Mary Ellen Schneider

Implementing evidence-based protocols related to vacuum-assisted delivery, early elective inductions, and labor augmentation helped reduce complications and liability claims in the first phase of a national perinatal safety initiative.

The Premier Perinatal Safety Initiative, which is a project of the Premier health care alliance, includes 14 hospitals from around the country that adopted team-based communications processes, participated in simulation training, and implemented evidence-based care bundles starting in 2008.

"We went to work on what would be an idealized design for perinatal care," Susan D. DeVore, president and CEO of the Premier health care alliance, said during a press conference to release the phase I results.

The results from phase I of the study (2008-2010) show that the interventions appear to be reducing maternal and neonatal harm.

Participating hospitals reduced birth hypoxia/asphyxia by 25%, dropping the instances of this type of neonatal injury from 1.6 per 1,000 deliveries in 2006-2007 to 1.2 per 1,000 during 2008-2010. Similarly, neonatal birth trauma fell from 1.8 to 1.4 per 1,000 deliveries in the same time periods, a reduction of 22%.

Postpartum hemorrhage, the most common cause of perinatal maternal death in the developed world, dropped 5.4% (from 30.0 to 28.4 instances per 1,000 deliveries) during phase I. Cardiac arrest and other cardiac complications resulting from administration of anesthesia during labor and delivery were reduced from 4.0 instances per 1,000 deliveries during the baseline period to 3.4 instances during phase I, a drop of 15%.

The study intervention also appears to be bringing down liability claims, though it sometimes takes 2 years or more following an injury before a claim is filed, Ms. DeVore said. Preliminary data show that the number of liability claims filed fell from an average of 18 during the baseline period to 10 in 2009; it is trending to be at 8 in 2010. Additionally, more claims were resolved without payment at the end of phase I than during the baseline period, according to Premier.

During phase I of the study, participating hospitals implemented three care bundles on elective induction, labor augmentation, and vacuum-assisted delivery. The hospitals had to show that they were providing all of the elements in the bundle to be considered adherent. For instance, the vacuum bundle requires that alternative labor strategies are considered, the patient is prepared, there is a high probability of success, the maximum application time and number of "pop-offs" is predetermined and documented, and cesarean and resuscitation teams are available at delivery.

Over the course of the study, adherence to the bundles has increased significantly. Compliance with the augmentation bundle rose from 33% at baseline to 72% at the end of phase I. Compliance with the elective induction bundle rose from 58% to 88%. And compliance with the vacuum bundle jumped from 9% at baseline to 51%.

Health care providers in the study also worked on improving communication throughout the labor and delivery team by adopting communication protocols used by the military, including TeamSTEPPS and Situation Background Assessment Recommendation (SBAR). They also performed simulations in which they role played worst-case scenarios using mannequins. "So, in real life, when some of these situations occur, it’s not the first time they’ve responded to it," Ms. DeVore said. "They’ve been through very serious simulations."

Phase II of the study, which will also look at the role of hospital culture in perinatal performance improvement, began in January 2011 and will be completed in December 2012. Premier expects to release final results from the project in the summer or fall of 2013.

Implementing evidence-based protocols related to vacuum-assisted delivery, early elective inductions, and labor augmentation helped reduce complications and liability claims in the first phase of a national perinatal safety initiative.

The Premier Perinatal Safety Initiative, which is a project of the Premier health care alliance, includes 14 hospitals from around the country that adopted team-based communications processes, participated in simulation training, and implemented evidence-based care bundles starting in 2008.

"We went to work on what would be an idealized design for perinatal care," Susan D. DeVore, president and CEO of the Premier health care alliance, said during a press conference to release the phase I results.

The results from phase I of the study (2008-2010) show that the interventions appear to be reducing maternal and neonatal harm.

Participating hospitals reduced birth hypoxia/asphyxia by 25%, dropping the instances of this type of neonatal injury from 1.6 per 1,000 deliveries in 2006-2007 to 1.2 per 1,000 during 2008-2010. Similarly, neonatal birth trauma fell from 1.8 to 1.4 per 1,000 deliveries in the same time periods, a reduction of 22%.

Postpartum hemorrhage, the most common cause of perinatal maternal death in the developed world, dropped 5.4% (from 30.0 to 28.4 instances per 1,000 deliveries) during phase I. Cardiac arrest and other cardiac complications resulting from administration of anesthesia during labor and delivery were reduced from 4.0 instances per 1,000 deliveries during the baseline period to 3.4 instances during phase I, a drop of 15%.

The study intervention also appears to be bringing down liability claims, though it sometimes takes 2 years or more following an injury before a claim is filed, Ms. DeVore said. Preliminary data show that the number of liability claims filed fell from an average of 18 during the baseline period to 10 in 2009; it is trending to be at 8 in 2010. Additionally, more claims were resolved without payment at the end of phase I than during the baseline period, according to Premier.

During phase I of the study, participating hospitals implemented three care bundles on elective induction, labor augmentation, and vacuum-assisted delivery. The hospitals had to show that they were providing all of the elements in the bundle to be considered adherent. For instance, the vacuum bundle requires that alternative labor strategies are considered, the patient is prepared, there is a high probability of success, the maximum application time and number of "pop-offs" is predetermined and documented, and cesarean and resuscitation teams are available at delivery.

Over the course of the study, adherence to the bundles has increased significantly. Compliance with the augmentation bundle rose from 33% at baseline to 72% at the end of phase I. Compliance with the elective induction bundle rose from 58% to 88%. And compliance with the vacuum bundle jumped from 9% at baseline to 51%.

Health care providers in the study also worked on improving communication throughout the labor and delivery team by adopting communication protocols used by the military, including TeamSTEPPS and Situation Background Assessment Recommendation (SBAR). They also performed simulations in which they role played worst-case scenarios using mannequins. "So, in real life, when some of these situations occur, it’s not the first time they’ve responded to it," Ms. DeVore said. "They’ve been through very serious simulations."

Phase II of the study, which will also look at the role of hospital culture in perinatal performance improvement, began in January 2011 and will be completed in December 2012. Premier expects to release final results from the project in the summer or fall of 2013.

Implementing evidence-based protocols related to vacuum-assisted delivery, early elective inductions, and labor augmentation helped reduce complications and liability claims in the first phase of a national perinatal safety initiative.

The Premier Perinatal Safety Initiative, which is a project of the Premier health care alliance, includes 14 hospitals from around the country that adopted team-based communications processes, participated in simulation training, and implemented evidence-based care bundles starting in 2008.

"We went to work on what would be an idealized design for perinatal care," Susan D. DeVore, president and CEO of the Premier health care alliance, said during a press conference to release the phase I results.

The results from phase I of the study (2008-2010) show that the interventions appear to be reducing maternal and neonatal harm.

Participating hospitals reduced birth hypoxia/asphyxia by 25%, dropping the instances of this type of neonatal injury from 1.6 per 1,000 deliveries in 2006-2007 to 1.2 per 1,000 during 2008-2010. Similarly, neonatal birth trauma fell from 1.8 to 1.4 per 1,000 deliveries in the same time periods, a reduction of 22%.

Postpartum hemorrhage, the most common cause of perinatal maternal death in the developed world, dropped 5.4% (from 30.0 to 28.4 instances per 1,000 deliveries) during phase I. Cardiac arrest and other cardiac complications resulting from administration of anesthesia during labor and delivery were reduced from 4.0 instances per 1,000 deliveries during the baseline period to 3.4 instances during phase I, a drop of 15%.

The study intervention also appears to be bringing down liability claims, though it sometimes takes 2 years or more following an injury before a claim is filed, Ms. DeVore said. Preliminary data show that the number of liability claims filed fell from an average of 18 during the baseline period to 10 in 2009; it is trending to be at 8 in 2010. Additionally, more claims were resolved without payment at the end of phase I than during the baseline period, according to Premier.

During phase I of the study, participating hospitals implemented three care bundles on elective induction, labor augmentation, and vacuum-assisted delivery. The hospitals had to show that they were providing all of the elements in the bundle to be considered adherent. For instance, the vacuum bundle requires that alternative labor strategies are considered, the patient is prepared, there is a high probability of success, the maximum application time and number of "pop-offs" is predetermined and documented, and cesarean and resuscitation teams are available at delivery.

Over the course of the study, adherence to the bundles has increased significantly. Compliance with the augmentation bundle rose from 33% at baseline to 72% at the end of phase I. Compliance with the elective induction bundle rose from 58% to 88%. And compliance with the vacuum bundle jumped from 9% at baseline to 51%.

Health care providers in the study also worked on improving communication throughout the labor and delivery team by adopting communication protocols used by the military, including TeamSTEPPS and Situation Background Assessment Recommendation (SBAR). They also performed simulations in which they role played worst-case scenarios using mannequins. "So, in real life, when some of these situations occur, it’s not the first time they’ve responded to it," Ms. DeVore said. "They’ve been through very serious simulations."

Phase II of the study, which will also look at the role of hospital culture in perinatal performance improvement, began in January 2011 and will be completed in December 2012. Premier expects to release final results from the project in the summer or fall of 2013.

Four leading physician groups have called on federal health officials to make emergency contraception available over the counter for girls under age 17.

In a Dec. 7 letter to Health and Human Services Secretary Kathleen Sebelius, the American Medical Association, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, and seven other organizations wrote that "extensive scientific research and medical expertise" support lifting the age restriction for Plan B One-Step.

"Requiring a prescription serves as an unnecessary barrier, especially when timely access is critical for optimal effectiveness of Plan B," according to the letter. "Studies have shown teen and adult women can read and follow instructions for safe and proper use of emergency contraception. Plan B is extremely safe for teenagers to use; moreover, there is no evidence that ready access to Plan B encourages risky behaviors among teens."

Plan B One-Step, a 1.5-mg levonorgestrel tablet, is currently available without a prescription for women aged 17 years and older, and by prescription only for girls younger than 17 years. In February 2011, the Plan B manufacturer, Teva Pharmaceuticals, requested that the Food and Drug Administration expand the nonprescription access to include minors.

Last December, FDA Commissioner Margaret Hamburg announced that the drug was safe and effective, and should be approved for use by all females of childbearing age without a prescription. However, her decision was overruled by Ms. Sebelius. In a memo, Ms. Sebelius argued that there is not enough evidence to demonstrate that adolescent girls can understand the label and use the product appropriately.

Four leading physician groups have called on federal health officials to make emergency contraception available over the counter for girls under age 17.

In a Dec. 7 letter to Health and Human Services Secretary Kathleen Sebelius, the American Medical Association, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, and seven other organizations wrote that "extensive scientific research and medical expertise" support lifting the age restriction for Plan B One-Step.

"Requiring a prescription serves as an unnecessary barrier, especially when timely access is critical for optimal effectiveness of Plan B," according to the letter. "Studies have shown teen and adult women can read and follow instructions for safe and proper use of emergency contraception. Plan B is extremely safe for teenagers to use; moreover, there is no evidence that ready access to Plan B encourages risky behaviors among teens."

Plan B One-Step, a 1.5-mg levonorgestrel tablet, is currently available without a prescription for women aged 17 years and older, and by prescription only for girls younger than 17 years. In February 2011, the Plan B manufacturer, Teva Pharmaceuticals, requested that the Food and Drug Administration expand the nonprescription access to include minors.

Last December, FDA Commissioner Margaret Hamburg announced that the drug was safe and effective, and should be approved for use by all females of childbearing age without a prescription. However, her decision was overruled by Ms. Sebelius. In a memo, Ms. Sebelius argued that there is not enough evidence to demonstrate that adolescent girls can understand the label and use the product appropriately.

Four leading physician groups have called on federal health officials to make emergency contraception available over the counter for girls under age 17.

In a Dec. 7 letter to Health and Human Services Secretary Kathleen Sebelius, the American Medical Association, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, and seven other organizations wrote that "extensive scientific research and medical expertise" support lifting the age restriction for Plan B One-Step.

"Requiring a prescription serves as an unnecessary barrier, especially when timely access is critical for optimal effectiveness of Plan B," according to the letter. "Studies have shown teen and adult women can read and follow instructions for safe and proper use of emergency contraception. Plan B is extremely safe for teenagers to use; moreover, there is no evidence that ready access to Plan B encourages risky behaviors among teens."

Plan B One-Step, a 1.5-mg levonorgestrel tablet, is currently available without a prescription for women aged 17 years and older, and by prescription only for girls younger than 17 years. In February 2011, the Plan B manufacturer, Teva Pharmaceuticals, requested that the Food and Drug Administration expand the nonprescription access to include minors.

Last December, FDA Commissioner Margaret Hamburg announced that the drug was safe and effective, and should be approved for use by all females of childbearing age without a prescription. However, her decision was overruled by Ms. Sebelius. In a memo, Ms. Sebelius argued that there is not enough evidence to demonstrate that adolescent girls can understand the label and use the product appropriately.

Medicare could save about $33 million a year on certain prostate cancer drugs if it reinstated policies that pay only the price of the least costly treatment among a group of clinically comparable drugs.

Limiting the payments for clinically comparable luteinizing hormone-releasing hormone (LHRH) agonists would bring down the cost of these prostate cancer treatments from $264.6 million to $231.3 million a year, or about 13%, according to a report from the Health and Human Services department’s Office of Inspector General (OIG). About 20% of the savings would go to patients, who would save $6.7 million in reduced coinsurance.

From 1995 until April 2010, the Centers for Medicare and Medicaid Services (CMS) imposed "least costly alternative" policies for many physician-administered drugs covered under Medicare Part B. If the patient or physician wanted to use a more expensive drug, one of them would have to pay the difference.

CMS rescinded the policies in April 2010 after a court ruled that the agency did not have the legal authority to set payments in this way.

The OIG began investigating the impact of the least costly alternative policies at the request of Rep. Ken Calvert (R-Calif.), who wanted to know if eliminating the policy had created an incentive for physicians to administer higher-priced treatments.

Based on the OIG report, that appears to have happened.

Looking at the use of triptorelin pamoate (Trelstar), goserelin acetate implant (Zoladex), and leuprolide acetate suspension (Lupron, Eligard), the OIG found that physicians favored use of the more expensive drugs while the least costly alternative policies were in place but that their use was slowly declining. At the same time, the use of the least expensive drug was slowing rising.

After the payment policies were rescinded, use of the more expensive treatments increased significantly.

In 2010, Lupron and Eligard, the most expensive drugs, were administered about twice as often as the least expensive drug, Trelstar. In the year after payment restrictions were removed, the use of Lupron and Eligard rose 31% while Trelstar use fell 74%, according to the OIG report.

Dr. Walter Stadler, professor of medicine and surgery at the University of Chicago, said that the spike in utilization of the more expensive agents is probably the result of marketing, not any clinical differences in the medications. "They are completely and totally equivalent in terms of their efficacy and how they work," he said.

Physicians may be basing their choice on which manufacturers offer them the best deal on the bulk purchase of the drugs, he said, even if that’s not the best deal for Medicare or the insurer.

The OIG report also noted another trend in the utilization of the LHRH agonists: their overall use in prostate cancer is declining. The decrease in utilization began more a year before the least costly alternative policies were rescinded and has continued, according to the OIG, making it likely that it is unrelated to the policy.

Dr. Stadler said that the overall decline is probably caused by a combination of decreasing payments to physicians for the drugs and increasing medical evidence that the LHRH agonists are not always the best treatment option.

Medicare could save about $33 million a year on certain prostate cancer drugs if it reinstated policies that pay only the price of the least costly treatment among a group of clinically comparable drugs.

Limiting the payments for clinically comparable luteinizing hormone-releasing hormone (LHRH) agonists would bring down the cost of these prostate cancer treatments from $264.6 million to $231.3 million a year, or about 13%, according to a report from the Health and Human Services department’s Office of Inspector General (OIG). About 20% of the savings would go to patients, who would save $6.7 million in reduced coinsurance.

From 1995 until April 2010, the Centers for Medicare and Medicaid Services (CMS) imposed "least costly alternative" policies for many physician-administered drugs covered under Medicare Part B. If the patient or physician wanted to use a more expensive drug, one of them would have to pay the difference.

CMS rescinded the policies in April 2010 after a court ruled that the agency did not have the legal authority to set payments in this way.

The OIG began investigating the impact of the least costly alternative policies at the request of Rep. Ken Calvert (R-Calif.), who wanted to know if eliminating the policy had created an incentive for physicians to administer higher-priced treatments.

Based on the OIG report, that appears to have happened.

Looking at the use of triptorelin pamoate (Trelstar), goserelin acetate implant (Zoladex), and leuprolide acetate suspension (Lupron, Eligard), the OIG found that physicians favored use of the more expensive drugs while the least costly alternative policies were in place but that their use was slowly declining. At the same time, the use of the least expensive drug was slowing rising.

After the payment policies were rescinded, use of the more expensive treatments increased significantly.

In 2010, Lupron and Eligard, the most expensive drugs, were administered about twice as often as the least expensive drug, Trelstar. In the year after payment restrictions were removed, the use of Lupron and Eligard rose 31% while Trelstar use fell 74%, according to the OIG report.

Dr. Walter Stadler, professor of medicine and surgery at the University of Chicago, said that the spike in utilization of the more expensive agents is probably the result of marketing, not any clinical differences in the medications. "They are completely and totally equivalent in terms of their efficacy and how they work," he said.

Physicians may be basing their choice on which manufacturers offer them the best deal on the bulk purchase of the drugs, he said, even if that’s not the best deal for Medicare or the insurer.

The OIG report also noted another trend in the utilization of the LHRH agonists: their overall use in prostate cancer is declining. The decrease in utilization began more a year before the least costly alternative policies were rescinded and has continued, according to the OIG, making it likely that it is unrelated to the policy.

Dr. Stadler said that the overall decline is probably caused by a combination of decreasing payments to physicians for the drugs and increasing medical evidence that the LHRH agonists are not always the best treatment option.

Medicare could save about $33 million a year on certain prostate cancer drugs if it reinstated policies that pay only the price of the least costly treatment among a group of clinically comparable drugs.

Limiting the payments for clinically comparable luteinizing hormone-releasing hormone (LHRH) agonists would bring down the cost of these prostate cancer treatments from $264.6 million to $231.3 million a year, or about 13%, according to a report from the Health and Human Services department’s Office of Inspector General (OIG). About 20% of the savings would go to patients, who would save $6.7 million in reduced coinsurance.

From 1995 until April 2010, the Centers for Medicare and Medicaid Services (CMS) imposed "least costly alternative" policies for many physician-administered drugs covered under Medicare Part B. If the patient or physician wanted to use a more expensive drug, one of them would have to pay the difference.

CMS rescinded the policies in April 2010 after a court ruled that the agency did not have the legal authority to set payments in this way.

The OIG began investigating the impact of the least costly alternative policies at the request of Rep. Ken Calvert (R-Calif.), who wanted to know if eliminating the policy had created an incentive for physicians to administer higher-priced treatments.

Based on the OIG report, that appears to have happened.

Looking at the use of triptorelin pamoate (Trelstar), goserelin acetate implant (Zoladex), and leuprolide acetate suspension (Lupron, Eligard), the OIG found that physicians favored use of the more expensive drugs while the least costly alternative policies were in place but that their use was slowly declining. At the same time, the use of the least expensive drug was slowing rising.

After the payment policies were rescinded, use of the more expensive treatments increased significantly.

In 2010, Lupron and Eligard, the most expensive drugs, were administered about twice as often as the least expensive drug, Trelstar. In the year after payment restrictions were removed, the use of Lupron and Eligard rose 31% while Trelstar use fell 74%, according to the OIG report.

Dr. Walter Stadler, professor of medicine and surgery at the University of Chicago, said that the spike in utilization of the more expensive agents is probably the result of marketing, not any clinical differences in the medications. "They are completely and totally equivalent in terms of their efficacy and how they work," he said.

Physicians may be basing their choice on which manufacturers offer them the best deal on the bulk purchase of the drugs, he said, even if that’s not the best deal for Medicare or the insurer.

The OIG report also noted another trend in the utilization of the LHRH agonists: their overall use in prostate cancer is declining. The decrease in utilization began more a year before the least costly alternative policies were rescinded and has continued, according to the OIG, making it likely that it is unrelated to the policy.

Dr. Stadler said that the overall decline is probably caused by a combination of decreasing payments to physicians for the drugs and increasing medical evidence that the LHRH agonists are not always the best treatment option.

The American Psychiatric Association has finalized its restructuring of the Diagnostic and Statistical Manual of Mental Disorders, clearing the way for publication of the fifth edition of the DSM in May 2013 and cementing some controversial changes.

On Dec. 1, the APA’s Board of Trustees approved the final diagnostic criteria, which had been developed by a task force of clinicians and researchers over the last 6 years. The document now will undergo final editing before being published by American Psychiatric Publishing.

Courtesy American Psychiatric Association

"We have sought to be very conservative in our approach to revising DSM-5," Dr. David J. Kupfer, chair of the DSM-5 Task Force, said in a statement. "Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry."

Along with a restructuring of how the diagnostic chapters are organized and the removal of the multiaxial system, the board of trustees also approved several controversial changes to common psychiatric disorders.

The DSM-5 will include a section on autism spectrum disorder that includes Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified). Previously, these had all been separate diagnoses. Critics have voiced concerns that this will lead to lower rates of diagnosis and a possible disruption in school services.

But the work group members that recommended the change said it would lead to move accurate diagnosis by recognizing differences from person to person.

The final DSM-5 also will include a new diagnosis of disruptive mood dysregulation disorder, which will be used to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is meant to help address the possible overdiagnosis of bipolar disorder in children, according to the APA. But Dr. Allen J. Frances, a psychiatrist who chaired the DSM task force that developed the DSM-IV, said this is an example of pathologizing normal behavior by turning "temper tantrums" into a psychiatric diagnosis.

Another change that drew the ire of critics is the removal of the bereavement exclusion. Under the DSM-IV, the exclusion was used to describe people who experienced depressive symptoms lasting less than 2 months after the death of a loved one. Instead, the text of the DSM-5 will include notes clarifying the differences between grief and depression. The APA said the change is intended to reflect the recognition that bereavement is a significant psychological stressor that can precipitate a major depressive episode after the death of a loved one.

But during the drafting of the DSM-5, the proposal was ridiculed by some opponents who said that removing the exclusion could lead clinicians to diagnose major depressive disorder in people experiencing brief periods of normal grief.

The DSM-5 also will include some new disorders, including excoriation (skin picking) disorder and hoarding disorder. Binge eating disorder will be moved out of the DSM-IV’s Appendix B, used for diagnoses requiring further study, and into the main manual. Posttraumatic stress disorder (PTSD) will be made part of a new chapter on Trauma- and Stressor-Related Disorders in the DSM-5. There will be a greater focus on the behavioral symptoms associated with PTSD, according to the APA.

The DSM-5 also combines the substance abuse and substance dependence categories into a single new category called substance use disorder. Instead of requiring only one symptom for diagnosis, the DSM-5 will require two to three symptoms for a diagnosis of mild substance abuse.

Many areas will remain relatively unchanged. For instance, the pedophilia criteria are the same as in the DSM-IV, but will undergo a name change in DSM-5, becoming pedophilic disorder.

The categorical model and criteria for the 10 personality disorders in the DSM-IV will remain the same in the new manual. However, to encourage further study on how personality disorders can be diagnosed, the DSM-5 will include a separate section with new trait-specific methodology.

The American Psychiatric Association has finalized its restructuring of the Diagnostic and Statistical Manual of Mental Disorders, clearing the way for publication of the fifth edition of the DSM in May 2013 and cementing some controversial changes.

On Dec. 1, the APA’s Board of Trustees approved the final diagnostic criteria, which had been developed by a task force of clinicians and researchers over the last 6 years. The document now will undergo final editing before being published by American Psychiatric Publishing.

Courtesy American Psychiatric Association

"We have sought to be very conservative in our approach to revising DSM-5," Dr. David J. Kupfer, chair of the DSM-5 Task Force, said in a statement. "Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry."

Along with a restructuring of how the diagnostic chapters are organized and the removal of the multiaxial system, the board of trustees also approved several controversial changes to common psychiatric disorders.

The DSM-5 will include a section on autism spectrum disorder that includes Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified). Previously, these had all been separate diagnoses. Critics have voiced concerns that this will lead to lower rates of diagnosis and a possible disruption in school services.

But the work group members that recommended the change said it would lead to move accurate diagnosis by recognizing differences from person to person.

The final DSM-5 also will include a new diagnosis of disruptive mood dysregulation disorder, which will be used to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is meant to help address the possible overdiagnosis of bipolar disorder in children, according to the APA. But Dr. Allen J. Frances, a psychiatrist who chaired the DSM task force that developed the DSM-IV, said this is an example of pathologizing normal behavior by turning "temper tantrums" into a psychiatric diagnosis.

Another change that drew the ire of critics is the removal of the bereavement exclusion. Under the DSM-IV, the exclusion was used to describe people who experienced depressive symptoms lasting less than 2 months after the death of a loved one. Instead, the text of the DSM-5 will include notes clarifying the differences between grief and depression. The APA said the change is intended to reflect the recognition that bereavement is a significant psychological stressor that can precipitate a major depressive episode after the death of a loved one.

But during the drafting of the DSM-5, the proposal was ridiculed by some opponents who said that removing the exclusion could lead clinicians to diagnose major depressive disorder in people experiencing brief periods of normal grief.

The DSM-5 also will include some new disorders, including excoriation (skin picking) disorder and hoarding disorder. Binge eating disorder will be moved out of the DSM-IV’s Appendix B, used for diagnoses requiring further study, and into the main manual. Posttraumatic stress disorder (PTSD) will be made part of a new chapter on Trauma- and Stressor-Related Disorders in the DSM-5. There will be a greater focus on the behavioral symptoms associated with PTSD, according to the APA.

The DSM-5 also combines the substance abuse and substance dependence categories into a single new category called substance use disorder. Instead of requiring only one symptom for diagnosis, the DSM-5 will require two to three symptoms for a diagnosis of mild substance abuse.

Many areas will remain relatively unchanged. For instance, the pedophilia criteria are the same as in the DSM-IV, but will undergo a name change in DSM-5, becoming pedophilic disorder.

The categorical model and criteria for the 10 personality disorders in the DSM-IV will remain the same in the new manual. However, to encourage further study on how personality disorders can be diagnosed, the DSM-5 will include a separate section with new trait-specific methodology.

The American Psychiatric Association has finalized its restructuring of the Diagnostic and Statistical Manual of Mental Disorders, clearing the way for publication of the fifth edition of the DSM in May 2013 and cementing some controversial changes.

On Dec. 1, the APA’s Board of Trustees approved the final diagnostic criteria, which had been developed by a task force of clinicians and researchers over the last 6 years. The document now will undergo final editing before being published by American Psychiatric Publishing.

Courtesy American Psychiatric Association

"We have sought to be very conservative in our approach to revising DSM-5," Dr. David J. Kupfer, chair of the DSM-5 Task Force, said in a statement. "Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry."

Along with a restructuring of how the diagnostic chapters are organized and the removal of the multiaxial system, the board of trustees also approved several controversial changes to common psychiatric disorders.

The DSM-5 will include a section on autism spectrum disorder that includes Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified). Previously, these had all been separate diagnoses. Critics have voiced concerns that this will lead to lower rates of diagnosis and a possible disruption in school services.

But the work group members that recommended the change said it would lead to move accurate diagnosis by recognizing differences from person to person.

The final DSM-5 also will include a new diagnosis of disruptive mood dysregulation disorder, which will be used to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is meant to help address the possible overdiagnosis of bipolar disorder in children, according to the APA. But Dr. Allen J. Frances, a psychiatrist who chaired the DSM task force that developed the DSM-IV, said this is an example of pathologizing normal behavior by turning "temper tantrums" into a psychiatric diagnosis.

Another change that drew the ire of critics is the removal of the bereavement exclusion. Under the DSM-IV, the exclusion was used to describe people who experienced depressive symptoms lasting less than 2 months after the death of a loved one. Instead, the text of the DSM-5 will include notes clarifying the differences between grief and depression. The APA said the change is intended to reflect the recognition that bereavement is a significant psychological stressor that can precipitate a major depressive episode after the death of a loved one.

But during the drafting of the DSM-5, the proposal was ridiculed by some opponents who said that removing the exclusion could lead clinicians to diagnose major depressive disorder in people experiencing brief periods of normal grief.

The DSM-5 also will include some new disorders, including excoriation (skin picking) disorder and hoarding disorder. Binge eating disorder will be moved out of the DSM-IV’s Appendix B, used for diagnoses requiring further study, and into the main manual. Posttraumatic stress disorder (PTSD) will be made part of a new chapter on Trauma- and Stressor-Related Disorders in the DSM-5. There will be a greater focus on the behavioral symptoms associated with PTSD, according to the APA.

The DSM-5 also combines the substance abuse and substance dependence categories into a single new category called substance use disorder. Instead of requiring only one symptom for diagnosis, the DSM-5 will require two to three symptoms for a diagnosis of mild substance abuse.

Many areas will remain relatively unchanged. For instance, the pedophilia criteria are the same as in the DSM-IV, but will undergo a name change in DSM-5, becoming pedophilic disorder.

The categorical model and criteria for the 10 personality disorders in the DSM-IV will remain the same in the new manual. However, to encourage further study on how personality disorders can be diagnosed, the DSM-5 will include a separate section with new trait-specific methodology.

It seems like officials at the Centers for Medicare and Medicaid Services are always announcing a new audit plan or a crackdown on Medicare providers. But on Nov. 29, the agency found itself in hot water with the Office of Inspector General for the Department of Health and Human Services for being too fast to send payments to physicians and hospitals.

At issue is the CMS oversight of the Medicare electronic health record (EHR) incentive program and the $6.6 billion in bonus payments that the agency expects to hand out to physicians, hospitals, and other health care providers between 2011 and 2016. The program, which was authorized by Congress in 2009 and kicked off in 2011, gives physicians a chance to earn up to $44,000 in incentives for the meaningful use of EHR technology. Physicians can’t just buy an EHR; they have to choose a certified system to meet and report on quality metrics. The program has left some physicians frustrated by what they see as confusing criteria and a too-quick progression to more requirements.

©Brian Jackson/iStockphoto.com

But a new report from the Office of Inspector General (OIG) found that the way the CMS is administering the meaningful use program could leave the agency open to fraud by providers. The OIG looked at how the CMS performed in 2011, the first year in which payments were made under the program. The first problem flagged by the OIG was that the CMS pays out incentives based on self-reported data, but doesn’t verify the information before paying. In fact, in many cases, the agency doesn’t even have access to the information it would need to check what’s being reported. And doctors and hospitals aren’t required to submit supporting documentation when they attest to their meaningful use.

The CMS does plan to conduct postpayment audits, though the OIG report does not review those since none had been conducted to date. Under the CMS audit plan, the agency would review supporting documentation and reports created by the physician or hospital’s EHR. But the OIG raised concerns with the audit plan too. For instance, certified EHRs aren’t able to produce reports on all of the meaningful use measures, and there have been instances of EHRs producing inaccurate reports due to glitches in the systems.

The OIG recommended that the CMS require certain high-risk professionals and hospitals to submit supporting documentation to back up their meaningful use claims before getting paid. But in comments on the report, the CMS officials said they had no plans to make that change. They wrote that asking for more documentation could slow down payments and create additional burdens for providers, something they were unwilling to risk.

The agency did agree to make other changes aimed at safeguarding the incentive payments, including issuing better guidance on the type of supporting documents physicians and hospitals should keep in case of an audit.

So the next time you perform your meaningful use attestation, remember it could be worse.

It seems like officials at the Centers for Medicare and Medicaid Services are always announcing a new audit plan or a crackdown on Medicare providers. But on Nov. 29, the agency found itself in hot water with the Office of Inspector General for the Department of Health and Human Services for being too fast to send payments to physicians and hospitals.

At issue is the CMS oversight of the Medicare electronic health record (EHR) incentive program and the $6.6 billion in bonus payments that the agency expects to hand out to physicians, hospitals, and other health care providers between 2011 and 2016. The program, which was authorized by Congress in 2009 and kicked off in 2011, gives physicians a chance to earn up to $44,000 in incentives for the meaningful use of EHR technology. Physicians can’t just buy an EHR; they have to choose a certified system to meet and report on quality metrics. The program has left some physicians frustrated by what they see as confusing criteria and a too-quick progression to more requirements.

©Brian Jackson/iStockphoto.com

But a new report from the Office of Inspector General (OIG) found that the way the CMS is administering the meaningful use program could leave the agency open to fraud by providers. The OIG looked at how the CMS performed in 2011, the first year in which payments were made under the program. The first problem flagged by the OIG was that the CMS pays out incentives based on self-reported data, but doesn’t verify the information before paying. In fact, in many cases, the agency doesn’t even have access to the information it would need to check what’s being reported. And doctors and hospitals aren’t required to submit supporting documentation when they attest to their meaningful use.

The CMS does plan to conduct postpayment audits, though the OIG report does not review those since none had been conducted to date. Under the CMS audit plan, the agency would review supporting documentation and reports created by the physician or hospital’s EHR. But the OIG raised concerns with the audit plan too. For instance, certified EHRs aren’t able to produce reports on all of the meaningful use measures, and there have been instances of EHRs producing inaccurate reports due to glitches in the systems.

The OIG recommended that the CMS require certain high-risk professionals and hospitals to submit supporting documentation to back up their meaningful use claims before getting paid. But in comments on the report, the CMS officials said they had no plans to make that change. They wrote that asking for more documentation could slow down payments and create additional burdens for providers, something they were unwilling to risk.

The agency did agree to make other changes aimed at safeguarding the incentive payments, including issuing better guidance on the type of supporting documents physicians and hospitals should keep in case of an audit.

So the next time you perform your meaningful use attestation, remember it could be worse.

It seems like officials at the Centers for Medicare and Medicaid Services are always announcing a new audit plan or a crackdown on Medicare providers. But on Nov. 29, the agency found itself in hot water with the Office of Inspector General for the Department of Health and Human Services for being too fast to send payments to physicians and hospitals.

At issue is the CMS oversight of the Medicare electronic health record (EHR) incentive program and the $6.6 billion in bonus payments that the agency expects to hand out to physicians, hospitals, and other health care providers between 2011 and 2016. The program, which was authorized by Congress in 2009 and kicked off in 2011, gives physicians a chance to earn up to $44,000 in incentives for the meaningful use of EHR technology. Physicians can’t just buy an EHR; they have to choose a certified system to meet and report on quality metrics. The program has left some physicians frustrated by what they see as confusing criteria and a too-quick progression to more requirements.

©Brian Jackson/iStockphoto.com

But a new report from the Office of Inspector General (OIG) found that the way the CMS is administering the meaningful use program could leave the agency open to fraud by providers. The OIG looked at how the CMS performed in 2011, the first year in which payments were made under the program. The first problem flagged by the OIG was that the CMS pays out incentives based on self-reported data, but doesn’t verify the information before paying. In fact, in many cases, the agency doesn’t even have access to the information it would need to check what’s being reported. And doctors and hospitals aren’t required to submit supporting documentation when they attest to their meaningful use.

The CMS does plan to conduct postpayment audits, though the OIG report does not review those since none had been conducted to date. Under the CMS audit plan, the agency would review supporting documentation and reports created by the physician or hospital’s EHR. But the OIG raised concerns with the audit plan too. For instance, certified EHRs aren’t able to produce reports on all of the meaningful use measures, and there have been instances of EHRs producing inaccurate reports due to glitches in the systems.

The OIG recommended that the CMS require certain high-risk professionals and hospitals to submit supporting documentation to back up their meaningful use claims before getting paid. But in comments on the report, the CMS officials said they had no plans to make that change. They wrote that asking for more documentation could slow down payments and create additional burdens for providers, something they were unwilling to risk.

The agency did agree to make other changes aimed at safeguarding the incentive payments, including issuing better guidance on the type of supporting documents physicians and hospitals should keep in case of an audit.

So the next time you perform your meaningful use attestation, remember it could be worse.

Medicare officials have slashed payments for a common pathology code, a move likely to affect the bottom line for many gastroenterologists.

In the Medicare Physician Fee Schedule final rule, published on Nov. 1, officials at the Centers for Medicare and Medicaid Services (CMS) announced plans to cut the technical component for the surgical pathology CPT code 88305 (tissue exam by a pathologist) by about 50%. Although the professional component of the service will increase by 2%, the global payment will drop by about one-third, according to Dr. Lawrence R. Kosinski, AGAF, chairman of the practice management and economics committee of the American Gastroenterological Association. The changes take effect on Jan. 1.

"Everybody is going to make less money on this," said Dr. Kosinski, who practices in Elgin, Ill.

The cuts are significant, he said, because many gastroenterologists either run their own labs or partner with a pathology lab to retain some of the revenue, he said.

The cuts were made as part of a larger effort to reduce payments for diagnostic services provided to the same beneficiary on the same day. In about one-third of the claims for CPT code 88305, multiple specimens from the same beneficiary were examined at the same time by the same pathologist, according to CMS. The agency estimates that Medicare spent $1.3 billion on that code alone in 2010.

Endoscopic codes could be next on the chopping block, Dr. Kosinski said. "We’re trying to catch a falling knife."

Gastroenterologists may, however, have new opportunities to make money in this era of declining reimbursement if they are willing to reconfigure their practices around the idea of value-based payments, Dr. Kosinski noted.

With the federal government’s growing focus on lowering costs and bundling payments, gastroenterologists may be able to retain some of their revenue in the future by assuming risk for the full episode of care and working to keep costs down and patients out of the hospital.

"Whenever you have massive change, it creates opportunities for someone," he said.

Medicare officials have slashed payments for a common pathology code, a move likely to affect the bottom line for many gastroenterologists.

In the Medicare Physician Fee Schedule final rule, published on Nov. 1, officials at the Centers for Medicare and Medicaid Services (CMS) announced plans to cut the technical component for the surgical pathology CPT code 88305 (tissue exam by a pathologist) by about 50%. Although the professional component of the service will increase by 2%, the global payment will drop by about one-third, according to Dr. Lawrence R. Kosinski, AGAF, chairman of the practice management and economics committee of the American Gastroenterological Association. The changes take effect on Jan. 1.

"Everybody is going to make less money on this," said Dr. Kosinski, who practices in Elgin, Ill.

The cuts are significant, he said, because many gastroenterologists either run their own labs or partner with a pathology lab to retain some of the revenue, he said.

The cuts were made as part of a larger effort to reduce payments for diagnostic services provided to the same beneficiary on the same day. In about one-third of the claims for CPT code 88305, multiple specimens from the same beneficiary were examined at the same time by the same pathologist, according to CMS. The agency estimates that Medicare spent $1.3 billion on that code alone in 2010.

Endoscopic codes could be next on the chopping block, Dr. Kosinski said. "We’re trying to catch a falling knife."

Gastroenterologists may, however, have new opportunities to make money in this era of declining reimbursement if they are willing to reconfigure their practices around the idea of value-based payments, Dr. Kosinski noted.

With the federal government’s growing focus on lowering costs and bundling payments, gastroenterologists may be able to retain some of their revenue in the future by assuming risk for the full episode of care and working to keep costs down and patients out of the hospital.

"Whenever you have massive change, it creates opportunities for someone," he said.

Medicare officials have slashed payments for a common pathology code, a move likely to affect the bottom line for many gastroenterologists.

In the Medicare Physician Fee Schedule final rule, published on Nov. 1, officials at the Centers for Medicare and Medicaid Services (CMS) announced plans to cut the technical component for the surgical pathology CPT code 88305 (tissue exam by a pathologist) by about 50%. Although the professional component of the service will increase by 2%, the global payment will drop by about one-third, according to Dr. Lawrence R. Kosinski, AGAF, chairman of the practice management and economics committee of the American Gastroenterological Association. The changes take effect on Jan. 1.

"Everybody is going to make less money on this," said Dr. Kosinski, who practices in Elgin, Ill.

The cuts are significant, he said, because many gastroenterologists either run their own labs or partner with a pathology lab to retain some of the revenue, he said.

The cuts were made as part of a larger effort to reduce payments for diagnostic services provided to the same beneficiary on the same day. In about one-third of the claims for CPT code 88305, multiple specimens from the same beneficiary were examined at the same time by the same pathologist, according to CMS. The agency estimates that Medicare spent $1.3 billion on that code alone in 2010.

Endoscopic codes could be next on the chopping block, Dr. Kosinski said. "We’re trying to catch a falling knife."

Gastroenterologists may, however, have new opportunities to make money in this era of declining reimbursement if they are willing to reconfigure their practices around the idea of value-based payments, Dr. Kosinski noted.

With the federal government’s growing focus on lowering costs and bundling payments, gastroenterologists may be able to retain some of their revenue in the future by assuming risk for the full episode of care and working to keep costs down and patients out of the hospital.

"Whenever you have massive change, it creates opportunities for someone," he said.

With only about a year to go before the major elements of the Affordable Care Act take effect, federal health officials released details Nov. 20 on how health plans must cover individuals with preexisting conditions, as well as what types of health plans can be offered in state insurance exchanges.

Under the ACA, health plans are barred beginning in 2014 from discriminating against adults with preexisting conditions. In its proposed rule, the Health and Human Services department prohibits insurers from denying or dropping coverage due to a preexisting illness starting on Jan. 1 of that year. The ACA already requires health plans to provide insurance for children regardless of preexisting conditions; that provision went into effect in 2010.

HHS estimates that currently in 45 states, health plans can legally deny coverage to adults with current or past medical conditions when those individuals are shopping for insurance on the individual market.

Under the proposal, insurers are also banned from raising premiums based on health status, preexisting conditions, claims history, gender, duration of coverage, occupation, or employer size. However, insurers can vary premiums somewhat based on age, tobacco use, family size, and geography. The proposed rules will apply to individual and small group plans beginning in 2014, and will be extended to large group plans entering the health insurance exchanges in 2017.

The proposed rule also requires health plans to set up a single statewide risk pool for their individual market and for their small employer market, with the goal of creating larger risk pools that will provide more stable rates for consumers.

Under the proposed rule, HHS also provided additional guidance on what health coverage will look like under the state health insurance exchanges when they debut in 2014.

Under the ACA, health plans operating in the exchanges will be required to offer an "essential health benefits" package that includes services from the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

In order to be offered for sale in the insurance exchanges, health plans will be required to cover the essential health benefits at roughly the same level as a benchmark plan in each state. Each state will choose a benchmark plan, which by law must be one of the largest plans in the state’s small group market, one of the largest state employee health benefit plans, one of the largest plans under the national Federal Employees Health Benefits Program, or the largest insured commercial HMO in the state.

The HHS proposal also outlines a system for identifying the level of consumer cost sharing among the plans offered on the exchange.

The department calls for plans to be identified as platinum, gold, silver, and bronze, with platinum offering lower beneficiary cost sharing but higher premiums. Platinum plans will pay for 90% of all covered services, with beneficiaries responsible for 10%. Gold plans will pick up 80% of the costs, silver plans will pay 70%, and bronze plans will pay 60%.

The requirements for health plans seeking to participate in the exchanges are largely similar to what HHS outlined in a policy bulletin issued last year. One difference, however, is the requirements for prescription drugs.

Under the previous proposal, HHS had floated the idea of requiring plans to cover at least one drug in each category and class covered by the benchmark plans. But following criticism that one drug in each category and class would not offer adequate coverage, HHS modified its approach. Now, health plans would be required to cover at least one drug in every category and class. If the benchmark plan covers more than one drug, the health plans in the exchange must cover the same number of drugs as the benchmark plan.

The proposed rules were slated to be published in the Federal Register on Nov. 26.

With only about a year to go before the major elements of the Affordable Care Act take effect, federal health officials released details Nov. 20 on how health plans must cover individuals with preexisting conditions, as well as what types of health plans can be offered in state insurance exchanges.

Under the ACA, health plans are barred beginning in 2014 from discriminating against adults with preexisting conditions. In its proposed rule, the Health and Human Services department prohibits insurers from denying or dropping coverage due to a preexisting illness starting on Jan. 1 of that year. The ACA already requires health plans to provide insurance for children regardless of preexisting conditions; that provision went into effect in 2010.

HHS estimates that currently in 45 states, health plans can legally deny coverage to adults with current or past medical conditions when those individuals are shopping for insurance on the individual market.

Under the proposal, insurers are also banned from raising premiums based on health status, preexisting conditions, claims history, gender, duration of coverage, occupation, or employer size. However, insurers can vary premiums somewhat based on age, tobacco use, family size, and geography. The proposed rules will apply to individual and small group plans beginning in 2014, and will be extended to large group plans entering the health insurance exchanges in 2017.

The proposed rule also requires health plans to set up a single statewide risk pool for their individual market and for their small employer market, with the goal of creating larger risk pools that will provide more stable rates for consumers.

Under the proposed rule, HHS also provided additional guidance on what health coverage will look like under the state health insurance exchanges when they debut in 2014.

Under the ACA, health plans operating in the exchanges will be required to offer an "essential health benefits" package that includes services from the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

In order to be offered for sale in the insurance exchanges, health plans will be required to cover the essential health benefits at roughly the same level as a benchmark plan in each state. Each state will choose a benchmark plan, which by law must be one of the largest plans in the state’s small group market, one of the largest state employee health benefit plans, one of the largest plans under the national Federal Employees Health Benefits Program, or the largest insured commercial HMO in the state.

The HHS proposal also outlines a system for identifying the level of consumer cost sharing among the plans offered on the exchange.

The department calls for plans to be identified as platinum, gold, silver, and bronze, with platinum offering lower beneficiary cost sharing but higher premiums. Platinum plans will pay for 90% of all covered services, with beneficiaries responsible for 10%. Gold plans will pick up 80% of the costs, silver plans will pay 70%, and bronze plans will pay 60%.

The requirements for health plans seeking to participate in the exchanges are largely similar to what HHS outlined in a policy bulletin issued last year. One difference, however, is the requirements for prescription drugs.

Under the previous proposal, HHS had floated the idea of requiring plans to cover at least one drug in each category and class covered by the benchmark plans. But following criticism that one drug in each category and class would not offer adequate coverage, HHS modified its approach. Now, health plans would be required to cover at least one drug in every category and class. If the benchmark plan covers more than one drug, the health plans in the exchange must cover the same number of drugs as the benchmark plan.

The proposed rules were slated to be published in the Federal Register on Nov. 26.

With only about a year to go before the major elements of the Affordable Care Act take effect, federal health officials released details Nov. 20 on how health plans must cover individuals with preexisting conditions, as well as what types of health plans can be offered in state insurance exchanges.

Under the ACA, health plans are barred beginning in 2014 from discriminating against adults with preexisting conditions. In its proposed rule, the Health and Human Services department prohibits insurers from denying or dropping coverage due to a preexisting illness starting on Jan. 1 of that year. The ACA already requires health plans to provide insurance for children regardless of preexisting conditions; that provision went into effect in 2010.

HHS estimates that currently in 45 states, health plans can legally deny coverage to adults with current or past medical conditions when those individuals are shopping for insurance on the individual market.

Under the proposal, insurers are also banned from raising premiums based on health status, preexisting conditions, claims history, gender, duration of coverage, occupation, or employer size. However, insurers can vary premiums somewhat based on age, tobacco use, family size, and geography. The proposed rules will apply to individual and small group plans beginning in 2014, and will be extended to large group plans entering the health insurance exchanges in 2017.

The proposed rule also requires health plans to set up a single statewide risk pool for their individual market and for their small employer market, with the goal of creating larger risk pools that will provide more stable rates for consumers.

Under the proposed rule, HHS also provided additional guidance on what health coverage will look like under the state health insurance exchanges when they debut in 2014.

Under the ACA, health plans operating in the exchanges will be required to offer an "essential health benefits" package that includes services from the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

In order to be offered for sale in the insurance exchanges, health plans will be required to cover the essential health benefits at roughly the same level as a benchmark plan in each state. Each state will choose a benchmark plan, which by law must be one of the largest plans in the state’s small group market, one of the largest state employee health benefit plans, one of the largest plans under the national Federal Employees Health Benefits Program, or the largest insured commercial HMO in the state.

The HHS proposal also outlines a system for identifying the level of consumer cost sharing among the plans offered on the exchange.

The department calls for plans to be identified as platinum, gold, silver, and bronze, with platinum offering lower beneficiary cost sharing but higher premiums. Platinum plans will pay for 90% of all covered services, with beneficiaries responsible for 10%. Gold plans will pick up 80% of the costs, silver plans will pay 70%, and bronze plans will pay 60%.

The requirements for health plans seeking to participate in the exchanges are largely similar to what HHS outlined in a policy bulletin issued last year. One difference, however, is the requirements for prescription drugs.

Under the previous proposal, HHS had floated the idea of requiring plans to cover at least one drug in each category and class covered by the benchmark plans. But following criticism that one drug in each category and class would not offer adequate coverage, HHS modified its approach. Now, health plans would be required to cover at least one drug in every category and class. If the benchmark plan covers more than one drug, the health plans in the exchange must cover the same number of drugs as the benchmark plan.

The proposed rules were slated to be published in the Federal Register on Nov. 26.

For the past 6 years, Dr. Ethan Cumbler has been immersed in figuring out how to reduce the time from when the medical staff first notices signs of new neurologic deficits in a hospitalized patient to when the patient receives an evaluation. Before he and his colleagues at the University of Colorado Hospital in Denver first started the project in October 2006, it took 4 1/2 hours, on average. Today, the average time to evaluation for an in-hospital stroke is 30 minutes, similar to the response time in the emergency department.

Dr. Cumbler credits their success, in part, to the formation of an in-hospital stroke alert program, in which the medical staff calls in a multidisciplinary stroke response team rather than the patient’s primary medical team. Earlier this year, the Society for Hospital Medicine awardedDr. Cumbler, and the multidisciplinary team at the University of Colorado School of Medicine, the Award for Excellence in Teamwork in Quality Improvement for their work on improving in-hospital stroke response and studying it.

In an interview, Dr. Cumbler, who is also the director of the University of Colorado Hospital Acute Care for the Elderly service, explained the essential elements to reducing response time and the critical role for hospitalists.

Question: How are most hospitals doing in terms of in-hospital stroke response time?

Dr. Cumbler: Hospitals are all over the map in terms of their sophistication in dealing with inpatient strokes. When I speak at hospitals around the country, I generally hear about one of three different types of responses to a patient with new neurologic deficits on the floor.

The first one is the traditional response, in which there is not a systematized approach to a patient with new neurologic deficits but rather the call goes to the primary team. You have to recognize the huge variability in stroke experience, knowledge, and comfort when you’re talking about calling any physician who might have a patient anywhere within the hospital.

The second response that I hear about is a rapid response team that is able to initiate a stroke evaluation. That’s not the path that we use here at the University of Colorado Hospital, but for many hospitals, this works out extremely well and ties in nicely to their existing system of rapid response for cardiopulmonary crisis. This does however create the imperative to make sure the rapid response team members are stroke trained.

The last approach is the system that we use here at the University of Colorado, which is a dedicated inpatient stroke alert system. For hospitals that use this approach, the response team is usually the same as the one that responds to strokes in the emergency department.

Question: Is there room for improvement?

Dr. Cumbler: There are two places where there is room for improvement. The first is response time. This is a classic opportunity for the application of Lean quality improvement methodology to reduce complexity, to eliminate steps which don’t add value, and to reduce variation. When we look at the data both from the National Stroke Association’s QI initiative, as well as from a Michigan stroke registry, we find that very few patients meet the goal of 25 minutes from recognition of stroke symptoms by medical staff to CT scan, if the stroke happened in the inpatient setting.

The second place where there’s room for improvement is in adherence to quality metrics. I’m actually doing research right now with the American Heart Association using the Get With the Guidelines national database to examine quality of care and outcomes for in-hospital stroke compared to those in the community. This is the largest analysis that’s been done on in-hospital stroke by a factor of about 30

Question: Are hospitalists equipped to respond to strokes?

Dr. Cumbler: I would argue that the hospitalist is equipped, or could be equipped, to be part of that response team for in-hospital strokes. In part because I think stroke is within the circle of expertise of hospitalists. But also because we have to recognize that not all stroke alerts are for stroke. When we have looked at this across a number of different analyses, ours and others, we find that somewhere between about 30% and 50% of all stroke alerts, are not for stroke. They are for one of the stroke mimics, such as severe hypoglycemia, or narcotic overdose, or delirium from a new systemic infection. Who is better to assess that new acute neurologic change in a complex, ill inpatient than the hospitalist?

Question: What’s the role for the neurohospitalist in the in-hospital response to stroke?

Dr. Cumbler: For hospitals that are lucky enough to have a neurohospitalist program, and ours is one, they are absolutely integral. In our hospital, the neurohospitalists lead the stroke program and form the backbone of the acute stroke response both in the ED and in the inpatient setting. Most hospitals, however, do not have dedicated neurohospitalists, much less an inpatient presence 24-7

Question: How important is the multidisciplinary team when you’re responding to a stroke in the hospital?

Dr. Cumbler: It is critical. All the cylinders have to be firing for an in-hospital stroke to be evaluated and treated within an hour. This team includes hospitalists, neurologists, radiologists, but also nursing, lab technicians, CT technicians, and pharmacists. It’s amazing to think about how many people have to touch the patient having a stroke in order for a patient to go all the way from recognition of new symptoms up on the wards to treatment with thrombolysis. At a minimum, in our institution, it’s eight different people from six different departments. And it may be significantly more, depending on where that patient is and what that patient needs.

So how do you get eight individuals from six different departments to coordinate in under 60 minutes? If you don’t have an interdisciplinary team mechanism, this is going to be extraordinarily difficult. For us, the key to coordinating that was involving the people that needed to be a part of the process from the beginning, which included making pharmacy and CT technicians part of the stroke alert that was sent out as soon as the patient was recognized to have deficits. We then used checklist process cards to keep all of the different members of the team on the same page.

—Mary Ellen Schneider

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

For the past 6 years, Dr. Ethan Cumbler has been immersed in figuring out how to reduce the time from when the medical staff first notices signs of new neurologic deficits in a hospitalized patient to when the patient receives an evaluation. Before he and his colleagues at the University of Colorado Hospital in Denver first started the project in October 2006, it took 4 1/2 hours, on average. Today, the average time to evaluation for an in-hospital stroke is 30 minutes, similar to the response time in the emergency department.

Dr. Cumbler credits their success, in part, to the formation of an in-hospital stroke alert program, in which the medical staff calls in a multidisciplinary stroke response team rather than the patient’s primary medical team. Earlier this year, the Society for Hospital Medicine awardedDr. Cumbler, and the multidisciplinary team at the University of Colorado School of Medicine, the Award for Excellence in Teamwork in Quality Improvement for their work on improving in-hospital stroke response and studying it.

In an interview, Dr. Cumbler, who is also the director of the University of Colorado Hospital Acute Care for the Elderly service, explained the essential elements to reducing response time and the critical role for hospitalists.

Question: How are most hospitals doing in terms of in-hospital stroke response time?

Dr. Cumbler: Hospitals are all over the map in terms of their sophistication in dealing with inpatient strokes. When I speak at hospitals around the country, I generally hear about one of three different types of responses to a patient with new neurologic deficits on the floor.

The first one is the traditional response, in which there is not a systematized approach to a patient with new neurologic deficits but rather the call goes to the primary team. You have to recognize the huge variability in stroke experience, knowledge, and comfort when you’re talking about calling any physician who might have a patient anywhere within the hospital.

The second response that I hear about is a rapid response team that is able to initiate a stroke evaluation. That’s not the path that we use here at the University of Colorado Hospital, but for many hospitals, this works out extremely well and ties in nicely to their existing system of rapid response for cardiopulmonary crisis. This does however create the imperative to make sure the rapid response team members are stroke trained.

The last approach is the system that we use here at the University of Colorado, which is a dedicated inpatient stroke alert system. For hospitals that use this approach, the response team is usually the same as the one that responds to strokes in the emergency department.

Question: Is there room for improvement?

Dr. Cumbler: There are two places where there is room for improvement. The first is response time. This is a classic opportunity for the application of Lean quality improvement methodology to reduce complexity, to eliminate steps which don’t add value, and to reduce variation. When we look at the data both from the National Stroke Association’s QI initiative, as well as from a Michigan stroke registry, we find that very few patients meet the goal of 25 minutes from recognition of stroke symptoms by medical staff to CT scan, if the stroke happened in the inpatient setting.

The second place where there’s room for improvement is in adherence to quality metrics. I’m actually doing research right now with the American Heart Association using the Get With the Guidelines national database to examine quality of care and outcomes for in-hospital stroke compared to those in the community. This is the largest analysis that’s been done on in-hospital stroke by a factor of about 30

Question: Are hospitalists equipped to respond to strokes?

Dr. Cumbler: I would argue that the hospitalist is equipped, or could be equipped, to be part of that response team for in-hospital strokes. In part because I think stroke is within the circle of expertise of hospitalists. But also because we have to recognize that not all stroke alerts are for stroke. When we have looked at this across a number of different analyses, ours and others, we find that somewhere between about 30% and 50% of all stroke alerts, are not for stroke. They are for one of the stroke mimics, such as severe hypoglycemia, or narcotic overdose, or delirium from a new systemic infection. Who is better to assess that new acute neurologic change in a complex, ill inpatient than the hospitalist?

Question: What’s the role for the neurohospitalist in the in-hospital response to stroke?

Dr. Cumbler: For hospitals that are lucky enough to have a neurohospitalist program, and ours is one, they are absolutely integral. In our hospital, the neurohospitalists lead the stroke program and form the backbone of the acute stroke response both in the ED and in the inpatient setting. Most hospitals, however, do not have dedicated neurohospitalists, much less an inpatient presence 24-7

Question: How important is the multidisciplinary team when you’re responding to a stroke in the hospital?

Dr. Cumbler: It is critical. All the cylinders have to be firing for an in-hospital stroke to be evaluated and treated within an hour. This team includes hospitalists, neurologists, radiologists, but also nursing, lab technicians, CT technicians, and pharmacists. It’s amazing to think about how many people have to touch the patient having a stroke in order for a patient to go all the way from recognition of new symptoms up on the wards to treatment with thrombolysis. At a minimum, in our institution, it’s eight different people from six different departments. And it may be significantly more, depending on where that patient is and what that patient needs.

So how do you get eight individuals from six different departments to coordinate in under 60 minutes? If you don’t have an interdisciplinary team mechanism, this is going to be extraordinarily difficult. For us, the key to coordinating that was involving the people that needed to be a part of the process from the beginning, which included making pharmacy and CT technicians part of the stroke alert that was sent out as soon as the patient was recognized to have deficits. We then used checklist process cards to keep all of the different members of the team on the same page.

—Mary Ellen Schneider

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

For the past 6 years, Dr. Ethan Cumbler has been immersed in figuring out how to reduce the time from when the medical staff first notices signs of new neurologic deficits in a hospitalized patient to when the patient receives an evaluation. Before he and his colleagues at the University of Colorado Hospital in Denver first started the project in October 2006, it took 4 1/2 hours, on average. Today, the average time to evaluation for an in-hospital stroke is 30 minutes, similar to the response time in the emergency department.

Dr. Cumbler credits their success, in part, to the formation of an in-hospital stroke alert program, in which the medical staff calls in a multidisciplinary stroke response team rather than the patient’s primary medical team. Earlier this year, the Society for Hospital Medicine awardedDr. Cumbler, and the multidisciplinary team at the University of Colorado School of Medicine, the Award for Excellence in Teamwork in Quality Improvement for their work on improving in-hospital stroke response and studying it.

In an interview, Dr. Cumbler, who is also the director of the University of Colorado Hospital Acute Care for the Elderly service, explained the essential elements to reducing response time and the critical role for hospitalists.

Question: How are most hospitals doing in terms of in-hospital stroke response time?

Dr. Cumbler: Hospitals are all over the map in terms of their sophistication in dealing with inpatient strokes. When I speak at hospitals around the country, I generally hear about one of three different types of responses to a patient with new neurologic deficits on the floor.

The first one is the traditional response, in which there is not a systematized approach to a patient with new neurologic deficits but rather the call goes to the primary team. You have to recognize the huge variability in stroke experience, knowledge, and comfort when you’re talking about calling any physician who might have a patient anywhere within the hospital.

The second response that I hear about is a rapid response team that is able to initiate a stroke evaluation. That’s not the path that we use here at the University of Colorado Hospital, but for many hospitals, this works out extremely well and ties in nicely to their existing system of rapid response for cardiopulmonary crisis. This does however create the imperative to make sure the rapid response team members are stroke trained.

The last approach is the system that we use here at the University of Colorado, which is a dedicated inpatient stroke alert system. For hospitals that use this approach, the response team is usually the same as the one that responds to strokes in the emergency department.

Question: Is there room for improvement?

Dr. Cumbler: There are two places where there is room for improvement. The first is response time. This is a classic opportunity for the application of Lean quality improvement methodology to reduce complexity, to eliminate steps which don’t add value, and to reduce variation. When we look at the data both from the National Stroke Association’s QI initiative, as well as from a Michigan stroke registry, we find that very few patients meet the goal of 25 minutes from recognition of stroke symptoms by medical staff to CT scan, if the stroke happened in the inpatient setting.

The second place where there’s room for improvement is in adherence to quality metrics. I’m actually doing research right now with the American Heart Association using the Get With the Guidelines national database to examine quality of care and outcomes for in-hospital stroke compared to those in the community. This is the largest analysis that’s been done on in-hospital stroke by a factor of about 30

Question: Are hospitalists equipped to respond to strokes?

Dr. Cumbler: I would argue that the hospitalist is equipped, or could be equipped, to be part of that response team for in-hospital strokes. In part because I think stroke is within the circle of expertise of hospitalists. But also because we have to recognize that not all stroke alerts are for stroke. When we have looked at this across a number of different analyses, ours and others, we find that somewhere between about 30% and 50% of all stroke alerts, are not for stroke. They are for one of the stroke mimics, such as severe hypoglycemia, or narcotic overdose, or delirium from a new systemic infection. Who is better to assess that new acute neurologic change in a complex, ill inpatient than the hospitalist?

Question: What’s the role for the neurohospitalist in the in-hospital response to stroke?

Dr. Cumbler: For hospitals that are lucky enough to have a neurohospitalist program, and ours is one, they are absolutely integral. In our hospital, the neurohospitalists lead the stroke program and form the backbone of the acute stroke response both in the ED and in the inpatient setting. Most hospitals, however, do not have dedicated neurohospitalists, much less an inpatient presence 24-7

Question: How important is the multidisciplinary team when you’re responding to a stroke in the hospital?

Dr. Cumbler: It is critical. All the cylinders have to be firing for an in-hospital stroke to be evaluated and treated within an hour. This team includes hospitalists, neurologists, radiologists, but also nursing, lab technicians, CT technicians, and pharmacists. It’s amazing to think about how many people have to touch the patient having a stroke in order for a patient to go all the way from recognition of new symptoms up on the wards to treatment with thrombolysis. At a minimum, in our institution, it’s eight different people from six different departments. And it may be significantly more, depending on where that patient is and what that patient needs.

So how do you get eight individuals from six different departments to coordinate in under 60 minutes? If you don’t have an interdisciplinary team mechanism, this is going to be extraordinarily difficult. For us, the key to coordinating that was involving the people that needed to be a part of the process from the beginning, which included making pharmacy and CT technicians part of the stroke alert that was sent out as soon as the patient was recognized to have deficits. We then used checklist process cards to keep all of the different members of the team on the same page.

—Mary Ellen Schneider

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

The overuse of tests, treatments, and procedures is getting increased attention as a patient safety issue.

The Joint Commission, along with the American Medical Association–convened Physician Consortium for Performance Improvement, recently held a summit to look at how to cut back on the overuse of certain medical interventions being performed even though they are not medically necessary and could cause harm.

The summit was centered on five common treatments and procedures:

• Percutaneous coronary intervention (PCI).

• Blood transfusions.

• Tympanostomy tubes for brief periods of fluid behind the eardrum.

• Antibiotics to treat viral upper respiratory infections.

• Early induction of labor without medical need.

"We have come to believe in American medicine that everything we do is beneficial," said Dr. Donna E. Sweet, an internist and professor of medicine at the University of Kansas, Wichita, who headed up the work group looking at antibiotic overuse for upper respiratory tract viral infections. "There’s always a downside."

Antibiotic Overuse

In the case of viral upper respiratory infections, commonly prescribed antibiotics do nothing to improve patients’ health and risk worsening the population-wide problem of antibiotic resistance. In the outpatient setting, the stumbling block is often that when patients come into the office, they expect to leave with a prescription. For physicians, it’s easier to write an antibiotic prescription than to explain why they don’t need it, Dr. Sweet said.

"American patients aren’t very patient," she said. "They want to be better now."

In the hospital, physicians have more tools at their disposal for managing the use of antibiotics, from good culture techniques, to advice from pharmacists, to an on-site laboratory. But overuse still happens. Hospitalists should try to make a specific diagnosis when they can and do a culture, Dr. Sweet said. If a patient comes into the hospital sick, febrile, hypotensive, and dehydrated, it’s probably appropriate to start them on a broad-spectrum antibiotic. But if after 24-48 hours, there’s nothing growing in the culture, it’s probably a viral infection and the antibiotics should be cut off, she said.

"Restricting both the length and then the spectrum of the antibiotic are the two things that we know will make a difference in trying to combat some of this antibiotic resistance," she said.

The antibiotic overuse work group is looking at ways to align the various definitions of a viral upper respiratory infection and the existing guidelines, Dr. Sweet said.

Transfusion Driven by Lack of Info

When it comes to blood transfusion, another work group will be considering ways to increase the amount of time spent on this topic in medical school.

"We know that there is a lack of knowledge," said Dr. Aryeh Shander, chief of the department of anesthesiology and critical care medicine at Englewood Hospital and Medical Center in New Jersey, who headed up the transfusion work group.

Medical schools devote only about 2-6 hours to the subject of blood transfusion, and most of that time is spent on blood type compatibility, not only the clinical situations in which blood transfusion is appropriate, said Dr. Shander, who is also the president of the Society for the Advancement of Blood Management, a group that advocates for reducing the number of blood transfusions.

"This is one of the 10 most common invasive procedures done in hospitalized patients," Dr. Shander said. "I don’t think you would want a cardiac surgeon doing heart surgery on you with 6 hours of education."

While it is well known that blood transfusions run the risk of complications, there is also a growing body of literature showing that transfusions don’t improve outcomes in patients who are regularly transfused, such as nonhemorrhaging patients and those who don’t have a functioning bone marrow, Dr. Shander said.

"The problem is that for physicians, the default is to transfuse," he said. "If there’s a question, they default to transfuse rather than looking at other options for patients, which are just as effective and carry less risk."

When physicians rush to transfuse, they deprive patients of better options, he said. For example, a patient with very low hemoglobin who is completely stable is likely to be transfused in many hospitals. But Dr. Shander said that patient is more likely to need iron.

Hitting Rock Bottom on PCI Overuse

When it comes to percutaneous coronary intervention, the experts at the National Overuse Summit were trying to figure out how to bring down an already low number.

Current estimates put the amount of overuse of the procedure at about 6-8% nationally, according to Dr. Carl T. Tommaso, an interventional cardiologist at NorthShore University HealthSystem in Skokie, Ill., who headed up the PCI work group.

The amount of overuse is so low because the field already has guidelines, appropriate use criteria, and a national database for reporting outcomes.

"What’s rock bottom?" Dr. Tommaso said. "We don’t know what those numbers are."

But Dr. Tommaso and the members of the PCI work group said the best path forward is to continue to push physicians to use the appropriate use criteria to guide their decisions on PCI.

"With the appropriate use criteria, and people using them, we will move toward better use of PCI for our patients," Dr. Tommaso said.

The Joint Commission and the AMA–convened Physician Consortium for Performance Improvement are currently analyzing results from the National Overuse Summit, and each of the five work groups is working on potential next steps.

The overuse of tests, treatments, and procedures is getting increased attention as a patient safety issue.

The Joint Commission, along with the American Medical Association–convened Physician Consortium for Performance Improvement, recently held a summit to look at how to cut back on the overuse of certain medical interventions being performed even though they are not medically necessary and could cause harm.

The summit was centered on five common treatments and procedures:

• Percutaneous coronary intervention (PCI).

• Blood transfusions.

• Tympanostomy tubes for brief periods of fluid behind the eardrum.

• Antibiotics to treat viral upper respiratory infections.

• Early induction of labor without medical need.

"We have come to believe in American medicine that everything we do is beneficial," said Dr. Donna E. Sweet, an internist and professor of medicine at the University of Kansas, Wichita, who headed up the work group looking at antibiotic overuse for upper respiratory tract viral infections. "There’s always a downside."

Antibiotic Overuse

In the case of viral upper respiratory infections, commonly prescribed antibiotics do nothing to improve patients’ health and risk worsening the population-wide problem of antibiotic resistance. In the outpatient setting, the stumbling block is often that when patients come into the office, they expect to leave with a prescription. For physicians, it’s easier to write an antibiotic prescription than to explain why they don’t need it, Dr. Sweet said.

"American patients aren’t very patient," she said. "They want to be better now."

In the hospital, physicians have more tools at their disposal for managing the use of antibiotics, from good culture techniques, to advice from pharmacists, to an on-site laboratory. But overuse still happens. Hospitalists should try to make a specific diagnosis when they can and do a culture, Dr. Sweet said. If a patient comes into the hospital sick, febrile, hypotensive, and dehydrated, it’s probably appropriate to start them on a broad-spectrum antibiotic. But if after 24-48 hours, there’s nothing growing in the culture, it’s probably a viral infection and the antibiotics should be cut off, she said.

"Restricting both the length and then the spectrum of the antibiotic are the two things that we know will make a difference in trying to combat some of this antibiotic resistance," she said.

The antibiotic overuse work group is looking at ways to align the various definitions of a viral upper respiratory infection and the existing guidelines, Dr. Sweet said.

Transfusion Driven by Lack of Info

When it comes to blood transfusion, another work group will be considering ways to increase the amount of time spent on this topic in medical school.

"We know that there is a lack of knowledge," said Dr. Aryeh Shander, chief of the department of anesthesiology and critical care medicine at Englewood Hospital and Medical Center in New Jersey, who headed up the transfusion work group.

Medical schools devote only about 2-6 hours to the subject of blood transfusion, and most of that time is spent on blood type compatibility, not only the clinical situations in which blood transfusion is appropriate, said Dr. Shander, who is also the president of the Society for the Advancement of Blood Management, a group that advocates for reducing the number of blood transfusions.

"This is one of the 10 most common invasive procedures done in hospitalized patients," Dr. Shander said. "I don’t think you would want a cardiac surgeon doing heart surgery on you with 6 hours of education."

While it is well known that blood transfusions run the risk of complications, there is also a growing body of literature showing that transfusions don’t improve outcomes in patients who are regularly transfused, such as nonhemorrhaging patients and those who don’t have a functioning bone marrow, Dr. Shander said.

"The problem is that for physicians, the default is to transfuse," he said. "If there’s a question, they default to transfuse rather than looking at other options for patients, which are just as effective and carry less risk."

When physicians rush to transfuse, they deprive patients of better options, he said. For example, a patient with very low hemoglobin who is completely stable is likely to be transfused in many hospitals. But Dr. Shander said that patient is more likely to need iron.

Hitting Rock Bottom on PCI Overuse

When it comes to percutaneous coronary intervention, the experts at the National Overuse Summit were trying to figure out how to bring down an already low number.

Current estimates put the amount of overuse of the procedure at about 6-8% nationally, according to Dr. Carl T. Tommaso, an interventional cardiologist at NorthShore University HealthSystem in Skokie, Ill., who headed up the PCI work group.

The amount of overuse is so low because the field already has guidelines, appropriate use criteria, and a national database for reporting outcomes.

"What’s rock bottom?" Dr. Tommaso said. "We don’t know what those numbers are."

But Dr. Tommaso and the members of the PCI work group said the best path forward is to continue to push physicians to use the appropriate use criteria to guide their decisions on PCI.

"With the appropriate use criteria, and people using them, we will move toward better use of PCI for our patients," Dr. Tommaso said.

The Joint Commission and the AMA–convened Physician Consortium for Performance Improvement are currently analyzing results from the National Overuse Summit, and each of the five work groups is working on potential next steps.

The overuse of tests, treatments, and procedures is getting increased attention as a patient safety issue.

The Joint Commission, along with the American Medical Association–convened Physician Consortium for Performance Improvement, recently held a summit to look at how to cut back on the overuse of certain medical interventions being performed even though they are not medically necessary and could cause harm.

The summit was centered on five common treatments and procedures:

• Percutaneous coronary intervention (PCI).

• Blood transfusions.

• Tympanostomy tubes for brief periods of fluid behind the eardrum.

• Antibiotics to treat viral upper respiratory infections.

• Early induction of labor without medical need.

"We have come to believe in American medicine that everything we do is beneficial," said Dr. Donna E. Sweet, an internist and professor of medicine at the University of Kansas, Wichita, who headed up the work group looking at antibiotic overuse for upper respiratory tract viral infections. "There’s always a downside."

Antibiotic Overuse

In the case of viral upper respiratory infections, commonly prescribed antibiotics do nothing to improve patients’ health and risk worsening the population-wide problem of antibiotic resistance. In the outpatient setting, the stumbling block is often that when patients come into the office, they expect to leave with a prescription. For physicians, it’s easier to write an antibiotic prescription than to explain why they don’t need it, Dr. Sweet said.

"American patients aren’t very patient," she said. "They want to be better now."

In the hospital, physicians have more tools at their disposal for managing the use of antibiotics, from good culture techniques, to advice from pharmacists, to an on-site laboratory. But overuse still happens. Hospitalists should try to make a specific diagnosis when they can and do a culture, Dr. Sweet said. If a patient comes into the hospital sick, febrile, hypotensive, and dehydrated, it’s probably appropriate to start them on a broad-spectrum antibiotic. But if after 24-48 hours, there’s nothing growing in the culture, it’s probably a viral infection and the antibiotics should be cut off, she said.

"Restricting both the length and then the spectrum of the antibiotic are the two things that we know will make a difference in trying to combat some of this antibiotic resistance," she said.

The antibiotic overuse work group is looking at ways to align the various definitions of a viral upper respiratory infection and the existing guidelines, Dr. Sweet said.

Transfusion Driven by Lack of Info

When it comes to blood transfusion, another work group will be considering ways to increase the amount of time spent on this topic in medical school.

"We know that there is a lack of knowledge," said Dr. Aryeh Shander, chief of the department of anesthesiology and critical care medicine at Englewood Hospital and Medical Center in New Jersey, who headed up the transfusion work group.

Medical schools devote only about 2-6 hours to the subject of blood transfusion, and most of that time is spent on blood type compatibility, not only the clinical situations in which blood transfusion is appropriate, said Dr. Shander, who is also the president of the Society for the Advancement of Blood Management, a group that advocates for reducing the number of blood transfusions.

"This is one of the 10 most common invasive procedures done in hospitalized patients," Dr. Shander said. "I don’t think you would want a cardiac surgeon doing heart surgery on you with 6 hours of education."

While it is well known that blood transfusions run the risk of complications, there is also a growing body of literature showing that transfusions don’t improve outcomes in patients who are regularly transfused, such as nonhemorrhaging patients and those who don’t have a functioning bone marrow, Dr. Shander said.

"The problem is that for physicians, the default is to transfuse," he said. "If there’s a question, they default to transfuse rather than looking at other options for patients, which are just as effective and carry less risk."

When physicians rush to transfuse, they deprive patients of better options, he said. For example, a patient with very low hemoglobin who is completely stable is likely to be transfused in many hospitals. But Dr. Shander said that patient is more likely to need iron.

Hitting Rock Bottom on PCI Overuse

When it comes to percutaneous coronary intervention, the experts at the National Overuse Summit were trying to figure out how to bring down an already low number.

Current estimates put the amount of overuse of the procedure at about 6-8% nationally, according to Dr. Carl T. Tommaso, an interventional cardiologist at NorthShore University HealthSystem in Skokie, Ill., who headed up the PCI work group.

The amount of overuse is so low because the field already has guidelines, appropriate use criteria, and a national database for reporting outcomes.

"What’s rock bottom?" Dr. Tommaso said. "We don’t know what those numbers are."

But Dr. Tommaso and the members of the PCI work group said the best path forward is to continue to push physicians to use the appropriate use criteria to guide their decisions on PCI.

"With the appropriate use criteria, and people using them, we will move toward better use of PCI for our patients," Dr. Tommaso said.

The Joint Commission and the AMA–convened Physician Consortium for Performance Improvement are currently analyzing results from the National Overuse Summit, and each of the five work groups is working on potential next steps.

Interventional cardiologists will be working with a number of new codes designed to better reflect the complexity of their patients and the intensive procedures they perform. But payments are still expected to decline in 2013.

The American Medical Association Current Procedural Terminology (CPT) Editorial Panel approved 13 new codes for reporting on percutaneous coronary interventions. The list includes several base codes for angioplasty, atherectomy, and stenting. In addition, the panel created add-on codes to be used by cardiologists when reporting on interventions conducted in additional branches of a major coronary artery.

The new code set also includes, for the first time, specific codes for the percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction (92941) and the percutaneous transluminal revascularization of chronic total occlusion (92943).

The changes represent a major paradigm shift in cardiac coding, according to Dr. Robert N. Piana, chair of the American College of Cardiology Coding Task Force.

Currently, if a physician performs a cardiac intervention in the main vessel plus one of the additional branches, it is coded with a single code. Under these new codes, cardiologists would use a base code to describe the procedure and an add-on code for each additional branch of a major coronary artery, according to Dr. Piana, director of the adult congenital interventional program at Vanderbilt Heart and Vascular Institute in Nashville, Tenn.

"We felt that this approach paralleled the methodology recently approved for lower extremity revascularization coding," he said, noting that the changes are geared to better reflect the work that cardiologists perform and to support appropriate valuation and reimbursement for more complex, intense, and time consuming procedures.

But it’s unclear if physicians will get a chance to use these new codes. In the 2013 Medicare Physician Fee Schedule final rule issued on Nov. 1, Medicare officials indicated that the agency would not pay physicians for the add-on codes.

In the rule, Medicare officials wrote that they rejected the add-on codes because of the potential that this type of coding system could provide an incentive for physicians to increase the placement of stents unnecessarily.

Officials at the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions (SCAI) are reviewing the Medicare fee schedule rule and developing recommendations on whether physicians should report the add-on CPT codes even if they won’t be paid by Medicare.

Financial Implications

The decision by officials at the Centers for Medicare and Medicaid Services is a blow to the new coding paradigm, but its financial impact on physicians may be somewhat mitigated because Medicare increased payments for the base codes when it decided not to pay for the add-on codes.

The bottom line is that under either of the coding methodologies, physicians would see a cut in payments for interventional cardiology services, Dr. Piana said.

"I don’t think that there’s any question that there will be some reduction in reimbursement for physicians," he said.

Here are some examples of how payments are falling in interventional cardiology.

• Stenting: Under the current system, percutaneous transcatheter placement of an intracoronary stent with coronary angioplasty was valued at 14.82 RVUs (relative value units). In 2013, the CMS has assigned 11.21 RVUs for the stenting with angioplasty code (92928).

• Atherectomy: This year, percutaneous transluminal coronary atherectomy with coronary angioplasty is valued at 12.07 RVUs. In 2013, the value for atherectomy with angioplasty (92924) will drop to 11.99 RVUs.

• Angioplasty: Currently, percutaneous transluminal coronary angioplasty conducted alone is allotted 10.96 RVUs. Next year, the new angioplasty code (92920) will be valued at 10.10 RVUs.

In a few cases, physicians have a chance to earn more money. For instance, the CMS approved the creation of new codes for percutaneous transluminal revascularizations for inpatients with acute myocardial infarctions (92941) and chronic total occlusion (92943). The CMS valued both services at 12.56 RVUs.

While these two services represent only a small percentage of the total practice of an average interventional cardiologist, they are very intensive services, Dr. Piana said. "They will now be recognized in a way they were not before," he said.

The New Codes

92920: percutaneous transluminal coronary angioplasty; single major coronary artery or branch.

92921: each additional branch of a major coronary artery (the CMS will not pay for this code).

92924: percutaneous transluminal coronary atherectomy, with coronary angioplasty.

92925: each additional branch of a major coronary artery (the CMS will not pay for this code).

92928: percutaneous transcatheter placement of intracoronary stent, with coronary angioplasty.

92929: each additional branch of a major coronary artery (the CMS will not pay for this code).

92933: percutaneous transluminal coronary atherectomy, with intracoronary stent, or with coronary angioplasty.

92934; each additional branch of a major coronary artery (the CMS will not pay for this code).

92937: percutaneous transluminal revascularization of or through coronary artery bypass graft, and any combination of intracoronary stent, atherectomy, and angioplasty.

92938: each additional branch subtended by the bypass graft (the CMS will not pay for this code).

92941: percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, or any combination of intracoronary stent, atherectomy, and angioplasty.

92943: percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, or any combination of intracoronary stent, atherectomy, and angioplasty.

92944: each additional coronary artery, coronary artery branch, or bypass graft (the CMS will not pay for this code).

The new codes replace CPT codes 92980-92984, 92995, and 92996.

Source: "CPT Changes 2013: An Insider’s View" (American Medical Association)

Interventional cardiologists will be working with a number of new codes designed to better reflect the complexity of their patients and the intensive procedures they perform. But payments are still expected to decline in 2013.

The American Medical Association Current Procedural Terminology (CPT) Editorial Panel approved 13 new codes for reporting on percutaneous coronary interventions. The list includes several base codes for angioplasty, atherectomy, and stenting. In addition, the panel created add-on codes to be used by cardiologists when reporting on interventions conducted in additional branches of a major coronary artery.

The new code set also includes, for the first time, specific codes for the percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction (92941) and the percutaneous transluminal revascularization of chronic total occlusion (92943).

The changes represent a major paradigm shift in cardiac coding, according to Dr. Robert N. Piana, chair of the American College of Cardiology Coding Task Force.

Currently, if a physician performs a cardiac intervention in the main vessel plus one of the additional branches, it is coded with a single code. Under these new codes, cardiologists would use a base code to describe the procedure and an add-on code for each additional branch of a major coronary artery, according to Dr. Piana, director of the adult congenital interventional program at Vanderbilt Heart and Vascular Institute in Nashville, Tenn.

"We felt that this approach paralleled the methodology recently approved for lower extremity revascularization coding," he said, noting that the changes are geared to better reflect the work that cardiologists perform and to support appropriate valuation and reimbursement for more complex, intense, and time consuming procedures.

But it’s unclear if physicians will get a chance to use these new codes. In the 2013 Medicare Physician Fee Schedule final rule issued on Nov. 1, Medicare officials indicated that the agency would not pay physicians for the add-on codes.

In the rule, Medicare officials wrote that they rejected the add-on codes because of the potential that this type of coding system could provide an incentive for physicians to increase the placement of stents unnecessarily.

Officials at the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions (SCAI) are reviewing the Medicare fee schedule rule and developing recommendations on whether physicians should report the add-on CPT codes even if they won’t be paid by Medicare.

Financial Implications

The decision by officials at the Centers for Medicare and Medicaid Services is a blow to the new coding paradigm, but its financial impact on physicians may be somewhat mitigated because Medicare increased payments for the base codes when it decided not to pay for the add-on codes.

The bottom line is that under either of the coding methodologies, physicians would see a cut in payments for interventional cardiology services, Dr. Piana said.

"I don’t think that there’s any question that there will be some reduction in reimbursement for physicians," he said.

Here are some examples of how payments are falling in interventional cardiology.

• Stenting: Under the current system, percutaneous transcatheter placement of an intracoronary stent with coronary angioplasty was valued at 14.82 RVUs (relative value units). In 2013, the CMS has assigned 11.21 RVUs for the stenting with angioplasty code (92928).

• Atherectomy: This year, percutaneous transluminal coronary atherectomy with coronary angioplasty is valued at 12.07 RVUs. In 2013, the value for atherectomy with angioplasty (92924) will drop to 11.99 RVUs.

• Angioplasty: Currently, percutaneous transluminal coronary angioplasty conducted alone is allotted 10.96 RVUs. Next year, the new angioplasty code (92920) will be valued at 10.10 RVUs.

In a few cases, physicians have a chance to earn more money. For instance, the CMS approved the creation of new codes for percutaneous transluminal revascularizations for inpatients with acute myocardial infarctions (92941) and chronic total occlusion (92943). The CMS valued both services at 12.56 RVUs.

While these two services represent only a small percentage of the total practice of an average interventional cardiologist, they are very intensive services, Dr. Piana said. "They will now be recognized in a way they were not before," he said.

The New Codes

92920: percutaneous transluminal coronary angioplasty; single major coronary artery or branch.

92921: each additional branch of a major coronary artery (the CMS will not pay for this code).

92924: percutaneous transluminal coronary atherectomy, with coronary angioplasty.

92925: each additional branch of a major coronary artery (the CMS will not pay for this code).

92928: percutaneous transcatheter placement of intracoronary stent, with coronary angioplasty.

92929: each additional branch of a major coronary artery (the CMS will not pay for this code).

92933: percutaneous transluminal coronary atherectomy, with intracoronary stent, or with coronary angioplasty.

92934; each additional branch of a major coronary artery (the CMS will not pay for this code).

92937: percutaneous transluminal revascularization of or through coronary artery bypass graft, and any combination of intracoronary stent, atherectomy, and angioplasty.

92938: each additional branch subtended by the bypass graft (the CMS will not pay for this code).

92941: percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, or any combination of intracoronary stent, atherectomy, and angioplasty.

92943: percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, or any combination of intracoronary stent, atherectomy, and angioplasty.

92944: each additional coronary artery, coronary artery branch, or bypass graft (the CMS will not pay for this code).

The new codes replace CPT codes 92980-92984, 92995, and 92996.

Source: "CPT Changes 2013: An Insider’s View" (American Medical Association)

Interventional cardiologists will be working with a number of new codes designed to better reflect the complexity of their patients and the intensive procedures they perform. But payments are still expected to decline in 2013.

The American Medical Association Current Procedural Terminology (CPT) Editorial Panel approved 13 new codes for reporting on percutaneous coronary interventions. The list includes several base codes for angioplasty, atherectomy, and stenting. In addition, the panel created add-on codes to be used by cardiologists when reporting on interventions conducted in additional branches of a major coronary artery.

The new code set also includes, for the first time, specific codes for the percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction (92941) and the percutaneous transluminal revascularization of chronic total occlusion (92943).

The changes represent a major paradigm shift in cardiac coding, according to Dr. Robert N. Piana, chair of the American College of Cardiology Coding Task Force.

Currently, if a physician performs a cardiac intervention in the main vessel plus one of the additional branches, it is coded with a single code. Under these new codes, cardiologists would use a base code to describe the procedure and an add-on code for each additional branch of a major coronary artery, according to Dr. Piana, director of the adult congenital interventional program at Vanderbilt Heart and Vascular Institute in Nashville, Tenn.

"We felt that this approach paralleled the methodology recently approved for lower extremity revascularization coding," he said, noting that the changes are geared to better reflect the work that cardiologists perform and to support appropriate valuation and reimbursement for more complex, intense, and time consuming procedures.

But it’s unclear if physicians will get a chance to use these new codes. In the 2013 Medicare Physician Fee Schedule final rule issued on Nov. 1, Medicare officials indicated that the agency would not pay physicians for the add-on codes.

In the rule, Medicare officials wrote that they rejected the add-on codes because of the potential that this type of coding system could provide an incentive for physicians to increase the placement of stents unnecessarily.

Officials at the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions (SCAI) are reviewing the Medicare fee schedule rule and developing recommendations on whether physicians should report the add-on CPT codes even if they won’t be paid by Medicare.

Financial Implications

The decision by officials at the Centers for Medicare and Medicaid Services is a blow to the new coding paradigm, but its financial impact on physicians may be somewhat mitigated because Medicare increased payments for the base codes when it decided not to pay for the add-on codes.

The bottom line is that under either of the coding methodologies, physicians would see a cut in payments for interventional cardiology services, Dr. Piana said.

"I don’t think that there’s any question that there will be some reduction in reimbursement for physicians," he said.

Here are some examples of how payments are falling in interventional cardiology.

• Stenting: Under the current system, percutaneous transcatheter placement of an intracoronary stent with coronary angioplasty was valued at 14.82 RVUs (relative value units). In 2013, the CMS has assigned 11.21 RVUs for the stenting with angioplasty code (92928).

• Atherectomy: This year, percutaneous transluminal coronary atherectomy with coronary angioplasty is valued at 12.07 RVUs. In 2013, the value for atherectomy with angioplasty (92924) will drop to 11.99 RVUs.

• Angioplasty: Currently, percutaneous transluminal coronary angioplasty conducted alone is allotted 10.96 RVUs. Next year, the new angioplasty code (92920) will be valued at 10.10 RVUs.

In a few cases, physicians have a chance to earn more money. For instance, the CMS approved the creation of new codes for percutaneous transluminal revascularizations for inpatients with acute myocardial infarctions (92941) and chronic total occlusion (92943). The CMS valued both services at 12.56 RVUs.

While these two services represent only a small percentage of the total practice of an average interventional cardiologist, they are very intensive services, Dr. Piana said. "They will now be recognized in a way they were not before," he said.

The New Codes

92920: percutaneous transluminal coronary angioplasty; single major coronary artery or branch.

92921: each additional branch of a major coronary artery (the CMS will not pay for this code).

92924: percutaneous transluminal coronary atherectomy, with coronary angioplasty.

92925: each additional branch of a major coronary artery (the CMS will not pay for this code).

92928: percutaneous transcatheter placement of intracoronary stent, with coronary angioplasty.

92929: each additional branch of a major coronary artery (the CMS will not pay for this code).

92933: percutaneous transluminal coronary atherectomy, with intracoronary stent, or with coronary angioplasty.

92934; each additional branch of a major coronary artery (the CMS will not pay for this code).

92937: percutaneous transluminal revascularization of or through coronary artery bypass graft, and any combination of intracoronary stent, atherectomy, and angioplasty.

92938: each additional branch subtended by the bypass graft (the CMS will not pay for this code).

92941: percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, or any combination of intracoronary stent, atherectomy, and angioplasty.

92943: percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, or any combination of intracoronary stent, atherectomy, and angioplasty.

92944: each additional coronary artery, coronary artery branch, or bypass graft (the CMS will not pay for this code).

The new codes replace CPT codes 92980-92984, 92995, and 92996.

Source: "CPT Changes 2013: An Insider’s View" (American Medical Association)