Mary Ellen Schneider

If Gov. Mitt Romney were elected president and moves ahead with his proposal to replace the Affordable Care Act with tax incentives to buy insurance and Medicaid block grants, 12 million Americans would lose their health insurance coverage, bringing the total number of uninsured to 72 million by 2022, according to an analysis from the Commonwealth Fund.

Conversely, if President Obama were reelected and the ACA remains intact, the number of uninsured would drop by 33 million, leaving 27 million Americans uninsured, according to the report.

The reason for the projected jump in the number of uninsured under Gov. Romney is due mainly to his pledge to repeal the ACA, which would greatly expand insurance coverage. The other factor driving up the number of uninsured is his proposal to provide states with block grants to fund the Medicaid program, said Sara R. Collins, vice president at the Commonwealth Fund.

The researchers assumed that the Medicaid block grants would grow at the rate of population growth plus 1% and that states would have to cut their own costs to account for this lower rate of spending growth. They estimated that about half the cuts would be in provider payments and reduced benefits; the other half of the cuts would come in the form of reduced eligibility for the program, which would lead to more people joining the ranks of the uninsured.

The report is based on modeling conducted by Jonathan Gruber, Ph.D., a professor of economics at Massachusetts Institute of Technology in Boston. He estimated what insurance coverage would be if the ACA had not been implemented, what it would be like if the law were fully implemented with all states participating in the Medicaid expansion, and how coverage would be affected if Gov. Romney moved forward with his Medicaid block grants and proposals to provide tax incentives for individuals purchasing health insurance on their own.

Dr. Gruber advised Gov. Romney on the development of the 2006 Massachusetts health insurance law and the Obama Administration on the ACA. He also contributed to a recent analysis by the consumer advocacy group Families USA, which found that health insurance would be more expensive under a Romney presidency.

If Gov. Mitt Romney were elected president and moves ahead with his proposal to replace the Affordable Care Act with tax incentives to buy insurance and Medicaid block grants, 12 million Americans would lose their health insurance coverage, bringing the total number of uninsured to 72 million by 2022, according to an analysis from the Commonwealth Fund.

Conversely, if President Obama were reelected and the ACA remains intact, the number of uninsured would drop by 33 million, leaving 27 million Americans uninsured, according to the report.

The reason for the projected jump in the number of uninsured under Gov. Romney is due mainly to his pledge to repeal the ACA, which would greatly expand insurance coverage. The other factor driving up the number of uninsured is his proposal to provide states with block grants to fund the Medicaid program, said Sara R. Collins, vice president at the Commonwealth Fund.

The researchers assumed that the Medicaid block grants would grow at the rate of population growth plus 1% and that states would have to cut their own costs to account for this lower rate of spending growth. They estimated that about half the cuts would be in provider payments and reduced benefits; the other half of the cuts would come in the form of reduced eligibility for the program, which would lead to more people joining the ranks of the uninsured.

The report is based on modeling conducted by Jonathan Gruber, Ph.D., a professor of economics at Massachusetts Institute of Technology in Boston. He estimated what insurance coverage would be if the ACA had not been implemented, what it would be like if the law were fully implemented with all states participating in the Medicaid expansion, and how coverage would be affected if Gov. Romney moved forward with his Medicaid block grants and proposals to provide tax incentives for individuals purchasing health insurance on their own.

Dr. Gruber advised Gov. Romney on the development of the 2006 Massachusetts health insurance law and the Obama Administration on the ACA. He also contributed to a recent analysis by the consumer advocacy group Families USA, which found that health insurance would be more expensive under a Romney presidency.

If Gov. Mitt Romney were elected president and moves ahead with his proposal to replace the Affordable Care Act with tax incentives to buy insurance and Medicaid block grants, 12 million Americans would lose their health insurance coverage, bringing the total number of uninsured to 72 million by 2022, according to an analysis from the Commonwealth Fund.

Conversely, if President Obama were reelected and the ACA remains intact, the number of uninsured would drop by 33 million, leaving 27 million Americans uninsured, according to the report.

The reason for the projected jump in the number of uninsured under Gov. Romney is due mainly to his pledge to repeal the ACA, which would greatly expand insurance coverage. The other factor driving up the number of uninsured is his proposal to provide states with block grants to fund the Medicaid program, said Sara R. Collins, vice president at the Commonwealth Fund.

The researchers assumed that the Medicaid block grants would grow at the rate of population growth plus 1% and that states would have to cut their own costs to account for this lower rate of spending growth. They estimated that about half the cuts would be in provider payments and reduced benefits; the other half of the cuts would come in the form of reduced eligibility for the program, which would lead to more people joining the ranks of the uninsured.

The report is based on modeling conducted by Jonathan Gruber, Ph.D., a professor of economics at Massachusetts Institute of Technology in Boston. He estimated what insurance coverage would be if the ACA had not been implemented, what it would be like if the law were fully implemented with all states participating in the Medicaid expansion, and how coverage would be affected if Gov. Romney moved forward with his Medicaid block grants and proposals to provide tax incentives for individuals purchasing health insurance on their own.

Dr. Gruber advised Gov. Romney on the development of the 2006 Massachusetts health insurance law and the Obama Administration on the ACA. He also contributed to a recent analysis by the consumer advocacy group Families USA, which found that health insurance would be more expensive under a Romney presidency.

The American Board of Psychiatry and Neurology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Dermatology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available – at the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Psychiatry and Neurology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Dermatology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available – at the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Psychiatry and Neurology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Dermatology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available – at the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Obstetrics and Gynecology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Dermatology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available at www.certificationmatters.org – the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Obstetrics and Gynecology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Dermatology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available at www.certificationmatters.org – the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

The American Board of Obstetrics and Gynecology and 10 other medical boards recently began publicly reporting whether physicians are up to date on their maintenance of certification requirements.

The trend toward disclosing maintenance of certification (MOC) status started in August 2011 when seven medical specialty boards, including the American Board of Dermatology, the American Board of Family Medicine, and the American Board of Surgery, began making the information publicly available at www.certificationmatters.org – the consumer-focused website of the American Board of Medical Specialties (ABMS).

Now only six ABMS member boards do not publicly post the MOC status of their diplomates. That list includes the American Board of Internal Medicine and American Board of Pediatrics.

However, all ABMS member boards are expected to publicly report MOC status by early 2014, according to Dr. Lois Nora, ABMS president and CEO.

The move to make MOC information readily available to the public is an important part medical professionalism, Dr. Nora said in an interview. "We have a covenant with the public that we will act in their best interest."

Consumers seem to be interested in learning whether their physicians are board certified and whether they participate in MOC. Since the launch of the certificationmatters.org site in February 2011, more than 1.1 million people have visited the site, according to ABMS. The site allows individuals to search for board certification and MOC status by physician name, location, or specialty.

If the physician’s certifying board is 1 of the 18 that publicly discloses its members’ MOC status, consumers will also see "Yes," "No," or "Not Required" displayed next to their MOC status. The "Not Required" response relates to physicians who have a lifetime certification with their board.

Congress needs to act soon to avert a scheduled 27% cut in physicians’ Medicare pay – and find a way to fix the failed system that calls for that cut – but, increasingly, experts say that the solution must be multipronged and adaptable to a variety of practice situations.

One reason that the current system has failed is that it holds individual physicians responsible for group behavior at a national level, according to Dr. Barbara Levy, vice president for health policy at the American College of Obstetricians and Gynecologists. Instead of leading to lower health costs, it actually increases them because the payment system drives physicians to increase their volume to make up for low reimbursement.

The Sustainable Growth Rate (SGR) formula – the mechanism that ties doctor pay to the gross domestic product in an effort to control costs – "was never really useful in terms of accomplishing the goal to bend the cost curve," Dr. Levy said.

Potential alternatives being evaluated provide an opportunity to get the incentives right, she said, and gear the system toward individual, not group, accountability. Payment models, however, will all need to be carefully studied over multiple years, she said, to know for sure if they will work. For instance, good preventive care is expensive in the short term but saves money over time. Looking at just 6 months of data is not enough to see if savings are possible, she said.

Legislation Offers Permanent Fix

One proposal favored by many physicians comes from Rep. Allyson Schwartz (D-Pa.) and Rep. Joe Heck (R-Nev.), an osteopathic physician. The bill (H.R. 5707) would permanently eliminate the SGR and set up a 10-year path to a new payment system.

Courtesy Office of Rep. Allyson Schwartz

During the initial years, physicians would receive small pay increases while Medicare officials tested new payment models, with primary care doctors getting slightly more during the transition.

After testing, physicians could choose from among a menu of alternative payment and delivery options. Those who didn’t participate in one of the new quality-based models would see their fee-for-service payments reduced starting in 2019.

Rep. Schwartz said there is an "outside hope" that the bill could be considered during the lame-duck session that follows the Nov. 6 election. If not then, it could come up in early 2013.

Overall, she said that she’s encouraged by the increasing agreement between physicians and lawmakers to move toward innovative payment models.

She advised doctors to keep talking to their members of Congress about the need to adopt a new system that pays adequately for high-quality care. The more bipartisan agreement around that concept, the better, she said.

"There’s no question that physicians should be looking at ways they can participate in new payment models," Rep. Schwartz said.

The House and Senate committees that oversee Medicare – the Senate Finance Committee, the House Energy and Commerce Committee, and the House Ways and Means Committee – also have been talking to physicians and insurers about what type of payment system could replace the SGR.

Committee members appear to be working toward legislation that would extend current Medicare payment rates temporarily while moving toward value-based payment models, according to Bob Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians.

If lawmakers went forward with that type of plan, physicians would probably have the chance to earn a small pay increase for participating in programs that reward value or care coordination. That approach would still leave the SGR in place, though, at least in the short-term.

"The hope is that, as more physicians begin to move to these other models and you get more experience with them, that will create a roadmap to eventually sunsetting the entire SGR and replacing it with these value-based payment models," Mr. Doherty said.

Although the emphasis on getting away from the current system is encouraging, Mr. Doherty said he’s concerned about any approach that falls short of repealing the SGR.

Variety Is Needed

It’s also looking like a plan to replace the SGR could include a variety of payment models, not just a single alternative, said Ray Quintero, director of government relations for the American Osteopathic Association.

"A one-size-fits-all solution is no longer possible," he said. "At the end of the day, every physician practices differently, the patients that they serve are different, the services that they provide are different, and the payment models should be reflective of that."

Some of those new models may come from the Center for Medicare and Medicaid Innovation, which was created under the Affordable Care Act and is testing new ways to pay for and deliver health care, but Congress is also looking to the private health plans for solutions that have already been tested and produced savings, Mr. Quintero said.

Copyright ACC

Time to Act Is Now

Dr. William Zoghbi, president of the American College of Cardiology, said that the problem is urgent and members of Congress need to look to payments models that are ready for implementation today.

The ACC has developed SMARTCare, a program to address variation in cost and quality in the treatment of stable ischemic heart disease. SMARTCare uses registry data to help physicians employ the most appropriate diagnostics and treatments. Such a program could be used hand-in-hand with a bundled payment model, he said.

"There are so many ways of doing it, but I think we really need to get together and make some early decisions to move forward," Dr. Zoghbi said.

He called on Congress and the administration to provide leadership. Physicians want to be involved in changing the system, but they are only one piece, he said. Policymakers also need to work with drug and device companies and hospitals to cut back on waste and make the health care system more sustainable.

"The further we delay these decisions, the more costly it is," Dr. Zoghbi said.

Gail Wilensky, Ph.D., who ran the Medicare and Medicaid programs from 1990 to 1992, agreed.

She suggested a number of payment alternatives Congress could consider, including bundling physician payments for high-cost, high-volume interventions.

Now Congress needs to direct the Centers for Medicare and Medicaid Services or the Medicare Payment Advisory Commission to come up with a plan and give them a firm deadline, she said. With that plan in hand, it would be easier for members of Congress to justify spending $300 billion to replace the SGR system.

"Until they do that, you don’t have anything to talk about," said Dr. Wilensky, who is currently an economist and senior fellow at Project HOPE.

Physicians can do their part to speed the legislative heavy lifting by presenting concrete alternatives with a real capacity to cut costs for the health care system, said Dr. Mark B. McClellan, who was the CMS administrator from 2004 to 2006 and is now director of the Engelberg Center for Health Care Reform at the Brookings Institution.

He cited some of the medical-home models that have been implemented by private health plans as good examples. These medical homes provide substantially better up-front payments for primary care physicians but also make physicians accountable for keeping overall costs down.

"Leadership on this is going to have to come from physicians and physician organizations," Dr. McClellan said. "Congress and the Medicare program are under a lot of pressure to do more to balance the budget, to do more to keep costs down while keeping quality up. They don’t have the best ideas. Physicians do."

Dealing with the Status Quo

Although most physicians don’t believe that Congress will allow large cuts to physician payment to go into effect, it’s possible that the trend of enacting temporary payment patches could continue for a few years.

Alicia Ault/ IMNG Medical Media

If the status quo persists, it would make it increasingly difficult for physicians to plan their expenses and run their offices, said Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"It tests people’s willingness to continue to participate in the Medicare program," Dr. Stream said. "So often we don’t look at doctors’ offices, particularly small offices, as businesses. And yet they are businesses and they have expenses that are going up all the time as far as insurance, utilities, and staff."

More practices will critically evaluate their continued participation in Medicare, he said.

No matter what the outcome of November’s election, lawmakers will have to address the physician payment issue, Dr. Stream said. His biggest concern right now is that the election continues the partisan stalemate of the last few years.

"That stalemate in a lot of ways could actually be more harmful to evolving so many things about our health care system, including the physician payment piece," he said.

Congress needs to act soon to avert a scheduled 27% cut in physicians’ Medicare pay – and find a way to fix the failed system that calls for that cut – but, increasingly, experts say that the solution must be multipronged and adaptable to a variety of practice situations.

One reason that the current system has failed is that it holds individual physicians responsible for group behavior at a national level, according to Dr. Barbara Levy, vice president for health policy at the American College of Obstetricians and Gynecologists. Instead of leading to lower health costs, it actually increases them because the payment system drives physicians to increase their volume to make up for low reimbursement.

The Sustainable Growth Rate (SGR) formula – the mechanism that ties doctor pay to the gross domestic product in an effort to control costs – "was never really useful in terms of accomplishing the goal to bend the cost curve," Dr. Levy said.

Potential alternatives being evaluated provide an opportunity to get the incentives right, she said, and gear the system toward individual, not group, accountability. Payment models, however, will all need to be carefully studied over multiple years, she said, to know for sure if they will work. For instance, good preventive care is expensive in the short term but saves money over time. Looking at just 6 months of data is not enough to see if savings are possible, she said.

Legislation Offers Permanent Fix

One proposal favored by many physicians comes from Rep. Allyson Schwartz (D-Pa.) and Rep. Joe Heck (R-Nev.), an osteopathic physician. The bill (H.R. 5707) would permanently eliminate the SGR and set up a 10-year path to a new payment system.

Courtesy Office of Rep. Allyson Schwartz

During the initial years, physicians would receive small pay increases while Medicare officials tested new payment models, with primary care doctors getting slightly more during the transition.

After testing, physicians could choose from among a menu of alternative payment and delivery options. Those who didn’t participate in one of the new quality-based models would see their fee-for-service payments reduced starting in 2019.

Rep. Schwartz said there is an "outside hope" that the bill could be considered during the lame-duck session that follows the Nov. 6 election. If not then, it could come up in early 2013.

Overall, she said that she’s encouraged by the increasing agreement between physicians and lawmakers to move toward innovative payment models.

She advised doctors to keep talking to their members of Congress about the need to adopt a new system that pays adequately for high-quality care. The more bipartisan agreement around that concept, the better, she said.

"There’s no question that physicians should be looking at ways they can participate in new payment models," Rep. Schwartz said.

The House and Senate committees that oversee Medicare – the Senate Finance Committee, the House Energy and Commerce Committee, and the House Ways and Means Committee – also have been talking to physicians and insurers about what type of payment system could replace the SGR.

Committee members appear to be working toward legislation that would extend current Medicare payment rates temporarily while moving toward value-based payment models, according to Bob Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians.

If lawmakers went forward with that type of plan, physicians would probably have the chance to earn a small pay increase for participating in programs that reward value or care coordination. That approach would still leave the SGR in place, though, at least in the short-term.

"The hope is that, as more physicians begin to move to these other models and you get more experience with them, that will create a roadmap to eventually sunsetting the entire SGR and replacing it with these value-based payment models," Mr. Doherty said.

Although the emphasis on getting away from the current system is encouraging, Mr. Doherty said he’s concerned about any approach that falls short of repealing the SGR.

Variety Is Needed

It’s also looking like a plan to replace the SGR could include a variety of payment models, not just a single alternative, said Ray Quintero, director of government relations for the American Osteopathic Association.

"A one-size-fits-all solution is no longer possible," he said. "At the end of the day, every physician practices differently, the patients that they serve are different, the services that they provide are different, and the payment models should be reflective of that."

Some of those new models may come from the Center for Medicare and Medicaid Innovation, which was created under the Affordable Care Act and is testing new ways to pay for and deliver health care, but Congress is also looking to the private health plans for solutions that have already been tested and produced savings, Mr. Quintero said.

Copyright ACC

Time to Act Is Now

Dr. William Zoghbi, president of the American College of Cardiology, said that the problem is urgent and members of Congress need to look to payments models that are ready for implementation today.

The ACC has developed SMARTCare, a program to address variation in cost and quality in the treatment of stable ischemic heart disease. SMARTCare uses registry data to help physicians employ the most appropriate diagnostics and treatments. Such a program could be used hand-in-hand with a bundled payment model, he said.

"There are so many ways of doing it, but I think we really need to get together and make some early decisions to move forward," Dr. Zoghbi said.

He called on Congress and the administration to provide leadership. Physicians want to be involved in changing the system, but they are only one piece, he said. Policymakers also need to work with drug and device companies and hospitals to cut back on waste and make the health care system more sustainable.

"The further we delay these decisions, the more costly it is," Dr. Zoghbi said.

Gail Wilensky, Ph.D., who ran the Medicare and Medicaid programs from 1990 to 1992, agreed.

She suggested a number of payment alternatives Congress could consider, including bundling physician payments for high-cost, high-volume interventions.

Now Congress needs to direct the Centers for Medicare and Medicaid Services or the Medicare Payment Advisory Commission to come up with a plan and give them a firm deadline, she said. With that plan in hand, it would be easier for members of Congress to justify spending $300 billion to replace the SGR system.

"Until they do that, you don’t have anything to talk about," said Dr. Wilensky, who is currently an economist and senior fellow at Project HOPE.

Physicians can do their part to speed the legislative heavy lifting by presenting concrete alternatives with a real capacity to cut costs for the health care system, said Dr. Mark B. McClellan, who was the CMS administrator from 2004 to 2006 and is now director of the Engelberg Center for Health Care Reform at the Brookings Institution.

He cited some of the medical-home models that have been implemented by private health plans as good examples. These medical homes provide substantially better up-front payments for primary care physicians but also make physicians accountable for keeping overall costs down.

"Leadership on this is going to have to come from physicians and physician organizations," Dr. McClellan said. "Congress and the Medicare program are under a lot of pressure to do more to balance the budget, to do more to keep costs down while keeping quality up. They don’t have the best ideas. Physicians do."

Dealing with the Status Quo

Although most physicians don’t believe that Congress will allow large cuts to physician payment to go into effect, it’s possible that the trend of enacting temporary payment patches could continue for a few years.

Alicia Ault/ IMNG Medical Media

If the status quo persists, it would make it increasingly difficult for physicians to plan their expenses and run their offices, said Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"It tests people’s willingness to continue to participate in the Medicare program," Dr. Stream said. "So often we don’t look at doctors’ offices, particularly small offices, as businesses. And yet they are businesses and they have expenses that are going up all the time as far as insurance, utilities, and staff."

More practices will critically evaluate their continued participation in Medicare, he said.

No matter what the outcome of November’s election, lawmakers will have to address the physician payment issue, Dr. Stream said. His biggest concern right now is that the election continues the partisan stalemate of the last few years.

"That stalemate in a lot of ways could actually be more harmful to evolving so many things about our health care system, including the physician payment piece," he said.

Congress needs to act soon to avert a scheduled 27% cut in physicians’ Medicare pay – and find a way to fix the failed system that calls for that cut – but, increasingly, experts say that the solution must be multipronged and adaptable to a variety of practice situations.

One reason that the current system has failed is that it holds individual physicians responsible for group behavior at a national level, according to Dr. Barbara Levy, vice president for health policy at the American College of Obstetricians and Gynecologists. Instead of leading to lower health costs, it actually increases them because the payment system drives physicians to increase their volume to make up for low reimbursement.

The Sustainable Growth Rate (SGR) formula – the mechanism that ties doctor pay to the gross domestic product in an effort to control costs – "was never really useful in terms of accomplishing the goal to bend the cost curve," Dr. Levy said.

Potential alternatives being evaluated provide an opportunity to get the incentives right, she said, and gear the system toward individual, not group, accountability. Payment models, however, will all need to be carefully studied over multiple years, she said, to know for sure if they will work. For instance, good preventive care is expensive in the short term but saves money over time. Looking at just 6 months of data is not enough to see if savings are possible, she said.

Legislation Offers Permanent Fix

One proposal favored by many physicians comes from Rep. Allyson Schwartz (D-Pa.) and Rep. Joe Heck (R-Nev.), an osteopathic physician. The bill (H.R. 5707) would permanently eliminate the SGR and set up a 10-year path to a new payment system.

Courtesy Office of Rep. Allyson Schwartz

During the initial years, physicians would receive small pay increases while Medicare officials tested new payment models, with primary care doctors getting slightly more during the transition.

After testing, physicians could choose from among a menu of alternative payment and delivery options. Those who didn’t participate in one of the new quality-based models would see their fee-for-service payments reduced starting in 2019.

Rep. Schwartz said there is an "outside hope" that the bill could be considered during the lame-duck session that follows the Nov. 6 election. If not then, it could come up in early 2013.

Overall, she said that she’s encouraged by the increasing agreement between physicians and lawmakers to move toward innovative payment models.

She advised doctors to keep talking to their members of Congress about the need to adopt a new system that pays adequately for high-quality care. The more bipartisan agreement around that concept, the better, she said.

"There’s no question that physicians should be looking at ways they can participate in new payment models," Rep. Schwartz said.

The House and Senate committees that oversee Medicare – the Senate Finance Committee, the House Energy and Commerce Committee, and the House Ways and Means Committee – also have been talking to physicians and insurers about what type of payment system could replace the SGR.

Committee members appear to be working toward legislation that would extend current Medicare payment rates temporarily while moving toward value-based payment models, according to Bob Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians.

If lawmakers went forward with that type of plan, physicians would probably have the chance to earn a small pay increase for participating in programs that reward value or care coordination. That approach would still leave the SGR in place, though, at least in the short-term.

"The hope is that, as more physicians begin to move to these other models and you get more experience with them, that will create a roadmap to eventually sunsetting the entire SGR and replacing it with these value-based payment models," Mr. Doherty said.

Although the emphasis on getting away from the current system is encouraging, Mr. Doherty said he’s concerned about any approach that falls short of repealing the SGR.

Variety Is Needed

It’s also looking like a plan to replace the SGR could include a variety of payment models, not just a single alternative, said Ray Quintero, director of government relations for the American Osteopathic Association.

"A one-size-fits-all solution is no longer possible," he said. "At the end of the day, every physician practices differently, the patients that they serve are different, the services that they provide are different, and the payment models should be reflective of that."

Some of those new models may come from the Center for Medicare and Medicaid Innovation, which was created under the Affordable Care Act and is testing new ways to pay for and deliver health care, but Congress is also looking to the private health plans for solutions that have already been tested and produced savings, Mr. Quintero said.

Copyright ACC

Time to Act Is Now

Dr. William Zoghbi, president of the American College of Cardiology, said that the problem is urgent and members of Congress need to look to payments models that are ready for implementation today.

The ACC has developed SMARTCare, a program to address variation in cost and quality in the treatment of stable ischemic heart disease. SMARTCare uses registry data to help physicians employ the most appropriate diagnostics and treatments. Such a program could be used hand-in-hand with a bundled payment model, he said.

"There are so many ways of doing it, but I think we really need to get together and make some early decisions to move forward," Dr. Zoghbi said.

He called on Congress and the administration to provide leadership. Physicians want to be involved in changing the system, but they are only one piece, he said. Policymakers also need to work with drug and device companies and hospitals to cut back on waste and make the health care system more sustainable.

"The further we delay these decisions, the more costly it is," Dr. Zoghbi said.

Gail Wilensky, Ph.D., who ran the Medicare and Medicaid programs from 1990 to 1992, agreed.

She suggested a number of payment alternatives Congress could consider, including bundling physician payments for high-cost, high-volume interventions.

Now Congress needs to direct the Centers for Medicare and Medicaid Services or the Medicare Payment Advisory Commission to come up with a plan and give them a firm deadline, she said. With that plan in hand, it would be easier for members of Congress to justify spending $300 billion to replace the SGR system.

"Until they do that, you don’t have anything to talk about," said Dr. Wilensky, who is currently an economist and senior fellow at Project HOPE.

Physicians can do their part to speed the legislative heavy lifting by presenting concrete alternatives with a real capacity to cut costs for the health care system, said Dr. Mark B. McClellan, who was the CMS administrator from 2004 to 2006 and is now director of the Engelberg Center for Health Care Reform at the Brookings Institution.

He cited some of the medical-home models that have been implemented by private health plans as good examples. These medical homes provide substantially better up-front payments for primary care physicians but also make physicians accountable for keeping overall costs down.

"Leadership on this is going to have to come from physicians and physician organizations," Dr. McClellan said. "Congress and the Medicare program are under a lot of pressure to do more to balance the budget, to do more to keep costs down while keeping quality up. They don’t have the best ideas. Physicians do."

Dealing with the Status Quo

Although most physicians don’t believe that Congress will allow large cuts to physician payment to go into effect, it’s possible that the trend of enacting temporary payment patches could continue for a few years.

Alicia Ault/ IMNG Medical Media

If the status quo persists, it would make it increasingly difficult for physicians to plan their expenses and run their offices, said Dr. Glen R. Stream, president of the American Academy of Family Physicians.

"It tests people’s willingness to continue to participate in the Medicare program," Dr. Stream said. "So often we don’t look at doctors’ offices, particularly small offices, as businesses. And yet they are businesses and they have expenses that are going up all the time as far as insurance, utilities, and staff."

More practices will critically evaluate their continued participation in Medicare, he said.

No matter what the outcome of November’s election, lawmakers will have to address the physician payment issue, Dr. Stream said. His biggest concern right now is that the election continues the partisan stalemate of the last few years.

"That stalemate in a lot of ways could actually be more harmful to evolving so many things about our health care system, including the physician payment piece," he said.

California has become the fifth state to require that women receive information about breast density along with the results of their mammograms. Gov. Jerry Brown (D) signed SB 1538 on Sept. 22.

Under the law, a mammography report must note if the patient has dense breasts, point out that dense breasts can make it harder to evaluate a mammogram, and inform patients that having dense breasts may be associated with an increased risk of breast cancer.

Courtesy Rhoda Baer/National Cancer Institute (NCI)

Once the law is in effect April 2, 2013, mammogram reports will advise women that the information is meant to inform conversations with their doctor so that together they can decide which screening options are right for them.

Gov. Brown vetoed similar legislation last year saying that it went too far by advising that additional screening may be beneficial. Four other states – Virginia, New York, Connecticut, and Texas – have also enacted breast density notification laws. Legislation is also being considered in a dozen other states and at the federal level, according to the advocacy group Are You Dense?.

California has become the fifth state to require that women receive information about breast density along with the results of their mammograms. Gov. Jerry Brown (D) signed SB 1538 on Sept. 22.

Under the law, a mammography report must note if the patient has dense breasts, point out that dense breasts can make it harder to evaluate a mammogram, and inform patients that having dense breasts may be associated with an increased risk of breast cancer.

Courtesy Rhoda Baer/National Cancer Institute (NCI)

Once the law is in effect April 2, 2013, mammogram reports will advise women that the information is meant to inform conversations with their doctor so that together they can decide which screening options are right for them.

Gov. Brown vetoed similar legislation last year saying that it went too far by advising that additional screening may be beneficial. Four other states – Virginia, New York, Connecticut, and Texas – have also enacted breast density notification laws. Legislation is also being considered in a dozen other states and at the federal level, according to the advocacy group Are You Dense?.

California has become the fifth state to require that women receive information about breast density along with the results of their mammograms. Gov. Jerry Brown (D) signed SB 1538 on Sept. 22.

Under the law, a mammography report must note if the patient has dense breasts, point out that dense breasts can make it harder to evaluate a mammogram, and inform patients that having dense breasts may be associated with an increased risk of breast cancer.

Courtesy Rhoda Baer/National Cancer Institute (NCI)

Once the law is in effect April 2, 2013, mammogram reports will advise women that the information is meant to inform conversations with their doctor so that together they can decide which screening options are right for them.

Gov. Brown vetoed similar legislation last year saying that it went too far by advising that additional screening may be beneficial. Four other states – Virginia, New York, Connecticut, and Texas – have also enacted breast density notification laws. Legislation is also being considered in a dozen other states and at the federal level, according to the advocacy group Are You Dense?.

With more hospitals seeking to cut costs through the use of reprocessed single-use medical devices, the American College of Obstetricians and Gynecologists is urging ob.gyns. to be alert about whether reprocessed instruments will be used in their surgeries and if they are safe.

ACOG’s Committee on Gynecologic Practice issued an opinion stating that physicians should be informed whether surgical instruments are original or have been reprocessed for additional use. Ultimately, though, it’s the physician’s responsibility to make a "good faith" effort to find out, according to the opinion. Physicians who have concerns about the quality or safety of an instrument have an ethical obligation not to use the instrument, the committee wrote.

The committee opinion was published in the October issue of Obstetrics & Gynecology (Obstet. Gynecol. 2012;120:974-6).

The ACOG committee didn’t take a position on whether reprocessed single-use medical devices should be used in obstetrics and gynecology, citing a lack of information on the safety, quality, and cost-effectiveness of these instruments.

For instance, in 2008 the Government Accountability Office issued a report saying that there appeared to be no increased health risk as a result of the greater use of reprocessed single-use devices. The ACOG committee pointed out, however, that the GAO assessment may have missed some safety issues because it relied only on voluntarily reported adverse events.

"Reprocessed devices result in cost savings for the hospital, but it is not apparent that there is any financial benefit to the patient or third-party payers," the committee wrote.

Other studies in orthopedics and laparoscopic surgery have found a significant rate of physical defects, performance issues, and improper decontamination of reprocessed single-use devices, according to the ACOG opinion, but those studies have been funded mainly by original device manufacturers.

The committee called for more independent studies on the safety, quality, and cost-effectiveness of reprocessed single-use medical devices in gynecologic surgery.

With more hospitals seeking to cut costs through the use of reprocessed single-use medical devices, the American College of Obstetricians and Gynecologists is urging ob.gyns. to be alert about whether reprocessed instruments will be used in their surgeries and if they are safe.

ACOG’s Committee on Gynecologic Practice issued an opinion stating that physicians should be informed whether surgical instruments are original or have been reprocessed for additional use. Ultimately, though, it’s the physician’s responsibility to make a "good faith" effort to find out, according to the opinion. Physicians who have concerns about the quality or safety of an instrument have an ethical obligation not to use the instrument, the committee wrote.

The committee opinion was published in the October issue of Obstetrics & Gynecology (Obstet. Gynecol. 2012;120:974-6).

The ACOG committee didn’t take a position on whether reprocessed single-use medical devices should be used in obstetrics and gynecology, citing a lack of information on the safety, quality, and cost-effectiveness of these instruments.

For instance, in 2008 the Government Accountability Office issued a report saying that there appeared to be no increased health risk as a result of the greater use of reprocessed single-use devices. The ACOG committee pointed out, however, that the GAO assessment may have missed some safety issues because it relied only on voluntarily reported adverse events.

"Reprocessed devices result in cost savings for the hospital, but it is not apparent that there is any financial benefit to the patient or third-party payers," the committee wrote.

Other studies in orthopedics and laparoscopic surgery have found a significant rate of physical defects, performance issues, and improper decontamination of reprocessed single-use devices, according to the ACOG opinion, but those studies have been funded mainly by original device manufacturers.

The committee called for more independent studies on the safety, quality, and cost-effectiveness of reprocessed single-use medical devices in gynecologic surgery.

With more hospitals seeking to cut costs through the use of reprocessed single-use medical devices, the American College of Obstetricians and Gynecologists is urging ob.gyns. to be alert about whether reprocessed instruments will be used in their surgeries and if they are safe.

ACOG’s Committee on Gynecologic Practice issued an opinion stating that physicians should be informed whether surgical instruments are original or have been reprocessed for additional use. Ultimately, though, it’s the physician’s responsibility to make a "good faith" effort to find out, according to the opinion. Physicians who have concerns about the quality or safety of an instrument have an ethical obligation not to use the instrument, the committee wrote.

The committee opinion was published in the October issue of Obstetrics & Gynecology (Obstet. Gynecol. 2012;120:974-6).

The ACOG committee didn’t take a position on whether reprocessed single-use medical devices should be used in obstetrics and gynecology, citing a lack of information on the safety, quality, and cost-effectiveness of these instruments.

For instance, in 2008 the Government Accountability Office issued a report saying that there appeared to be no increased health risk as a result of the greater use of reprocessed single-use devices. The ACOG committee pointed out, however, that the GAO assessment may have missed some safety issues because it relied only on voluntarily reported adverse events.

"Reprocessed devices result in cost savings for the hospital, but it is not apparent that there is any financial benefit to the patient or third-party payers," the committee wrote.

Other studies in orthopedics and laparoscopic surgery have found a significant rate of physical defects, performance issues, and improper decontamination of reprocessed single-use devices, according to the ACOG opinion, but those studies have been funded mainly by original device manufacturers.

The committee called for more independent studies on the safety, quality, and cost-effectiveness of reprocessed single-use medical devices in gynecologic surgery.

Dr. Smitha R. Chadaga, associate chief of hospital medicine at Denver Health Medical Center, has been experimenting with ways to improve the flow of patients through the hospital since the early days of her career.

Now, thanks to an experiment conducted with the help of colleagues across the emergency department (ED) and the department of medicine, she has identified a model in which a hospitalist-led team located in the ED can improve both patient diversion and boarding, while saving money for the hospital.

The results of the project, which were published in the September issue of the Journal of Hospital Medicine, show that creating the hospitalist-led team in the ED generated more than $525,000 in increased annual revenues for the hospital due solely to a reduction in ED diversion (J. Hosp. Med. 2012;7:562-6).

In an interview with Hospitalist News, Dr. Chadaga explained why they started the project and why it might be useful in other hospitals.

Hospitalist News: What prompted you to launch this project?

Dr. Chadaga: It was a twofold problem. One is the constant issue of patient diversion, which I think a lot of hospitalists deal with. As a corollary to that, we often had inpatients boarding in the emergency department. Both the medicine side and the emergency department side found this frustrating. On the emergency department side, the nursing staff often didn’t know who to go to for orders because any one of eight teams could be taking care of their patients. The emergency physicians, who were no longer taking care of the patients, would often get asked questions. On the medicine side, our medicine floors are fairly far away from the emergency department, so those patients often were the last to be seen.

In order to address both of those issues, we did a rapid improvement experiment over 4 days and had emergency department physicians, hospitalists, nurses, social workers, and patient managers all sitting in a room together to try to come up with a solution. The solution that we came up with was to have a hospitalist team housed in the ED to both help with patient flow, as well as care for those boarded patients.

HN: Describe the team. How large is it and how are the shifts scheduled?

Dr. Chadaga: During the daytime hours, from 7 a.m. to 5 p.m., we have a dedicated attending physician and an allied health professional who both work on patient flow and take care of boarded patients. When taking care of these patients, they round on anyone who is there as of 7 a.m. and has already been worked up, and they continue their work-up until discharge or transfer to the medical floor. And they see any new patients who need to be boarded. From 5 p.m. onward, those duties are rolled into existing hospitalist swing and night shifts. Our entire group knows how to do this, but we have a dedicated group of nine attendings who rotate through the daytime shift because it does require a certain skill set.

HN: What were some of the challenges in working with the ED physicians?

Dr. Chadaga: Since we had the Toyota Lean Rapid Improvement Event, all of the stakeholders were in the same room, including the director of the emergency department. It gave us all the opportunity to take this back to our groups and get buy in. While I think there could have been some issues with buy in on both sides, when it actually came to implementing it, there wasn’t a lot of resistance. The emergency physicians were excited to not have to answer questions about these patients. Nurses were excited to know whom to call. And all the floor teams were glad to know they didn’t have to come to the ED.

I think that most of the potential challenges in terms of communication, territory, and chain of command were already hashed out in that room before the project started. For anyone considering a project like this, I would advocate for getting buy in ahead of time.

One of the challenges we did encounter was how to create a steady workflow for this team. There are times when there are so many patients who are boarding that you have to flex up. But there are also times when there weren’t that many patients boarding and you had to flex down.

HN: How much does this cost to implement?

Dr. Chadaga: We were lucky that we didn’t require additional staffing. So whether this is cost effective will depend on how your group is staffed. If you want a dedicated, attending physician for the service 7 days a week, it does take approximately 2 full-time employees to accomplish that.

HN: Is this a model that could work in other hospitals, regardless of size?

Dr. Chadaga: This project is made up of a few different parts. There is a part to deal with patient flow, which is working with nurses and supervisors to make sure patients get to the right room the first time. There is another piece involving communication with the ED to help navigate patients. And then there’s the work of actually taking care of boarded patients. I think almost any institution can benefit from one of those, depending on how you want to attack diversion or how you want to take care of these patients.

In terms of instituting the entire program, I think you have to look at your staffing, look at the support you have from your administration, and actually see if you have both diversion and boarded patients. But any one of those strategies can be instituted in almost any situation because I think we all have issues of patient flow.

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

Dr. Smitha R. Chadaga, associate chief of hospital medicine at Denver Health Medical Center, has been experimenting with ways to improve the flow of patients through the hospital since the early days of her career.

Now, thanks to an experiment conducted with the help of colleagues across the emergency department (ED) and the department of medicine, she has identified a model in which a hospitalist-led team located in the ED can improve both patient diversion and boarding, while saving money for the hospital.

The results of the project, which were published in the September issue of the Journal of Hospital Medicine, show that creating the hospitalist-led team in the ED generated more than $525,000 in increased annual revenues for the hospital due solely to a reduction in ED diversion (J. Hosp. Med. 2012;7:562-6).

In an interview with Hospitalist News, Dr. Chadaga explained why they started the project and why it might be useful in other hospitals.

Hospitalist News: What prompted you to launch this project?

Dr. Chadaga: It was a twofold problem. One is the constant issue of patient diversion, which I think a lot of hospitalists deal with. As a corollary to that, we often had inpatients boarding in the emergency department. Both the medicine side and the emergency department side found this frustrating. On the emergency department side, the nursing staff often didn’t know who to go to for orders because any one of eight teams could be taking care of their patients. The emergency physicians, who were no longer taking care of the patients, would often get asked questions. On the medicine side, our medicine floors are fairly far away from the emergency department, so those patients often were the last to be seen.

In order to address both of those issues, we did a rapid improvement experiment over 4 days and had emergency department physicians, hospitalists, nurses, social workers, and patient managers all sitting in a room together to try to come up with a solution. The solution that we came up with was to have a hospitalist team housed in the ED to both help with patient flow, as well as care for those boarded patients.

HN: Describe the team. How large is it and how are the shifts scheduled?

Dr. Chadaga: During the daytime hours, from 7 a.m. to 5 p.m., we have a dedicated attending physician and an allied health professional who both work on patient flow and take care of boarded patients. When taking care of these patients, they round on anyone who is there as of 7 a.m. and has already been worked up, and they continue their work-up until discharge or transfer to the medical floor. And they see any new patients who need to be boarded. From 5 p.m. onward, those duties are rolled into existing hospitalist swing and night shifts. Our entire group knows how to do this, but we have a dedicated group of nine attendings who rotate through the daytime shift because it does require a certain skill set.

HN: What were some of the challenges in working with the ED physicians?

Dr. Chadaga: Since we had the Toyota Lean Rapid Improvement Event, all of the stakeholders were in the same room, including the director of the emergency department. It gave us all the opportunity to take this back to our groups and get buy in. While I think there could have been some issues with buy in on both sides, when it actually came to implementing it, there wasn’t a lot of resistance. The emergency physicians were excited to not have to answer questions about these patients. Nurses were excited to know whom to call. And all the floor teams were glad to know they didn’t have to come to the ED.

I think that most of the potential challenges in terms of communication, territory, and chain of command were already hashed out in that room before the project started. For anyone considering a project like this, I would advocate for getting buy in ahead of time.

One of the challenges we did encounter was how to create a steady workflow for this team. There are times when there are so many patients who are boarding that you have to flex up. But there are also times when there weren’t that many patients boarding and you had to flex down.

HN: How much does this cost to implement?

Dr. Chadaga: We were lucky that we didn’t require additional staffing. So whether this is cost effective will depend on how your group is staffed. If you want a dedicated, attending physician for the service 7 days a week, it does take approximately 2 full-time employees to accomplish that.

HN: Is this a model that could work in other hospitals, regardless of size?

Dr. Chadaga: This project is made up of a few different parts. There is a part to deal with patient flow, which is working with nurses and supervisors to make sure patients get to the right room the first time. There is another piece involving communication with the ED to help navigate patients. And then there’s the work of actually taking care of boarded patients. I think almost any institution can benefit from one of those, depending on how you want to attack diversion or how you want to take care of these patients.

In terms of instituting the entire program, I think you have to look at your staffing, look at the support you have from your administration, and actually see if you have both diversion and boarded patients. But any one of those strategies can be instituted in almost any situation because I think we all have issues of patient flow.

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

Dr. Smitha R. Chadaga, associate chief of hospital medicine at Denver Health Medical Center, has been experimenting with ways to improve the flow of patients through the hospital since the early days of her career.

Now, thanks to an experiment conducted with the help of colleagues across the emergency department (ED) and the department of medicine, she has identified a model in which a hospitalist-led team located in the ED can improve both patient diversion and boarding, while saving money for the hospital.

The results of the project, which were published in the September issue of the Journal of Hospital Medicine, show that creating the hospitalist-led team in the ED generated more than $525,000 in increased annual revenues for the hospital due solely to a reduction in ED diversion (J. Hosp. Med. 2012;7:562-6).

In an interview with Hospitalist News, Dr. Chadaga explained why they started the project and why it might be useful in other hospitals.

Hospitalist News: What prompted you to launch this project?

Dr. Chadaga: It was a twofold problem. One is the constant issue of patient diversion, which I think a lot of hospitalists deal with. As a corollary to that, we often had inpatients boarding in the emergency department. Both the medicine side and the emergency department side found this frustrating. On the emergency department side, the nursing staff often didn’t know who to go to for orders because any one of eight teams could be taking care of their patients. The emergency physicians, who were no longer taking care of the patients, would often get asked questions. On the medicine side, our medicine floors are fairly far away from the emergency department, so those patients often were the last to be seen.

In order to address both of those issues, we did a rapid improvement experiment over 4 days and had emergency department physicians, hospitalists, nurses, social workers, and patient managers all sitting in a room together to try to come up with a solution. The solution that we came up with was to have a hospitalist team housed in the ED to both help with patient flow, as well as care for those boarded patients.

HN: Describe the team. How large is it and how are the shifts scheduled?

Dr. Chadaga: During the daytime hours, from 7 a.m. to 5 p.m., we have a dedicated attending physician and an allied health professional who both work on patient flow and take care of boarded patients. When taking care of these patients, they round on anyone who is there as of 7 a.m. and has already been worked up, and they continue their work-up until discharge or transfer to the medical floor. And they see any new patients who need to be boarded. From 5 p.m. onward, those duties are rolled into existing hospitalist swing and night shifts. Our entire group knows how to do this, but we have a dedicated group of nine attendings who rotate through the daytime shift because it does require a certain skill set.

HN: What were some of the challenges in working with the ED physicians?

Dr. Chadaga: Since we had the Toyota Lean Rapid Improvement Event, all of the stakeholders were in the same room, including the director of the emergency department. It gave us all the opportunity to take this back to our groups and get buy in. While I think there could have been some issues with buy in on both sides, when it actually came to implementing it, there wasn’t a lot of resistance. The emergency physicians were excited to not have to answer questions about these patients. Nurses were excited to know whom to call. And all the floor teams were glad to know they didn’t have to come to the ED.

I think that most of the potential challenges in terms of communication, territory, and chain of command were already hashed out in that room before the project started. For anyone considering a project like this, I would advocate for getting buy in ahead of time.

One of the challenges we did encounter was how to create a steady workflow for this team. There are times when there are so many patients who are boarding that you have to flex up. But there are also times when there weren’t that many patients boarding and you had to flex down.

HN: How much does this cost to implement?

Dr. Chadaga: We were lucky that we didn’t require additional staffing. So whether this is cost effective will depend on how your group is staffed. If you want a dedicated, attending physician for the service 7 days a week, it does take approximately 2 full-time employees to accomplish that.

HN: Is this a model that could work in other hospitals, regardless of size?

Dr. Chadaga: This project is made up of a few different parts. There is a part to deal with patient flow, which is working with nurses and supervisors to make sure patients get to the right room the first time. There is another piece involving communication with the ED to help navigate patients. And then there’s the work of actually taking care of boarded patients. I think almost any institution can benefit from one of those, depending on how you want to attack diversion or how you want to take care of these patients.

In terms of instituting the entire program, I think you have to look at your staffing, look at the support you have from your administration, and actually see if you have both diversion and boarded patients. But any one of those strategies can be instituted in almost any situation because I think we all have issues of patient flow.

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 long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

(See the related video here.)

Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.

Dr. William T. Carpenter Jr., chair of the DSM-5’s Psychotic Disorders Work Group, said he and his colleagues do not want to unnecessarily pathologize young people. But he said they hoped to avoid that type of unintended consequence, since patients getting this diagnosis would have sought clinical care after demonstrating distress and disability.

As for stigma, Dr. Carpenter said the self-stigma, and the stigma from family and friends when people begin to exhibit potential psychotic behaviors outweighs the impact of a medical diagnosis.

"Doctors don’t label," said Dr. Carpenter, professor of psychiatry and pharmacology at the University of Maryland in Baltimore. "Doctors diagnose, take care of, and treat. That’s not to say that something cannot be stigmatizing, but ‘labeling’ kind of gets right into the antipsychiatry component of it."

The third public comment period for the DSM-5 closed on June 15. Since then, members of the 13 DSM-5 Work Groups have been formulating their final recommendations. In addition to the public comments, the work groups are considering data from a field trial of the proposals and research reviews.

Once the work groups are finished, their final revisions will be reviewed by the DSM-5 Task Force, as well as the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will make its recommendations to the American Psychiatric Association’s Board of Trustees, which has the final say in the process.

Dr. Kupfer cautions that anything could change during the final review of the DSM-5 draft this fall, here are some of the most recent proposed changes:

Autism Spectrum Disorder

As currently proposed, the DSM-5 would create a new name for the category – autism spectrum disorder – that would include autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Combining these conditions into a single spectrum disorder is a "better reflection of the state of knowledge about pathology and clinical presentation," according to the Neurodevelopment Disorders Work Group.

Major Depressive Episode

The Mood Disorders Work Group is seeking to eliminate the traditional bereavement exclusion that was part of the criteria for major depressive episodes. They made the change because of evidence of the significant similarities between bereavement-related depression and depression caused by other stressors. However, the work group added a footnote to clarifying that normal bereavement might resemble a depressive episode but that a major depressive episode would be characterized by feelings of worthlessness, suicidal ideas, psychomotor retardation, and severe impairment of overall function.

Disruptive Dysregulation Disorder

The draft DSM-5 features a new disorder called disruptive mood dysregulation disorder, which originally was proposed as temper dysregulation disorder. The proposed disorder is characterized by severe temper outbursts that are out of proportion in intensity or duration to the situation. To be eligible for this diagnosis, the patient should have outbursts three or more times a week, on average, and be persistently irritable or angry between these episodes. To avoid confusion from overlapping symptoms with oppositional defiant disorder, the Mood Disorders Work Group recommended that youth who meet criteria for both disorders should only be assigned the diagnosis of disruptive mood dysregulation disorder, which is the more severe diagnosis.

Binge Eating Disorder

The Eating Disorders Work Group members are proposing that the binge eating disorder be moved out of the DSM appendix and into the main manual. They decided to recommend binge eating disorder as a stand-alone diagnosis after a literature review showed that the condition runs in families and that it has a distinct demographic profile. The literature also showed that binge eating disorder had a better response to specialized treatments than to generic behavioral weight loss treatment.

Suicidal Behavior Disorder

The DSM-5 draft includes a new diagnosis called suicidal behavior disorder that would apply to a person who has attempted suicide in the last 24 months. Non–suicidal self-injury does not count as suicidal behavior under this definition, but having one or more acts of non-suicidal self-injury is not incompatible with the diagnosis. Having a separate diagnosis for suicidal behavior should improve the assessment of preventive measures and drug safety monitoring, according to the draft proposal.

But even as the more than decade-long process of developing the DSM-5 comes to a close, Dr. Kupfer said the document will not be fixed. Instead, the Task Force has been promoting the DSM-5 as a "living document" that can be more easily changed in the future to keep up with the latest scientific developments. Dr. Kupfer said there will likely be a DSM 5.1 at some point.

In addition to updates to the DSM-5, the APA is planning to produce another version of the manual that can be used in primary care practices. Plans are still being drawn up, but field trials designed to test the utility of the diagnoses in the primary care setting could occur in 2013 or 2014, Dr. Kupfer said.

The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

(See the related video here.)

Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.

Dr. William T. Carpenter Jr., chair of the DSM-5’s Psychotic Disorders Work Group, said he and his colleagues do not want to unnecessarily pathologize young people. But he said they hoped to avoid that type of unintended consequence, since patients getting this diagnosis would have sought clinical care after demonstrating distress and disability.

As for stigma, Dr. Carpenter said the self-stigma, and the stigma from family and friends when people begin to exhibit potential psychotic behaviors outweighs the impact of a medical diagnosis.

"Doctors don’t label," said Dr. Carpenter, professor of psychiatry and pharmacology at the University of Maryland in Baltimore. "Doctors diagnose, take care of, and treat. That’s not to say that something cannot be stigmatizing, but ‘labeling’ kind of gets right into the antipsychiatry component of it."

The third public comment period for the DSM-5 closed on June 15. Since then, members of the 13 DSM-5 Work Groups have been formulating their final recommendations. In addition to the public comments, the work groups are considering data from a field trial of the proposals and research reviews.

Once the work groups are finished, their final revisions will be reviewed by the DSM-5 Task Force, as well as the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will make its recommendations to the American Psychiatric Association’s Board of Trustees, which has the final say in the process.

Dr. Kupfer cautions that anything could change during the final review of the DSM-5 draft this fall, here are some of the most recent proposed changes:

Autism Spectrum Disorder

As currently proposed, the DSM-5 would create a new name for the category – autism spectrum disorder – that would include autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Combining these conditions into a single spectrum disorder is a "better reflection of the state of knowledge about pathology and clinical presentation," according to the Neurodevelopment Disorders Work Group.

Major Depressive Episode

The Mood Disorders Work Group is seeking to eliminate the traditional bereavement exclusion that was part of the criteria for major depressive episodes. They made the change because of evidence of the significant similarities between bereavement-related depression and depression caused by other stressors. However, the work group added a footnote to clarifying that normal bereavement might resemble a depressive episode but that a major depressive episode would be characterized by feelings of worthlessness, suicidal ideas, psychomotor retardation, and severe impairment of overall function.

Disruptive Dysregulation Disorder

The draft DSM-5 features a new disorder called disruptive mood dysregulation disorder, which originally was proposed as temper dysregulation disorder. The proposed disorder is characterized by severe temper outbursts that are out of proportion in intensity or duration to the situation. To be eligible for this diagnosis, the patient should have outbursts three or more times a week, on average, and be persistently irritable or angry between these episodes. To avoid confusion from overlapping symptoms with oppositional defiant disorder, the Mood Disorders Work Group recommended that youth who meet criteria for both disorders should only be assigned the diagnosis of disruptive mood dysregulation disorder, which is the more severe diagnosis.

Binge Eating Disorder

The Eating Disorders Work Group members are proposing that the binge eating disorder be moved out of the DSM appendix and into the main manual. They decided to recommend binge eating disorder as a stand-alone diagnosis after a literature review showed that the condition runs in families and that it has a distinct demographic profile. The literature also showed that binge eating disorder had a better response to specialized treatments than to generic behavioral weight loss treatment.

Suicidal Behavior Disorder

The DSM-5 draft includes a new diagnosis called suicidal behavior disorder that would apply to a person who has attempted suicide in the last 24 months. Non–suicidal self-injury does not count as suicidal behavior under this definition, but having one or more acts of non-suicidal self-injury is not incompatible with the diagnosis. Having a separate diagnosis for suicidal behavior should improve the assessment of preventive measures and drug safety monitoring, according to the draft proposal.

But even as the more than decade-long process of developing the DSM-5 comes to a close, Dr. Kupfer said the document will not be fixed. Instead, the Task Force has been promoting the DSM-5 as a "living document" that can be more easily changed in the future to keep up with the latest scientific developments. Dr. Kupfer said there will likely be a DSM 5.1 at some point.

In addition to updates to the DSM-5, the APA is planning to produce another version of the manual that can be used in primary care practices. Plans are still being drawn up, but field trials designed to test the utility of the diagnoses in the primary care setting could occur in 2013 or 2014, Dr. Kupfer said.

The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

(See the related video here.)

Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.

Dr. William T. Carpenter Jr., chair of the DSM-5’s Psychotic Disorders Work Group, said he and his colleagues do not want to unnecessarily pathologize young people. But he said they hoped to avoid that type of unintended consequence, since patients getting this diagnosis would have sought clinical care after demonstrating distress and disability.

As for stigma, Dr. Carpenter said the self-stigma, and the stigma from family and friends when people begin to exhibit potential psychotic behaviors outweighs the impact of a medical diagnosis.

"Doctors don’t label," said Dr. Carpenter, professor of psychiatry and pharmacology at the University of Maryland in Baltimore. "Doctors diagnose, take care of, and treat. That’s not to say that something cannot be stigmatizing, but ‘labeling’ kind of gets right into the antipsychiatry component of it."

The third public comment period for the DSM-5 closed on June 15. Since then, members of the 13 DSM-5 Work Groups have been formulating their final recommendations. In addition to the public comments, the work groups are considering data from a field trial of the proposals and research reviews.

Once the work groups are finished, their final revisions will be reviewed by the DSM-5 Task Force, as well as the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will make its recommendations to the American Psychiatric Association’s Board of Trustees, which has the final say in the process.

Dr. Kupfer cautions that anything could change during the final review of the DSM-5 draft this fall, here are some of the most recent proposed changes:

Autism Spectrum Disorder

As currently proposed, the DSM-5 would create a new name for the category – autism spectrum disorder – that would include autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Combining these conditions into a single spectrum disorder is a "better reflection of the state of knowledge about pathology and clinical presentation," according to the Neurodevelopment Disorders Work Group.

Major Depressive Episode

The Mood Disorders Work Group is seeking to eliminate the traditional bereavement exclusion that was part of the criteria for major depressive episodes. They made the change because of evidence of the significant similarities between bereavement-related depression and depression caused by other stressors. However, the work group added a footnote to clarifying that normal bereavement might resemble a depressive episode but that a major depressive episode would be characterized by feelings of worthlessness, suicidal ideas, psychomotor retardation, and severe impairment of overall function.

Disruptive Dysregulation Disorder

The draft DSM-5 features a new disorder called disruptive mood dysregulation disorder, which originally was proposed as temper dysregulation disorder. The proposed disorder is characterized by severe temper outbursts that are out of proportion in intensity or duration to the situation. To be eligible for this diagnosis, the patient should have outbursts three or more times a week, on average, and be persistently irritable or angry between these episodes. To avoid confusion from overlapping symptoms with oppositional defiant disorder, the Mood Disorders Work Group recommended that youth who meet criteria for both disorders should only be assigned the diagnosis of disruptive mood dysregulation disorder, which is the more severe diagnosis.

Binge Eating Disorder

The Eating Disorders Work Group members are proposing that the binge eating disorder be moved out of the DSM appendix and into the main manual. They decided to recommend binge eating disorder as a stand-alone diagnosis after a literature review showed that the condition runs in families and that it has a distinct demographic profile. The literature also showed that binge eating disorder had a better response to specialized treatments than to generic behavioral weight loss treatment.

Suicidal Behavior Disorder

The DSM-5 draft includes a new diagnosis called suicidal behavior disorder that would apply to a person who has attempted suicide in the last 24 months. Non–suicidal self-injury does not count as suicidal behavior under this definition, but having one or more acts of non-suicidal self-injury is not incompatible with the diagnosis. Having a separate diagnosis for suicidal behavior should improve the assessment of preventive measures and drug safety monitoring, according to the draft proposal.

But even as the more than decade-long process of developing the DSM-5 comes to a close, Dr. Kupfer said the document will not be fixed. Instead, the Task Force has been promoting the DSM-5 as a "living document" that can be more easily changed in the future to keep up with the latest scientific developments. Dr. Kupfer said there will likely be a DSM 5.1 at some point.

In addition to updates to the DSM-5, the APA is planning to produce another version of the manual that can be used in primary care practices. Plans are still being drawn up, but field trials designed to test the utility of the diagnoses in the primary care setting could occur in 2013 or 2014, Dr. Kupfer said.

The number of Americans with health insurance increased to more than 260 million in 2011, rising for the first time since 2007, according to a report released Sept. 12 by the U.S. Census Bureau.

The expansion in health care coverage came mostly from increases in the number of people enrolling in public insurance programs such as Medicare and Medicaid. Enrollment in private insurance, which covers nearly 64% of Americans, was statistically unchanged from 2010. However, this is the first time in the last decade that private insurance coverage has not declined, according to the report.

The biggest increase in health insurance coverage was among adults aged 19-25 years, a group that is now eligible to remain as a dependent on their parents’ health insurance under the Affordable Care Act.

In 2011, the number of people without health insurance dropped to 48.6 million or about 15.7% uninsured, down from 50 million (16.3%) in the previous year.

About 9.7% of children (7.6 million) were uninsured in 2011. This is statistically unchanged from 2010, according to the Census Bureau. However, small upticks in insurance coverage were seen in every other age group.

The Census Bureau findings are based on information collected in the 2012 Current Population Survey Annual Social and Economic Supplement.

The number of Americans with health insurance increased to more than 260 million in 2011, rising for the first time since 2007, according to a report released Sept. 12 by the U.S. Census Bureau.

The expansion in health care coverage came mostly from increases in the number of people enrolling in public insurance programs such as Medicare and Medicaid. Enrollment in private insurance, which covers nearly 64% of Americans, was statistically unchanged from 2010. However, this is the first time in the last decade that private insurance coverage has not declined, according to the report.

The biggest increase in health insurance coverage was among adults aged 19-25 years, a group that is now eligible to remain as a dependent on their parents’ health insurance under the Affordable Care Act.

In 2011, the number of people without health insurance dropped to 48.6 million or about 15.7% uninsured, down from 50 million (16.3%) in the previous year.

About 9.7% of children (7.6 million) were uninsured in 2011. This is statistically unchanged from 2010, according to the Census Bureau. However, small upticks in insurance coverage were seen in every other age group.

The Census Bureau findings are based on information collected in the 2012 Current Population Survey Annual Social and Economic Supplement.

The number of Americans with health insurance increased to more than 260 million in 2011, rising for the first time since 2007, according to a report released Sept. 12 by the U.S. Census Bureau.

The expansion in health care coverage came mostly from increases in the number of people enrolling in public insurance programs such as Medicare and Medicaid. Enrollment in private insurance, which covers nearly 64% of Americans, was statistically unchanged from 2010. However, this is the first time in the last decade that private insurance coverage has not declined, according to the report.

The biggest increase in health insurance coverage was among adults aged 19-25 years, a group that is now eligible to remain as a dependent on their parents’ health insurance under the Affordable Care Act.

In 2011, the number of people without health insurance dropped to 48.6 million or about 15.7% uninsured, down from 50 million (16.3%) in the previous year.

About 9.7% of children (7.6 million) were uninsured in 2011. This is statistically unchanged from 2010, according to the Census Bureau. However, small upticks in insurance coverage were seen in every other age group.

The Census Bureau findings are based on information collected in the 2012 Current Population Survey Annual Social and Economic Supplement.

Medicare payments are set to increase 2.8% in fiscal year 2013 to general acute care hospitals that successfully participate in Medicare’s Inpatient Quality Reporting Program. Hospitals that don’t participate will get just a 0.8% increase, though Medicare officials estimate that almost all hospitals will participate.

Medicare payments to long-term care facilities will increase by 1.7% in the coming fiscal years, which starts Oct. 1, according to the Centers for Medicare and Medicaid Services.

The new payment rates were announced Aug. 1 as part of the final rule for the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System.

In its original pay proposal published in May, the CMS said it would increase payments to general acute care hospitals by 2.3% because of cuts the agency was making to account for hospital coding that was too high. Based on public comments in opposition to the coding adjustments, the CMS backed off the cuts for now. The American Hospital Association estimates that the initial proposal would have cost hospitals nationwide a total of $850 million.

The final rule, to be published in the Federal Register August 31, also lays out a new quality program that debut in October. Under the Hospital Readmissions Reduction Program, hospitals’ base operating diagnosis-related-group (DRG) payment will be cut by 1% if their readmission rate for three conditions – acute myocardial infarction, heart failure, and pneumonia – is deemed too high. The agency estimates the program will reduce overall payments to hospitals by about $280 million in FY 2013.

For the Hospital Value-Based Purchasing (VBP) Program, which also begins on Oct. 1, the final rule specifies hospitals will receive their total performance scores, indicates how the 1% penalty will be applied to base operating charges, and provides the timeline for making incentive payments. New measures were added to the program for FY 2015: a central line – associated bloodstream infection measure, a patient safety indicator composite measure, and an efficiency measure that looks at Medicare spending per beneficiary.

The CMS is revising its list of hospital-acquired conditions for which it will not pay. Starting this fall, surgical site infection following cardiac implantable electronic device procedures will make the do-not-pay list, along with iatrogenic pneumothorax with venous catheterization.

The agency is adding two new codes to the list of hospital-acquired conditions: bloodstream infection due to central catheter (999.32) and local infection due to central venous catheter (999.33).

Medicare payments are set to increase 2.8% in fiscal year 2013 to general acute care hospitals that successfully participate in Medicare’s Inpatient Quality Reporting Program. Hospitals that don’t participate will get just a 0.8% increase, though Medicare officials estimate that almost all hospitals will participate.

Medicare payments to long-term care facilities will increase by 1.7% in the coming fiscal years, which starts Oct. 1, according to the Centers for Medicare and Medicaid Services.

The new payment rates were announced Aug. 1 as part of the final rule for the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System.

In its original pay proposal published in May, the CMS said it would increase payments to general acute care hospitals by 2.3% because of cuts the agency was making to account for hospital coding that was too high. Based on public comments in opposition to the coding adjustments, the CMS backed off the cuts for now. The American Hospital Association estimates that the initial proposal would have cost hospitals nationwide a total of $850 million.

The final rule, to be published in the Federal Register August 31, also lays out a new quality program that debut in October. Under the Hospital Readmissions Reduction Program, hospitals’ base operating diagnosis-related-group (DRG) payment will be cut by 1% if their readmission rate for three conditions – acute myocardial infarction, heart failure, and pneumonia – is deemed too high. The agency estimates the program will reduce overall payments to hospitals by about $280 million in FY 2013.

For the Hospital Value-Based Purchasing (VBP) Program, which also begins on Oct. 1, the final rule specifies hospitals will receive their total performance scores, indicates how the 1% penalty will be applied to base operating charges, and provides the timeline for making incentive payments. New measures were added to the program for FY 2015: a central line – associated bloodstream infection measure, a patient safety indicator composite measure, and an efficiency measure that looks at Medicare spending per beneficiary.

The CMS is revising its list of hospital-acquired conditions for which it will not pay. Starting this fall, surgical site infection following cardiac implantable electronic device procedures will make the do-not-pay list, along with iatrogenic pneumothorax with venous catheterization.

The agency is adding two new codes to the list of hospital-acquired conditions: bloodstream infection due to central catheter (999.32) and local infection due to central venous catheter (999.33).

Medicare payments are set to increase 2.8% in fiscal year 2013 to general acute care hospitals that successfully participate in Medicare’s Inpatient Quality Reporting Program. Hospitals that don’t participate will get just a 0.8% increase, though Medicare officials estimate that almost all hospitals will participate.

Medicare payments to long-term care facilities will increase by 1.7% in the coming fiscal years, which starts Oct. 1, according to the Centers for Medicare and Medicaid Services.

The new payment rates were announced Aug. 1 as part of the final rule for the Inpatient Prospective Payment System and the Long-Term Care Hospital Prospective Payment System.

In its original pay proposal published in May, the CMS said it would increase payments to general acute care hospitals by 2.3% because of cuts the agency was making to account for hospital coding that was too high. Based on public comments in opposition to the coding adjustments, the CMS backed off the cuts for now. The American Hospital Association estimates that the initial proposal would have cost hospitals nationwide a total of $850 million.

The final rule, to be published in the Federal Register August 31, also lays out a new quality program that debut in October. Under the Hospital Readmissions Reduction Program, hospitals’ base operating diagnosis-related-group (DRG) payment will be cut by 1% if their readmission rate for three conditions – acute myocardial infarction, heart failure, and pneumonia – is deemed too high. The agency estimates the program will reduce overall payments to hospitals by about $280 million in FY 2013.

For the Hospital Value-Based Purchasing (VBP) Program, which also begins on Oct. 1, the final rule specifies hospitals will receive their total performance scores, indicates how the 1% penalty will be applied to base operating charges, and provides the timeline for making incentive payments. New measures were added to the program for FY 2015: a central line – associated bloodstream infection measure, a patient safety indicator composite measure, and an efficiency measure that looks at Medicare spending per beneficiary.

The CMS is revising its list of hospital-acquired conditions for which it will not pay. Starting this fall, surgical site infection following cardiac implantable electronic device procedures will make the do-not-pay list, along with iatrogenic pneumothorax with venous catheterization.

The agency is adding two new codes to the list of hospital-acquired conditions: bloodstream infection due to central catheter (999.32) and local infection due to central venous catheter (999.33).