t kick in for another month, according to the Centers for Medicare and Medicaid Services.

The Medicare cut will impact physicians, hospitals, other health care providers, health plans, and prescription drug plans but will not directly impact beneficiaries.

Although the 2% cut is lower than the reductions in other federal agencies, physicians said it will still have a significant impact. Dr. Jeremy Lazarus, president of the American Medical Association, said that the cut comes at an especially bad time because physician payment rates have risen only about 4% over the last decade or so while the cost of caring for patients has climbed by more than 20%.

"A 2% cut erases half of what’s been gained over the past 12 years and continues to widen that gap between what Medicare pays and what it actually costs to care for patients," Dr. Lazarus said. "This is on top of the yearly concerns about even larger cuts that we’ve been going through over the last decade."

The cuts, and the back-and-forth in Washington over sequestration, add to physicians’ general concerns about the instability of Medicare payments, Dr. Lazarus said. That could lead some physicians to stop accepting Medicare patients.

"It’s a very difficult time to plan your practice and plan hiring new employees because you don’t understand what you’re going to be getting paid and what you can afford," said Dr. David L. Bronson, president of the American College of Physicians.

Other federal health agencies also will be affected by the cuts. The sequester calls for across-the-board cuts of about 5% annually from nondefense discretionary programs, but since the cuts will spread over 7 months instead of 12, the real percentage reductions will be closer to 9% for nondefense programs, according to a spokesperson from the Health Resources and Services Administration, which handles physician training and loan repayment programs.

At the National Institutes of Health, for example, officials estimate that they will have to cut about $1.6 billion from their biomedical research portfolio. That means the agency will be unable to award hundreds of new grants that otherwise would have been funded. It also will slow the pace of research in areas like cancer, development of a universal influenza vaccine covering all flu strains, and Alzheimer’s research, according to NIH Director Francis Collins.

"We will slow down research as a result of this," Dr. Collins said on a press call on Feb. 25.

[email protected]

It’s no April Fool’s joke: Brace for a 2% Medicare pay cut starting April 1 now that Congress and the president have failed to reach a deficit-reduction agreement to avoid $85 billion in federal spending cuts known as the sequester.

The deadline for an agreement was March 1, but the pay cut won’t kick in for another month, according to the Centers for Medicare and Medicaid Services.

The Medicare cut will impact physicians, hospitals, other health care providers, health plans, and prescription drug plans but will not directly impact beneficiaries.

Although the 2% cut is lower than the reductions in other federal agencies, physicians said it will still have a significant impact. Dr. Jeremy Lazarus, president of the American Medical Association, said that the cut comes at an especially bad time because physician payment rates have risen only about 4% over the last decade or so while the cost of caring for patients has climbed by more than 20%.

"A 2% cut erases half of what’s been gained over the past 12 years and continues to widen that gap between what Medicare pays and what it actually costs to care for patients," Dr. Lazarus said. "This is on top of the yearly concerns about even larger cuts that we’ve been going through over the last decade."

The cuts, and the back-and-forth in Washington over sequestration, add to physicians’ general concerns about the instability of Medicare payments, Dr. Lazarus said. That could lead some physicians to stop accepting Medicare patients.

"It’s a very difficult time to plan your practice and plan hiring new employees because you don’t understand what you’re going to be getting paid and what you can afford," said Dr. David L. Bronson, president of the American College of Physicians.

Other federal health agencies also will be affected by the cuts. The sequester calls for across-the-board cuts of about 5% annually from nondefense discretionary programs, but since the cuts will spread over 7 months instead of 12, the real percentage reductions will be closer to 9% for nondefense programs, according to a spokesperson from the Health Resources and Services Administration, which handles physician training and loan repayment programs.

At the National Institutes of Health, for example, officials estimate that they will have to cut about $1.6 billion from their biomedical research portfolio. That means the agency will be unable to award hundreds of new grants that otherwise would have been funded. It also will slow the pace of research in areas like cancer, development of a universal influenza vaccine covering all flu strains, and Alzheimer’s research, according to NIH Director Francis Collins.

"We will slow down research as a result of this," Dr. Collins said on a press call on Feb. 25.

[email protected]

Medicare overpaid for certain infusion drugs by more than $300 million over 7 years, according to a new report from the Health and Human Services Office of Inspector General.

Medicare paid $765 million between 2005 and 2011 for drugs administered using external or implantable infusion pumps, but the OIG asserted that the program and its beneficiaries could have saved $334 million by using a more accurate payment system.

Since 2005, Medicare has paid for most Part B drugs at 106% of the average sales price (ASP). Prior to then, Medicare paid 95% of the average wholesale price (AWP). AWP, which is the list price set by drug manufacturers, is often higher than the ASP and has little to do with the real cost of obtaining a drug, according to the OIG.

But infusion drugs administered in conjunction with durable medical equipment (DME), such as infusion pumps, continue to be paid under the old system. Providers receive 95% of the AWP that was in effect on Oct. 1, 2003.

The OIG report estimated that, if Medicare had paid for these DME infusion drugs based on the ASP instead of the AWP, Medicare Part B spending would have dropped from $765 million to $431 million between 2005 and 2011. Most of the savings would have been realized by the government, but Medicare beneficiaries would have saved $67 million in lower coinsurance payments.

Only about 30 drugs fall into the DME infusion drug category and even fewer contribute significantly to Medicare spending, according to the OIG report.

One drug – milrinone – accounted for 24%-62% of the total annual spending for DME infusion drugs between 2005 and 2011. In 2011, the ASP for milrinone, a short-term treatment for congestive heart failure, was $4.32, but Medicare paid $51.58, almost 12 times that amount, under the AWP-based payment system.

Although the report showed that, in general, Medicare is overpaying for DME infusion drugs, it’s not overpaying for all of them. In 2011, about one-third of the DME infusion drugs were being paid at a lower rate than the current ASP. Part of the reason for the underpayments is that the price is based on the AWP from 2003 but drugs have increased in price. For example, in 2005 the annual ASP for the antiviral drug ganciclovir was $34.33 and providers received a payment of $35.25 based on the AWP. By 2011, however, the ASP for ganciclovir had risen to $65.03 but providers were still being paid $35.25.

The OIG recommended that Medicare officials ask Congress to change the law to allow the small category of DME infusion drugs to be paid using the ASP methodology used for other Part B drugs. It also recommended that DME infusion drugs be included in the next round of Medicare’s DME, Prosthetics, Orthotics, and Supplies competitive bidding program.

[email protected]

Medicare overpaid for certain infusion drugs by more than $300 million over 7 years, according to a new report from the Health and Human Services Office of Inspector General.

Medicare paid $765 million between 2005 and 2011 for drugs administered using external or implantable infusion pumps, but the OIG asserted that the program and its beneficiaries could have saved $334 million by using a more accurate payment system.

Since 2005, Medicare has paid for most Part B drugs at 106% of the average sales price (ASP). Prior to then, Medicare paid 95% of the average wholesale price (AWP). AWP, which is the list price set by drug manufacturers, is often higher than the ASP and has little to do with the real cost of obtaining a drug, according to the OIG.

But infusion drugs administered in conjunction with durable medical equipment (DME), such as infusion pumps, continue to be paid under the old system. Providers receive 95% of the AWP that was in effect on Oct. 1, 2003.

The OIG report estimated that, if Medicare had paid for these DME infusion drugs based on the ASP instead of the AWP, Medicare Part B spending would have dropped from $765 million to $431 million between 2005 and 2011. Most of the savings would have been realized by the government, but Medicare beneficiaries would have saved $67 million in lower coinsurance payments.

Only about 30 drugs fall into the DME infusion drug category and even fewer contribute significantly to Medicare spending, according to the OIG report.

One drug – milrinone – accounted for 24%-62% of the total annual spending for DME infusion drugs between 2005 and 2011. In 2011, the ASP for milrinone, a short-term treatment for congestive heart failure, was $4.32, but Medicare paid $51.58, almost 12 times that amount, under the AWP-based payment system.

Although the report showed that, in general, Medicare is overpaying for DME infusion drugs, it’s not overpaying for all of them. In 2011, about one-third of the DME infusion drugs were being paid at a lower rate than the current ASP. Part of the reason for the underpayments is that the price is based on the AWP from 2003 but drugs have increased in price. For example, in 2005 the annual ASP for the antiviral drug ganciclovir was $34.33 and providers received a payment of $35.25 based on the AWP. By 2011, however, the ASP for ganciclovir had risen to $65.03 but providers were still being paid $35.25.

The OIG recommended that Medicare officials ask Congress to change the law to allow the small category of DME infusion drugs to be paid using the ASP methodology used for other Part B drugs. It also recommended that DME infusion drugs be included in the next round of Medicare’s DME, Prosthetics, Orthotics, and Supplies competitive bidding program.

[email protected]

Medicare overpaid for certain infusion drugs by more than $300 million over 7 years, according to a new report from the Health and Human Services Office of Inspector General.

Medicare paid $765 million between 2005 and 2011 for drugs administered using external or implantable infusion pumps, but the OIG asserted that the program and its beneficiaries could have saved $334 million by using a more accurate payment system.

Since 2005, Medicare has paid for most Part B drugs at 106% of the average sales price (ASP). Prior to then, Medicare paid 95% of the average wholesale price (AWP). AWP, which is the list price set by drug manufacturers, is often higher than the ASP and has little to do with the real cost of obtaining a drug, according to the OIG.

But infusion drugs administered in conjunction with durable medical equipment (DME), such as infusion pumps, continue to be paid under the old system. Providers receive 95% of the AWP that was in effect on Oct. 1, 2003.

The OIG report estimated that, if Medicare had paid for these DME infusion drugs based on the ASP instead of the AWP, Medicare Part B spending would have dropped from $765 million to $431 million between 2005 and 2011. Most of the savings would have been realized by the government, but Medicare beneficiaries would have saved $67 million in lower coinsurance payments.

Only about 30 drugs fall into the DME infusion drug category and even fewer contribute significantly to Medicare spending, according to the OIG report.

One drug – milrinone – accounted for 24%-62% of the total annual spending for DME infusion drugs between 2005 and 2011. In 2011, the ASP for milrinone, a short-term treatment for congestive heart failure, was $4.32, but Medicare paid $51.58, almost 12 times that amount, under the AWP-based payment system.

Although the report showed that, in general, Medicare is overpaying for DME infusion drugs, it’s not overpaying for all of them. In 2011, about one-third of the DME infusion drugs were being paid at a lower rate than the current ASP. Part of the reason for the underpayments is that the price is based on the AWP from 2003 but drugs have increased in price. For example, in 2005 the annual ASP for the antiviral drug ganciclovir was $34.33 and providers received a payment of $35.25 based on the AWP. By 2011, however, the ASP for ganciclovir had risen to $65.03 but providers were still being paid $35.25.

The OIG recommended that Medicare officials ask Congress to change the law to allow the small category of DME infusion drugs to be paid using the ASP methodology used for other Part B drugs. It also recommended that DME infusion drugs be included in the next round of Medicare’s DME, Prosthetics, Orthotics, and Supplies competitive bidding program.

[email protected]

Repeat or duplicative medical imaging is frequently cited by politicians as a quick and painless way to cut health care costs. It’s a political no-brainer in many ways, especially when the idea is backed up by estimates from the Institute of Medicine and the Medicare Payment Advisory Commission (MedPAC) that repeat tests waste billions of dollars each year.

But the American College of Radiology (ACR) has released a report that attempts to frame the issue in a different way. The ACR said that while there is plenty of unnecessary testing going on, not all repeat tests fall into that category. The ACR’s in-house research institute, the Harvey L. Neiman Health Policy Institute, has proposed a new classification system to help researchers and policy makers tell the difference between a test that’s medically necessary and one that it is not.

©picsfive/Fotolia.com

"Instead of maintaining a blanket presumption that repeat tests are a waste of time and resources, we need to more clearly understand what we mean by repeat imaging," Dr. Richard Duszak, the coauthor of the report and the CEO of the Harvey L. Neiman Health Policy Institute, Memphis, said during a press conference.

The seven-page report breaks down repeat tests into the following categories: supplementary imaging, duplicative imaging, follow-up imaging, and unrelated imaging. The categories are designed to help researchers when considering the appropriateness of repeat imaging on the same anatomic site within a test or condition-specific interval of time. The report outlines a series of clinical scenarios.

Here’s an example of medical necessary repeat testing from the "supplementary imaging" category: A physician orders a noncontrast abdominal CT scan to evaluate suspected kidney stones. A rounded low-density structure is identified in the left kidney. This could reflect either a benign simple cyst or a necrotic mass. As a result, a renal ultrasound is performed.

On the other hand, some supplementary tests offer little value, according to the report. Consider a situation in which a physician orders a CT, an ultrasound, and an MRI of the abdomen at the same time for an inpatient with abdominal pain with the hope that at least one of the studies will provide some useful information.

The new classification system will help researchers, in particular, to follow a "clinically meaningful approach" when evaluating some repeat medical testing contributes to health care costs, Dr. Duszak said.

So is medical imaging an area ripe for reform or are policy makers unfairly lumping all repeat imaging together as unnecessary?

[email protected]

Repeat or duplicative medical imaging is frequently cited by politicians as a quick and painless way to cut health care costs. It’s a political no-brainer in many ways, especially when the idea is backed up by estimates from the Institute of Medicine and the Medicare Payment Advisory Commission (MedPAC) that repeat tests waste billions of dollars each year.

But the American College of Radiology (ACR) has released a report that attempts to frame the issue in a different way. The ACR said that while there is plenty of unnecessary testing going on, not all repeat tests fall into that category. The ACR’s in-house research institute, the Harvey L. Neiman Health Policy Institute, has proposed a new classification system to help researchers and policy makers tell the difference between a test that’s medically necessary and one that it is not.

©picsfive/Fotolia.com

"Instead of maintaining a blanket presumption that repeat tests are a waste of time and resources, we need to more clearly understand what we mean by repeat imaging," Dr. Richard Duszak, the coauthor of the report and the CEO of the Harvey L. Neiman Health Policy Institute, Memphis, said during a press conference.

The seven-page report breaks down repeat tests into the following categories: supplementary imaging, duplicative imaging, follow-up imaging, and unrelated imaging. The categories are designed to help researchers when considering the appropriateness of repeat imaging on the same anatomic site within a test or condition-specific interval of time. The report outlines a series of clinical scenarios.

Here’s an example of medical necessary repeat testing from the "supplementary imaging" category: A physician orders a noncontrast abdominal CT scan to evaluate suspected kidney stones. A rounded low-density structure is identified in the left kidney. This could reflect either a benign simple cyst or a necrotic mass. As a result, a renal ultrasound is performed.

On the other hand, some supplementary tests offer little value, according to the report. Consider a situation in which a physician orders a CT, an ultrasound, and an MRI of the abdomen at the same time for an inpatient with abdominal pain with the hope that at least one of the studies will provide some useful information.

The new classification system will help researchers, in particular, to follow a "clinically meaningful approach" when evaluating some repeat medical testing contributes to health care costs, Dr. Duszak said.

So is medical imaging an area ripe for reform or are policy makers unfairly lumping all repeat imaging together as unnecessary?

[email protected]

Repeat or duplicative medical imaging is frequently cited by politicians as a quick and painless way to cut health care costs. It’s a political no-brainer in many ways, especially when the idea is backed up by estimates from the Institute of Medicine and the Medicare Payment Advisory Commission (MedPAC) that repeat tests waste billions of dollars each year.

But the American College of Radiology (ACR) has released a report that attempts to frame the issue in a different way. The ACR said that while there is plenty of unnecessary testing going on, not all repeat tests fall into that category. The ACR’s in-house research institute, the Harvey L. Neiman Health Policy Institute, has proposed a new classification system to help researchers and policy makers tell the difference between a test that’s medically necessary and one that it is not.

©picsfive/Fotolia.com

"Instead of maintaining a blanket presumption that repeat tests are a waste of time and resources, we need to more clearly understand what we mean by repeat imaging," Dr. Richard Duszak, the coauthor of the report and the CEO of the Harvey L. Neiman Health Policy Institute, Memphis, said during a press conference.

The seven-page report breaks down repeat tests into the following categories: supplementary imaging, duplicative imaging, follow-up imaging, and unrelated imaging. The categories are designed to help researchers when considering the appropriateness of repeat imaging on the same anatomic site within a test or condition-specific interval of time. The report outlines a series of clinical scenarios.

Here’s an example of medical necessary repeat testing from the "supplementary imaging" category: A physician orders a noncontrast abdominal CT scan to evaluate suspected kidney stones. A rounded low-density structure is identified in the left kidney. This could reflect either a benign simple cyst or a necrotic mass. As a result, a renal ultrasound is performed.

On the other hand, some supplementary tests offer little value, according to the report. Consider a situation in which a physician orders a CT, an ultrasound, and an MRI of the abdomen at the same time for an inpatient with abdominal pain with the hope that at least one of the studies will provide some useful information.

The new classification system will help researchers, in particular, to follow a "clinically meaningful approach" when evaluating some repeat medical testing contributes to health care costs, Dr. Duszak said.

So is medical imaging an area ripe for reform or are policy makers unfairly lumping all repeat imaging together as unnecessary?

[email protected]

Doctors need to spend more time with patients and less time dealing with insurance paperwork and government-hassles, according to recommendations from the American College of Physicians.

In a report on the "State of the Nation’s Health Care," ACP officials outlined a series of policy recommendations aimed at reducing the regulatory requirements that they said get in the way of the physician-patient relationship.

At the top of their list: Paying physicians more for time-intensive visits with complex patients under the current fee-for-service system. For new models, such as capitation and bundled payments, they urged policy makers to ensure that there are explicit incentives to spend an appropriate amount of time with patients.

The ACP also called on the government and insurers to dramatically reduce clinical "micromanagement" such as preauthorization requirements and detailed documentation of clinical encounters. They recommended that the Centers for Medicare and Medicaid Services (CMS) harmonize and reduce the number of measures used in their various reporting programs, moving away from process measures and toward composite outcomes measures.

"Measurement can be a good tool in helping to improve outcomes, but not if the measures themselves don’t make sense, if they are in conflict with each other, or [are] too difficult to report on," Robert Doherty, ACP senior vice president of government affairs and public policy, said during a press conference on Feb. 20.

The CMS should not require physicians to transition to the new ICD-10 coding system, according to the ACP. The conversion process would place "enormous costs and administrative burdens" on physicians, Mr. Doherty said. Instead, the government should adopt a clinical terminology system to be used by physicians and then use automated crosswalks to generate codes for payment and reporting.

Also in the ACP’s sights: The current medical liability system and the strain it puts on the physician-patient relationship. Reforms such as caps on noneconomic damages, limits on attorney contingency fees, early disclosure of medical errors, and the use of specialized health courts should be enacted, according to college officials.

"The current adversarial tort system interferes with the patient-physician relationship and inhibits physicians from responsibly ordering tests and procedures based primarily on clinical and cost effectiveness and their patients’ needs in accordance with good practice guidelines," Mr. Doherty said.

The ACP also warned state and federal officials to stop trying to legislate how physicians talk to patients. Several states have laws or pending legislation that limit what physicians can say about certain risk factors or require them to provide diagnostic tests not supported by evidence.

"The inevitable result of the unrelenting assault on the patient-physician relationship is physician burnout, causing many physicians to leave their beloved profession," Dr. David Bronson, ACP president, said during the press conference.

The ACP report also outlines a series of recommendations aimed at improving the overall U.S. health care system:

• All states should participate in the expansion of Medicaid eligibility and set up health insurance exchanges on their own or in partnership with the federal government.

• Congress and the Obama administration should replace the across-the-board sequestration cuts scheduled to take effect on March 1.

• Congress should eliminate the Sustainable Growth Rate formula used to set Medicare physician payments

• Policy makers should preserve funding for graduate medical education and narrow the gap between primary care and specialist pay

• Congress should enact gun control legislation that includes improved access to mental health services, requires background checks on gun sales, bans high-capacity magazines, and bans certain semiautomatic weapons.

Convincing lawmakers to tackle the ACP’s list of priorities will be a "tall order," Mr. Doherty said, but he said he’s hopeful they will make headway since these are "commonsense" changes.

[email protected]

Doctors need to spend more time with patients and less time dealing with insurance paperwork and government-hassles, according to recommendations from the American College of Physicians.

In a report on the "State of the Nation’s Health Care," ACP officials outlined a series of policy recommendations aimed at reducing the regulatory requirements that they said get in the way of the physician-patient relationship.

At the top of their list: Paying physicians more for time-intensive visits with complex patients under the current fee-for-service system. For new models, such as capitation and bundled payments, they urged policy makers to ensure that there are explicit incentives to spend an appropriate amount of time with patients.

The ACP also called on the government and insurers to dramatically reduce clinical "micromanagement" such as preauthorization requirements and detailed documentation of clinical encounters. They recommended that the Centers for Medicare and Medicaid Services (CMS) harmonize and reduce the number of measures used in their various reporting programs, moving away from process measures and toward composite outcomes measures.

"Measurement can be a good tool in helping to improve outcomes, but not if the measures themselves don’t make sense, if they are in conflict with each other, or [are] too difficult to report on," Robert Doherty, ACP senior vice president of government affairs and public policy, said during a press conference on Feb. 20.

The CMS should not require physicians to transition to the new ICD-10 coding system, according to the ACP. The conversion process would place "enormous costs and administrative burdens" on physicians, Mr. Doherty said. Instead, the government should adopt a clinical terminology system to be used by physicians and then use automated crosswalks to generate codes for payment and reporting.

Also in the ACP’s sights: The current medical liability system and the strain it puts on the physician-patient relationship. Reforms such as caps on noneconomic damages, limits on attorney contingency fees, early disclosure of medical errors, and the use of specialized health courts should be enacted, according to college officials.

"The current adversarial tort system interferes with the patient-physician relationship and inhibits physicians from responsibly ordering tests and procedures based primarily on clinical and cost effectiveness and their patients’ needs in accordance with good practice guidelines," Mr. Doherty said.

The ACP also warned state and federal officials to stop trying to legislate how physicians talk to patients. Several states have laws or pending legislation that limit what physicians can say about certain risk factors or require them to provide diagnostic tests not supported by evidence.

"The inevitable result of the unrelenting assault on the patient-physician relationship is physician burnout, causing many physicians to leave their beloved profession," Dr. David Bronson, ACP president, said during the press conference.

The ACP report also outlines a series of recommendations aimed at improving the overall U.S. health care system:

• All states should participate in the expansion of Medicaid eligibility and set up health insurance exchanges on their own or in partnership with the federal government.

• Congress and the Obama administration should replace the across-the-board sequestration cuts scheduled to take effect on March 1.

• Congress should eliminate the Sustainable Growth Rate formula used to set Medicare physician payments

• Policy makers should preserve funding for graduate medical education and narrow the gap between primary care and specialist pay

• Congress should enact gun control legislation that includes improved access to mental health services, requires background checks on gun sales, bans high-capacity magazines, and bans certain semiautomatic weapons.

Convincing lawmakers to tackle the ACP’s list of priorities will be a "tall order," Mr. Doherty said, but he said he’s hopeful they will make headway since these are "commonsense" changes.

[email protected]

Doctors need to spend more time with patients and less time dealing with insurance paperwork and government-hassles, according to recommendations from the American College of Physicians.

In a report on the "State of the Nation’s Health Care," ACP officials outlined a series of policy recommendations aimed at reducing the regulatory requirements that they said get in the way of the physician-patient relationship.

At the top of their list: Paying physicians more for time-intensive visits with complex patients under the current fee-for-service system. For new models, such as capitation and bundled payments, they urged policy makers to ensure that there are explicit incentives to spend an appropriate amount of time with patients.

The ACP also called on the government and insurers to dramatically reduce clinical "micromanagement" such as preauthorization requirements and detailed documentation of clinical encounters. They recommended that the Centers for Medicare and Medicaid Services (CMS) harmonize and reduce the number of measures used in their various reporting programs, moving away from process measures and toward composite outcomes measures.

"Measurement can be a good tool in helping to improve outcomes, but not if the measures themselves don’t make sense, if they are in conflict with each other, or [are] too difficult to report on," Robert Doherty, ACP senior vice president of government affairs and public policy, said during a press conference on Feb. 20.

The CMS should not require physicians to transition to the new ICD-10 coding system, according to the ACP. The conversion process would place "enormous costs and administrative burdens" on physicians, Mr. Doherty said. Instead, the government should adopt a clinical terminology system to be used by physicians and then use automated crosswalks to generate codes for payment and reporting.

Also in the ACP’s sights: The current medical liability system and the strain it puts on the physician-patient relationship. Reforms such as caps on noneconomic damages, limits on attorney contingency fees, early disclosure of medical errors, and the use of specialized health courts should be enacted, according to college officials.

"The current adversarial tort system interferes with the patient-physician relationship and inhibits physicians from responsibly ordering tests and procedures based primarily on clinical and cost effectiveness and their patients’ needs in accordance with good practice guidelines," Mr. Doherty said.

The ACP also warned state and federal officials to stop trying to legislate how physicians talk to patients. Several states have laws or pending legislation that limit what physicians can say about certain risk factors or require them to provide diagnostic tests not supported by evidence.

"The inevitable result of the unrelenting assault on the patient-physician relationship is physician burnout, causing many physicians to leave their beloved profession," Dr. David Bronson, ACP president, said during the press conference.

The ACP report also outlines a series of recommendations aimed at improving the overall U.S. health care system:

• All states should participate in the expansion of Medicaid eligibility and set up health insurance exchanges on their own or in partnership with the federal government.

• Congress and the Obama administration should replace the across-the-board sequestration cuts scheduled to take effect on March 1.

• Congress should eliminate the Sustainable Growth Rate formula used to set Medicare physician payments

• Policy makers should preserve funding for graduate medical education and narrow the gap between primary care and specialist pay

• Congress should enact gun control legislation that includes improved access to mental health services, requires background checks on gun sales, bans high-capacity magazines, and bans certain semiautomatic weapons.

Convincing lawmakers to tackle the ACP’s list of priorities will be a "tall order," Mr. Doherty said, but he said he’s hopeful they will make headway since these are "commonsense" changes.

[email protected]

Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?

Officials at the American Medical Association say there's a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.

"The fact that we've got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.

On Jan. 1, lawmakers passed legislation providing a short-term, 1-year delay to the scheduled 26.5% SGR cut. The bill also included a 2-month delay to scheduled tax hikes and federal spending cuts that were planned as part of a deficit- reduction process known as sequestration. That gives Congress several weeks to craft a new plan to deal with the nation’s debt and the growth in Medicare spending.

It wouldn't be unprecedented for a permanent SGR fix to be considered as part of comprehensive deficit-reduction legislation. SGR repeal was included in bipartisan plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others, Dr. Lazarus said..

Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.

The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.

"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.

ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn't want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services. Instead, lawmakers financed the 1-year SGR fix mainly through cuts to hospital payments.

"These fixes cannot be on the backs of the professionals providing care," Dr. Zoghbi said.

ACA milestones

This year also will see some practice-impacting milestones under the Affordable Care Act.

Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.

The law also provides an additional 2 years of funding to the Children's Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.

The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.

Some of the biggest changes under the ACA - the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges - are coming in 2014, but physician leaders said that doctors need to start preparing this year.

Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.

Penalties kick in

This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don't participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don't successfully report data during 2014.

"People don't realize that if they get past 2013, they won't have an opportunity to fix it for the next year," said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.

There are also penalties coming in Medicare's Electronic Prescribing (eRx) Incentive Program. To avoid a 2% penalty in 2014, physicians must meet Medicare's e-prescribing requirements by June 30, 2013.

Penalties from the Medicare Electronic Health Record (EHR) Incentive Program aren't coming until 2015, but Dr. Bagley said that physicians should take a good look at this program now to try to earn some money to offset the cost of EHR implementation. "The sooner you get going on this stuff, the better," he said.

A physician who starts participating this year can earn up to $39,000 over 4 years. Start next year and the bonus drops to $24,000. A 1% penalty takes effect in 2015, increasing to 2% the following year.

The transition to the ICD-10 coding set is another requirement that physicians need to keep in mind, ACP's Mr. Doherty said. The Department of Health and Human Services delayed the move to ICD-10 until October 2014, but Mr. Doherty said physicians can't afford to wait that long to prepare. The ACP is trying to convince federal officials to accept some alternative ways of coding that would both satisfy the ICD-10 requirements and be clinically relevant, he said.

Primary care gets a boost

Overall, the 2013 outlook will probably vary by specialty. The 2013 Medicare Physician Fee Schedule dealt some tough blows to subspecialists, making deep payment cuts in interventional cardiology, among others..

The 2013 fee schedule included two new transitional care management services codes (99495 and 99496) that will pay physicians for managing complex patients who have recently been discharged from a hospital or skilled nursing facility.

CPT code 99495 requires physicians or their staffs to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge. CPT code 99496 requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

The ACP, the AMA, and other groups are developing a series of proposals calling on Medicare to begin paying for more of the non-face-to-face work involved in chronic care management.

[email protected]

Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?

Officials at the American Medical Association say there's a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.

"The fact that we've got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.

On Jan. 1, lawmakers passed legislation providing a short-term, 1-year delay to the scheduled 26.5% SGR cut. The bill also included a 2-month delay to scheduled tax hikes and federal spending cuts that were planned as part of a deficit- reduction process known as sequestration. That gives Congress several weeks to craft a new plan to deal with the nation’s debt and the growth in Medicare spending.

It wouldn't be unprecedented for a permanent SGR fix to be considered as part of comprehensive deficit-reduction legislation. SGR repeal was included in bipartisan plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others, Dr. Lazarus said..

Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.

The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.

"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.

ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn't want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services. Instead, lawmakers financed the 1-year SGR fix mainly through cuts to hospital payments.

"These fixes cannot be on the backs of the professionals providing care," Dr. Zoghbi said.

ACA milestones

This year also will see some practice-impacting milestones under the Affordable Care Act.

Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.

The law also provides an additional 2 years of funding to the Children's Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.

The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.

Some of the biggest changes under the ACA - the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges - are coming in 2014, but physician leaders said that doctors need to start preparing this year.

Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.

Penalties kick in

This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don't participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don't successfully report data during 2014.

"People don't realize that if they get past 2013, they won't have an opportunity to fix it for the next year," said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.

There are also penalties coming in Medicare's Electronic Prescribing (eRx) Incentive Program. To avoid a 2% penalty in 2014, physicians must meet Medicare's e-prescribing requirements by June 30, 2013.

Penalties from the Medicare Electronic Health Record (EHR) Incentive Program aren't coming until 2015, but Dr. Bagley said that physicians should take a good look at this program now to try to earn some money to offset the cost of EHR implementation. "The sooner you get going on this stuff, the better," he said.

A physician who starts participating this year can earn up to $39,000 over 4 years. Start next year and the bonus drops to $24,000. A 1% penalty takes effect in 2015, increasing to 2% the following year.

The transition to the ICD-10 coding set is another requirement that physicians need to keep in mind, ACP's Mr. Doherty said. The Department of Health and Human Services delayed the move to ICD-10 until October 2014, but Mr. Doherty said physicians can't afford to wait that long to prepare. The ACP is trying to convince federal officials to accept some alternative ways of coding that would both satisfy the ICD-10 requirements and be clinically relevant, he said.

Primary care gets a boost

Overall, the 2013 outlook will probably vary by specialty. The 2013 Medicare Physician Fee Schedule dealt some tough blows to subspecialists, making deep payment cuts in interventional cardiology, among others..

The 2013 fee schedule included two new transitional care management services codes (99495 and 99496) that will pay physicians for managing complex patients who have recently been discharged from a hospital or skilled nursing facility.

CPT code 99495 requires physicians or their staffs to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge. CPT code 99496 requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

The ACP, the AMA, and other groups are developing a series of proposals calling on Medicare to begin paying for more of the non-face-to-face work involved in chronic care management.

[email protected]

Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?

Officials at the American Medical Association say there's a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.

"The fact that we've got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.

On Jan. 1, lawmakers passed legislation providing a short-term, 1-year delay to the scheduled 26.5% SGR cut. The bill also included a 2-month delay to scheduled tax hikes and federal spending cuts that were planned as part of a deficit- reduction process known as sequestration. That gives Congress several weeks to craft a new plan to deal with the nation’s debt and the growth in Medicare spending.

It wouldn't be unprecedented for a permanent SGR fix to be considered as part of comprehensive deficit-reduction legislation. SGR repeal was included in bipartisan plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others, Dr. Lazarus said..

Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.

The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.

"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.

ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn't want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services. Instead, lawmakers financed the 1-year SGR fix mainly through cuts to hospital payments.

"These fixes cannot be on the backs of the professionals providing care," Dr. Zoghbi said.

ACA milestones

This year also will see some practice-impacting milestones under the Affordable Care Act.

Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.

The law also provides an additional 2 years of funding to the Children's Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.

The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.

Some of the biggest changes under the ACA - the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges - are coming in 2014, but physician leaders said that doctors need to start preparing this year.

Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.

Penalties kick in

This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don't participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don't successfully report data during 2014.

"People don't realize that if they get past 2013, they won't have an opportunity to fix it for the next year," said Dr. Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians.

There are also penalties coming in Medicare's Electronic Prescribing (eRx) Incentive Program. To avoid a 2% penalty in 2014, physicians must meet Medicare's e-prescribing requirements by June 30, 2013.

Penalties from the Medicare Electronic Health Record (EHR) Incentive Program aren't coming until 2015, but Dr. Bagley said that physicians should take a good look at this program now to try to earn some money to offset the cost of EHR implementation. "The sooner you get going on this stuff, the better," he said.

A physician who starts participating this year can earn up to $39,000 over 4 years. Start next year and the bonus drops to $24,000. A 1% penalty takes effect in 2015, increasing to 2% the following year.

The transition to the ICD-10 coding set is another requirement that physicians need to keep in mind, ACP's Mr. Doherty said. The Department of Health and Human Services delayed the move to ICD-10 until October 2014, but Mr. Doherty said physicians can't afford to wait that long to prepare. The ACP is trying to convince federal officials to accept some alternative ways of coding that would both satisfy the ICD-10 requirements and be clinically relevant, he said.

Primary care gets a boost

Overall, the 2013 outlook will probably vary by specialty. The 2013 Medicare Physician Fee Schedule dealt some tough blows to subspecialists, making deep payment cuts in interventional cardiology, among others..

The 2013 fee schedule included two new transitional care management services codes (99495 and 99496) that will pay physicians for managing complex patients who have recently been discharged from a hospital or skilled nursing facility.

CPT code 99495 requires physicians or their staffs to make direct contact, by phone or electronically, with the patient or caregiver within 2 business days of discharge. A face-to-face visit with the patient is required within 14 calendar days of discharge. CPT code 99496 requires direct contact with the patient or caregiver within 2 business days and a face-to-face visit within 7 calendar days.

The ACP, the AMA, and other groups are developing a series of proposals calling on Medicare to begin paying for more of the non-face-to-face work involved in chronic care management.

[email protected]

Dr. Kathlyn E. Fletcher was fresh out of residency and completing her fellowship training at the University of Michigan when the Accreditation Council for Graduate Medical Education (ACGME) began limiting resident duty hours in 2003. She grew concerned that the limits would lead to unintended consequences, such as poor patient handoffs and less prepared trainees.

So she teamed up with one of her mentors, Dr. Sanjay Saint, and other colleagues at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center, on a research project that would examine the link between resident work hours and patient safety (Ann. Intern. Med. 2004;141:851-7). Over the next decade, Dr. Fletcher published research examining several aspects of the duty-hour issue, from how it impacts patient perceptions to transitions of care.

Now an associate professor of medicine at the Medical College of Wisconsin, Milwaukee, and a hospitalist at the Milwaukee Veterans Affairs Medical Center, Dr. Fletcher explained how resident duty-hour restrictions have changed the way hospitalists work.

Hospitalist News: You analyzed the impact of resident work-hour restrictions in 2004 and 2011. What have we learned over the last decade?

Dr. Fletcher: In 2004, there really wasn’t very much data about the impact of reducing hours. We had some data from New York because they had actually gone through a similar restriction process a number of years prior to that. There was quite a bit of data available about the impact on residents’ lives, but very little on what was likely to happen to patients. Even back then, it seemed clear that the quality of life for residents would improve during residency.

Fast-forward to the reviews that I published in 2011 with Dr. Vineet Arora and Dr. Darcy Reed to help the ACGME decide what they should do next (J. Gen. Intern. Med. 2011; 26: 907-19). We looked at the impact of the first round of duty-hour rules. It’s pretty clear from the resident standpoint that they are less tired and probably less burned out, and that other quality of life factors have likely improved. From the patient perspective, things have at least stayed the same, if not gotten a little bit better. There are a few very-high-quality studies looking at this issue, but no randomized controlled trials, so it’s impossible to say for sure. For the most part, it looks like these changes haven’t had an impact on the quality of care that’s occurring right now. Patient care has probably stayed the same and resident quality of life has improved.

HN: Transitions of care are increasingly important for hospitalists. How do resident work hours impact this area?

Dr. Fletcher: The whole duty-hour rules debate has cast a lot more light on how important an issue high-quality transitions are. We’re all paying more attention to it. With the residents working fewer hours and working fewer consecutive hours, that’s opened up the field for hospitalists to move in and take over some of the responsibilities that had previously fallen to residents. Hospitalists have more transitions to deal with because they have more patients. But I think that this whole change has really given hospitalists the opportunity to take the lead on defining what high-quality transitions are and doing some of the really good research on what high-quality transitions look like. Look at Dr. Vineet Arora’s body of work. She has really worked on defining what a high-quality transition is, and how you assess that. I think that’s probably one of the main ways that the duty-hour rules have impacted hospitalists. They brought to light this issue, and the hospitalists just ran with it.

HN: How have these restrictions impacted the training of future hospitalists? Are they prepared when they step out of training?

Dr. Fletcher: The good news for hospitalists is that the way residents are trained is really to become hospitalists. Of all of the specialties, residents are probably most ready to take on that job. But I still think they are coming out of training less qualified than they were before. I am starting to see this in my practice. The education is starting to lag behind a little bit, and I think that this is mostly because residents just aren’t getting exposed to as much before. Figuring out how to balance overwork with exposure to more clinical situations is the most important question for training right now. Moving forward in the next decade, we have to ask, are the physicians being trained ready to be independent practitioners? I’m worried that they are not.

HN: What is next for you in terms of research?

Dr. Fletcher: I have been spending more time writing about and researching workload for inpatient physicians. I still focus quite a bit on resident physicians. It’s not totally independent of work hours because one of the concerns with decreasing work hours is that the intensity of the work increases. The amount of work doesn’t decrease in proportion to the time, so there’s still more work to be done in less time. How does that impact the residents and the patients? That’s where I’m going now.

–Mary Ellen Schneider

[email protected]

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

Dr. Kathlyn E. Fletcher was fresh out of residency and completing her fellowship training at the University of Michigan when the Accreditation Council for Graduate Medical Education (ACGME) began limiting resident duty hours in 2003. She grew concerned that the limits would lead to unintended consequences, such as poor patient handoffs and less prepared trainees.

So she teamed up with one of her mentors, Dr. Sanjay Saint, and other colleagues at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center, on a research project that would examine the link between resident work hours and patient safety (Ann. Intern. Med. 2004;141:851-7). Over the next decade, Dr. Fletcher published research examining several aspects of the duty-hour issue, from how it impacts patient perceptions to transitions of care.

Now an associate professor of medicine at the Medical College of Wisconsin, Milwaukee, and a hospitalist at the Milwaukee Veterans Affairs Medical Center, Dr. Fletcher explained how resident duty-hour restrictions have changed the way hospitalists work.

Hospitalist News: You analyzed the impact of resident work-hour restrictions in 2004 and 2011. What have we learned over the last decade?

Dr. Fletcher: In 2004, there really wasn’t very much data about the impact of reducing hours. We had some data from New York because they had actually gone through a similar restriction process a number of years prior to that. There was quite a bit of data available about the impact on residents’ lives, but very little on what was likely to happen to patients. Even back then, it seemed clear that the quality of life for residents would improve during residency.

Fast-forward to the reviews that I published in 2011 with Dr. Vineet Arora and Dr. Darcy Reed to help the ACGME decide what they should do next (J. Gen. Intern. Med. 2011; 26: 907-19). We looked at the impact of the first round of duty-hour rules. It’s pretty clear from the resident standpoint that they are less tired and probably less burned out, and that other quality of life factors have likely improved. From the patient perspective, things have at least stayed the same, if not gotten a little bit better. There are a few very-high-quality studies looking at this issue, but no randomized controlled trials, so it’s impossible to say for sure. For the most part, it looks like these changes haven’t had an impact on the quality of care that’s occurring right now. Patient care has probably stayed the same and resident quality of life has improved.

HN: Transitions of care are increasingly important for hospitalists. How do resident work hours impact this area?

Dr. Fletcher: The whole duty-hour rules debate has cast a lot more light on how important an issue high-quality transitions are. We’re all paying more attention to it. With the residents working fewer hours and working fewer consecutive hours, that’s opened up the field for hospitalists to move in and take over some of the responsibilities that had previously fallen to residents. Hospitalists have more transitions to deal with because they have more patients. But I think that this whole change has really given hospitalists the opportunity to take the lead on defining what high-quality transitions are and doing some of the really good research on what high-quality transitions look like. Look at Dr. Vineet Arora’s body of work. She has really worked on defining what a high-quality transition is, and how you assess that. I think that’s probably one of the main ways that the duty-hour rules have impacted hospitalists. They brought to light this issue, and the hospitalists just ran with it.

HN: How have these restrictions impacted the training of future hospitalists? Are they prepared when they step out of training?

Dr. Fletcher: The good news for hospitalists is that the way residents are trained is really to become hospitalists. Of all of the specialties, residents are probably most ready to take on that job. But I still think they are coming out of training less qualified than they were before. I am starting to see this in my practice. The education is starting to lag behind a little bit, and I think that this is mostly because residents just aren’t getting exposed to as much before. Figuring out how to balance overwork with exposure to more clinical situations is the most important question for training right now. Moving forward in the next decade, we have to ask, are the physicians being trained ready to be independent practitioners? I’m worried that they are not.

HN: What is next for you in terms of research?

Dr. Fletcher: I have been spending more time writing about and researching workload for inpatient physicians. I still focus quite a bit on resident physicians. It’s not totally independent of work hours because one of the concerns with decreasing work hours is that the intensity of the work increases. The amount of work doesn’t decrease in proportion to the time, so there’s still more work to be done in less time. How does that impact the residents and the patients? That’s where I’m going now.

–Mary Ellen Schneider

[email protected]

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

Dr. Kathlyn E. Fletcher was fresh out of residency and completing her fellowship training at the University of Michigan when the Accreditation Council for Graduate Medical Education (ACGME) began limiting resident duty hours in 2003. She grew concerned that the limits would lead to unintended consequences, such as poor patient handoffs and less prepared trainees.

So she teamed up with one of her mentors, Dr. Sanjay Saint, and other colleagues at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center, on a research project that would examine the link between resident work hours and patient safety (Ann. Intern. Med. 2004;141:851-7). Over the next decade, Dr. Fletcher published research examining several aspects of the duty-hour issue, from how it impacts patient perceptions to transitions of care.

Now an associate professor of medicine at the Medical College of Wisconsin, Milwaukee, and a hospitalist at the Milwaukee Veterans Affairs Medical Center, Dr. Fletcher explained how resident duty-hour restrictions have changed the way hospitalists work.

Hospitalist News: You analyzed the impact of resident work-hour restrictions in 2004 and 2011. What have we learned over the last decade?

Dr. Fletcher: In 2004, there really wasn’t very much data about the impact of reducing hours. We had some data from New York because they had actually gone through a similar restriction process a number of years prior to that. There was quite a bit of data available about the impact on residents’ lives, but very little on what was likely to happen to patients. Even back then, it seemed clear that the quality of life for residents would improve during residency.

Fast-forward to the reviews that I published in 2011 with Dr. Vineet Arora and Dr. Darcy Reed to help the ACGME decide what they should do next (J. Gen. Intern. Med. 2011; 26: 907-19). We looked at the impact of the first round of duty-hour rules. It’s pretty clear from the resident standpoint that they are less tired and probably less burned out, and that other quality of life factors have likely improved. From the patient perspective, things have at least stayed the same, if not gotten a little bit better. There are a few very-high-quality studies looking at this issue, but no randomized controlled trials, so it’s impossible to say for sure. For the most part, it looks like these changes haven’t had an impact on the quality of care that’s occurring right now. Patient care has probably stayed the same and resident quality of life has improved.

HN: Transitions of care are increasingly important for hospitalists. How do resident work hours impact this area?

Dr. Fletcher: The whole duty-hour rules debate has cast a lot more light on how important an issue high-quality transitions are. We’re all paying more attention to it. With the residents working fewer hours and working fewer consecutive hours, that’s opened up the field for hospitalists to move in and take over some of the responsibilities that had previously fallen to residents. Hospitalists have more transitions to deal with because they have more patients. But I think that this whole change has really given hospitalists the opportunity to take the lead on defining what high-quality transitions are and doing some of the really good research on what high-quality transitions look like. Look at Dr. Vineet Arora’s body of work. She has really worked on defining what a high-quality transition is, and how you assess that. I think that’s probably one of the main ways that the duty-hour rules have impacted hospitalists. They brought to light this issue, and the hospitalists just ran with it.

HN: How have these restrictions impacted the training of future hospitalists? Are they prepared when they step out of training?

Dr. Fletcher: The good news for hospitalists is that the way residents are trained is really to become hospitalists. Of all of the specialties, residents are probably most ready to take on that job. But I still think they are coming out of training less qualified than they were before. I am starting to see this in my practice. The education is starting to lag behind a little bit, and I think that this is mostly because residents just aren’t getting exposed to as much before. Figuring out how to balance overwork with exposure to more clinical situations is the most important question for training right now. Moving forward in the next decade, we have to ask, are the physicians being trained ready to be independent practitioners? I’m worried that they are not.

HN: What is next for you in terms of research?

Dr. Fletcher: I have been spending more time writing about and researching workload for inpatient physicians. I still focus quite a bit on resident physicians. It’s not totally independent of work hours because one of the concerns with decreasing work hours is that the intensity of the work increases. The amount of work doesn’t decrease in proportion to the time, so there’s still more work to be done in less time. How does that impact the residents and the patients? That’s where I’m going now.

–Mary Ellen Schneider

[email protected]

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected]. Read previous columns at ehospitalistnews.com.

A small group of Republicans and Democrats in the House has introduced federal legislation to limit patients’ out-of-pocket costs for biologics and other specialty medications often used to treat rheumatoid arthritis, psoriasis, lupus, multiple sclerosis, and some cancers.

The Patients’ Access to Treatments Act (H.R. 460), which was introduced on Feb. 4, would require health plans to charge the same copayments for biologics and specialty drugs that they do for other off-formulary brand-name medications.

Typically, health plans use a three-tier system with set copays for generic drugs (tier 1), brand-name drugs (tier 2), and off-formulary brand-name drugs (tier 3). But some insurers have moved biologics and other high-cost medications into a fourth tier, where patients pay a percentage of the cost of the drug. The costs of the affected medications range from $12,000 to $48,000 a year or more, and the copays can range from 25% to 33%, according to the American College of Rheumatology.

"Over the past 2 years, hearing the stories of patients struggling to pay for medications that would dramatically improve their lives has been heartbreaking," Rep. David McKinley (R-W.Va.), the sponsor of the bill, said in a statement. "After talking with a number of people in these situations, it was clear action was needed."

Rep. McKinley introduced this legislation in the last session of Congress, but the bill stalled in committee.

[email protected]

A small group of Republicans and Democrats in the House has introduced federal legislation to limit patients’ out-of-pocket costs for biologics and other specialty medications often used to treat rheumatoid arthritis, psoriasis, lupus, multiple sclerosis, and some cancers.

The Patients’ Access to Treatments Act (H.R. 460), which was introduced on Feb. 4, would require health plans to charge the same copayments for biologics and specialty drugs that they do for other off-formulary brand-name medications.

Typically, health plans use a three-tier system with set copays for generic drugs (tier 1), brand-name drugs (tier 2), and off-formulary brand-name drugs (tier 3). But some insurers have moved biologics and other high-cost medications into a fourth tier, where patients pay a percentage of the cost of the drug. The costs of the affected medications range from $12,000 to $48,000 a year or more, and the copays can range from 25% to 33%, according to the American College of Rheumatology.

"Over the past 2 years, hearing the stories of patients struggling to pay for medications that would dramatically improve their lives has been heartbreaking," Rep. David McKinley (R-W.Va.), the sponsor of the bill, said in a statement. "After talking with a number of people in these situations, it was clear action was needed."

Rep. McKinley introduced this legislation in the last session of Congress, but the bill stalled in committee.

[email protected]

A small group of Republicans and Democrats in the House has introduced federal legislation to limit patients’ out-of-pocket costs for biologics and other specialty medications often used to treat rheumatoid arthritis, psoriasis, lupus, multiple sclerosis, and some cancers.

The Patients’ Access to Treatments Act (H.R. 460), which was introduced on Feb. 4, would require health plans to charge the same copayments for biologics and specialty drugs that they do for other off-formulary brand-name medications.

Typically, health plans use a three-tier system with set copays for generic drugs (tier 1), brand-name drugs (tier 2), and off-formulary brand-name drugs (tier 3). But some insurers have moved biologics and other high-cost medications into a fourth tier, where patients pay a percentage of the cost of the drug. The costs of the affected medications range from $12,000 to $48,000 a year or more, and the copays can range from 25% to 33%, according to the American College of Rheumatology.

"Over the past 2 years, hearing the stories of patients struggling to pay for medications that would dramatically improve their lives has been heartbreaking," Rep. David McKinley (R-W.Va.), the sponsor of the bill, said in a statement. "After talking with a number of people in these situations, it was clear action was needed."

Rep. McKinley introduced this legislation in the last session of Congress, but the bill stalled in committee.

[email protected]

Leaders in the field of pediatric hospital medicine will meet with the American Board of Pediatrics this spring in an attempt to develop a pathway for standardized training and certification in the field.

Although pediatric hospitalists have been around for decades and have created large bodies of work in both research and quality improvement, training in the field is variable. Some pediatric hospitalists go through years of fellowship, while others get on-the-job training after residency.

With that in mind, a large group of pediatric hospitalists began meeting about 2 years ago to figure out if the time had come for some type of standardized training and certification and what that would look like.

Courtesy Dr. Joseph Cramer

"It’s still a little up in the air," said Dr. Christopher G. Maloney, who cochaired the strategic planning committee comprised of volunteers from the American Academy of Pediatrics Section on Hospital Medicine, the Academic Pediatric Association, and the Society of Hospital Medicine.

The committee of nearly 50 physicians was formed in December 2010 to evaluate a range of options that would set pediatric hospital medicine apart as a distinct specialty. The options included everything from a 3-year fellowship under the direction of the American Board of Pediatrics to a continuation of the status quo.

There was a lot of interest and excitement about finding a way forward, Dr. Maloney, chief of pediatric inpatient medicine at the University of Utah and Primary Children’s Medical Center in Salt Lake City, said in an interview.

The committee held conference calls and meetings for several months to look at the pros and cons of various options. What developed was a general consensus that additional training is needed for pediatric hospitalists, said Dr. Suzanne Swanson Mendez, committee cochair and a pediatric hospitalist at Santa Clara Valley Medical Center in San Jose, Calif.

But how to operationalize that idea is still an open question.

In addition to the 3-year fellowship option, the committee also considered 2 years of fellowship, a hospital medicine residency track combined with 1 year of fellowship, or a fast-track approach that would require 2 years of residency and 2-3 years of fellowship training.

Courtesy Ariel Mendez

And they considered options outside of the traditional fellowship, such as creating a hospital medicine track during general pediatric residency. Other possibilities include a mandatory mentorship program after training or a Recognition of Focused Practice for pediatric hospital medicine, similar to what is offered by the American Board of Internal Medicine for hospitalists.

One of the reasons that reaching agreement on a specific option has been so difficult is that whatever is chosen must meet the needs of both academic and community hospitalists, Dr. Mendez said in an interview.

Another problem is that adding more training could impact interest among debt-burdened medical students.

One reason that hospital medicine is so attractive is that physicians can enter without completing fellowship training, said Dr. Tamara D. Simon, a pediatric hospitalist at Seattle Children’s Hospital who was closely involved in the strategic planning committee process. But on the other hand, there are additional skills necessary to care for hospitalized children, she said.

"I do think that there are specific skills learned in the course of fellowship that can really facilitate our ability to care for hospitalized children in both academic and community settings," Dr. Simon said in an interview.

Members of the strategic planning committee aren’t the only ones struggling with this issue.

During a 2-week period in July 2011, the committee surveyed pediatric hospitalists who were on listservs sponsored by the American Academy of Pediatrics Section on Hospital Medicine, the Academic Pediatric Association, and the Society of Hospital Medicine. Of the 132 respondents to the convenience sample, 33% preferred Recognition of Focused Practice, 30% favored a 2-year fellowship with subspecialty designation, and 17% selected a hospital medicine track within a pediatric residency (Hospital Pediatrics 2012;2:187-90).

Polls taken at last summer’s Pediatric Hospital Medicine meeting in Kentucky showed that physicians continue to be all over the map on this issue.

Among 109 audience members who attended a presentation about the strategic planning committee’s work and responded to questions, 27% said a 2-year fellowship under the American Board of Pediatrics guidelines was the best option. Another 18% favored the Recognition of Focused Practice, 14% selected a hospital medicine residency track with a 1-year fellowship, and 13% chose the status quo with the option for specialized training. The rest of the respondents were split among other training options or were undecided, according to Dr. Simon.

Dr. Erin Stucky Fisher, who runs the pediatric hospital medicine fellowship program at Rady Children’s Hospital in San Diego, offered her views while the committee was gathering comments. She said there’s a need for codified, credible training for everyone who cares for hospitalized children. That would let hospitals and patients know that training in pediatric hospital medicine results in a certain specific set of skills.

"That’s what I think kids need. We need to ask, ‘What is best for the hospitalized child?’ " Dr. Fisher said.

But while that training could lead to subspecialty board certification, it doesn’t have to, she said. However, the training program does need to teach the core competencies of the specialty. What a program looks like, and what form of certification should be considered, is under review, she said. The only option she would rule out is doing nothing.

"Staying still is hard and isn’t what pediatric hospitalists have done," Dr. Fisher said.

But Kenneth Pituch, director of the division of pediatric hospital medicine at C.S. Mott Children’s Hospital in Ann Arbor, Mich., is on the other end of the spectrum. He told the committee it’s too early to consider carving out a certification pathway that potentially requires 2 or 3 additional years of training. "We’re not quite there yet for a couple of reasons," he said.

For instance, requiring additional years of training for pediatric hospital medicine could make the specialty significantly less attractive to young doctors, he said. That would put a drain on the workforce needed to care for sick children in the hospital.

He’s also concerned about widening the gap in training between pediatricians working in the hospital and those in the outpatient setting at a time when collaboration in the care of chronically ill children is so important.

Right now, there are outpatient physicians who see a high volume of relatively healthy children, and pediatric hospitalists who care for acutely ill children. The problem is that there is little going on to address the care for the chronically ill children who bounce back and forth between the two settings, Dr. Pituch said. There could be a role for pediatric hospitalists in improving that care, but moving forward now with certification could make it more difficult to figure out what this other model would look like, he said.

"I’m just saying, let’s hold off," he added.

[email protected]

Leaders in the field of pediatric hospital medicine will meet with the American Board of Pediatrics this spring in an attempt to develop a pathway for standardized training and certification in the field.

Although pediatric hospitalists have been around for decades and have created large bodies of work in both research and quality improvement, training in the field is variable. Some pediatric hospitalists go through years of fellowship, while others get on-the-job training after residency.

With that in mind, a large group of pediatric hospitalists began meeting about 2 years ago to figure out if the time had come for some type of standardized training and certification and what that would look like.

Courtesy Dr. Joseph Cramer

"It’s still a little up in the air," said Dr. Christopher G. Maloney, who cochaired the strategic planning committee comprised of volunteers from the American Academy of Pediatrics Section on Hospital Medicine, the Academic Pediatric Association, and the Society of Hospital Medicine.

The committee of nearly 50 physicians was formed in December 2010 to evaluate a range of options that would set pediatric hospital medicine apart as a distinct specialty. The options included everything from a 3-year fellowship under the direction of the American Board of Pediatrics to a continuation of the status quo.

There was a lot of interest and excitement about finding a way forward, Dr. Maloney, chief of pediatric inpatient medicine at the University of Utah and Primary Children’s Medical Center in Salt Lake City, said in an interview.

The committee held conference calls and meetings for several months to look at the pros and cons of various options. What developed was a general consensus that additional training is needed for pediatric hospitalists, said Dr. Suzanne Swanson Mendez, committee cochair and a pediatric hospitalist at Santa Clara Valley Medical Center in San Jose, Calif.

But how to operationalize that idea is still an open question.

In addition to the 3-year fellowship option, the committee also considered 2 years of fellowship, a hospital medicine residency track combined with 1 year of fellowship, or a fast-track approach that would require 2 years of residency and 2-3 years of fellowship training.

Courtesy Ariel Mendez

And they considered options outside of the traditional fellowship, such as creating a hospital medicine track during general pediatric residency. Other possibilities include a mandatory mentorship program after training or a Recognition of Focused Practice for pediatric hospital medicine, similar to what is offered by the American Board of Internal Medicine for hospitalists.

One of the reasons that reaching agreement on a specific option has been so difficult is that whatever is chosen must meet the needs of both academic and community hospitalists, Dr. Mendez said in an interview.

Another problem is that adding more training could impact interest among debt-burdened medical students.

One reason that hospital medicine is so attractive is that physicians can enter without completing fellowship training, said Dr. Tamara D. Simon, a pediatric hospitalist at Seattle Children’s Hospital who was closely involved in the strategic planning committee process. But on the other hand, there are additional skills necessary to care for hospitalized children, she said.

"I do think that there are specific skills learned in the course of fellowship that can really facilitate our ability to care for hospitalized children in both academic and community settings," Dr. Simon said in an interview.

Members of the strategic planning committee aren’t the only ones struggling with this issue.

During a 2-week period in July 2011, the committee surveyed pediatric hospitalists who were on listservs sponsored by the American Academy of Pediatrics Section on Hospital Medicine, the Academic Pediatric Association, and the Society of Hospital Medicine. Of the 132 respondents to the convenience sample, 33% preferred Recognition of Focused Practice, 30% favored a 2-year fellowship with subspecialty designation, and 17% selected a hospital medicine track within a pediatric residency (Hospital Pediatrics 2012;2:187-90).

Polls taken at last summer’s Pediatric Hospital Medicine meeting in Kentucky showed that physicians continue to be all over the map on this issue.

Among 109 audience members who attended a presentation about the strategic planning committee’s work and responded to questions, 27% said a 2-year fellowship under the American Board of Pediatrics guidelines was the best option. Another 18% favored the Recognition of Focused Practice, 14% selected a hospital medicine residency track with a 1-year fellowship, and 13% chose the status quo with the option for specialized training. The rest of the respondents were split among other training options or were undecided, according to Dr. Simon.

Dr. Erin Stucky Fisher, who runs the pediatric hospital medicine fellowship program at Rady Children’s Hospital in San Diego, offered her views while the committee was gathering comments. She said there’s a need for codified, credible training for everyone who cares for hospitalized children. That would let hospitals and patients know that training in pediatric hospital medicine results in a certain specific set of skills.

"That’s what I think kids need. We need to ask, ‘What is best for the hospitalized child?’ " Dr. Fisher said.

But while that training could lead to subspecialty board certification, it doesn’t have to, she said. However, the training program does need to teach the core competencies of the specialty. What a program looks like, and what form of certification should be considered, is under review, she said. The only option she would rule out is doing nothing.

"Staying still is hard and isn’t what pediatric hospitalists have done," Dr. Fisher said.

But Kenneth Pituch, director of the division of pediatric hospital medicine at C.S. Mott Children’s Hospital in Ann Arbor, Mich., is on the other end of the spectrum. He told the committee it’s too early to consider carving out a certification pathway that potentially requires 2 or 3 additional years of training. "We’re not quite there yet for a couple of reasons," he said.

For instance, requiring additional years of training for pediatric hospital medicine could make the specialty significantly less attractive to young doctors, he said. That would put a drain on the workforce needed to care for sick children in the hospital.

He’s also concerned about widening the gap in training between pediatricians working in the hospital and those in the outpatient setting at a time when collaboration in the care of chronically ill children is so important.

Right now, there are outpatient physicians who see a high volume of relatively healthy children, and pediatric hospitalists who care for acutely ill children. The problem is that there is little going on to address the care for the chronically ill children who bounce back and forth between the two settings, Dr. Pituch said. There could be a role for pediatric hospitalists in improving that care, but moving forward now with certification could make it more difficult to figure out what this other model would look like, he said.

"I’m just saying, let’s hold off," he added.

[email protected]

Leaders in the field of pediatric hospital medicine will meet with the American Board of Pediatrics this spring in an attempt to develop a pathway for standardized training and certification in the field.

Although pediatric hospitalists have been around for decades and have created large bodies of work in both research and quality improvement, training in the field is variable. Some pediatric hospitalists go through years of fellowship, while others get on-the-job training after residency.

With that in mind, a large group of pediatric hospitalists began meeting about 2 years ago to figure out if the time had come for some type of standardized training and certification and what that would look like.

Courtesy Dr. Joseph Cramer

"It’s still a little up in the air," said Dr. Christopher G. Maloney, who cochaired the strategic planning committee comprised of volunteers from the American Academy of Pediatrics Section on Hospital Medicine, the Academic Pediatric Association, and the Society of Hospital Medicine.

The committee of nearly 50 physicians was formed in December 2010 to evaluate a range of options that would set pediatric hospital medicine apart as a distinct specialty. The options included everything from a 3-year fellowship under the direction of the American Board of Pediatrics to a continuation of the status quo.

There was a lot of interest and excitement about finding a way forward, Dr. Maloney, chief of pediatric inpatient medicine at the University of Utah and Primary Children’s Medical Center in Salt Lake City, said in an interview.

The committee held conference calls and meetings for several months to look at the pros and cons of various options. What developed was a general consensus that additional training is needed for pediatric hospitalists, said Dr. Suzanne Swanson Mendez, committee cochair and a pediatric hospitalist at Santa Clara Valley Medical Center in San Jose, Calif.

But how to operationalize that idea is still an open question.

In addition to the 3-year fellowship option, the committee also considered 2 years of fellowship, a hospital medicine residency track combined with 1 year of fellowship, or a fast-track approach that would require 2 years of residency and 2-3 years of fellowship training.

Courtesy Ariel Mendez

And they considered options outside of the traditional fellowship, such as creating a hospital medicine track during general pediatric residency. Other possibilities include a mandatory mentorship program after training or a Recognition of Focused Practice for pediatric hospital medicine, similar to what is offered by the American Board of Internal Medicine for hospitalists.

One of the reasons that reaching agreement on a specific option has been so difficult is that whatever is chosen must meet the needs of both academic and community hospitalists, Dr. Mendez said in an interview.

Another problem is that adding more training could impact interest among debt-burdened medical students.

One reason that hospital medicine is so attractive is that physicians can enter without completing fellowship training, said Dr. Tamara D. Simon, a pediatric hospitalist at Seattle Children’s Hospital who was closely involved in the strategic planning committee process. But on the other hand, there are additional skills necessary to care for hospitalized children, she said.

"I do think that there are specific skills learned in the course of fellowship that can really facilitate our ability to care for hospitalized children in both academic and community settings," Dr. Simon said in an interview.

Members of the strategic planning committee aren’t the only ones struggling with this issue.

During a 2-week period in July 2011, the committee surveyed pediatric hospitalists who were on listservs sponsored by the American Academy of Pediatrics Section on Hospital Medicine, the Academic Pediatric Association, and the Society of Hospital Medicine. Of the 132 respondents to the convenience sample, 33% preferred Recognition of Focused Practice, 30% favored a 2-year fellowship with subspecialty designation, and 17% selected a hospital medicine track within a pediatric residency (Hospital Pediatrics 2012;2:187-90).

Polls taken at last summer’s Pediatric Hospital Medicine meeting in Kentucky showed that physicians continue to be all over the map on this issue.

Among 109 audience members who attended a presentation about the strategic planning committee’s work and responded to questions, 27% said a 2-year fellowship under the American Board of Pediatrics guidelines was the best option. Another 18% favored the Recognition of Focused Practice, 14% selected a hospital medicine residency track with a 1-year fellowship, and 13% chose the status quo with the option for specialized training. The rest of the respondents were split among other training options or were undecided, according to Dr. Simon.

Dr. Erin Stucky Fisher, who runs the pediatric hospital medicine fellowship program at Rady Children’s Hospital in San Diego, offered her views while the committee was gathering comments. She said there’s a need for codified, credible training for everyone who cares for hospitalized children. That would let hospitals and patients know that training in pediatric hospital medicine results in a certain specific set of skills.

"That’s what I think kids need. We need to ask, ‘What is best for the hospitalized child?’ " Dr. Fisher said.

But while that training could lead to subspecialty board certification, it doesn’t have to, she said. However, the training program does need to teach the core competencies of the specialty. What a program looks like, and what form of certification should be considered, is under review, she said. The only option she would rule out is doing nothing.

"Staying still is hard and isn’t what pediatric hospitalists have done," Dr. Fisher said.

But Kenneth Pituch, director of the division of pediatric hospital medicine at C.S. Mott Children’s Hospital in Ann Arbor, Mich., is on the other end of the spectrum. He told the committee it’s too early to consider carving out a certification pathway that potentially requires 2 or 3 additional years of training. "We’re not quite there yet for a couple of reasons," he said.

For instance, requiring additional years of training for pediatric hospital medicine could make the specialty significantly less attractive to young doctors, he said. That would put a drain on the workforce needed to care for sick children in the hospital.

He’s also concerned about widening the gap in training between pediatricians working in the hospital and those in the outpatient setting at a time when collaboration in the care of chronically ill children is so important.

Right now, there are outpatient physicians who see a high volume of relatively healthy children, and pediatric hospitalists who care for acutely ill children. The problem is that there is little going on to address the care for the chronically ill children who bounce back and forth between the two settings, Dr. Pituch said. There could be a role for pediatric hospitalists in improving that care, but moving forward now with certification could make it more difficult to figure out what this other model would look like, he said.

"I’m just saying, let’s hold off," he added.

[email protected]

Federal health officials have finally released the details on how online public reporting of industry payments to physicians will work.

Under the final rule released on Feb. 1 by the Centers for Medicare and Medicaid Services (CMS), drug, device, and medical supply manufacturers who participate in Medicare, Medicaid, or the Children’s Health Insurance Program will be required to submit annual reports to the federal government on any payments of $10 or more that they made to physicians and teaching hospitals. They also will be required to report on all payments if the payments and transfers of value to a single physician reach $100 in aggregate value for a year.

Manufacturers and group purchasing organizations (GPOs) must also report on physician ownership and investment interests each year. CMS will post the information on a public website. The requirements are mandated under the Affordable Care Act (ACA).

"You should know when your doctor has a financial relationship with the companies that manufacture or supply the medicines or medical devices you may need," Dr. Peter Budetti, CMS deputy administrator for Program Integrity, said in a statement. "Disclosure of these relationships allows patients to have more informed discussions with their doctors."

Manufacturers and GPOs have until Aug. 1 to begin collecting data. They must submit their reports on payments made in 2013 by March 31, 2014. CMS will post the data online by Sept. 30, 2014.

CMS did not meet the deadline set by law for issuing this final regulation: Under the ACA, data collection was supposed to begin in January 2012.

The final rule contains plenty of exceptions, however. For instance, reporting is not required for gifts between individuals with an existing personal relationship. Other exclusions include small payments of less than $10, educational materials that directly benefit patients or are intended for patient use, discounts for rebates for drugs and devices, in-kind items for charity care, and samples.

Indirect payments made to speakers at accredited or certified continuing medical education (CME) events also do not need to be reported as long as the manufacturer doesn’t suggest speakers.

The final rule also clarifies that companies sponsoring large-scale conferences do not need to track and report on small gifts and food items worth less than $10 such as pens and bottles of water. These items also won’t count toward the minimum yearly reporting threshold of $100, according to CMS.

"I think this will make life easier, because it will contribute toward a more relaxed atmosphere at meetings so that attendees won’t have to worry every time they pick up a bottle of water or a granola bar," said Dr. Daniel Carlat, project director for the Pew Prescription Project, which works for greater transparency in physician-industry relationships.

Dr. Carlat said the final rule strikes the right balance between increasing payment transparency and not overburdening physicians with the requirements.

Although the data collection and reporting requirements are on the drug and device industry, physicians are responsible for reviewing their information before publication. Under the final rule, physicians will have 45 days to review the reports and another 15 days to work with the manufacturers to correct any disputed reports. After that, if there are still disputes, the information will be posted publicly but will include a disclaimer that it is disputed, according to the final rule.

The new transparency initiative will likely enhance the public’s trust and confidence in their physicians, Dr. Carlat said. Consumers often hear about the worst-case scenarios, where physicians are taking millions of dollars that may cause conflicts of interest, but the new reporting is likely to show that is rare, he said.

"I think we’ll find with these transparency reports that the vast majority of payments and gifts are of very low value and are the equivalent of $50 to $100 or a few hundred dollars a year," Dr. Carlat said. "I think when patients see these figures, their concerns about relationships between doctors and companies will be to some extent allayed."

[email protected]

Federal health officials have finally released the details on how online public reporting of industry payments to physicians will work.

Under the final rule released on Feb. 1 by the Centers for Medicare and Medicaid Services (CMS), drug, device, and medical supply manufacturers who participate in Medicare, Medicaid, or the Children’s Health Insurance Program will be required to submit annual reports to the federal government on any payments of $10 or more that they made to physicians and teaching hospitals. They also will be required to report on all payments if the payments and transfers of value to a single physician reach $100 in aggregate value for a year.

Manufacturers and group purchasing organizations (GPOs) must also report on physician ownership and investment interests each year. CMS will post the information on a public website. The requirements are mandated under the Affordable Care Act (ACA).

"You should know when your doctor has a financial relationship with the companies that manufacture or supply the medicines or medical devices you may need," Dr. Peter Budetti, CMS deputy administrator for Program Integrity, said in a statement. "Disclosure of these relationships allows patients to have more informed discussions with their doctors."

Manufacturers and GPOs have until Aug. 1 to begin collecting data. They must submit their reports on payments made in 2013 by March 31, 2014. CMS will post the data online by Sept. 30, 2014.

CMS did not meet the deadline set by law for issuing this final regulation: Under the ACA, data collection was supposed to begin in January 2012.

The final rule contains plenty of exceptions, however. For instance, reporting is not required for gifts between individuals with an existing personal relationship. Other exclusions include small payments of less than $10, educational materials that directly benefit patients or are intended for patient use, discounts for rebates for drugs and devices, in-kind items for charity care, and samples.

Indirect payments made to speakers at accredited or certified continuing medical education (CME) events also do not need to be reported as long as the manufacturer doesn’t suggest speakers.

The final rule also clarifies that companies sponsoring large-scale conferences do not need to track and report on small gifts and food items worth less than $10 such as pens and bottles of water. These items also won’t count toward the minimum yearly reporting threshold of $100, according to CMS.

"I think this will make life easier, because it will contribute toward a more relaxed atmosphere at meetings so that attendees won’t have to worry every time they pick up a bottle of water or a granola bar," said Dr. Daniel Carlat, project director for the Pew Prescription Project, which works for greater transparency in physician-industry relationships.

Dr. Carlat said the final rule strikes the right balance between increasing payment transparency and not overburdening physicians with the requirements.

Although the data collection and reporting requirements are on the drug and device industry, physicians are responsible for reviewing their information before publication. Under the final rule, physicians will have 45 days to review the reports and another 15 days to work with the manufacturers to correct any disputed reports. After that, if there are still disputes, the information will be posted publicly but will include a disclaimer that it is disputed, according to the final rule.

The new transparency initiative will likely enhance the public’s trust and confidence in their physicians, Dr. Carlat said. Consumers often hear about the worst-case scenarios, where physicians are taking millions of dollars that may cause conflicts of interest, but the new reporting is likely to show that is rare, he said.

"I think we’ll find with these transparency reports that the vast majority of payments and gifts are of very low value and are the equivalent of $50 to $100 or a few hundred dollars a year," Dr. Carlat said. "I think when patients see these figures, their concerns about relationships between doctors and companies will be to some extent allayed."

[email protected]

Federal health officials have finally released the details on how online public reporting of industry payments to physicians will work.

Under the final rule released on Feb. 1 by the Centers for Medicare and Medicaid Services (CMS), drug, device, and medical supply manufacturers who participate in Medicare, Medicaid, or the Children’s Health Insurance Program will be required to submit annual reports to the federal government on any payments of $10 or more that they made to physicians and teaching hospitals. They also will be required to report on all payments if the payments and transfers of value to a single physician reach $100 in aggregate value for a year.

Manufacturers and group purchasing organizations (GPOs) must also report on physician ownership and investment interests each year. CMS will post the information on a public website. The requirements are mandated under the Affordable Care Act (ACA).

"You should know when your doctor has a financial relationship with the companies that manufacture or supply the medicines or medical devices you may need," Dr. Peter Budetti, CMS deputy administrator for Program Integrity, said in a statement. "Disclosure of these relationships allows patients to have more informed discussions with their doctors."

Manufacturers and GPOs have until Aug. 1 to begin collecting data. They must submit their reports on payments made in 2013 by March 31, 2014. CMS will post the data online by Sept. 30, 2014.

CMS did not meet the deadline set by law for issuing this final regulation: Under the ACA, data collection was supposed to begin in January 2012.

The final rule contains plenty of exceptions, however. For instance, reporting is not required for gifts between individuals with an existing personal relationship. Other exclusions include small payments of less than $10, educational materials that directly benefit patients or are intended for patient use, discounts for rebates for drugs and devices, in-kind items for charity care, and samples.

Indirect payments made to speakers at accredited or certified continuing medical education (CME) events also do not need to be reported as long as the manufacturer doesn’t suggest speakers.

The final rule also clarifies that companies sponsoring large-scale conferences do not need to track and report on small gifts and food items worth less than $10 such as pens and bottles of water. These items also won’t count toward the minimum yearly reporting threshold of $100, according to CMS.

"I think this will make life easier, because it will contribute toward a more relaxed atmosphere at meetings so that attendees won’t have to worry every time they pick up a bottle of water or a granola bar," said Dr. Daniel Carlat, project director for the Pew Prescription Project, which works for greater transparency in physician-industry relationships.

Dr. Carlat said the final rule strikes the right balance between increasing payment transparency and not overburdening physicians with the requirements.

Although the data collection and reporting requirements are on the drug and device industry, physicians are responsible for reviewing their information before publication. Under the final rule, physicians will have 45 days to review the reports and another 15 days to work with the manufacturers to correct any disputed reports. After that, if there are still disputes, the information will be posted publicly but will include a disclaimer that it is disputed, according to the final rule.

The new transparency initiative will likely enhance the public’s trust and confidence in their physicians, Dr. Carlat said. Consumers often hear about the worst-case scenarios, where physicians are taking millions of dollars that may cause conflicts of interest, but the new reporting is likely to show that is rare, he said.

"I think we’ll find with these transparency reports that the vast majority of payments and gifts are of very low value and are the equivalent of $50 to $100 or a few hundred dollars a year," Dr. Carlat said. "I think when patients see these figures, their concerns about relationships between doctors and companies will be to some extent allayed."

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