Mary Ellen Schneider

Radiation oncologists could see a nearly 15% cut to their payments under the proposed 2013 Medicare Physician Fee Schedule.

About half of the planned cut is as a result of changes in the way the Medicare calculates the time involved in performing intensity-modulated radiation treatment (IMRT) delivery and stereotactic body radiation therapy (SBRT) delivery. Using patient education materials published by leading medical societies, officials at the Centers for Medicare and Medicaid Services determined that they were paying too much for IMRT and SBRT because these services don’t take as long to perform as had previously been calculated.

For example, the current CPT code for IMRT treatment delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly faster procedure time. As a result, the CMS is proposing to base payment on a procedure time of 30 minutes.

For SBRT treatment delivery (CPT code 77373), the current procedure time assumption is 90 minutes. The proposed procedure time assumption is 60 minutes, based on publicly available patient education materials.

The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

Officials at ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, criticized the proposal, saying that it would curb patient access to treatment, particularly in rural communities. They pointed to the preliminary results of a member survey that showed that some radiation oncology practices may be forced to close, while others would delay the purchase of new equipment, lay off staff, or limit the new Medicare patients they treat.

The organization also took issue with the process the CMS used in evaluating the procedures.

"ASTRO believes that [the CMS] should utilize the rigorous processes and methodologies already in place and utilized for the past 20 years to set reimbursement rates," Dr. Leonard L. Gunderson, chairman of ASTRO’s Board of Directors, said in a statement.

Dr. Gunderson said that ASTRO would like to see a comprehensive review of treatment costs through the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), a panel of 31 physicians who offer advice to the CMS on how to value physician services.

Radiation oncologists could see a nearly 15% cut to their payments under the proposed 2013 Medicare Physician Fee Schedule.

About half of the planned cut is as a result of changes in the way the Medicare calculates the time involved in performing intensity-modulated radiation treatment (IMRT) delivery and stereotactic body radiation therapy (SBRT) delivery. Using patient education materials published by leading medical societies, officials at the Centers for Medicare and Medicaid Services determined that they were paying too much for IMRT and SBRT because these services don’t take as long to perform as had previously been calculated.

For example, the current CPT code for IMRT treatment delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly faster procedure time. As a result, the CMS is proposing to base payment on a procedure time of 30 minutes.

For SBRT treatment delivery (CPT code 77373), the current procedure time assumption is 90 minutes. The proposed procedure time assumption is 60 minutes, based on publicly available patient education materials.

The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

Officials at ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, criticized the proposal, saying that it would curb patient access to treatment, particularly in rural communities. They pointed to the preliminary results of a member survey that showed that some radiation oncology practices may be forced to close, while others would delay the purchase of new equipment, lay off staff, or limit the new Medicare patients they treat.

The organization also took issue with the process the CMS used in evaluating the procedures.

"ASTRO believes that [the CMS] should utilize the rigorous processes and methodologies already in place and utilized for the past 20 years to set reimbursement rates," Dr. Leonard L. Gunderson, chairman of ASTRO’s Board of Directors, said in a statement.

Dr. Gunderson said that ASTRO would like to see a comprehensive review of treatment costs through the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), a panel of 31 physicians who offer advice to the CMS on how to value physician services.

Radiation oncologists could see a nearly 15% cut to their payments under the proposed 2013 Medicare Physician Fee Schedule.

About half of the planned cut is as a result of changes in the way the Medicare calculates the time involved in performing intensity-modulated radiation treatment (IMRT) delivery and stereotactic body radiation therapy (SBRT) delivery. Using patient education materials published by leading medical societies, officials at the Centers for Medicare and Medicaid Services determined that they were paying too much for IMRT and SBRT because these services don’t take as long to perform as had previously been calculated.

For example, the current CPT code for IMRT treatment delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly faster procedure time. As a result, the CMS is proposing to base payment on a procedure time of 30 minutes.

For SBRT treatment delivery (CPT code 77373), the current procedure time assumption is 90 minutes. The proposed procedure time assumption is 60 minutes, based on publicly available patient education materials.

The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

Officials at ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, criticized the proposal, saying that it would curb patient access to treatment, particularly in rural communities. They pointed to the preliminary results of a member survey that showed that some radiation oncology practices may be forced to close, while others would delay the purchase of new equipment, lay off staff, or limit the new Medicare patients they treat.

The organization also took issue with the process the CMS used in evaluating the procedures.

"ASTRO believes that [the CMS] should utilize the rigorous processes and methodologies already in place and utilized for the past 20 years to set reimbursement rates," Dr. Leonard L. Gunderson, chairman of ASTRO’s Board of Directors, said in a statement.

Dr. Gunderson said that ASTRO would like to see a comprehensive review of treatment costs through the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), a panel of 31 physicians who offer advice to the CMS on how to value physician services.

Doctors providing primary care services could earn some additional money next year under a new Medicare proposal that would pay them for coordinating the care of their patients who have been discharged from a hospital or nursing home.

Medicare proposes to create a new G code that would allow physicians to bill for postdischarge transitional care services such as obtaining and reviewing the patient’s discharge summary; reviewing diagnostic tests and treatments; updating the medical record within 14 business days post discharge; establishing a new care plan; educating the patient or caregiver within 2 business days post discharge; and communicating with other health care providers.

The G code would apply when a Medicare beneficiary is discharged from an inpatient stay, a skilled nursing facility, an outpatient hospital observation unit, partial hospitalization services, or a community mental health center.

Officials at the Centers for Medicare and Medicaid Services (CMS) estimate that the use of the new G code could increase payments to family physicians by 7%; other doctors who provide primary care services could see a bump of 3%-5% starting in January 2013.

"Helping primary care doctors will help improve patient care and lower health care costs long term," CMS Acting Administrator Marilyn B. Tavenner said in a statement.

The addition of the new G codes is a "good step," said Dr. Glen Stream, president of the American Academy of Family Physicians. The AAFP has been working on this issue for awhile and earlier this year issued recommendations on better ways to pay for primary care services. Dr. Stream said they would next like to see the CMS develop evaluation and management codes that are specific to primary care, rather than simply increase payments for the 99213 and 99214 codes that are used by many specialties.

The postdischarge transitional care services plan was part of the 2013 Medicare Physician Fee Schedule proposed rule, which was released July 6.

But the fee schedule proposal is not all good news. The proposed rule also details the 27% across-the-board cut to physician fees scheduled to take effect on Jan. 1. The reduction is required by law, based in part on spending targets set under the Sustainable Growth Rate (SGR) formula, which links fees to changes in the gross domestic product.

That formula has been criticized by physicians and lawmakers for years. While no long-term solution to the SGR problem has ever been formulated, lawmakers have taken short-term measures to keep the physician fee cuts from going into effect over the last several years.

The proposed rule would also mean cuts to payments for many cardiology diagnostic tests. Under the proposal, CMS is seeking to expand its multiple-procedure payment reduction policy to diagnostic tests in both cardiology and ophthalmology.

Starting in January 2013, there would be an across-the-board reduction of 25% to the technical component for second and subsequent procedures performed by the same physician or physicians in the same group practice for the same patient on the same day. The cut will not apply to the professional component of the fee. The proposed rule lists 131 diagnostic cardiovascular services that would be subject to the multiple-procedure payment reduction policy.

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients.

"This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

The 2013 fee schedule proposal also outlines the implementation of the physician value-based payment modifier, which adjusts physician payments based on the quality and cost of the care they provide. The program, which was mandated under the Affordable Care Act, will be phased in over 3 years starting in 2015.

The proposed rule also would implement the physician value-based payment modifier for all medical groups with 25 or more eligible providers starting in 2015.

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance. Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

CMS will publish the proposed rule in the Federal Register on July 30, and will accept public comments until Sept. 4. The agency plans to finalize the physician payment rule by Nov. 1.

Doctors providing primary care services could earn some additional money next year under a new Medicare proposal that would pay them for coordinating the care of their patients who have been discharged from a hospital or nursing home.

Medicare proposes to create a new G code that would allow physicians to bill for postdischarge transitional care services such as obtaining and reviewing the patient’s discharge summary; reviewing diagnostic tests and treatments; updating the medical record within 14 business days post discharge; establishing a new care plan; educating the patient or caregiver within 2 business days post discharge; and communicating with other health care providers.

The G code would apply when a Medicare beneficiary is discharged from an inpatient stay, a skilled nursing facility, an outpatient hospital observation unit, partial hospitalization services, or a community mental health center.

Officials at the Centers for Medicare and Medicaid Services (CMS) estimate that the use of the new G code could increase payments to family physicians by 7%; other doctors who provide primary care services could see a bump of 3%-5% starting in January 2013.

"Helping primary care doctors will help improve patient care and lower health care costs long term," CMS Acting Administrator Marilyn B. Tavenner said in a statement.

The addition of the new G codes is a "good step," said Dr. Glen Stream, president of the American Academy of Family Physicians. The AAFP has been working on this issue for awhile and earlier this year issued recommendations on better ways to pay for primary care services. Dr. Stream said they would next like to see the CMS develop evaluation and management codes that are specific to primary care, rather than simply increase payments for the 99213 and 99214 codes that are used by many specialties.

The postdischarge transitional care services plan was part of the 2013 Medicare Physician Fee Schedule proposed rule, which was released July 6.

But the fee schedule proposal is not all good news. The proposed rule also details the 27% across-the-board cut to physician fees scheduled to take effect on Jan. 1. The reduction is required by law, based in part on spending targets set under the Sustainable Growth Rate (SGR) formula, which links fees to changes in the gross domestic product.

That formula has been criticized by physicians and lawmakers for years. While no long-term solution to the SGR problem has ever been formulated, lawmakers have taken short-term measures to keep the physician fee cuts from going into effect over the last several years.

The proposed rule would also mean cuts to payments for many cardiology diagnostic tests. Under the proposal, CMS is seeking to expand its multiple-procedure payment reduction policy to diagnostic tests in both cardiology and ophthalmology.

Starting in January 2013, there would be an across-the-board reduction of 25% to the technical component for second and subsequent procedures performed by the same physician or physicians in the same group practice for the same patient on the same day. The cut will not apply to the professional component of the fee. The proposed rule lists 131 diagnostic cardiovascular services that would be subject to the multiple-procedure payment reduction policy.

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients.

"This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

The 2013 fee schedule proposal also outlines the implementation of the physician value-based payment modifier, which adjusts physician payments based on the quality and cost of the care they provide. The program, which was mandated under the Affordable Care Act, will be phased in over 3 years starting in 2015.

The proposed rule also would implement the physician value-based payment modifier for all medical groups with 25 or more eligible providers starting in 2015.

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance. Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

CMS will publish the proposed rule in the Federal Register on July 30, and will accept public comments until Sept. 4. The agency plans to finalize the physician payment rule by Nov. 1.

Doctors providing primary care services could earn some additional money next year under a new Medicare proposal that would pay them for coordinating the care of their patients who have been discharged from a hospital or nursing home.

Medicare proposes to create a new G code that would allow physicians to bill for postdischarge transitional care services such as obtaining and reviewing the patient’s discharge summary; reviewing diagnostic tests and treatments; updating the medical record within 14 business days post discharge; establishing a new care plan; educating the patient or caregiver within 2 business days post discharge; and communicating with other health care providers.

The G code would apply when a Medicare beneficiary is discharged from an inpatient stay, a skilled nursing facility, an outpatient hospital observation unit, partial hospitalization services, or a community mental health center.

Officials at the Centers for Medicare and Medicaid Services (CMS) estimate that the use of the new G code could increase payments to family physicians by 7%; other doctors who provide primary care services could see a bump of 3%-5% starting in January 2013.

"Helping primary care doctors will help improve patient care and lower health care costs long term," CMS Acting Administrator Marilyn B. Tavenner said in a statement.

The addition of the new G codes is a "good step," said Dr. Glen Stream, president of the American Academy of Family Physicians. The AAFP has been working on this issue for awhile and earlier this year issued recommendations on better ways to pay for primary care services. Dr. Stream said they would next like to see the CMS develop evaluation and management codes that are specific to primary care, rather than simply increase payments for the 99213 and 99214 codes that are used by many specialties.

The postdischarge transitional care services plan was part of the 2013 Medicare Physician Fee Schedule proposed rule, which was released July 6.

But the fee schedule proposal is not all good news. The proposed rule also details the 27% across-the-board cut to physician fees scheduled to take effect on Jan. 1. The reduction is required by law, based in part on spending targets set under the Sustainable Growth Rate (SGR) formula, which links fees to changes in the gross domestic product.

That formula has been criticized by physicians and lawmakers for years. While no long-term solution to the SGR problem has ever been formulated, lawmakers have taken short-term measures to keep the physician fee cuts from going into effect over the last several years.

The proposed rule would also mean cuts to payments for many cardiology diagnostic tests. Under the proposal, CMS is seeking to expand its multiple-procedure payment reduction policy to diagnostic tests in both cardiology and ophthalmology.

Starting in January 2013, there would be an across-the-board reduction of 25% to the technical component for second and subsequent procedures performed by the same physician or physicians in the same group practice for the same patient on the same day. The cut will not apply to the professional component of the fee. The proposed rule lists 131 diagnostic cardiovascular services that would be subject to the multiple-procedure payment reduction policy.

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients.

"This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

The 2013 fee schedule proposal also outlines the implementation of the physician value-based payment modifier, which adjusts physician payments based on the quality and cost of the care they provide. The program, which was mandated under the Affordable Care Act, will be phased in over 3 years starting in 2015.

The proposed rule also would implement the physician value-based payment modifier for all medical groups with 25 or more eligible providers starting in 2015.

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance. Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

CMS will publish the proposed rule in the Federal Register on July 30, and will accept public comments until Sept. 4. The agency plans to finalize the physician payment rule by Nov. 1.

The federal government plans to delay for 1 year a requirement that doctors and other health care providers begin using the ICD-10 standard for diagnosis and procedure codes for 1 year. Physicians will now have until Oct. 1, 2014, to come into compliance with the standard.

Federal officials are also hoping to ease administrative burdens by requiring health plans to use a single, uniform identifier for all their transactions. Both changes were addressed in a proposed rule released this spring.

Health and Human Services Secretary Kathleen Sebelius announced earlier this year that the health care community would get more time to get up to speed on ICD-10 (formally known as the International Classification of Diseases, 10th Revision), but the proposed rule firms up that commitment.

Many physician organizations, including the American Medical Association, complained to the HHS and members of Congress, arguing that the implementation of the ICD-10 codes will create a significant burden. And it would carry a hefty price tag – close to $100,000 for smaller practices and more than $2 million for large ones, according to the AMA.

Part of the problem, according to the HHS, is that medical practices are having trouble meeting the compliance deadline for a necessary prerequisite for ICD-10, the Associated Standard Committee’s X12 Version 5010 standards (Version 5010) for electronic health care transactions. Moving the compliance deadline for the so-called 5010 standard from October 2013 to October 2014 will give physicians more time to prepare and test their systems, the HHS wrote in its proposed rule.

The proposed rule also outlines a related measure: a plan to require health insurers to adopt a standard national unique health plan identifier, or HPID. Currently, health plans use multiple identifiers of differing lengths and formats. The vagaries of these identifiers can cause improper routing of transactions, difficulty in determining patient eligibility, and other claims processing errors. Health insurers must begin to use the standardized HPID by Oct. 1, 2012.

The use of a unique identifier will allow medical practices to make greater use of automation in claims processing, according to the proposed rule, in turn saving time and money. And, cleaner claims with fewer errors should compound the savings. HHS officials estimate that over 10 years, the return on investment for the entire health care industry will be between $700 million and $4.6 billion. The adoption of the unique health plan identifier is one of a series of regulations mandated by the Affordable Care Act and aimed at simplifying health care administrative transactions.

The federal government plans to delay for 1 year a requirement that doctors and other health care providers begin using the ICD-10 standard for diagnosis and procedure codes for 1 year. Physicians will now have until Oct. 1, 2014, to come into compliance with the standard.

Federal officials are also hoping to ease administrative burdens by requiring health plans to use a single, uniform identifier for all their transactions. Both changes were addressed in a proposed rule released this spring.

Health and Human Services Secretary Kathleen Sebelius announced earlier this year that the health care community would get more time to get up to speed on ICD-10 (formally known as the International Classification of Diseases, 10th Revision), but the proposed rule firms up that commitment.

Many physician organizations, including the American Medical Association, complained to the HHS and members of Congress, arguing that the implementation of the ICD-10 codes will create a significant burden. And it would carry a hefty price tag – close to $100,000 for smaller practices and more than $2 million for large ones, according to the AMA.

Part of the problem, according to the HHS, is that medical practices are having trouble meeting the compliance deadline for a necessary prerequisite for ICD-10, the Associated Standard Committee’s X12 Version 5010 standards (Version 5010) for electronic health care transactions. Moving the compliance deadline for the so-called 5010 standard from October 2013 to October 2014 will give physicians more time to prepare and test their systems, the HHS wrote in its proposed rule.

The proposed rule also outlines a related measure: a plan to require health insurers to adopt a standard national unique health plan identifier, or HPID. Currently, health plans use multiple identifiers of differing lengths and formats. The vagaries of these identifiers can cause improper routing of transactions, difficulty in determining patient eligibility, and other claims processing errors. Health insurers must begin to use the standardized HPID by Oct. 1, 2012.

The use of a unique identifier will allow medical practices to make greater use of automation in claims processing, according to the proposed rule, in turn saving time and money. And, cleaner claims with fewer errors should compound the savings. HHS officials estimate that over 10 years, the return on investment for the entire health care industry will be between $700 million and $4.6 billion. The adoption of the unique health plan identifier is one of a series of regulations mandated by the Affordable Care Act and aimed at simplifying health care administrative transactions.

The federal government plans to delay for 1 year a requirement that doctors and other health care providers begin using the ICD-10 standard for diagnosis and procedure codes for 1 year. Physicians will now have until Oct. 1, 2014, to come into compliance with the standard.

Federal officials are also hoping to ease administrative burdens by requiring health plans to use a single, uniform identifier for all their transactions. Both changes were addressed in a proposed rule released this spring.

Health and Human Services Secretary Kathleen Sebelius announced earlier this year that the health care community would get more time to get up to speed on ICD-10 (formally known as the International Classification of Diseases, 10th Revision), but the proposed rule firms up that commitment.

Many physician organizations, including the American Medical Association, complained to the HHS and members of Congress, arguing that the implementation of the ICD-10 codes will create a significant burden. And it would carry a hefty price tag – close to $100,000 for smaller practices and more than $2 million for large ones, according to the AMA.

Part of the problem, according to the HHS, is that medical practices are having trouble meeting the compliance deadline for a necessary prerequisite for ICD-10, the Associated Standard Committee’s X12 Version 5010 standards (Version 5010) for electronic health care transactions. Moving the compliance deadline for the so-called 5010 standard from October 2013 to October 2014 will give physicians more time to prepare and test their systems, the HHS wrote in its proposed rule.

The proposed rule also outlines a related measure: a plan to require health insurers to adopt a standard national unique health plan identifier, or HPID. Currently, health plans use multiple identifiers of differing lengths and formats. The vagaries of these identifiers can cause improper routing of transactions, difficulty in determining patient eligibility, and other claims processing errors. Health insurers must begin to use the standardized HPID by Oct. 1, 2012.

The use of a unique identifier will allow medical practices to make greater use of automation in claims processing, according to the proposed rule, in turn saving time and money. And, cleaner claims with fewer errors should compound the savings. HHS officials estimate that over 10 years, the return on investment for the entire health care industry will be between $700 million and $4.6 billion. The adoption of the unique health plan identifier is one of a series of regulations mandated by the Affordable Care Act and aimed at simplifying health care administrative transactions.

Methadone was involved in more than 30% of opioid-related deaths in the United States in 2009, second only to the painkiller oxycodone, according to new data from the Centers for Disease Control and Prevention.

The high rate of overdose deaths from methadone occurred even though the drug accounted for less than 2% of opioid prescriptions in 2009. Part of problem is that methadone is more likely than other opioids to cause an overdose, according to the CDC. For example, a toxic level of methadone can accumulate in the body, leading to severe respiratory depression. Methadone can also cause major disturbances in cardiac rhythm.

"It acts differently in different people’s bodies," Dr. Thomas R. Frieden, director of the CDC, said during a press conference to announce the new data. "So it’s possible that someone can take just a small amount, but it may last for days in their system and cause serious health problems."

 Dr. Frieden noted that the increase in overdose deaths from methadone is primarily due to increased use of the drug in pain treatment, not as part of addiction treatment programs.

The findings, which were published on July 3 in Morbidity and Mortality Weekly Report, show that as the use of methadone for pain relief has risen, so has the number of overdose deaths associated with the drug (MMWR 2012;61:1-5).

The annual rate of methadone prescriptions for pain rose to 1.5 per 100 persons in 2008 and held steady in 2009. At the same time, the mortality for the drug reached 1.8 deaths per 100,000 persons in 2007 and then dropped slightly in the next 2 years. Between 1999 and 2009, the number of overdose deaths involving methadone increased 5.5 times. Methadone was involved in 31.4% of the 3,294 opioid deaths in the United States in 2009.

The findings are based on national data from the CDC, the Food and Drug Administration (FDA), and the Drug Enforcement Administration, as well as data from 13 states that are part of the Drug Abuse Warning Network.

Health officials urged physicians not to prescribe the drug unless they had experience with it, and to limit its use to areas where the benefits outweigh the risks, such as in the treatment of cancer pain or for palliative care.

In the MMWR article, the CDC researchers said that the current uses of the drug in pain treatment might be inappropriate. They pointed to a study from the FDA showing that musculoskeletal problems such as back pain and arthritis were the most common diagnoses associated with methadone use for pain in 2009. The researchers specifically urged physicians not to prescribe methadone for low back pain because studies have not shown benefits to using opioids for this condition.

Methadone also should not be prescribed for acute pain or to opioid-naive patients, and should be avoided in patients taking benzodiazepines because of the risk for severe respiratory depression, according to the researchers.

"There are plenty of safer alternatives to methadone," Dr. Frieden said. "We want to ensure that methadone remains available for appropriately treating addiction and pain and also address the thousands of overdose deaths involving methadone."

The study showed a slight decrease in methadone-related overdose deaths in 2008 and 2009, which Dr. Frieden attributed to government efforts to reduce the availability of high-dose forms of methadone and improve its labeling. But there’s still more work to do, he said.

Physicians can do their part by following guidelines for prescribing methadone and other opioids, including screening for substance abuse, he said.

CDC officials urged insurers and pharmaceutical companies to play a role as well. For example, insurers could require authorization for starting doses of methadone for pain that exceed 30 mg/day and stop including methadone on formularies as a preferred drug for the treatment of chronic noncancer pain. Health officials also called on pharmaceutical companies to introduce a low-dose formulation of methadone.

The study was conducted by researchers from the National Center for Injury Prevention and Control at the CDC.

Methadone was involved in more than 30% of opioid-related deaths in the United States in 2009, second only to the painkiller oxycodone, according to new data from the Centers for Disease Control and Prevention.

The high rate of overdose deaths from methadone occurred even though the drug accounted for less than 2% of opioid prescriptions in 2009. Part of problem is that methadone is more likely than other opioids to cause an overdose, according to the CDC. For example, a toxic level of methadone can accumulate in the body, leading to severe respiratory depression. Methadone can also cause major disturbances in cardiac rhythm.

"It acts differently in different people’s bodies," Dr. Thomas R. Frieden, director of the CDC, said during a press conference to announce the new data. "So it’s possible that someone can take just a small amount, but it may last for days in their system and cause serious health problems."

 Dr. Frieden noted that the increase in overdose deaths from methadone is primarily due to increased use of the drug in pain treatment, not as part of addiction treatment programs.

The findings, which were published on July 3 in Morbidity and Mortality Weekly Report, show that as the use of methadone for pain relief has risen, so has the number of overdose deaths associated with the drug (MMWR 2012;61:1-5).

The annual rate of methadone prescriptions for pain rose to 1.5 per 100 persons in 2008 and held steady in 2009. At the same time, the mortality for the drug reached 1.8 deaths per 100,000 persons in 2007 and then dropped slightly in the next 2 years. Between 1999 and 2009, the number of overdose deaths involving methadone increased 5.5 times. Methadone was involved in 31.4% of the 3,294 opioid deaths in the United States in 2009.

The findings are based on national data from the CDC, the Food and Drug Administration (FDA), and the Drug Enforcement Administration, as well as data from 13 states that are part of the Drug Abuse Warning Network.

Health officials urged physicians not to prescribe the drug unless they had experience with it, and to limit its use to areas where the benefits outweigh the risks, such as in the treatment of cancer pain or for palliative care.

In the MMWR article, the CDC researchers said that the current uses of the drug in pain treatment might be inappropriate. They pointed to a study from the FDA showing that musculoskeletal problems such as back pain and arthritis were the most common diagnoses associated with methadone use for pain in 2009. The researchers specifically urged physicians not to prescribe methadone for low back pain because studies have not shown benefits to using opioids for this condition.

Methadone also should not be prescribed for acute pain or to opioid-naive patients, and should be avoided in patients taking benzodiazepines because of the risk for severe respiratory depression, according to the researchers.

"There are plenty of safer alternatives to methadone," Dr. Frieden said. "We want to ensure that methadone remains available for appropriately treating addiction and pain and also address the thousands of overdose deaths involving methadone."

The study showed a slight decrease in methadone-related overdose deaths in 2008 and 2009, which Dr. Frieden attributed to government efforts to reduce the availability of high-dose forms of methadone and improve its labeling. But there’s still more work to do, he said.

Physicians can do their part by following guidelines for prescribing methadone and other opioids, including screening for substance abuse, he said.

CDC officials urged insurers and pharmaceutical companies to play a role as well. For example, insurers could require authorization for starting doses of methadone for pain that exceed 30 mg/day and stop including methadone on formularies as a preferred drug for the treatment of chronic noncancer pain. Health officials also called on pharmaceutical companies to introduce a low-dose formulation of methadone.

The study was conducted by researchers from the National Center for Injury Prevention and Control at the CDC.

Methadone was involved in more than 30% of opioid-related deaths in the United States in 2009, second only to the painkiller oxycodone, according to new data from the Centers for Disease Control and Prevention.

The high rate of overdose deaths from methadone occurred even though the drug accounted for less than 2% of opioid prescriptions in 2009. Part of problem is that methadone is more likely than other opioids to cause an overdose, according to the CDC. For example, a toxic level of methadone can accumulate in the body, leading to severe respiratory depression. Methadone can also cause major disturbances in cardiac rhythm.

"It acts differently in different people’s bodies," Dr. Thomas R. Frieden, director of the CDC, said during a press conference to announce the new data. "So it’s possible that someone can take just a small amount, but it may last for days in their system and cause serious health problems."

 Dr. Frieden noted that the increase in overdose deaths from methadone is primarily due to increased use of the drug in pain treatment, not as part of addiction treatment programs.

The findings, which were published on July 3 in Morbidity and Mortality Weekly Report, show that as the use of methadone for pain relief has risen, so has the number of overdose deaths associated with the drug (MMWR 2012;61:1-5).

The annual rate of methadone prescriptions for pain rose to 1.5 per 100 persons in 2008 and held steady in 2009. At the same time, the mortality for the drug reached 1.8 deaths per 100,000 persons in 2007 and then dropped slightly in the next 2 years. Between 1999 and 2009, the number of overdose deaths involving methadone increased 5.5 times. Methadone was involved in 31.4% of the 3,294 opioid deaths in the United States in 2009.

The findings are based on national data from the CDC, the Food and Drug Administration (FDA), and the Drug Enforcement Administration, as well as data from 13 states that are part of the Drug Abuse Warning Network.

Health officials urged physicians not to prescribe the drug unless they had experience with it, and to limit its use to areas where the benefits outweigh the risks, such as in the treatment of cancer pain or for palliative care.

In the MMWR article, the CDC researchers said that the current uses of the drug in pain treatment might be inappropriate. They pointed to a study from the FDA showing that musculoskeletal problems such as back pain and arthritis were the most common diagnoses associated with methadone use for pain in 2009. The researchers specifically urged physicians not to prescribe methadone for low back pain because studies have not shown benefits to using opioids for this condition.

Methadone also should not be prescribed for acute pain or to opioid-naive patients, and should be avoided in patients taking benzodiazepines because of the risk for severe respiratory depression, according to the researchers.

"There are plenty of safer alternatives to methadone," Dr. Frieden said. "We want to ensure that methadone remains available for appropriately treating addiction and pain and also address the thousands of overdose deaths involving methadone."

The study showed a slight decrease in methadone-related overdose deaths in 2008 and 2009, which Dr. Frieden attributed to government efforts to reduce the availability of high-dose forms of methadone and improve its labeling. But there’s still more work to do, he said.

Physicians can do their part by following guidelines for prescribing methadone and other opioids, including screening for substance abuse, he said.

CDC officials urged insurers and pharmaceutical companies to play a role as well. For example, insurers could require authorization for starting doses of methadone for pain that exceed 30 mg/day and stop including methadone on formularies as a preferred drug for the treatment of chronic noncancer pain. Health officials also called on pharmaceutical companies to introduce a low-dose formulation of methadone.

The study was conducted by researchers from the National Center for Injury Prevention and Control at the CDC.

GlaxoSmithKline has agreed to pay $3 billion to the federal government and plead guilty to charges of illegally promoting two antidepressants and withholding key safety information about the diabetes drug Avandia.

As part of the settlement announced on July 2, the pharmaceutical company is admitting to promoting the drugs Paxil (paroxetine) and Wellbutrin (bupropion) for off-label uses and failing to report safety data about Avandia (rosiglitazone) to the Food and Drug Administration.

In the case of Paxil, the government charges that from 1998 to 2003, GSK sponsored dinner and spa programs to encourage physicians to prescribe the drug for children and adolescents, even though it was not approved for pediatric use. The government also alleges that the company prepared and published a misleading medical journal article providing false information about the efficacy of Paxil in patients under age 18. The government also charged that GSK paid physicians to promote off-label uses of Wellbutrin ranging from weight loss to the treatment of sexual dysfunction.

GSK also withheld safety data about the diabetes drug Avandia, including data from post-marketing studies and two other studies conducted in response to concerns about the cardiovascular side effects of the drug, according to the U.S. Department of Justice.

GSK will pay about $1 billion in penalties to the federal government for the illegal promotion of Avandia, Wellbutrin, and Paxil. GSK has agreed to pay another $2 billion in civil penalties to resolve allegations of fraud, including failure to give proper rebates to the Medicaid program.

The settlement is the largest health care fraud settlement in U.S. history and the $3 billion penalty will be the largest ever paid by a drug company, according to the U.S. Department of Justice.

Government officials said they want the settlement to serve as a warning to other drug manufacturers and companies that might seek to defraud the government.

"For a long time, our health care system has been a target for cheaters who thought they could make an easy profit at the expense of public safety, taxpayers, and the millions of Americans who depend on programs like Medicare and Medicaid," Bill Corr, deputy secretary of the Department of Health and Human Services, said in a statement. "But thanks to strong enforcement actions like those we have announced today, that equation is rapidly changing."

In addition to the monetary penalties, GSK has entered into a 5-year Corporate Integrity Agreement with HHS. Among the provisions, GSK is required to change its pay structure to remove compensation based on sales goals for territories, which was considered a factor in driving the illegal promotion of the drugs. The company will also require company executives to forfeit their bonuses if they or their employees engage in significant misconduct.

Sir Andrew Witty, GSK’s CEO, issued a statement saying that company officials have learned from their mistakes. "In the U.S., we have taken action at all levels in the company," he said. "We have fundamentally changed our procedures for compliance, marketing, and selling. When necessary, we have removed employees who have engaged in misconduct."

The settlement must be accepted by the U.S. District Court before it is finalized.

GlaxoSmithKline has agreed to pay $3 billion to the federal government and plead guilty to charges of illegally promoting two antidepressants and withholding key safety information about the diabetes drug Avandia.

As part of the settlement announced on July 2, the pharmaceutical company is admitting to promoting the drugs Paxil (paroxetine) and Wellbutrin (bupropion) for off-label uses and failing to report safety data about Avandia (rosiglitazone) to the Food and Drug Administration.

In the case of Paxil, the government charges that from 1998 to 2003, GSK sponsored dinner and spa programs to encourage physicians to prescribe the drug for children and adolescents, even though it was not approved for pediatric use. The government also alleges that the company prepared and published a misleading medical journal article providing false information about the efficacy of Paxil in patients under age 18. The government also charged that GSK paid physicians to promote off-label uses of Wellbutrin ranging from weight loss to the treatment of sexual dysfunction.

GSK also withheld safety data about the diabetes drug Avandia, including data from post-marketing studies and two other studies conducted in response to concerns about the cardiovascular side effects of the drug, according to the U.S. Department of Justice.

GSK will pay about $1 billion in penalties to the federal government for the illegal promotion of Avandia, Wellbutrin, and Paxil. GSK has agreed to pay another $2 billion in civil penalties to resolve allegations of fraud, including failure to give proper rebates to the Medicaid program.

The settlement is the largest health care fraud settlement in U.S. history and the $3 billion penalty will be the largest ever paid by a drug company, according to the U.S. Department of Justice.

Government officials said they want the settlement to serve as a warning to other drug manufacturers and companies that might seek to defraud the government.

"For a long time, our health care system has been a target for cheaters who thought they could make an easy profit at the expense of public safety, taxpayers, and the millions of Americans who depend on programs like Medicare and Medicaid," Bill Corr, deputy secretary of the Department of Health and Human Services, said in a statement. "But thanks to strong enforcement actions like those we have announced today, that equation is rapidly changing."

In addition to the monetary penalties, GSK has entered into a 5-year Corporate Integrity Agreement with HHS. Among the provisions, GSK is required to change its pay structure to remove compensation based on sales goals for territories, which was considered a factor in driving the illegal promotion of the drugs. The company will also require company executives to forfeit their bonuses if they or their employees engage in significant misconduct.

Sir Andrew Witty, GSK’s CEO, issued a statement saying that company officials have learned from their mistakes. "In the U.S., we have taken action at all levels in the company," he said. "We have fundamentally changed our procedures for compliance, marketing, and selling. When necessary, we have removed employees who have engaged in misconduct."

The settlement must be accepted by the U.S. District Court before it is finalized.

GlaxoSmithKline has agreed to pay $3 billion to the federal government and plead guilty to charges of illegally promoting two antidepressants and withholding key safety information about the diabetes drug Avandia.

As part of the settlement announced on July 2, the pharmaceutical company is admitting to promoting the drugs Paxil (paroxetine) and Wellbutrin (bupropion) for off-label uses and failing to report safety data about Avandia (rosiglitazone) to the Food and Drug Administration.

In the case of Paxil, the government charges that from 1998 to 2003, GSK sponsored dinner and spa programs to encourage physicians to prescribe the drug for children and adolescents, even though it was not approved for pediatric use. The government also alleges that the company prepared and published a misleading medical journal article providing false information about the efficacy of Paxil in patients under age 18. The government also charged that GSK paid physicians to promote off-label uses of Wellbutrin ranging from weight loss to the treatment of sexual dysfunction.

GSK also withheld safety data about the diabetes drug Avandia, including data from post-marketing studies and two other studies conducted in response to concerns about the cardiovascular side effects of the drug, according to the U.S. Department of Justice.

GSK will pay about $1 billion in penalties to the federal government for the illegal promotion of Avandia, Wellbutrin, and Paxil. GSK has agreed to pay another $2 billion in civil penalties to resolve allegations of fraud, including failure to give proper rebates to the Medicaid program.

The settlement is the largest health care fraud settlement in U.S. history and the $3 billion penalty will be the largest ever paid by a drug company, according to the U.S. Department of Justice.

Government officials said they want the settlement to serve as a warning to other drug manufacturers and companies that might seek to defraud the government.

"For a long time, our health care system has been a target for cheaters who thought they could make an easy profit at the expense of public safety, taxpayers, and the millions of Americans who depend on programs like Medicare and Medicaid," Bill Corr, deputy secretary of the Department of Health and Human Services, said in a statement. "But thanks to strong enforcement actions like those we have announced today, that equation is rapidly changing."

In addition to the monetary penalties, GSK has entered into a 5-year Corporate Integrity Agreement with HHS. Among the provisions, GSK is required to change its pay structure to remove compensation based on sales goals for territories, which was considered a factor in driving the illegal promotion of the drugs. The company will also require company executives to forfeit their bonuses if they or their employees engage in significant misconduct.

Sir Andrew Witty, GSK’s CEO, issued a statement saying that company officials have learned from their mistakes. "In the U.S., we have taken action at all levels in the company," he said. "We have fundamentally changed our procedures for compliance, marketing, and selling. When necessary, we have removed employees who have engaged in misconduct."

The settlement must be accepted by the U.S. District Court before it is finalized.

For Dr. Stephen K. Liu, a clinical hospitalist at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., prevention has always been a passion.

During his residency, Dr. Liu began a program to provide smoking-cessation counseling and outpatient referrals for hospitalized patients while he worked with a team focused on improving inpatient care for community-acquired pneumonia patients. Now, as medical director for the inpatient medicine unit, he is looking at whether a specialized team of elder care providers can increase the likelihood that geriatric patients will be discharged to home rather than to a skilled nursing facility by preventing deconditioning during their hospital stay and improving communication among providers.

Last December, Dr. Liu was named as one of 73 "Innovation Advisors" in the newly created Center for Medicare and Medicaid Innovation (CMMI). The advisors, who were selected from among more than 900 applicants, are each working on a local quality improvement project and are receiving special training from the CMMI. During his tenure as an innovation advisor, Dr. Liu will be analyzing the progress of his elder care initiative with the goal of expanding it throughout the Dartmouth-Hitchcock Medical Center.

In an interview, Dr. Liu discussed his quality improvement project and his role as an innovation advisor.

QUESTION: Why did you decide to look at this specific population of patients?

Dr. Liu: Patients who come to the hospital from home generally don’t want to go to a nursing home after discharge. I’ve often seen this huge discordance between patients who want to go home and providers in the hospital who tell them that they need to go to a skilled nursing facility (SNF). That made me wonder how many of these transfers to the nursing home could we prevent if we could reduce deconditioning while patients are hospitalized, and if we could better understand a patient’s home environment. If we are able to assess patients’ functional status and home needs while they are hospitalized, we can connect them to resources [to] help them achieve their goal of staying at home and ultimately avoid SNF stays after discharge.

QUESTION: How are you doing so far, specifically in increasing the number of transitions to home?

Dr. Liu: We compared medicine patients older than age 70 who were discharged from our medicine unit vs. medicine patients who were discharged from other units, and so far we’ve seen that more patients were being discharged to home from our inpatient medicine unit who underwent screening and treatment from the elder care team, ranging from around 5% to 10% more patients each month going home, compared with other units. However, we’re still early on in our improvement process. Right now we have the elder care team assessing patients for the potential for functional decline on admission and working with patients to prevent deconditioning on a daily basis.

I think the bigger piece will be thinking about the shared decision-making process around whether patients go home or to an SNF. We’re trying to improve that process and are developing criteria for that decision and communicating it across the treatment teams.

QUESTION: What challenges are you encountering so far?

Dr. Liu: Our biggest discovery in undergoing this improvement work has been that reducing the deconditioning of patients in the hospital is just one driver. The bigger driver may be that the providers and physicians who are making the decision to refer patients to skilled nursing facilities often don’t know a patient’s home situation and functional status. The information needed to make that decision isn’t always apparent because it isn’t in the medical record.

One challenge we face is that as physicians we see patients for 30 minutes in the morning and they’re always in bed. That’s all that we know about their mobility and strength. We’re focusing on the acute medical issue and not on their functional status and living situation.

Another challenge is the ability to adapt the plan for changes in a patient’s status. We’ve had a couple of cases where patients recovered during the hospitalization and improved their strength and conditioning to the point where they probably could have gone home, but the decision had already been made that they should go to an SNF, and they end up being transferred to an SNF.

QUESTION: How are the results of your project going to be used by the Center for Medicare and Medicaid Innovation?

Dr. Liu: CMMI is hoping to take the results from all the innovation advisors’ improvement projects and scale them up to a larger population if they are successful. They are also hoping that we will serve as local advisors for other CMMI initiatives.

QUESTION: Why did you apply to be an innovation advisor?

Dr. Liu: I was interested in learning a lot more about the effects of cost and payment policies to improve health care systems. I saw the innovation advisors program as an opportunity to join a community of like-minded health care providers who are interested in improving care. It was also a chance to take our elder care program to the next level by examining process and outcome measures, and – if successful – potentially spreading the program to the rest of the hospital.

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

For Dr. Stephen K. Liu, a clinical hospitalist at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., prevention has always been a passion.

During his residency, Dr. Liu began a program to provide smoking-cessation counseling and outpatient referrals for hospitalized patients while he worked with a team focused on improving inpatient care for community-acquired pneumonia patients. Now, as medical director for the inpatient medicine unit, he is looking at whether a specialized team of elder care providers can increase the likelihood that geriatric patients will be discharged to home rather than to a skilled nursing facility by preventing deconditioning during their hospital stay and improving communication among providers.

Last December, Dr. Liu was named as one of 73 "Innovation Advisors" in the newly created Center for Medicare and Medicaid Innovation (CMMI). The advisors, who were selected from among more than 900 applicants, are each working on a local quality improvement project and are receiving special training from the CMMI. During his tenure as an innovation advisor, Dr. Liu will be analyzing the progress of his elder care initiative with the goal of expanding it throughout the Dartmouth-Hitchcock Medical Center.

In an interview, Dr. Liu discussed his quality improvement project and his role as an innovation advisor.

QUESTION: Why did you decide to look at this specific population of patients?

Dr. Liu: Patients who come to the hospital from home generally don’t want to go to a nursing home after discharge. I’ve often seen this huge discordance between patients who want to go home and providers in the hospital who tell them that they need to go to a skilled nursing facility (SNF). That made me wonder how many of these transfers to the nursing home could we prevent if we could reduce deconditioning while patients are hospitalized, and if we could better understand a patient’s home environment. If we are able to assess patients’ functional status and home needs while they are hospitalized, we can connect them to resources [to] help them achieve their goal of staying at home and ultimately avoid SNF stays after discharge.

QUESTION: How are you doing so far, specifically in increasing the number of transitions to home?

Dr. Liu: We compared medicine patients older than age 70 who were discharged from our medicine unit vs. medicine patients who were discharged from other units, and so far we’ve seen that more patients were being discharged to home from our inpatient medicine unit who underwent screening and treatment from the elder care team, ranging from around 5% to 10% more patients each month going home, compared with other units. However, we’re still early on in our improvement process. Right now we have the elder care team assessing patients for the potential for functional decline on admission and working with patients to prevent deconditioning on a daily basis.

I think the bigger piece will be thinking about the shared decision-making process around whether patients go home or to an SNF. We’re trying to improve that process and are developing criteria for that decision and communicating it across the treatment teams.

QUESTION: What challenges are you encountering so far?

Dr. Liu: Our biggest discovery in undergoing this improvement work has been that reducing the deconditioning of patients in the hospital is just one driver. The bigger driver may be that the providers and physicians who are making the decision to refer patients to skilled nursing facilities often don’t know a patient’s home situation and functional status. The information needed to make that decision isn’t always apparent because it isn’t in the medical record.

One challenge we face is that as physicians we see patients for 30 minutes in the morning and they’re always in bed. That’s all that we know about their mobility and strength. We’re focusing on the acute medical issue and not on their functional status and living situation.

Another challenge is the ability to adapt the plan for changes in a patient’s status. We’ve had a couple of cases where patients recovered during the hospitalization and improved their strength and conditioning to the point where they probably could have gone home, but the decision had already been made that they should go to an SNF, and they end up being transferred to an SNF.

QUESTION: How are the results of your project going to be used by the Center for Medicare and Medicaid Innovation?

Dr. Liu: CMMI is hoping to take the results from all the innovation advisors’ improvement projects and scale them up to a larger population if they are successful. They are also hoping that we will serve as local advisors for other CMMI initiatives.

QUESTION: Why did you apply to be an innovation advisor?

Dr. Liu: I was interested in learning a lot more about the effects of cost and payment policies to improve health care systems. I saw the innovation advisors program as an opportunity to join a community of like-minded health care providers who are interested in improving care. It was also a chance to take our elder care program to the next level by examining process and outcome measures, and – if successful – potentially spreading the program to the rest of the hospital.

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

For Dr. Stephen K. Liu, a clinical hospitalist at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., prevention has always been a passion.

During his residency, Dr. Liu began a program to provide smoking-cessation counseling and outpatient referrals for hospitalized patients while he worked with a team focused on improving inpatient care for community-acquired pneumonia patients. Now, as medical director for the inpatient medicine unit, he is looking at whether a specialized team of elder care providers can increase the likelihood that geriatric patients will be discharged to home rather than to a skilled nursing facility by preventing deconditioning during their hospital stay and improving communication among providers.

Last December, Dr. Liu was named as one of 73 "Innovation Advisors" in the newly created Center for Medicare and Medicaid Innovation (CMMI). The advisors, who were selected from among more than 900 applicants, are each working on a local quality improvement project and are receiving special training from the CMMI. During his tenure as an innovation advisor, Dr. Liu will be analyzing the progress of his elder care initiative with the goal of expanding it throughout the Dartmouth-Hitchcock Medical Center.

In an interview, Dr. Liu discussed his quality improvement project and his role as an innovation advisor.

QUESTION: Why did you decide to look at this specific population of patients?

Dr. Liu: Patients who come to the hospital from home generally don’t want to go to a nursing home after discharge. I’ve often seen this huge discordance between patients who want to go home and providers in the hospital who tell them that they need to go to a skilled nursing facility (SNF). That made me wonder how many of these transfers to the nursing home could we prevent if we could reduce deconditioning while patients are hospitalized, and if we could better understand a patient’s home environment. If we are able to assess patients’ functional status and home needs while they are hospitalized, we can connect them to resources [to] help them achieve their goal of staying at home and ultimately avoid SNF stays after discharge.

QUESTION: How are you doing so far, specifically in increasing the number of transitions to home?

Dr. Liu: We compared medicine patients older than age 70 who were discharged from our medicine unit vs. medicine patients who were discharged from other units, and so far we’ve seen that more patients were being discharged to home from our inpatient medicine unit who underwent screening and treatment from the elder care team, ranging from around 5% to 10% more patients each month going home, compared with other units. However, we’re still early on in our improvement process. Right now we have the elder care team assessing patients for the potential for functional decline on admission and working with patients to prevent deconditioning on a daily basis.

I think the bigger piece will be thinking about the shared decision-making process around whether patients go home or to an SNF. We’re trying to improve that process and are developing criteria for that decision and communicating it across the treatment teams.

QUESTION: What challenges are you encountering so far?

Dr. Liu: Our biggest discovery in undergoing this improvement work has been that reducing the deconditioning of patients in the hospital is just one driver. The bigger driver may be that the providers and physicians who are making the decision to refer patients to skilled nursing facilities often don’t know a patient’s home situation and functional status. The information needed to make that decision isn’t always apparent because it isn’t in the medical record.

One challenge we face is that as physicians we see patients for 30 minutes in the morning and they’re always in bed. That’s all that we know about their mobility and strength. We’re focusing on the acute medical issue and not on their functional status and living situation.

Another challenge is the ability to adapt the plan for changes in a patient’s status. We’ve had a couple of cases where patients recovered during the hospitalization and improved their strength and conditioning to the point where they probably could have gone home, but the decision had already been made that they should go to an SNF, and they end up being transferred to an SNF.

QUESTION: How are the results of your project going to be used by the Center for Medicare and Medicaid Innovation?

Dr. Liu: CMMI is hoping to take the results from all the innovation advisors’ improvement projects and scale them up to a larger population if they are successful. They are also hoping that we will serve as local advisors for other CMMI initiatives.

QUESTION: Why did you apply to be an innovation advisor?

Dr. Liu: I was interested in learning a lot more about the effects of cost and payment policies to improve health care systems. I saw the innovation advisors program as an opportunity to join a community of like-minded health care providers who are interested in improving care. It was also a chance to take our elder care program to the next level by examining process and outcome measures, and – if successful – potentially spreading the program to the rest of the hospital.

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

More than 110,000 physicians and other health care providers have received federal incentive payments based on their use of electronic health record technology, according to new data from the Health and Human Services department.

The payments were made by the Medicare and Medicaid programs between May 2011 and May 2012 for the meaningful use of certified electronic health record (EHR) technology. Under the Medicare and Medicaid EHR Incentive Programs, physicians, other health care providers, and hospitals can earn bonus payments from the federal government by demonstrating that they used EHRs to meet certain quality measures.

Physicians can earn up to $44,000 over 5 years through the Medicare incentive program. However, those who don’t meet program requirements by 2015 face a 1% cut to the total Medicare payments. Under the Medicaid program, physicians can earn up to $63,750 over 6 years, with no associated penalty.

Participation by physicians and other health care providers has exceeded goals set by the Centers for Medicare and Medicaid Services. In April, Acting CMS Administrator Marilyn Tavenner and National Coordinator for Health Information Technology Dr. Farzad Mostashari said they wanted to see 100,000 providers receive incentives under the EHR program by the end of 2012.

"Meeting this goal so early in the year is a testament to the commitment of everyone who has worked hard to meet the challenges of integrating EHRs and health information technology into clinical practice," Ms. Tavenner said in a statement. "Not only have state Medicaid programs, public health departments, and many other stakeholders given their support to the Medicare and Medicaid EHR Incentive Programs, but numerous health professionals and hospitals have recognized the potential of EHRs to provide better patient care, cut down on paperwork, and eliminate duplicate screening and tests."

The incentive programs have helped to jump-start the use of EHRs by providers across the country, Dr. Mostashari said. Regional extension centers sponsored by his office are a big part of the increase in use, he said. Through the end of May, more than 133,000 primary care providers and 10,000 specialists were working with these centers to overcome barriers to adoption.

Overall, the federal government has spent more than $5.7 billion on EHR incentive payments between January 2011 and the end of May, 2012 – more than $3 billion was paid by Medicare and more than $2.6 billion by Medicaid.

More than 110,000 physicians and other health care providers have received federal incentive payments based on their use of electronic health record technology, according to new data from the Health and Human Services department.

The payments were made by the Medicare and Medicaid programs between May 2011 and May 2012 for the meaningful use of certified electronic health record (EHR) technology. Under the Medicare and Medicaid EHR Incentive Programs, physicians, other health care providers, and hospitals can earn bonus payments from the federal government by demonstrating that they used EHRs to meet certain quality measures.

Physicians can earn up to $44,000 over 5 years through the Medicare incentive program. However, those who don’t meet program requirements by 2015 face a 1% cut to the total Medicare payments. Under the Medicaid program, physicians can earn up to $63,750 over 6 years, with no associated penalty.

Participation by physicians and other health care providers has exceeded goals set by the Centers for Medicare and Medicaid Services. In April, Acting CMS Administrator Marilyn Tavenner and National Coordinator for Health Information Technology Dr. Farzad Mostashari said they wanted to see 100,000 providers receive incentives under the EHR program by the end of 2012.

"Meeting this goal so early in the year is a testament to the commitment of everyone who has worked hard to meet the challenges of integrating EHRs and health information technology into clinical practice," Ms. Tavenner said in a statement. "Not only have state Medicaid programs, public health departments, and many other stakeholders given their support to the Medicare and Medicaid EHR Incentive Programs, but numerous health professionals and hospitals have recognized the potential of EHRs to provide better patient care, cut down on paperwork, and eliminate duplicate screening and tests."

The incentive programs have helped to jump-start the use of EHRs by providers across the country, Dr. Mostashari said. Regional extension centers sponsored by his office are a big part of the increase in use, he said. Through the end of May, more than 133,000 primary care providers and 10,000 specialists were working with these centers to overcome barriers to adoption.

Overall, the federal government has spent more than $5.7 billion on EHR incentive payments between January 2011 and the end of May, 2012 – more than $3 billion was paid by Medicare and more than $2.6 billion by Medicaid.

More than 110,000 physicians and other health care providers have received federal incentive payments based on their use of electronic health record technology, according to new data from the Health and Human Services department.

The payments were made by the Medicare and Medicaid programs between May 2011 and May 2012 for the meaningful use of certified electronic health record (EHR) technology. Under the Medicare and Medicaid EHR Incentive Programs, physicians, other health care providers, and hospitals can earn bonus payments from the federal government by demonstrating that they used EHRs to meet certain quality measures.

Physicians can earn up to $44,000 over 5 years through the Medicare incentive program. However, those who don’t meet program requirements by 2015 face a 1% cut to the total Medicare payments. Under the Medicaid program, physicians can earn up to $63,750 over 6 years, with no associated penalty.

Participation by physicians and other health care providers has exceeded goals set by the Centers for Medicare and Medicaid Services. In April, Acting CMS Administrator Marilyn Tavenner and National Coordinator for Health Information Technology Dr. Farzad Mostashari said they wanted to see 100,000 providers receive incentives under the EHR program by the end of 2012.

"Meeting this goal so early in the year is a testament to the commitment of everyone who has worked hard to meet the challenges of integrating EHRs and health information technology into clinical practice," Ms. Tavenner said in a statement. "Not only have state Medicaid programs, public health departments, and many other stakeholders given their support to the Medicare and Medicaid EHR Incentive Programs, but numerous health professionals and hospitals have recognized the potential of EHRs to provide better patient care, cut down on paperwork, and eliminate duplicate screening and tests."

The incentive programs have helped to jump-start the use of EHRs by providers across the country, Dr. Mostashari said. Regional extension centers sponsored by his office are a big part of the increase in use, he said. Through the end of May, more than 133,000 primary care providers and 10,000 specialists were working with these centers to overcome barriers to adoption.

Overall, the federal government has spent more than $5.7 billion on EHR incentive payments between January 2011 and the end of May, 2012 – more than $3 billion was paid by Medicare and more than $2.6 billion by Medicaid.

The Food and Drug Administration has started laying the groundwork for approving so-called biosimilar products. As part of the Affordable Care Act, Congress created an abbreviated licensure pathway for biologic products that can be shown to be "highly similar" to an already approved biologic drug. The Biologics Price Competition and Innovation Act, which lawmakers had been working on for years, was passed in 2010 as part of the ACA. It will make it possible for biosimilar manufacturers to bring their products to market with less clinical testing than is required of originator biopharmaceuticals and therefore at a significantly lower cost to consumers.

Under the new pathway, biosimilars must be shown to be highly similar to an already approved product. The biosimilar may have minor differences in clinically inactive components, but there must be no clinically meaningful differences between the original and the biosimilar in terms of safety, purity, and potency, according to the FDA. The Agency is moving forward with the process and, in February, issued draft guidance on biosimilar product development.

While several companies are developing biosimilar products, it’s unclear when the first biosimilar will hit the market in the United States. Dr. Jonathan Kay, a rheumatologist who has written extensively about biosimilar development and the new approval process, shared his thoughts on how the products will be received by clinicians and patients.

Question: How does the FDA draft guidance balance safety concerns within the abbreviated approval pathway?

Dr. Kay: The designation of "biosimilar" allows a biopharmaceutical to follow an abbreviated pathway for approval. Because the therapeutically effective dose of the originator biopharmaceutical already has been determined, the biosimilar can skip phase II testing, which is usually conducted to ascertain the optimal therapeutic dose of a novel drug. However, the biosimilar has to undergo a number of analytic studies to prove that it is chemically and mechanistically very similar to the originator biopharmaceutical before it can be tested in human subjects. Once these analytic studies have been completed and are successful, phase I studies of the biosimilar are then conducted in human subjects, usually in patients with the disease of interest but sometimes in normal human volunteers. In these studies, the pharmacodynamic and pharmacokinetic properties of the biosimilar are compared to those of the originator biopharmaceutical. The biosimilar must be shown to be similar, but neither more nor less effective within a prespecified range (usually 80%-125%), than the originator biopharmaceutical. The FDA’s draft guidance requires at least that at least one clinical trial be conducted in patients with the disease that is most sensitive to assess the efficacy of the drug. Although one clinical trial of 3- to 6-months’ duration may satisfy the regulatory requirements, additional trials may be needed. There is also the expectation that post-approval pharmacovigilance surveillance will be conducted for several years to monitor safety of the biosimilar. However, given all of the analytic, pharmacodynamic, pharmacokinetic, and clinical studies that are required to show similarity, as well as the years of clinical experience with the originator biopharmaceutical, it’s unlikely that new safety issues will arise with a biosimilar.

Question: Are physicians likely to trust these medicines and prescribe them routinely?

Dr. Kay: Physicians most likely will be skeptical about the safety and efficacy of biosimilars, when they are first introduced, because of their unfamiliarity. However, having reviewed the various regulatory pathways that have been proposed to evaluate these drugs, I’m quite comfortable that, if approved, there will not be a significantly increased risk of toxicity or of inadequate efficacy. Personally, I will be comfortable using biosimilars that have been approved according the FDA’s abbreviated licensure pathway. Physicians should remember that, when a patient is started on an originator biopharmaceutical, it is impossible to know whether the patient will respond to that biopharmaceutical. Until the patient has taken the biologic agent for several months, there is a chance that she or he may be a nonresponder. With a biosimilar, the same risk holds true. Just because the drug is a biosimilar, there is not a greater likelihood that any given patient will not respond to the biosimilar than to another innovator biopharmaceutical.

Question: What about patients? Will they be comfortable using biosimilars?

Dr. Kay: The degree of comfort that a patient will have using a biosimilar will depend upon how much information is available regarding comparability of the biosimilar with the originator biopharmaceutical. Patients are very concerned about the out-of-pocket costs that they face with expensive medications. I’ve encountered patients who require biologic agents to treat their rheumatoid arthritis who could not afford high monthly copayments of nearly $500. If a lower-priced drug with similar efficacy and similar safety were available, patients in that situation would probably opt to try the less-expensive medication for financial reasons. The regulatory pathway requires that these medications be studied adequately. Thus, there should not be the expectation that patients would be receiving a less effective medication. The FDA will have subjected biosimilars to rigorous analytical and clinical testing before approval.

Question: What impact will the introduction of biosimilar products have on the cost of health care?

Dr. Kay: It is anticipated that biosimilars will likely be marketed at prices 50% to 70% lower than those of the originator biopharmaceuticals. If most patients who currently are treated with biologic agents are switched to biosimilars, the acquisition cost of biologic agents will be reduced significantly. However, if the availability of biosimilars facilitates treating a larger number of patients with biologic agents, the total acquisition cost of lower-priced biosimilars for an increased number of patients might offset any direct cost savings. Thus, the impact of an expanded market for biologic agents would have to be assessed in terms of the economic effects of a potential increase in workplace productivity and reduction of other health care costs resulting from effective treatment. For example, successful treatment with TNF inhibitors of more patients might reduce the incidence and, therefore, the cost of treating cardiovascular comorbidities in patients with rheumatoid arthritis.

Dr. Kay is the director of clinical research in the division of rheumatology at UMass Memorial Medical Center and a professor of medicine at the University of Massachusetts Medical School, both in Worcester. He disclosed consulting relationships and grant funding from a number of companies that make biologic therapies*

*ADDITION 6/19/2012: Dr. Kay's disclosures have been added to this story.

The Food and Drug Administration has started laying the groundwork for approving so-called biosimilar products. As part of the Affordable Care Act, Congress created an abbreviated licensure pathway for biologic products that can be shown to be "highly similar" to an already approved biologic drug. The Biologics Price Competition and Innovation Act, which lawmakers had been working on for years, was passed in 2010 as part of the ACA. It will make it possible for biosimilar manufacturers to bring their products to market with less clinical testing than is required of originator biopharmaceuticals and therefore at a significantly lower cost to consumers.

Under the new pathway, biosimilars must be shown to be highly similar to an already approved product. The biosimilar may have minor differences in clinically inactive components, but there must be no clinically meaningful differences between the original and the biosimilar in terms of safety, purity, and potency, according to the FDA. The Agency is moving forward with the process and, in February, issued draft guidance on biosimilar product development.

While several companies are developing biosimilar products, it’s unclear when the first biosimilar will hit the market in the United States. Dr. Jonathan Kay, a rheumatologist who has written extensively about biosimilar development and the new approval process, shared his thoughts on how the products will be received by clinicians and patients.

Question: How does the FDA draft guidance balance safety concerns within the abbreviated approval pathway?

Dr. Kay: The designation of "biosimilar" allows a biopharmaceutical to follow an abbreviated pathway for approval. Because the therapeutically effective dose of the originator biopharmaceutical already has been determined, the biosimilar can skip phase II testing, which is usually conducted to ascertain the optimal therapeutic dose of a novel drug. However, the biosimilar has to undergo a number of analytic studies to prove that it is chemically and mechanistically very similar to the originator biopharmaceutical before it can be tested in human subjects. Once these analytic studies have been completed and are successful, phase I studies of the biosimilar are then conducted in human subjects, usually in patients with the disease of interest but sometimes in normal human volunteers. In these studies, the pharmacodynamic and pharmacokinetic properties of the biosimilar are compared to those of the originator biopharmaceutical. The biosimilar must be shown to be similar, but neither more nor less effective within a prespecified range (usually 80%-125%), than the originator biopharmaceutical. The FDA’s draft guidance requires at least that at least one clinical trial be conducted in patients with the disease that is most sensitive to assess the efficacy of the drug. Although one clinical trial of 3- to 6-months’ duration may satisfy the regulatory requirements, additional trials may be needed. There is also the expectation that post-approval pharmacovigilance surveillance will be conducted for several years to monitor safety of the biosimilar. However, given all of the analytic, pharmacodynamic, pharmacokinetic, and clinical studies that are required to show similarity, as well as the years of clinical experience with the originator biopharmaceutical, it’s unlikely that new safety issues will arise with a biosimilar.

Question: Are physicians likely to trust these medicines and prescribe them routinely?

Dr. Kay: Physicians most likely will be skeptical about the safety and efficacy of biosimilars, when they are first introduced, because of their unfamiliarity. However, having reviewed the various regulatory pathways that have been proposed to evaluate these drugs, I’m quite comfortable that, if approved, there will not be a significantly increased risk of toxicity or of inadequate efficacy. Personally, I will be comfortable using biosimilars that have been approved according the FDA’s abbreviated licensure pathway. Physicians should remember that, when a patient is started on an originator biopharmaceutical, it is impossible to know whether the patient will respond to that biopharmaceutical. Until the patient has taken the biologic agent for several months, there is a chance that she or he may be a nonresponder. With a biosimilar, the same risk holds true. Just because the drug is a biosimilar, there is not a greater likelihood that any given patient will not respond to the biosimilar than to another innovator biopharmaceutical.

Question: What about patients? Will they be comfortable using biosimilars?

Dr. Kay: The degree of comfort that a patient will have using a biosimilar will depend upon how much information is available regarding comparability of the biosimilar with the originator biopharmaceutical. Patients are very concerned about the out-of-pocket costs that they face with expensive medications. I’ve encountered patients who require biologic agents to treat their rheumatoid arthritis who could not afford high monthly copayments of nearly $500. If a lower-priced drug with similar efficacy and similar safety were available, patients in that situation would probably opt to try the less-expensive medication for financial reasons. The regulatory pathway requires that these medications be studied adequately. Thus, there should not be the expectation that patients would be receiving a less effective medication. The FDA will have subjected biosimilars to rigorous analytical and clinical testing before approval.

Question: What impact will the introduction of biosimilar products have on the cost of health care?

Dr. Kay: It is anticipated that biosimilars will likely be marketed at prices 50% to 70% lower than those of the originator biopharmaceuticals. If most patients who currently are treated with biologic agents are switched to biosimilars, the acquisition cost of biologic agents will be reduced significantly. However, if the availability of biosimilars facilitates treating a larger number of patients with biologic agents, the total acquisition cost of lower-priced biosimilars for an increased number of patients might offset any direct cost savings. Thus, the impact of an expanded market for biologic agents would have to be assessed in terms of the economic effects of a potential increase in workplace productivity and reduction of other health care costs resulting from effective treatment. For example, successful treatment with TNF inhibitors of more patients might reduce the incidence and, therefore, the cost of treating cardiovascular comorbidities in patients with rheumatoid arthritis.

Dr. Kay is the director of clinical research in the division of rheumatology at UMass Memorial Medical Center and a professor of medicine at the University of Massachusetts Medical School, both in Worcester. He disclosed consulting relationships and grant funding from a number of companies that make biologic therapies*

*ADDITION 6/19/2012: Dr. Kay's disclosures have been added to this story.

The Food and Drug Administration has started laying the groundwork for approving so-called biosimilar products. As part of the Affordable Care Act, Congress created an abbreviated licensure pathway for biologic products that can be shown to be "highly similar" to an already approved biologic drug. The Biologics Price Competition and Innovation Act, which lawmakers had been working on for years, was passed in 2010 as part of the ACA. It will make it possible for biosimilar manufacturers to bring their products to market with less clinical testing than is required of originator biopharmaceuticals and therefore at a significantly lower cost to consumers.

Under the new pathway, biosimilars must be shown to be highly similar to an already approved product. The biosimilar may have minor differences in clinically inactive components, but there must be no clinically meaningful differences between the original and the biosimilar in terms of safety, purity, and potency, according to the FDA. The Agency is moving forward with the process and, in February, issued draft guidance on biosimilar product development.

While several companies are developing biosimilar products, it’s unclear when the first biosimilar will hit the market in the United States. Dr. Jonathan Kay, a rheumatologist who has written extensively about biosimilar development and the new approval process, shared his thoughts on how the products will be received by clinicians and patients.

Question: How does the FDA draft guidance balance safety concerns within the abbreviated approval pathway?

Dr. Kay: The designation of "biosimilar" allows a biopharmaceutical to follow an abbreviated pathway for approval. Because the therapeutically effective dose of the originator biopharmaceutical already has been determined, the biosimilar can skip phase II testing, which is usually conducted to ascertain the optimal therapeutic dose of a novel drug. However, the biosimilar has to undergo a number of analytic studies to prove that it is chemically and mechanistically very similar to the originator biopharmaceutical before it can be tested in human subjects. Once these analytic studies have been completed and are successful, phase I studies of the biosimilar are then conducted in human subjects, usually in patients with the disease of interest but sometimes in normal human volunteers. In these studies, the pharmacodynamic and pharmacokinetic properties of the biosimilar are compared to those of the originator biopharmaceutical. The biosimilar must be shown to be similar, but neither more nor less effective within a prespecified range (usually 80%-125%), than the originator biopharmaceutical. The FDA’s draft guidance requires at least that at least one clinical trial be conducted in patients with the disease that is most sensitive to assess the efficacy of the drug. Although one clinical trial of 3- to 6-months’ duration may satisfy the regulatory requirements, additional trials may be needed. There is also the expectation that post-approval pharmacovigilance surveillance will be conducted for several years to monitor safety of the biosimilar. However, given all of the analytic, pharmacodynamic, pharmacokinetic, and clinical studies that are required to show similarity, as well as the years of clinical experience with the originator biopharmaceutical, it’s unlikely that new safety issues will arise with a biosimilar.

Question: Are physicians likely to trust these medicines and prescribe them routinely?

Dr. Kay: Physicians most likely will be skeptical about the safety and efficacy of biosimilars, when they are first introduced, because of their unfamiliarity. However, having reviewed the various regulatory pathways that have been proposed to evaluate these drugs, I’m quite comfortable that, if approved, there will not be a significantly increased risk of toxicity or of inadequate efficacy. Personally, I will be comfortable using biosimilars that have been approved according the FDA’s abbreviated licensure pathway. Physicians should remember that, when a patient is started on an originator biopharmaceutical, it is impossible to know whether the patient will respond to that biopharmaceutical. Until the patient has taken the biologic agent for several months, there is a chance that she or he may be a nonresponder. With a biosimilar, the same risk holds true. Just because the drug is a biosimilar, there is not a greater likelihood that any given patient will not respond to the biosimilar than to another innovator biopharmaceutical.

Question: What about patients? Will they be comfortable using biosimilars?

Dr. Kay: The degree of comfort that a patient will have using a biosimilar will depend upon how much information is available regarding comparability of the biosimilar with the originator biopharmaceutical. Patients are very concerned about the out-of-pocket costs that they face with expensive medications. I’ve encountered patients who require biologic agents to treat their rheumatoid arthritis who could not afford high monthly copayments of nearly $500. If a lower-priced drug with similar efficacy and similar safety were available, patients in that situation would probably opt to try the less-expensive medication for financial reasons. The regulatory pathway requires that these medications be studied adequately. Thus, there should not be the expectation that patients would be receiving a less effective medication. The FDA will have subjected biosimilars to rigorous analytical and clinical testing before approval.

Question: What impact will the introduction of biosimilar products have on the cost of health care?

Dr. Kay: It is anticipated that biosimilars will likely be marketed at prices 50% to 70% lower than those of the originator biopharmaceuticals. If most patients who currently are treated with biologic agents are switched to biosimilars, the acquisition cost of biologic agents will be reduced significantly. However, if the availability of biosimilars facilitates treating a larger number of patients with biologic agents, the total acquisition cost of lower-priced biosimilars for an increased number of patients might offset any direct cost savings. Thus, the impact of an expanded market for biologic agents would have to be assessed in terms of the economic effects of a potential increase in workplace productivity and reduction of other health care costs resulting from effective treatment. For example, successful treatment with TNF inhibitors of more patients might reduce the incidence and, therefore, the cost of treating cardiovascular comorbidities in patients with rheumatoid arthritis.

Dr. Kay is the director of clinical research in the division of rheumatology at UMass Memorial Medical Center and a professor of medicine at the University of Massachusetts Medical School, both in Worcester. He disclosed consulting relationships and grant funding from a number of companies that make biologic therapies*

*ADDITION 6/19/2012: Dr. Kay's disclosures have been added to this story.

Medicare officials are offering physician organizations another opportunity to apply for the Advance Payment Accountable Care Organization Model program.

The Center for Medicare and Medicaid Innovation (CMMI) will begin accepting applications on Aug. 1 for a new round of the program, which begins Jan. 1, 2013. Organizations must file a notice of intent to apply by June 29.

The program is targeted to physician-based and rural ACOs that lack the capital to invest in the infrastructure and care coordination changes needed to develop an ACO. Through the program, being run by the innovation center, ACOs will receive both upfront payments and monthly payments to offset their start-up costs. The Advance Payment ACO Model is part of the large Medicare Shared Savings Program. The details on both programs were released last year.

The Advance Payment ACO Model is open to ACOs with no inpatient facilities and less than $50 million in total annual revenue. ACOs can also apply if their only inpatient facilities are a critical access hospital or Medicare low-volume rural hospitals with less than $80 million in total annual revenue.

ACOs that are co-owned with a health plan are not eligible.

Medicare officials are offering physician organizations another opportunity to apply for the Advance Payment Accountable Care Organization Model program.

The Center for Medicare and Medicaid Innovation (CMMI) will begin accepting applications on Aug. 1 for a new round of the program, which begins Jan. 1, 2013. Organizations must file a notice of intent to apply by June 29.

The program is targeted to physician-based and rural ACOs that lack the capital to invest in the infrastructure and care coordination changes needed to develop an ACO. Through the program, being run by the innovation center, ACOs will receive both upfront payments and monthly payments to offset their start-up costs. The Advance Payment ACO Model is part of the large Medicare Shared Savings Program. The details on both programs were released last year.

The Advance Payment ACO Model is open to ACOs with no inpatient facilities and less than $50 million in total annual revenue. ACOs can also apply if their only inpatient facilities are a critical access hospital or Medicare low-volume rural hospitals with less than $80 million in total annual revenue.

ACOs that are co-owned with a health plan are not eligible.

Medicare officials are offering physician organizations another opportunity to apply for the Advance Payment Accountable Care Organization Model program.

The Center for Medicare and Medicaid Innovation (CMMI) will begin accepting applications on Aug. 1 for a new round of the program, which begins Jan. 1, 2013. Organizations must file a notice of intent to apply by June 29.

The program is targeted to physician-based and rural ACOs that lack the capital to invest in the infrastructure and care coordination changes needed to develop an ACO. Through the program, being run by the innovation center, ACOs will receive both upfront payments and monthly payments to offset their start-up costs. The Advance Payment ACO Model is part of the large Medicare Shared Savings Program. The details on both programs were released last year.

The Advance Payment ACO Model is open to ACOs with no inpatient facilities and less than $50 million in total annual revenue. ACOs can also apply if their only inpatient facilities are a critical access hospital or Medicare low-volume rural hospitals with less than $80 million in total annual revenue.

ACOs that are co-owned with a health plan are not eligible.

UPDATE 6/14/12: At least two other large insurers are following UnitedHealthcare’s lead in pledging to maintain certain preventive care benefits should the Affordable Care Act be declared unconstitutional by the Supreme Court. In a statement issued on June 11, Humana announced that it would voluntarily continue the same provisions announced by UnitedHealthcare. Aetna will also keep those provisions in place, according to press reports.

No matter how the Supreme Court rules on the constitutionality of the Affordable Care Act, UnitedHealthcare will continue to offer several benefits currently required under the law.

On June 11, the insurance giant announced that it will continue to offer coverage for preventive health care without consumer cost sharing, cover dependents up to age 26 years, and refrain from imposing lifetime dollar limits on coverage. The insurer also pledged to provide a simple, accessible external appeals process and to limit the practice of rescinding individual coverage to cases of fraud. These benefits, which are all required under the Affordable Care Act (ACA), will continue to be available to all current and future customers, according to a company announcement.

"The protections we are voluntarily extending are good for people’s health, promote broader access to quality care and contribute to helping control rising health care costs," Stephen J. Hemsley, president and CEO of UnitedHealth Group, said in a statement.

Absent from the list is coverage for children with pre-existing medical conditions. That popular provision went into effect on Sept. 23, 2010, but UnitedHealthcare said that "one company acting alone cannot take that step," so it plans to work with other health plans to try to maintain that coverage.

Ron Pollack, executive director of Families USA, said if UnitedHealthcare were to go ahead on its own and guarantee coverage for children regardless of pre-existing medical conditions, it would put them at a competitive disadvantage. That kind of coverage is only possible if all plans are required by law to provide it, he said.

Mr. Pollack noted that UnitedHealthcare has not volunteered to continue all ACA benefits. Notably, the company’s announcement did not address charging higher premiums on the basis of health status, age, and gender.

Given UnitedHealthcare’s large market share, other health insurers could follow the company’s lead in continuing some ACA benefits, Mr. Pollack said, but it’s too early to say for sure.

UPDATE 6/14/12: At least two other large insurers are following UnitedHealthcare’s lead in pledging to maintain certain preventive care benefits should the Affordable Care Act be declared unconstitutional by the Supreme Court. In a statement issued on June 11, Humana announced that it would voluntarily continue the same provisions announced by UnitedHealthcare. Aetna will also keep those provisions in place, according to press reports.

No matter how the Supreme Court rules on the constitutionality of the Affordable Care Act, UnitedHealthcare will continue to offer several benefits currently required under the law.

On June 11, the insurance giant announced that it will continue to offer coverage for preventive health care without consumer cost sharing, cover dependents up to age 26 years, and refrain from imposing lifetime dollar limits on coverage. The insurer also pledged to provide a simple, accessible external appeals process and to limit the practice of rescinding individual coverage to cases of fraud. These benefits, which are all required under the Affordable Care Act (ACA), will continue to be available to all current and future customers, according to a company announcement.

"The protections we are voluntarily extending are good for people’s health, promote broader access to quality care and contribute to helping control rising health care costs," Stephen J. Hemsley, president and CEO of UnitedHealth Group, said in a statement.

Absent from the list is coverage for children with pre-existing medical conditions. That popular provision went into effect on Sept. 23, 2010, but UnitedHealthcare said that "one company acting alone cannot take that step," so it plans to work with other health plans to try to maintain that coverage.

Ron Pollack, executive director of Families USA, said if UnitedHealthcare were to go ahead on its own and guarantee coverage for children regardless of pre-existing medical conditions, it would put them at a competitive disadvantage. That kind of coverage is only possible if all plans are required by law to provide it, he said.

Mr. Pollack noted that UnitedHealthcare has not volunteered to continue all ACA benefits. Notably, the company’s announcement did not address charging higher premiums on the basis of health status, age, and gender.

Given UnitedHealthcare’s large market share, other health insurers could follow the company’s lead in continuing some ACA benefits, Mr. Pollack said, but it’s too early to say for sure.

UPDATE 6/14/12: At least two other large insurers are following UnitedHealthcare’s lead in pledging to maintain certain preventive care benefits should the Affordable Care Act be declared unconstitutional by the Supreme Court. In a statement issued on June 11, Humana announced that it would voluntarily continue the same provisions announced by UnitedHealthcare. Aetna will also keep those provisions in place, according to press reports.

No matter how the Supreme Court rules on the constitutionality of the Affordable Care Act, UnitedHealthcare will continue to offer several benefits currently required under the law.

On June 11, the insurance giant announced that it will continue to offer coverage for preventive health care without consumer cost sharing, cover dependents up to age 26 years, and refrain from imposing lifetime dollar limits on coverage. The insurer also pledged to provide a simple, accessible external appeals process and to limit the practice of rescinding individual coverage to cases of fraud. These benefits, which are all required under the Affordable Care Act (ACA), will continue to be available to all current and future customers, according to a company announcement.

"The protections we are voluntarily extending are good for people’s health, promote broader access to quality care and contribute to helping control rising health care costs," Stephen J. Hemsley, president and CEO of UnitedHealth Group, said in a statement.

Absent from the list is coverage for children with pre-existing medical conditions. That popular provision went into effect on Sept. 23, 2010, but UnitedHealthcare said that "one company acting alone cannot take that step," so it plans to work with other health plans to try to maintain that coverage.

Ron Pollack, executive director of Families USA, said if UnitedHealthcare were to go ahead on its own and guarantee coverage for children regardless of pre-existing medical conditions, it would put them at a competitive disadvantage. That kind of coverage is only possible if all plans are required by law to provide it, he said.

Mr. Pollack noted that UnitedHealthcare has not volunteered to continue all ACA benefits. Notably, the company’s announcement did not address charging higher premiums on the basis of health status, age, and gender.

Given UnitedHealthcare’s large market share, other health insurers could follow the company’s lead in continuing some ACA benefits, Mr. Pollack said, but it’s too early to say for sure.