Mary Ellen Schneider

Psoriatic arthritis patients who are taking a tumor necrosis factor inhibitor for the first time do about the same with or without the addition of methotrexate, Dr. Karen M. Fagerli said at the annual European Congress of Rheumatology.

Patients who received concomitant methotrexate, however, were more likely to still be taking that therapy after 3 years than were patients on anti-TNF monotherapy.

Dr. Fagerli of the Diakonhjemmet Hospital, Oslo, and her colleagues presented new data on the impact of concomitant medication with methotrexate for psoriatic arthritis patients who are taking a TNF inhibitor for the first time. Although comedication with methotrexate is known to be helpful in rheumatoid arthritis and ineffective in ankylosing spondylitis, its value has been unclear when comes to psoriatic arthritis.

"The jury is very much still out on this," Dr. Fagerli said in an interview.

The new data indicate that the combination of methotrexate and a TNF inhibitor doesn’t have the same synergistic effect in psoriatic arthritis as it does in rheumatoid arthritis, but the fact that patients on combination therapy had superior drug survival indicates that there is a role for methotrexate with a TNF inhibitor, she said.

"We saw similar responses in patients with or without concomitant methotrexate. However, there were improved 3-year drug survival rates seen with concomitant methotrexate. This was most prominent in patients on infliximab, but there was no clear trend in patients receiving etanercept," she reported.

Figuring out exactly what that role is and which patients can most benefit from this combination of treatments will require more research. Examining the treatment effect in psoriatic arthritis is a growing area of study, Dr. Fagerli said, as more researchers look for effects specifically in that condition, rather than adopting practice from other diseases.

"I think this is really an emerging issue," Dr. Fagerli said.

In this study, the researchers analyzed data from the NOR-DMARD register, a repository of data on adult patients with inflammatory arthropathies who are starting a new DMARD (disease-modifying antirheumatic drug) treatment. The register, which began in 2000, includes patients consecutively from across five rheumatology departments in Norway. The current analysis included 370 psoriatic arthritis patients who were being treated with their first TNF inhibitor. The patients were receiving either combined treatment with methotrexate or were not receiving a concomitant DMARD.

At 3 months, there was very little difference in either the state of disease or the change from baseline between the two groups. The researchers considered responses on the patient and physician global assessments and the Modified Health Assessment Questionnaire and SF-6D health status instruments. However, there was an improved 3-year drug survival in the group receiving combination treatment.

Dr. Fagerli reported that she has received speakers honoraria from Abbott, MSD, Pfizer, and Roche.

Psoriatic arthritis patients who are taking a tumor necrosis factor inhibitor for the first time do about the same with or without the addition of methotrexate, Dr. Karen M. Fagerli said at the annual European Congress of Rheumatology.

Patients who received concomitant methotrexate, however, were more likely to still be taking that therapy after 3 years than were patients on anti-TNF monotherapy.

Dr. Fagerli of the Diakonhjemmet Hospital, Oslo, and her colleagues presented new data on the impact of concomitant medication with methotrexate for psoriatic arthritis patients who are taking a TNF inhibitor for the first time. Although comedication with methotrexate is known to be helpful in rheumatoid arthritis and ineffective in ankylosing spondylitis, its value has been unclear when comes to psoriatic arthritis.

"The jury is very much still out on this," Dr. Fagerli said in an interview.

The new data indicate that the combination of methotrexate and a TNF inhibitor doesn’t have the same synergistic effect in psoriatic arthritis as it does in rheumatoid arthritis, but the fact that patients on combination therapy had superior drug survival indicates that there is a role for methotrexate with a TNF inhibitor, she said.

"We saw similar responses in patients with or without concomitant methotrexate. However, there were improved 3-year drug survival rates seen with concomitant methotrexate. This was most prominent in patients on infliximab, but there was no clear trend in patients receiving etanercept," she reported.

Figuring out exactly what that role is and which patients can most benefit from this combination of treatments will require more research. Examining the treatment effect in psoriatic arthritis is a growing area of study, Dr. Fagerli said, as more researchers look for effects specifically in that condition, rather than adopting practice from other diseases.

"I think this is really an emerging issue," Dr. Fagerli said.

In this study, the researchers analyzed data from the NOR-DMARD register, a repository of data on adult patients with inflammatory arthropathies who are starting a new DMARD (disease-modifying antirheumatic drug) treatment. The register, which began in 2000, includes patients consecutively from across five rheumatology departments in Norway. The current analysis included 370 psoriatic arthritis patients who were being treated with their first TNF inhibitor. The patients were receiving either combined treatment with methotrexate or were not receiving a concomitant DMARD.

At 3 months, there was very little difference in either the state of disease or the change from baseline between the two groups. The researchers considered responses on the patient and physician global assessments and the Modified Health Assessment Questionnaire and SF-6D health status instruments. However, there was an improved 3-year drug survival in the group receiving combination treatment.

Dr. Fagerli reported that she has received speakers honoraria from Abbott, MSD, Pfizer, and Roche.

Psoriatic arthritis patients who are taking a tumor necrosis factor inhibitor for the first time do about the same with or without the addition of methotrexate, Dr. Karen M. Fagerli said at the annual European Congress of Rheumatology.

Patients who received concomitant methotrexate, however, were more likely to still be taking that therapy after 3 years than were patients on anti-TNF monotherapy.

Dr. Fagerli of the Diakonhjemmet Hospital, Oslo, and her colleagues presented new data on the impact of concomitant medication with methotrexate for psoriatic arthritis patients who are taking a TNF inhibitor for the first time. Although comedication with methotrexate is known to be helpful in rheumatoid arthritis and ineffective in ankylosing spondylitis, its value has been unclear when comes to psoriatic arthritis.

"The jury is very much still out on this," Dr. Fagerli said in an interview.

The new data indicate that the combination of methotrexate and a TNF inhibitor doesn’t have the same synergistic effect in psoriatic arthritis as it does in rheumatoid arthritis, but the fact that patients on combination therapy had superior drug survival indicates that there is a role for methotrexate with a TNF inhibitor, she said.

"We saw similar responses in patients with or without concomitant methotrexate. However, there were improved 3-year drug survival rates seen with concomitant methotrexate. This was most prominent in patients on infliximab, but there was no clear trend in patients receiving etanercept," she reported.

Figuring out exactly what that role is and which patients can most benefit from this combination of treatments will require more research. Examining the treatment effect in psoriatic arthritis is a growing area of study, Dr. Fagerli said, as more researchers look for effects specifically in that condition, rather than adopting practice from other diseases.

"I think this is really an emerging issue," Dr. Fagerli said.

In this study, the researchers analyzed data from the NOR-DMARD register, a repository of data on adult patients with inflammatory arthropathies who are starting a new DMARD (disease-modifying antirheumatic drug) treatment. The register, which began in 2000, includes patients consecutively from across five rheumatology departments in Norway. The current analysis included 370 psoriatic arthritis patients who were being treated with their first TNF inhibitor. The patients were receiving either combined treatment with methotrexate or were not receiving a concomitant DMARD.

At 3 months, there was very little difference in either the state of disease or the change from baseline between the two groups. The researchers considered responses on the patient and physician global assessments and the Modified Health Assessment Questionnaire and SF-6D health status instruments. However, there was an improved 3-year drug survival in the group receiving combination treatment.

Dr. Fagerli reported that she has received speakers honoraria from Abbott, MSD, Pfizer, and Roche.

Primary care physicians in seven insurance markets will soon have the chance to earn monthly bonus payments in exchange for offering longer hours and better care coordination.

Medicare, along with several private health plans, state Medicaid agencies, and self-insured employers, has agreed to pay primary care practices in certain regions a monthly care coordination fee if they provide additional services for patients. On average, the fee works out to about $20 per patient per month.

The idea behind the demonstration project is to provide payment for services that physicians aren’t currently reimbursed for or don’t have the time to provide, such as reviewing test results over the phone or helping patients to manage their weight.

To be eligible to participate, primary care practices must agree to offer a range of enhanced services including longer and more flexible hours, use of electronic health records, preventive care, coordination of care with other providers, helping patients and caregivers to manage their own care, and individualized care for patients with multiple chronic diseases, according to the Centers for Medicare and Medicaid Services (CMS).

The 4-year program, which is administered by the Center for Medicare and Medicaid Innovation, will be available in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Okla. CMS will select about 75 primary care practices in each market to participate.

Practices interested in participating in the program must complete an online prescreen tool and an application. The deadline for applications is July 20.

CMS officials announced the Comprehensive Primary Care Initiative last September, and since then have been working to recruit private insurers to join in offering the care management. Overall, 45 commercial, federal, and state insurers will participate across the seven markets, according to CMS.

Practices are more likely to be selected for the program if they are already using a certified electronic health record system and have achieved state or national recognition as a patient-centered medical home, according to CMS. Practices that already participate in shared savings programs such as the Medicare Shared Savings Program, the Pioneer ACO Model, and the Independence at Home Demonstration Program are not eligible to participate.

Primary care physicians in seven insurance markets will soon have the chance to earn monthly bonus payments in exchange for offering longer hours and better care coordination.

Medicare, along with several private health plans, state Medicaid agencies, and self-insured employers, has agreed to pay primary care practices in certain regions a monthly care coordination fee if they provide additional services for patients. On average, the fee works out to about $20 per patient per month.

The idea behind the demonstration project is to provide payment for services that physicians aren’t currently reimbursed for or don’t have the time to provide, such as reviewing test results over the phone or helping patients to manage their weight.

To be eligible to participate, primary care practices must agree to offer a range of enhanced services including longer and more flexible hours, use of electronic health records, preventive care, coordination of care with other providers, helping patients and caregivers to manage their own care, and individualized care for patients with multiple chronic diseases, according to the Centers for Medicare and Medicaid Services (CMS).

The 4-year program, which is administered by the Center for Medicare and Medicaid Innovation, will be available in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Okla. CMS will select about 75 primary care practices in each market to participate.

Practices interested in participating in the program must complete an online prescreen tool and an application. The deadline for applications is July 20.

CMS officials announced the Comprehensive Primary Care Initiative last September, and since then have been working to recruit private insurers to join in offering the care management. Overall, 45 commercial, federal, and state insurers will participate across the seven markets, according to CMS.

Practices are more likely to be selected for the program if they are already using a certified electronic health record system and have achieved state or national recognition as a patient-centered medical home, according to CMS. Practices that already participate in shared savings programs such as the Medicare Shared Savings Program, the Pioneer ACO Model, and the Independence at Home Demonstration Program are not eligible to participate.

Primary care physicians in seven insurance markets will soon have the chance to earn monthly bonus payments in exchange for offering longer hours and better care coordination.

Medicare, along with several private health plans, state Medicaid agencies, and self-insured employers, has agreed to pay primary care practices in certain regions a monthly care coordination fee if they provide additional services for patients. On average, the fee works out to about $20 per patient per month.

The idea behind the demonstration project is to provide payment for services that physicians aren’t currently reimbursed for or don’t have the time to provide, such as reviewing test results over the phone or helping patients to manage their weight.

To be eligible to participate, primary care practices must agree to offer a range of enhanced services including longer and more flexible hours, use of electronic health records, preventive care, coordination of care with other providers, helping patients and caregivers to manage their own care, and individualized care for patients with multiple chronic diseases, according to the Centers for Medicare and Medicaid Services (CMS).

The 4-year program, which is administered by the Center for Medicare and Medicaid Innovation, will be available in Arkansas, Colorado, New Jersey, Oregon, New York’s Capital District-Hudson Valley Region, Ohio’s and Kentucky’s Cincinnati-Dayton Region, and greater Tulsa, Okla. CMS will select about 75 primary care practices in each market to participate.

Practices interested in participating in the program must complete an online prescreen tool and an application. The deadline for applications is July 20.

CMS officials announced the Comprehensive Primary Care Initiative last September, and since then have been working to recruit private insurers to join in offering the care management. Overall, 45 commercial, federal, and state insurers will participate across the seven markets, according to CMS.

Practices are more likely to be selected for the program if they are already using a certified electronic health record system and have achieved state or national recognition as a patient-centered medical home, according to CMS. Practices that already participate in shared savings programs such as the Medicare Shared Savings Program, the Pioneer ACO Model, and the Independence at Home Demonstration Program are not eligible to participate.

The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.

Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.

(See the list)

©rangizzz/fotolia.com

She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.

Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.

Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.

The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.

"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.

It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.

The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.

The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.

To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.

The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.

Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.

Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.

Checklist for Processing Errors and Adverse Events

Must-Ask Questions

• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?

Follow-Up Questions

• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?

The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.

Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.

(See the list)

©rangizzz/fotolia.com

She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.

Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.

Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.

The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.

"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.

It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.

The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.

The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.

To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.

The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.

Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.

Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.

Checklist for Processing Errors and Adverse Events

Must-Ask Questions

• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?

Follow-Up Questions

• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?

The aftermath of a medical error can be an endless tangle of bad feelings, or it can yield valuable lessons for hospital teams.

Adverse events need to be approached as learning opportunities, and a short checklist can start the process, according to Dr. Kimberly D. Manning of Emory University, Atlanta.

(See the list)

©rangizzz/fotolia.com

She and her colleague Dr. Neil H. Winawer have developed a standardized list of questions for assessing one’s role in adverse events and medical errors. The checklist gets at what went right, what could have been done better, and how to approach similar situations differently in the future.

Taking a standardized approach to medical errors is aimed at bringing more personal accountability into the analysis of adverse events, said Dr. Winawer, director of the hospital medicine unit at Grady Memorial Hospital, Atlanta. "Not every mistake has its origins inside of a system, and there needs to a balance of a no-fault systems culture and accountability," he said.

Dr. Manning added that not every adverse event requires a systems change. "Sometimes it just involves ... sitting down with your team, or alone, and working through exactly what happened to get the lessons and move forward," she said.

The checklist includes a series of must-ask questions, starting with a description of the adverse outcome or pivotal event. Other questions elicit explanations of what the physician did (or did not do) that was not ideal for the patient. And the checklist asks physicians to think about what they did that was good for the patient.

"What we found from having these discussions with our house staff is that the patients we tend to feel the most terrible about are usually the people that we’ve invested a lot into," said Dr. Manning, who is the director of Emory’s transitional year residency program.

It’s important to think about all the high-quality care that was provided, before and after something went wrong, rather than just dwelling on the adverse event, she said.

The checklist also focuses on the future, asking physicians what they could have done differently, what they have learned from the situation, and what safeguards could be implemented to avoid a similar outcome going forward.

The goal is to provide closure, but even more importantly, to honor the patient, Dr. Manning and Dr. Winawer explained.

To help physicians deal with the complex emotions surrounding an adverse event, the checklist includes some follow-up questions. The idea, Dr. Manning said, is to avoid the depression and burnout that can result unless perceived errors in care are discussed and dealt with.

The checklist can be used by individuals or with colleagues as a group. But it’s important to keep in mind that different members of the care team have different levels of responsibility and may have different views about the same event. Sometimes, the intern on the team did everything that he or she could do, Dr. Manning said, but the more senior physician could have done more to help the patient.

Because many adverse events are discovered by colleagues, the checklist also offers an objective way to discuss the problem and minimize some of the awkwardness.

Dr. Manning and Dr. Winawer spoke at the annual meeting of the Society of Hospital Medicine.

Checklist for Processing Errors and Adverse Events

Must-Ask Questions

• What was the adverse outcome or medical error?
• What did I do that was good for this patient?
• What did I do or not do that was not ideal?
• How high are the stakes?
• What could I have done differently?
• What did I learn?
• What can I do to avoid this happening again?

Follow-Up Questions

• How do I feel about what happened?
• What bothers me the most about this situation?
• What advice would you give to someone who was in this situation?
• How can I honor my patient now?
• What can I do to be of further support to my team members?

Federal officials are asking physicians to try to reduce the use of antipsychotic medications among nursing home residents by 15% by the end of this year.

Physicians at nursing homes should instead consider nonpharmacologic options such as increased exercise and time outdoors, better management of acute and chronic pain, and consistent assignment of the same staff members to care for nursing home residents, according to the Centers for Medicare and Medicaid Services.

Dr. Shari Ling, deputy chief medical officer of the CMS, said that health officials are particularly concerned about the use of antipsychotic medications by individuals with dementia. Since 2008, the Food and Drug Administration has advised physicians that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients who are treated for dementia-related psychosis. Antipsychotics are not indicated for the treatment of dementia-related psychosis, according to the agency.

Despite those warnings, dementia patients are continuing to receive the drugs. In 2010, about 39% of nursing home patients with signs of dementia receive antipsychotics drugs at some point, according to a CMS nursing home report. Those patients did not have a diagnosis of psychosis. Also in 2010, more than 17% of nursing home patients received daily doses of antipsychotics that exceeded recommended levels, according to CMS data.

"We believe these antipsychotic medications are overprescribed and we must do more to reduce the use of these drugs among people living with dementia," said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an organization which represents long-term care facilities.

The American Health Care Association has already called on its member facilities to reduce the use of antipsychotic medications by using alternative therapies, such as the ones recommended by the CMS, he said. For instance, they are promoting the use of "consistent assignment," where the same staff members are taking care of the same residents on a regular basis. This way, the staff becomes familiar with the residents’ behaviors and won’t unintentionally trigger outbursts that might lead to the use of these medications, he said.

It can be a fine line to determine the appropriate use of antipsychotic drugs, said Dr. Cheryl Phillips, senior vice president for public policy and advocacy at LeadingAge, a group of aging services organizations. Simply using the drugs off label doesn’t make it an inappropriate use, she said. For instance, there may be cases in which it is appropriate to use antipsychotics on a short-term basis in dementia patients. However, it’s essential that the use be closely monitored and that patients be put on the lowest dose possible for the shortest period of time, Dr. Phillips said.

The push to decrease antipsychotic drug use in nursing home residents is part of a larger initiative to improve dementia care in long-term care facilities. The Partnership to Improve Dementia Care, which was announced on May 30, includes federal and state health agencies, nursing home facilities, physicians and other providers, and patient advocates.

As part of the initiative, CMS officials will train nursing home staff members on person-centered care, abuse prevention, and quality of care improvement. The CMS is also conducting research in about 20 nursing homes across the country to better understand the decision making involved in whether to prescribed antipsychotic drugs to residents.

Starting in July, the CMS will publish data on antipsychotic drug use on the Nursing Home Compare website.

Dr. Ling said that over time, CMS officials aims to reduce the use of antipsychotic medications in other care settings as well.

Federal officials are asking physicians to try to reduce the use of antipsychotic medications among nursing home residents by 15% by the end of this year.

Physicians at nursing homes should instead consider nonpharmacologic options such as increased exercise and time outdoors, better management of acute and chronic pain, and consistent assignment of the same staff members to care for nursing home residents, according to the Centers for Medicare and Medicaid Services.

Dr. Shari Ling, deputy chief medical officer of the CMS, said that health officials are particularly concerned about the use of antipsychotic medications by individuals with dementia. Since 2008, the Food and Drug Administration has advised physicians that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients who are treated for dementia-related psychosis. Antipsychotics are not indicated for the treatment of dementia-related psychosis, according to the agency.

Despite those warnings, dementia patients are continuing to receive the drugs. In 2010, about 39% of nursing home patients with signs of dementia receive antipsychotics drugs at some point, according to a CMS nursing home report. Those patients did not have a diagnosis of psychosis. Also in 2010, more than 17% of nursing home patients received daily doses of antipsychotics that exceeded recommended levels, according to CMS data.

"We believe these antipsychotic medications are overprescribed and we must do more to reduce the use of these drugs among people living with dementia," said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an organization which represents long-term care facilities.

The American Health Care Association has already called on its member facilities to reduce the use of antipsychotic medications by using alternative therapies, such as the ones recommended by the CMS, he said. For instance, they are promoting the use of "consistent assignment," where the same staff members are taking care of the same residents on a regular basis. This way, the staff becomes familiar with the residents’ behaviors and won’t unintentionally trigger outbursts that might lead to the use of these medications, he said.

It can be a fine line to determine the appropriate use of antipsychotic drugs, said Dr. Cheryl Phillips, senior vice president for public policy and advocacy at LeadingAge, a group of aging services organizations. Simply using the drugs off label doesn’t make it an inappropriate use, she said. For instance, there may be cases in which it is appropriate to use antipsychotics on a short-term basis in dementia patients. However, it’s essential that the use be closely monitored and that patients be put on the lowest dose possible for the shortest period of time, Dr. Phillips said.

The push to decrease antipsychotic drug use in nursing home residents is part of a larger initiative to improve dementia care in long-term care facilities. The Partnership to Improve Dementia Care, which was announced on May 30, includes federal and state health agencies, nursing home facilities, physicians and other providers, and patient advocates.

As part of the initiative, CMS officials will train nursing home staff members on person-centered care, abuse prevention, and quality of care improvement. The CMS is also conducting research in about 20 nursing homes across the country to better understand the decision making involved in whether to prescribed antipsychotic drugs to residents.

Starting in July, the CMS will publish data on antipsychotic drug use on the Nursing Home Compare website.

Dr. Ling said that over time, CMS officials aims to reduce the use of antipsychotic medications in other care settings as well.

Federal officials are asking physicians to try to reduce the use of antipsychotic medications among nursing home residents by 15% by the end of this year.

Physicians at nursing homes should instead consider nonpharmacologic options such as increased exercise and time outdoors, better management of acute and chronic pain, and consistent assignment of the same staff members to care for nursing home residents, according to the Centers for Medicare and Medicaid Services.

Dr. Shari Ling, deputy chief medical officer of the CMS, said that health officials are particularly concerned about the use of antipsychotic medications by individuals with dementia. Since 2008, the Food and Drug Administration has advised physicians that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients who are treated for dementia-related psychosis. Antipsychotics are not indicated for the treatment of dementia-related psychosis, according to the agency.

Despite those warnings, dementia patients are continuing to receive the drugs. In 2010, about 39% of nursing home patients with signs of dementia receive antipsychotics drugs at some point, according to a CMS nursing home report. Those patients did not have a diagnosis of psychosis. Also in 2010, more than 17% of nursing home patients received daily doses of antipsychotics that exceeded recommended levels, according to CMS data.

"We believe these antipsychotic medications are overprescribed and we must do more to reduce the use of these drugs among people living with dementia," said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an organization which represents long-term care facilities.

The American Health Care Association has already called on its member facilities to reduce the use of antipsychotic medications by using alternative therapies, such as the ones recommended by the CMS, he said. For instance, they are promoting the use of "consistent assignment," where the same staff members are taking care of the same residents on a regular basis. This way, the staff becomes familiar with the residents’ behaviors and won’t unintentionally trigger outbursts that might lead to the use of these medications, he said.

It can be a fine line to determine the appropriate use of antipsychotic drugs, said Dr. Cheryl Phillips, senior vice president for public policy and advocacy at LeadingAge, a group of aging services organizations. Simply using the drugs off label doesn’t make it an inappropriate use, she said. For instance, there may be cases in which it is appropriate to use antipsychotics on a short-term basis in dementia patients. However, it’s essential that the use be closely monitored and that patients be put on the lowest dose possible for the shortest period of time, Dr. Phillips said.

The push to decrease antipsychotic drug use in nursing home residents is part of a larger initiative to improve dementia care in long-term care facilities. The Partnership to Improve Dementia Care, which was announced on May 30, includes federal and state health agencies, nursing home facilities, physicians and other providers, and patient advocates.

As part of the initiative, CMS officials will train nursing home staff members on person-centered care, abuse prevention, and quality of care improvement. The CMS is also conducting research in about 20 nursing homes across the country to better understand the decision making involved in whether to prescribed antipsychotic drugs to residents.

Starting in July, the CMS will publish data on antipsychotic drug use on the Nursing Home Compare website.

Dr. Ling said that over time, CMS officials aims to reduce the use of antipsychotic medications in other care settings as well.

Dr. Jennifer S. Myers, an academic hospitalist and the director of quality and safety education for the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, became interested in improving hospital quality almost as soon as she walked through the doors at Penn in 2001. She started with small improvement projects, and within a few years became one of the hospital’s patient safety officers.

But what has really captured her interest over the years has been working with medical students and residents on quality and safety improvement. With that in mind, she launched a regular patient safety conference for residents so they could bring up errors and near misses and work on potential solutions. In 2010, Dr. Myers became the first director of quality and safety education at the medical school. The idea behind creating the position was to better align the quality and safety goals of the hospital with what is happening at the medical school, she said.

In an interview with Hospitalist News, Dr. Myers discussed how quality and safety improvement are handled in training.

Question: What are medical student attitudes about safety and quality improvement? Do they see these as areas worth spending time on during training?

Dr. Myers: I think we have a lot more work to do with the medical schools. I think the students themselves are incredibly energetic, passionate, idealistic, and interested in this area. Just here at Penn, there’s been a lot of interest since we started to open up opportunities for them to become more involved in projects and interest groups. It’s really up to the medical schools now to design curricula that make sense for them and that they can learn from.

Question: How much time do medical students typically spend learning about quality improvement and patient safety?

Dr. Myers: It depends. If you ask 10 medical schools, you’ll get 10 different answers. In the past, students spent hardly any time at all on these areas. The residency focus has been stronger because of the policies of the ACGME (Accreditation Council for Graduate Medical Education). But at the medical school level, there has not been a policy that has been as explicit about the requirements. I think that is coming. The Liaison Committee on Medical Education, which oversees medical schools, is beginning to talk much more about quality and safety. Several thought leaders in the field have written white papers about this that clearly indicate that quality and safety should be taught from the beginning of health professions education – not just to physicians, but also to nurses and pharmacists. We should be doing a lot of this work inter-professionally since that’s how processes are improved in the hospital. At Penn, we are on our journey. We were doing a little. Now we’re doing more. A lot of my job is to make that happen.

Question: On the resident side, are they equally excited about this?

Dr. Myers: The residents are the master problem identifiers and problem solvers in a lot of ways. They are on the front lines. They see what doesn’t work well and what could harm a patient, and they have ideas for how to make it better. One challenge in residency education is having the right culture within the institution that allows and actually incentivizes residents to report problems and participate in their solutions. The second challenge in residency is the time. The training is very condensed, and there are also the strict work-hour restrictions. So you’re taking what was already a very busy curriculum and training program and introducing new content.

Question: There’s been a lot of discussion recently about the need for greater personal accountability by physicians to better balance the "no blame" patient safety culture that has developed in the last 20 years. How do you communicate that idea to students and residents without giving them a mixed message?

Dr. Myers: It’s a very delicate topic to teach. On the one hand, we’re focusing on systems, but on the other hand occasionally we have individual providers who didn’t execute their role or responsibilities correctly or responsibly. Each error has to be considered individually. The most important thing is not to jump to the conclusion that it was someone’s fault. Always look to the system first and see if it was "set up to fail" or failed the clinicians.

Question: What are the areas where you think hospitalists need to be doing more on quality improvement?

Dr. Myers: They definitely need to be leading and innovating in the area of quality and safety education. This is not just for academic hospitalists who teach residents and students, but also for community hospitalists because they are seen as the physician leads on their floors. Educating their group, or other groups, or the interdisciplinary team on their unit, is definitely a role.

The other area of growth and leadership for hospitalists is in the actual "doing" of improvement. It’s a skill, and it’s increasingly a needed skill for physicians. The third area is information technology integration and education. This means not only thinking of how health information systems should be built for hospital providers, but also thinking of how to educate users about why they were created in a certain way, how to use them safety, and what’s available.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

Dr. Jennifer S. Myers, an academic hospitalist and the director of quality and safety education for the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, became interested in improving hospital quality almost as soon as she walked through the doors at Penn in 2001. She started with small improvement projects, and within a few years became one of the hospital’s patient safety officers.

But what has really captured her interest over the years has been working with medical students and residents on quality and safety improvement. With that in mind, she launched a regular patient safety conference for residents so they could bring up errors and near misses and work on potential solutions. In 2010, Dr. Myers became the first director of quality and safety education at the medical school. The idea behind creating the position was to better align the quality and safety goals of the hospital with what is happening at the medical school, she said.

In an interview with Hospitalist News, Dr. Myers discussed how quality and safety improvement are handled in training.

Question: What are medical student attitudes about safety and quality improvement? Do they see these as areas worth spending time on during training?

Dr. Myers: I think we have a lot more work to do with the medical schools. I think the students themselves are incredibly energetic, passionate, idealistic, and interested in this area. Just here at Penn, there’s been a lot of interest since we started to open up opportunities for them to become more involved in projects and interest groups. It’s really up to the medical schools now to design curricula that make sense for them and that they can learn from.

Question: How much time do medical students typically spend learning about quality improvement and patient safety?

Dr. Myers: It depends. If you ask 10 medical schools, you’ll get 10 different answers. In the past, students spent hardly any time at all on these areas. The residency focus has been stronger because of the policies of the ACGME (Accreditation Council for Graduate Medical Education). But at the medical school level, there has not been a policy that has been as explicit about the requirements. I think that is coming. The Liaison Committee on Medical Education, which oversees medical schools, is beginning to talk much more about quality and safety. Several thought leaders in the field have written white papers about this that clearly indicate that quality and safety should be taught from the beginning of health professions education – not just to physicians, but also to nurses and pharmacists. We should be doing a lot of this work inter-professionally since that’s how processes are improved in the hospital. At Penn, we are on our journey. We were doing a little. Now we’re doing more. A lot of my job is to make that happen.

Question: On the resident side, are they equally excited about this?

Dr. Myers: The residents are the master problem identifiers and problem solvers in a lot of ways. They are on the front lines. They see what doesn’t work well and what could harm a patient, and they have ideas for how to make it better. One challenge in residency education is having the right culture within the institution that allows and actually incentivizes residents to report problems and participate in their solutions. The second challenge in residency is the time. The training is very condensed, and there are also the strict work-hour restrictions. So you’re taking what was already a very busy curriculum and training program and introducing new content.

Question: There’s been a lot of discussion recently about the need for greater personal accountability by physicians to better balance the "no blame" patient safety culture that has developed in the last 20 years. How do you communicate that idea to students and residents without giving them a mixed message?

Dr. Myers: It’s a very delicate topic to teach. On the one hand, we’re focusing on systems, but on the other hand occasionally we have individual providers who didn’t execute their role or responsibilities correctly or responsibly. Each error has to be considered individually. The most important thing is not to jump to the conclusion that it was someone’s fault. Always look to the system first and see if it was "set up to fail" or failed the clinicians.

Question: What are the areas where you think hospitalists need to be doing more on quality improvement?

Dr. Myers: They definitely need to be leading and innovating in the area of quality and safety education. This is not just for academic hospitalists who teach residents and students, but also for community hospitalists because they are seen as the physician leads on their floors. Educating their group, or other groups, or the interdisciplinary team on their unit, is definitely a role.

The other area of growth and leadership for hospitalists is in the actual "doing" of improvement. It’s a skill, and it’s increasingly a needed skill for physicians. The third area is information technology integration and education. This means not only thinking of how health information systems should be built for hospital providers, but also thinking of how to educate users about why they were created in a certain way, how to use them safety, and what’s available.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

Dr. Jennifer S. Myers, an academic hospitalist and the director of quality and safety education for the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, became interested in improving hospital quality almost as soon as she walked through the doors at Penn in 2001. She started with small improvement projects, and within a few years became one of the hospital’s patient safety officers.

But what has really captured her interest over the years has been working with medical students and residents on quality and safety improvement. With that in mind, she launched a regular patient safety conference for residents so they could bring up errors and near misses and work on potential solutions. In 2010, Dr. Myers became the first director of quality and safety education at the medical school. The idea behind creating the position was to better align the quality and safety goals of the hospital with what is happening at the medical school, she said.

In an interview with Hospitalist News, Dr. Myers discussed how quality and safety improvement are handled in training.

Question: What are medical student attitudes about safety and quality improvement? Do they see these as areas worth spending time on during training?

Dr. Myers: I think we have a lot more work to do with the medical schools. I think the students themselves are incredibly energetic, passionate, idealistic, and interested in this area. Just here at Penn, there’s been a lot of interest since we started to open up opportunities for them to become more involved in projects and interest groups. It’s really up to the medical schools now to design curricula that make sense for them and that they can learn from.

Question: How much time do medical students typically spend learning about quality improvement and patient safety?

Dr. Myers: It depends. If you ask 10 medical schools, you’ll get 10 different answers. In the past, students spent hardly any time at all on these areas. The residency focus has been stronger because of the policies of the ACGME (Accreditation Council for Graduate Medical Education). But at the medical school level, there has not been a policy that has been as explicit about the requirements. I think that is coming. The Liaison Committee on Medical Education, which oversees medical schools, is beginning to talk much more about quality and safety. Several thought leaders in the field have written white papers about this that clearly indicate that quality and safety should be taught from the beginning of health professions education – not just to physicians, but also to nurses and pharmacists. We should be doing a lot of this work inter-professionally since that’s how processes are improved in the hospital. At Penn, we are on our journey. We were doing a little. Now we’re doing more. A lot of my job is to make that happen.

Question: On the resident side, are they equally excited about this?

Dr. Myers: The residents are the master problem identifiers and problem solvers in a lot of ways. They are on the front lines. They see what doesn’t work well and what could harm a patient, and they have ideas for how to make it better. One challenge in residency education is having the right culture within the institution that allows and actually incentivizes residents to report problems and participate in their solutions. The second challenge in residency is the time. The training is very condensed, and there are also the strict work-hour restrictions. So you’re taking what was already a very busy curriculum and training program and introducing new content.

Question: There’s been a lot of discussion recently about the need for greater personal accountability by physicians to better balance the "no blame" patient safety culture that has developed in the last 20 years. How do you communicate that idea to students and residents without giving them a mixed message?

Dr. Myers: It’s a very delicate topic to teach. On the one hand, we’re focusing on systems, but on the other hand occasionally we have individual providers who didn’t execute their role or responsibilities correctly or responsibly. Each error has to be considered individually. The most important thing is not to jump to the conclusion that it was someone’s fault. Always look to the system first and see if it was "set up to fail" or failed the clinicians.

Question: What are the areas where you think hospitalists need to be doing more on quality improvement?

Dr. Myers: They definitely need to be leading and innovating in the area of quality and safety education. This is not just for academic hospitalists who teach residents and students, but also for community hospitalists because they are seen as the physician leads on their floors. Educating their group, or other groups, or the interdisciplinary team on their unit, is definitely a role.

The other area of growth and leadership for hospitalists is in the actual "doing" of improvement. It’s a skill, and it’s increasingly a needed skill for physicians. The third area is information technology integration and education. This means not only thinking of how health information systems should be built for hospital providers, but also thinking of how to educate users about why they were created in a certain way, how to use them safety, and what’s available.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to [email protected].

So far, the Centers for Medicare and Medicaid has touted the "carrots" associated with the use of health information technology. Come June 30, it will start using one of its first "sticks."

Physicians have until June 30 to report on the use of electronic prescribing under Medicare Part B or apply for a hardship exemption. Those who fail to do either face a 1.5% reduction in their Medicare payments starting on Jan. 1, 2013.

The e-prescribing requirement is not difficult to achieve by itself. Instead, it is one more burden faced by physicians who are already trying to find the time and money to manage Medicare requirements related to the meaningful use of health information technology and quality reporting, according to Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs at the American College of Physicians.

Courtesy Noel Ramos

For those who aren’t already e-prescribing, the decision will be whether to find an inexpensive e-prescribing program and submit the information necessary to avoid the penalty, or to invest in the transition to a full-scale electronic health record (EHR) system.

For a typical physician with a 2,000-patient panel whose practice is 40% Medicare, the 1.5% penalty could add up to $3,000 to $4,000 in 2013, Dr. Kirschner said.

Dr. Mary Newman, an internist in Lutherville, Md., isn’t worried about the e-prescribing penalty. Her multispecialty practice has been e-prescribing since 2005, and they’ve been doing it as an integrated part of their EHR system since 2007. She writes paper prescriptions just a couple times a month now.

Dr. Newman said she wouldn’t go back to paper prescribing. E-prescribing is better and safer, she said. With consent from her patients, she now can see medications prescribed by her patients’ other physicians. It helps prevent double prescribing, misprescribing, and drug interactions, she noted. There also is less time spent on the phone with the pharmacy. In addition, the electronic system helps improve documentation and record keeping, Dr. Newman said.

But while the system is virtually seamless today, Dr. Newman said she and her colleagues first approached the idea with "trepidation and aggravation."

"Especially for primary care, we’re so busy, it’s very threatening to make any kind of change," she said.

Dr. Jasdip Brar, an internist in Glendale Heights, Ill., jumped right into e-prescribing through his EHR system, but has struggled since.

Last year, Dr. Brar thought he was well on his way to successful e-prescribing through the Medicare Electronic Prescribing (eRx) Incentive Program when he got a letter from CMS stating that Medicare was cutting his payments by 1% in 2012 for failure to use e-prescribing.

It turns out that the EHR, which had come free with his billing system, never sent the appropriate G codes. He’s still waiting to hear from CMS if it will accept his backup documentation as proof of e-prescribing.

"My experience has been kind of rough," Dr. Brar said.

This year, he said that he has switched to a different free EHR system and is being more vigilant about ensuring CMS receives his codes.

But regardless of what happens with the payments, Dr. Brar said he’s dissatisfied with the electronic products on the market and the requirement that he must e-prescribe.

Dr. Brar, who opened a hybrid concierge practice about a year and a half ago, said he’s still much faster when writing prescriptions by hand. When he uses the EHR, it’s as if he’s being turned into a "point-and-click data entry clerk," he said, and it’s not how he wants to spend his time.

"It really becomes frustrating when you’re spending more time dealing with a computer than you are the patient," Dr. Brar said.

Despite the obstacles, a majority of physicians are engaged in e-prescribing, according to a new report from Surescripts, which operates the nation’s largest health information network.

By the end of 2011, 58% of U.S. office-based physicians had adopted e-prescribing, compared with about 10% of physicians 3 years earlier.

That rapid adoption trend is likely to continue, according to Seth Joseph, director of strategy and innovation at Surescripts and the lead researcher on the report. The federal dollars available through the Medicare and Medicaid EHR incentive programs appear to be one of the driving forces behind the uptick in adoption, he said.

As a result, many physicians are starting to see the use of EHRs and e-prescribing technology as inevitable and a standard of care, he said. Another important factor is the development of less expensive, "cloud-based" EHR products, which are making a comprehensive electronic system a more reasonable investment even in smaller practices, Mr. Joseph said.

Those physicians who do adopt EHRs seem to be doing a better job of e-prescribing. Surescripts found significantly higher utilization of e-prescribing among EHR users than among physicians with stand-alone e-prescribing systems. Mr. Joseph said that’s probably due to the significant investment of time and money involved in most EHR adoptions.

"They have skin in the game," Mr. Joseph said.

The Fine Print

Under the Medicare eRx Incentive Program, individual physicians and other eligible providers must submit information on at least 10 e-prescriptions on their Medicare Part B claim forms between Jan. 1 and June 30, 2012. The information must be submitted using either a qualified e-prescribing program or a certified EHR. The claim form must include the e-prescribing G code (G8553) or it doesn’t count.

Small group practices participating in the eRx Group Practice Reporting Option must submit codes for 625 e-prescriptions.

Large group practices participating in the program are required to submit codes for 2,500 e-prescriptions.

Individuals who are unable to submit information on at least 10 e-prescriptions can seek a hardship exemption under a few circumstances:

• if they cannot e-prescribe due to local, state, or federal laws,

• if they will write fewer than 100 prescriptions between Jan. 1 and June 30,

• if they practice in a rural area with insufficient high-speed Internet access (use code G8642), or 

• if they practice where there are not enough pharmacies that can receive electronic prescriptions (G8643).

Submit hardship requests to CMS via the Quality Reporting Communication Support Page by June 30. If the hardship has an associated G code, submit the request through the Communication Support Page or use the G code on at least one claim before June 30. 

Those who successfully reported on 25 e-prescriptions in 2011 need not worry about the 2013 penalty.

So far, the Centers for Medicare and Medicaid has touted the "carrots" associated with the use of health information technology. Come June 30, it will start using one of its first "sticks."

Physicians have until June 30 to report on the use of electronic prescribing under Medicare Part B or apply for a hardship exemption. Those who fail to do either face a 1.5% reduction in their Medicare payments starting on Jan. 1, 2013.

The e-prescribing requirement is not difficult to achieve by itself. Instead, it is one more burden faced by physicians who are already trying to find the time and money to manage Medicare requirements related to the meaningful use of health information technology and quality reporting, according to Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs at the American College of Physicians.

Courtesy Noel Ramos

For those who aren’t already e-prescribing, the decision will be whether to find an inexpensive e-prescribing program and submit the information necessary to avoid the penalty, or to invest in the transition to a full-scale electronic health record (EHR) system.

For a typical physician with a 2,000-patient panel whose practice is 40% Medicare, the 1.5% penalty could add up to $3,000 to $4,000 in 2013, Dr. Kirschner said.

Dr. Mary Newman, an internist in Lutherville, Md., isn’t worried about the e-prescribing penalty. Her multispecialty practice has been e-prescribing since 2005, and they’ve been doing it as an integrated part of their EHR system since 2007. She writes paper prescriptions just a couple times a month now.

Dr. Newman said she wouldn’t go back to paper prescribing. E-prescribing is better and safer, she said. With consent from her patients, she now can see medications prescribed by her patients’ other physicians. It helps prevent double prescribing, misprescribing, and drug interactions, she noted. There also is less time spent on the phone with the pharmacy. In addition, the electronic system helps improve documentation and record keeping, Dr. Newman said.

But while the system is virtually seamless today, Dr. Newman said she and her colleagues first approached the idea with "trepidation and aggravation."

"Especially for primary care, we’re so busy, it’s very threatening to make any kind of change," she said.

Dr. Jasdip Brar, an internist in Glendale Heights, Ill., jumped right into e-prescribing through his EHR system, but has struggled since.

Last year, Dr. Brar thought he was well on his way to successful e-prescribing through the Medicare Electronic Prescribing (eRx) Incentive Program when he got a letter from CMS stating that Medicare was cutting his payments by 1% in 2012 for failure to use e-prescribing.

It turns out that the EHR, which had come free with his billing system, never sent the appropriate G codes. He’s still waiting to hear from CMS if it will accept his backup documentation as proof of e-prescribing.

"My experience has been kind of rough," Dr. Brar said.

This year, he said that he has switched to a different free EHR system and is being more vigilant about ensuring CMS receives his codes.

But regardless of what happens with the payments, Dr. Brar said he’s dissatisfied with the electronic products on the market and the requirement that he must e-prescribe.

Dr. Brar, who opened a hybrid concierge practice about a year and a half ago, said he’s still much faster when writing prescriptions by hand. When he uses the EHR, it’s as if he’s being turned into a "point-and-click data entry clerk," he said, and it’s not how he wants to spend his time.

"It really becomes frustrating when you’re spending more time dealing with a computer than you are the patient," Dr. Brar said.

Despite the obstacles, a majority of physicians are engaged in e-prescribing, according to a new report from Surescripts, which operates the nation’s largest health information network.

By the end of 2011, 58% of U.S. office-based physicians had adopted e-prescribing, compared with about 10% of physicians 3 years earlier.

That rapid adoption trend is likely to continue, according to Seth Joseph, director of strategy and innovation at Surescripts and the lead researcher on the report. The federal dollars available through the Medicare and Medicaid EHR incentive programs appear to be one of the driving forces behind the uptick in adoption, he said.

As a result, many physicians are starting to see the use of EHRs and e-prescribing technology as inevitable and a standard of care, he said. Another important factor is the development of less expensive, "cloud-based" EHR products, which are making a comprehensive electronic system a more reasonable investment even in smaller practices, Mr. Joseph said.

Those physicians who do adopt EHRs seem to be doing a better job of e-prescribing. Surescripts found significantly higher utilization of e-prescribing among EHR users than among physicians with stand-alone e-prescribing systems. Mr. Joseph said that’s probably due to the significant investment of time and money involved in most EHR adoptions.

"They have skin in the game," Mr. Joseph said.

The Fine Print

Under the Medicare eRx Incentive Program, individual physicians and other eligible providers must submit information on at least 10 e-prescriptions on their Medicare Part B claim forms between Jan. 1 and June 30, 2012. The information must be submitted using either a qualified e-prescribing program or a certified EHR. The claim form must include the e-prescribing G code (G8553) or it doesn’t count.

Small group practices participating in the eRx Group Practice Reporting Option must submit codes for 625 e-prescriptions.

Large group practices participating in the program are required to submit codes for 2,500 e-prescriptions.

Individuals who are unable to submit information on at least 10 e-prescriptions can seek a hardship exemption under a few circumstances:

• if they cannot e-prescribe due to local, state, or federal laws,

• if they will write fewer than 100 prescriptions between Jan. 1 and June 30,

• if they practice in a rural area with insufficient high-speed Internet access (use code G8642), or 

• if they practice where there are not enough pharmacies that can receive electronic prescriptions (G8643).

Submit hardship requests to CMS via the Quality Reporting Communication Support Page by June 30. If the hardship has an associated G code, submit the request through the Communication Support Page or use the G code on at least one claim before June 30. 

Those who successfully reported on 25 e-prescriptions in 2011 need not worry about the 2013 penalty.

So far, the Centers for Medicare and Medicaid has touted the "carrots" associated with the use of health information technology. Come June 30, it will start using one of its first "sticks."

Physicians have until June 30 to report on the use of electronic prescribing under Medicare Part B or apply for a hardship exemption. Those who fail to do either face a 1.5% reduction in their Medicare payments starting on Jan. 1, 2013.

The e-prescribing requirement is not difficult to achieve by itself. Instead, it is one more burden faced by physicians who are already trying to find the time and money to manage Medicare requirements related to the meaningful use of health information technology and quality reporting, according to Neil Kirschner, Ph.D., senior associate for regulatory and insurer affairs at the American College of Physicians.

Courtesy Noel Ramos

For those who aren’t already e-prescribing, the decision will be whether to find an inexpensive e-prescribing program and submit the information necessary to avoid the penalty, or to invest in the transition to a full-scale electronic health record (EHR) system.

For a typical physician with a 2,000-patient panel whose practice is 40% Medicare, the 1.5% penalty could add up to $3,000 to $4,000 in 2013, Dr. Kirschner said.

Dr. Mary Newman, an internist in Lutherville, Md., isn’t worried about the e-prescribing penalty. Her multispecialty practice has been e-prescribing since 2005, and they’ve been doing it as an integrated part of their EHR system since 2007. She writes paper prescriptions just a couple times a month now.

Dr. Newman said she wouldn’t go back to paper prescribing. E-prescribing is better and safer, she said. With consent from her patients, she now can see medications prescribed by her patients’ other physicians. It helps prevent double prescribing, misprescribing, and drug interactions, she noted. There also is less time spent on the phone with the pharmacy. In addition, the electronic system helps improve documentation and record keeping, Dr. Newman said.

But while the system is virtually seamless today, Dr. Newman said she and her colleagues first approached the idea with "trepidation and aggravation."

"Especially for primary care, we’re so busy, it’s very threatening to make any kind of change," she said.

Dr. Jasdip Brar, an internist in Glendale Heights, Ill., jumped right into e-prescribing through his EHR system, but has struggled since.

Last year, Dr. Brar thought he was well on his way to successful e-prescribing through the Medicare Electronic Prescribing (eRx) Incentive Program when he got a letter from CMS stating that Medicare was cutting his payments by 1% in 2012 for failure to use e-prescribing.

It turns out that the EHR, which had come free with his billing system, never sent the appropriate G codes. He’s still waiting to hear from CMS if it will accept his backup documentation as proof of e-prescribing.

"My experience has been kind of rough," Dr. Brar said.

This year, he said that he has switched to a different free EHR system and is being more vigilant about ensuring CMS receives his codes.

But regardless of what happens with the payments, Dr. Brar said he’s dissatisfied with the electronic products on the market and the requirement that he must e-prescribe.

Dr. Brar, who opened a hybrid concierge practice about a year and a half ago, said he’s still much faster when writing prescriptions by hand. When he uses the EHR, it’s as if he’s being turned into a "point-and-click data entry clerk," he said, and it’s not how he wants to spend his time.

"It really becomes frustrating when you’re spending more time dealing with a computer than you are the patient," Dr. Brar said.

Despite the obstacles, a majority of physicians are engaged in e-prescribing, according to a new report from Surescripts, which operates the nation’s largest health information network.

By the end of 2011, 58% of U.S. office-based physicians had adopted e-prescribing, compared with about 10% of physicians 3 years earlier.

That rapid adoption trend is likely to continue, according to Seth Joseph, director of strategy and innovation at Surescripts and the lead researcher on the report. The federal dollars available through the Medicare and Medicaid EHR incentive programs appear to be one of the driving forces behind the uptick in adoption, he said.

As a result, many physicians are starting to see the use of EHRs and e-prescribing technology as inevitable and a standard of care, he said. Another important factor is the development of less expensive, "cloud-based" EHR products, which are making a comprehensive electronic system a more reasonable investment even in smaller practices, Mr. Joseph said.

Those physicians who do adopt EHRs seem to be doing a better job of e-prescribing. Surescripts found significantly higher utilization of e-prescribing among EHR users than among physicians with stand-alone e-prescribing systems. Mr. Joseph said that’s probably due to the significant investment of time and money involved in most EHR adoptions.

"They have skin in the game," Mr. Joseph said.

The Fine Print

Under the Medicare eRx Incentive Program, individual physicians and other eligible providers must submit information on at least 10 e-prescriptions on their Medicare Part B claim forms between Jan. 1 and June 30, 2012. The information must be submitted using either a qualified e-prescribing program or a certified EHR. The claim form must include the e-prescribing G code (G8553) or it doesn’t count.

Small group practices participating in the eRx Group Practice Reporting Option must submit codes for 625 e-prescriptions.

Large group practices participating in the program are required to submit codes for 2,500 e-prescriptions.

Individuals who are unable to submit information on at least 10 e-prescriptions can seek a hardship exemption under a few circumstances:

• if they cannot e-prescribe due to local, state, or federal laws,

• if they will write fewer than 100 prescriptions between Jan. 1 and June 30,

• if they practice in a rural area with insufficient high-speed Internet access (use code G8642), or 

• if they practice where there are not enough pharmacies that can receive electronic prescriptions (G8643).

Submit hardship requests to CMS via the Quality Reporting Communication Support Page by June 30. If the hardship has an associated G code, submit the request through the Communication Support Page or use the G code on at least one claim before June 30. 

Those who successfully reported on 25 e-prescriptions in 2011 need not worry about the 2013 penalty.

Hospitals will now have option of including advanced practice nurses, physician assistants, and pharmacists as part of the medical staff under new rules governing hospital participation in the Medicare program.

The change is one of many that officials at the Centers for Medicare and Medicaid Services made as part of their revision of the Medicare Conditions of Participation for hospitals and critical access hospitals. The goal of the overhaul is reduce unnecessary, obsolete, and burdensome regulations on hospitals and physicians.

The final regulation, which was released on May 10, also gives hospitals the added flexibility to use standing orders. Along with that change, CMS has added a requirement that the medical, nursing, and pharmacy staff must approve written and electronic standing orders, order sets, and protocols. The orders and protocols must be based on nationally recognized and evidence-based guidelines and recommendations.

The rule also eliminates some requirements that CMS officials now view as unnecessary or redundant.

CMS abolished the requirement for hospitals to maintain an infection-control log. Hospitals already are required to monitor infections through various surveillance methods. Similarly, hospitals will no longer be required to have a single director of outpatient services to supervise all outpatient departments in the hospital. Since hospitals already have directors for each of those departments, an overall director is duplicative, according to the new rules.

CMS estimates that the overall changes will save hospitals and critical access hospitals nearly $940 million in the first year and nearly $5 billion over the next 5 years. For instance, by allowing advanced practice nurses and other nonphysician providers to practice to the full extent of their state license, physicians will have more time to devote to complex patients, according to CMS.

Federal officials also released the Medicare Regulatory Reform rule, a final regulation that aims to eliminate similar burdensome and unnecessary rules related to providers and beneficiaries in the Medicare and Medicaid programs. That regulation includes a number of changes, including retiring older versions of electronic prescribing transactions for Medicare’s Part D prescription drug program and adopting newer versions. CMS estimates that this rule will save about $200 million in the first year.

Hospitals will now have option of including advanced practice nurses, physician assistants, and pharmacists as part of the medical staff under new rules governing hospital participation in the Medicare program.

The change is one of many that officials at the Centers for Medicare and Medicaid Services made as part of their revision of the Medicare Conditions of Participation for hospitals and critical access hospitals. The goal of the overhaul is reduce unnecessary, obsolete, and burdensome regulations on hospitals and physicians.

The final regulation, which was released on May 10, also gives hospitals the added flexibility to use standing orders. Along with that change, CMS has added a requirement that the medical, nursing, and pharmacy staff must approve written and electronic standing orders, order sets, and protocols. The orders and protocols must be based on nationally recognized and evidence-based guidelines and recommendations.

The rule also eliminates some requirements that CMS officials now view as unnecessary or redundant.

CMS abolished the requirement for hospitals to maintain an infection-control log. Hospitals already are required to monitor infections through various surveillance methods. Similarly, hospitals will no longer be required to have a single director of outpatient services to supervise all outpatient departments in the hospital. Since hospitals already have directors for each of those departments, an overall director is duplicative, according to the new rules.

CMS estimates that the overall changes will save hospitals and critical access hospitals nearly $940 million in the first year and nearly $5 billion over the next 5 years. For instance, by allowing advanced practice nurses and other nonphysician providers to practice to the full extent of their state license, physicians will have more time to devote to complex patients, according to CMS.

Federal officials also released the Medicare Regulatory Reform rule, a final regulation that aims to eliminate similar burdensome and unnecessary rules related to providers and beneficiaries in the Medicare and Medicaid programs. That regulation includes a number of changes, including retiring older versions of electronic prescribing transactions for Medicare’s Part D prescription drug program and adopting newer versions. CMS estimates that this rule will save about $200 million in the first year.

Hospitals will now have option of including advanced practice nurses, physician assistants, and pharmacists as part of the medical staff under new rules governing hospital participation in the Medicare program.

The change is one of many that officials at the Centers for Medicare and Medicaid Services made as part of their revision of the Medicare Conditions of Participation for hospitals and critical access hospitals. The goal of the overhaul is reduce unnecessary, obsolete, and burdensome regulations on hospitals and physicians.

The final regulation, which was released on May 10, also gives hospitals the added flexibility to use standing orders. Along with that change, CMS has added a requirement that the medical, nursing, and pharmacy staff must approve written and electronic standing orders, order sets, and protocols. The orders and protocols must be based on nationally recognized and evidence-based guidelines and recommendations.

The rule also eliminates some requirements that CMS officials now view as unnecessary or redundant.

CMS abolished the requirement for hospitals to maintain an infection-control log. Hospitals already are required to monitor infections through various surveillance methods. Similarly, hospitals will no longer be required to have a single director of outpatient services to supervise all outpatient departments in the hospital. Since hospitals already have directors for each of those departments, an overall director is duplicative, according to the new rules.

CMS estimates that the overall changes will save hospitals and critical access hospitals nearly $940 million in the first year and nearly $5 billion over the next 5 years. For instance, by allowing advanced practice nurses and other nonphysician providers to practice to the full extent of their state license, physicians will have more time to devote to complex patients, according to CMS.

Federal officials also released the Medicare Regulatory Reform rule, a final regulation that aims to eliminate similar burdensome and unnecessary rules related to providers and beneficiaries in the Medicare and Medicaid programs. That regulation includes a number of changes, including retiring older versions of electronic prescribing transactions for Medicare’s Part D prescription drug program and adopting newer versions. CMS estimates that this rule will save about $200 million in the first year.

UnitedHealthcare has agreed to use physician data from the American Gastroenterological Association's Digestive Health Outcomes Registry in its physician performance measurement programs.

The health plan has a "premium designation program" that awards 0-2 stars to physicians based on quality of care and cost efficiency. Under the agreement, cost efficiency would continue to be based on claims data, but quality would be assessed using information reported to the American Gastroenterological Association (AGA) registry.

UnitedHealthcare will begin by testing the process in 20 markets across the country.

The collaboration is good news for gastroenterologists because it means that they can be sure they are being evaluated based on reliable information, said Dr. John I. Allen, AGAF, vice president of the AGA Institute and chair of the AGA Registry Executive Management Board. That’s critical as both public and commercial payers move toward value-based payments, which link quality and resource use to reimbursement.

"Everybody knows that fee-for-service, volume-based reimbursement is probably not the best way to do things. So there has to be some link with outcomes. This is the best effort to try to form a partnership that can develop at least the beginnings of a validated measure set," said Dr. Allen, a gastroenterologist in Minneapolis, Minn. "I think in the long run it will be beneficial."

The AGA registry, which has been up and running for 2 years, uses evidence-based clinical guidelines and outcomes measures developed by GI physicians. The registry is certified by the Centers for Medicare and Medicaid Services, which means that GI physicians enrolled in the registry can use those data to report to Medicare’s Physician Quality Reporting System.

Currently, physicians can use the registry to report data on hepatitis C and inflammatory bowel disease measures.

UnitedHealthcare is the first commercial insurer to partner with the AGA, but Dr. Allen said they probably won’t be the last. AGA officials are in talks with most of the major insurers to see how the AGA’s registry could be used as part of their physician ratings.

Until recently, the physician ratings programs developed by insurers were variable and disjointed, Dr. Allen said. But changes put in place following a 2007 agreement between then-New York Attorney General Andrew Cuomo and several insurers over standards for the ratings systems have helped to make the programs more coordinated. Medicare’s experience operating the Hospital Compare website, which publishes quality information on hospitals, has also added to the knowledge base on quality reporting, he said.

"It’s beginning to get a little bit more organized," Dr. Allen said. "But it’s still difficult."

For its part, the AGA is focused on creating a national performance measure set for gastroenterology that can be used by all payers. The approach, Dr. Allen said, has been to develop a single set of valid measures and go through the endorsement process with the National Quality Forum.

UnitedHealthcare has agreed to use physician data from the American Gastroenterological Association's Digestive Health Outcomes Registry in its physician performance measurement programs.

The health plan has a "premium designation program" that awards 0-2 stars to physicians based on quality of care and cost efficiency. Under the agreement, cost efficiency would continue to be based on claims data, but quality would be assessed using information reported to the American Gastroenterological Association (AGA) registry.

UnitedHealthcare will begin by testing the process in 20 markets across the country.

The collaboration is good news for gastroenterologists because it means that they can be sure they are being evaluated based on reliable information, said Dr. John I. Allen, AGAF, vice president of the AGA Institute and chair of the AGA Registry Executive Management Board. That’s critical as both public and commercial payers move toward value-based payments, which link quality and resource use to reimbursement.

"Everybody knows that fee-for-service, volume-based reimbursement is probably not the best way to do things. So there has to be some link with outcomes. This is the best effort to try to form a partnership that can develop at least the beginnings of a validated measure set," said Dr. Allen, a gastroenterologist in Minneapolis, Minn. "I think in the long run it will be beneficial."

The AGA registry, which has been up and running for 2 years, uses evidence-based clinical guidelines and outcomes measures developed by GI physicians. The registry is certified by the Centers for Medicare and Medicaid Services, which means that GI physicians enrolled in the registry can use those data to report to Medicare’s Physician Quality Reporting System.

Currently, physicians can use the registry to report data on hepatitis C and inflammatory bowel disease measures.

UnitedHealthcare is the first commercial insurer to partner with the AGA, but Dr. Allen said they probably won’t be the last. AGA officials are in talks with most of the major insurers to see how the AGA’s registry could be used as part of their physician ratings.

Until recently, the physician ratings programs developed by insurers were variable and disjointed, Dr. Allen said. But changes put in place following a 2007 agreement between then-New York Attorney General Andrew Cuomo and several insurers over standards for the ratings systems have helped to make the programs more coordinated. Medicare’s experience operating the Hospital Compare website, which publishes quality information on hospitals, has also added to the knowledge base on quality reporting, he said.

"It’s beginning to get a little bit more organized," Dr. Allen said. "But it’s still difficult."

For its part, the AGA is focused on creating a national performance measure set for gastroenterology that can be used by all payers. The approach, Dr. Allen said, has been to develop a single set of valid measures and go through the endorsement process with the National Quality Forum.

UnitedHealthcare has agreed to use physician data from the American Gastroenterological Association's Digestive Health Outcomes Registry in its physician performance measurement programs.

The health plan has a "premium designation program" that awards 0-2 stars to physicians based on quality of care and cost efficiency. Under the agreement, cost efficiency would continue to be based on claims data, but quality would be assessed using information reported to the American Gastroenterological Association (AGA) registry.

UnitedHealthcare will begin by testing the process in 20 markets across the country.

The collaboration is good news for gastroenterologists because it means that they can be sure they are being evaluated based on reliable information, said Dr. John I. Allen, AGAF, vice president of the AGA Institute and chair of the AGA Registry Executive Management Board. That’s critical as both public and commercial payers move toward value-based payments, which link quality and resource use to reimbursement.

"Everybody knows that fee-for-service, volume-based reimbursement is probably not the best way to do things. So there has to be some link with outcomes. This is the best effort to try to form a partnership that can develop at least the beginnings of a validated measure set," said Dr. Allen, a gastroenterologist in Minneapolis, Minn. "I think in the long run it will be beneficial."

The AGA registry, which has been up and running for 2 years, uses evidence-based clinical guidelines and outcomes measures developed by GI physicians. The registry is certified by the Centers for Medicare and Medicaid Services, which means that GI physicians enrolled in the registry can use those data to report to Medicare’s Physician Quality Reporting System.

Currently, physicians can use the registry to report data on hepatitis C and inflammatory bowel disease measures.

UnitedHealthcare is the first commercial insurer to partner with the AGA, but Dr. Allen said they probably won’t be the last. AGA officials are in talks with most of the major insurers to see how the AGA’s registry could be used as part of their physician ratings.

Until recently, the physician ratings programs developed by insurers were variable and disjointed, Dr. Allen said. But changes put in place following a 2007 agreement between then-New York Attorney General Andrew Cuomo and several insurers over standards for the ratings systems have helped to make the programs more coordinated. Medicare’s experience operating the Hospital Compare website, which publishes quality information on hospitals, has also added to the knowledge base on quality reporting, he said.

"It’s beginning to get a little bit more organized," Dr. Allen said. "But it’s still difficult."

For its part, the AGA is focused on creating a national performance measure set for gastroenterology that can be used by all payers. The approach, Dr. Allen said, has been to develop a single set of valid measures and go through the endorsement process with the National Quality Forum.

The federal government is giving primary care physicians who treat Medicaid patients a pay raise in 2013 and 2014.

Starting on Jan. 1, the Medicaid program will pay Medicare rates for providing certain primary care services to its beneficiaries. The temporary payment boost is mandated under the Affordable Care Act and will run through the end of 2014. Officials at the Centers for Medicare and Medicaid Services outlined the specifics of the move to parity with Medicare payments in a proposed rule released May 9.

For many, this will mean a significant increase in Medicaid payments, according to Dr. Roland A. Goertz, board chair of the American Academy of Family Physicians. Data from 2008 shows that Medicaid rates are on average only 66% of Medicare rates for primary care services.

Dr. Goertz, who spoke at a press conference announcing the proposed rule, said that while the increased payments are good news, he is concerned about what happens at the end of 2014 when they are rolled back.

Right now, about two-thirds of his organization’s members accept Medicaid patients despite the lower payment from the program. But that’s not the basis for good public policy, he said.

"We can’t continue depending on the goodwill of physicians who provide care for less than the cost of that care," said Dr. Goertz of Waco, Tex.

Under the proposed rule, the higher payments will apply only to primary care services provided by family physicians, general internists, and pediatricians.

Higher rates will also be available for primary care services provided by related subspecialists. Any subspecialties within family medicine, general internal medicine, and pediatric medicine that are recognized by the American Board of Medical Specialties will be eligible, according to the proposed rule. A rheumatologist or a pediatric cardiologist, for instance, would qualify for the increased payment if he or she delivered certain primary care services.

Some nonphysician providers also will be eligible for increased payments. For instance, nurse practitioners who provide primary care services would be able to receive the higher payment if they work under the supervision of a qualifying physician and bill under that physician’s Medicaid provider number.

The payment policy applies to Medicaid fee-for-service patients and those enrolled in managed care plans, according to CMS.

The federal government will cover the full cost of the increase in provider payments, at an estimated cost of $11 billion over 2 years. That estimate does not take into account the potential savings to the Medicaid program from beneficiaries having increased access to preventive care, CMS officials said.

The federal government is giving primary care physicians who treat Medicaid patients a pay raise in 2013 and 2014.

Starting on Jan. 1, the Medicaid program will pay Medicare rates for providing certain primary care services to its beneficiaries. The temporary payment boost is mandated under the Affordable Care Act and will run through the end of 2014. Officials at the Centers for Medicare and Medicaid Services outlined the specifics of the move to parity with Medicare payments in a proposed rule released May 9.

For many, this will mean a significant increase in Medicaid payments, according to Dr. Roland A. Goertz, board chair of the American Academy of Family Physicians. Data from 2008 shows that Medicaid rates are on average only 66% of Medicare rates for primary care services.

Dr. Goertz, who spoke at a press conference announcing the proposed rule, said that while the increased payments are good news, he is concerned about what happens at the end of 2014 when they are rolled back.

Right now, about two-thirds of his organization’s members accept Medicaid patients despite the lower payment from the program. But that’s not the basis for good public policy, he said.

"We can’t continue depending on the goodwill of physicians who provide care for less than the cost of that care," said Dr. Goertz of Waco, Tex.

Under the proposed rule, the higher payments will apply only to primary care services provided by family physicians, general internists, and pediatricians.

Higher rates will also be available for primary care services provided by related subspecialists. Any subspecialties within family medicine, general internal medicine, and pediatric medicine that are recognized by the American Board of Medical Specialties will be eligible, according to the proposed rule. A rheumatologist or a pediatric cardiologist, for instance, would qualify for the increased payment if he or she delivered certain primary care services.

Some nonphysician providers also will be eligible for increased payments. For instance, nurse practitioners who provide primary care services would be able to receive the higher payment if they work under the supervision of a qualifying physician and bill under that physician’s Medicaid provider number.

The payment policy applies to Medicaid fee-for-service patients and those enrolled in managed care plans, according to CMS.

The federal government will cover the full cost of the increase in provider payments, at an estimated cost of $11 billion over 2 years. That estimate does not take into account the potential savings to the Medicaid program from beneficiaries having increased access to preventive care, CMS officials said.

The federal government is giving primary care physicians who treat Medicaid patients a pay raise in 2013 and 2014.

Starting on Jan. 1, the Medicaid program will pay Medicare rates for providing certain primary care services to its beneficiaries. The temporary payment boost is mandated under the Affordable Care Act and will run through the end of 2014. Officials at the Centers for Medicare and Medicaid Services outlined the specifics of the move to parity with Medicare payments in a proposed rule released May 9.

For many, this will mean a significant increase in Medicaid payments, according to Dr. Roland A. Goertz, board chair of the American Academy of Family Physicians. Data from 2008 shows that Medicaid rates are on average only 66% of Medicare rates for primary care services.

Dr. Goertz, who spoke at a press conference announcing the proposed rule, said that while the increased payments are good news, he is concerned about what happens at the end of 2014 when they are rolled back.

Right now, about two-thirds of his organization’s members accept Medicaid patients despite the lower payment from the program. But that’s not the basis for good public policy, he said.

"We can’t continue depending on the goodwill of physicians who provide care for less than the cost of that care," said Dr. Goertz of Waco, Tex.

Under the proposed rule, the higher payments will apply only to primary care services provided by family physicians, general internists, and pediatricians.

Higher rates will also be available for primary care services provided by related subspecialists. Any subspecialties within family medicine, general internal medicine, and pediatric medicine that are recognized by the American Board of Medical Specialties will be eligible, according to the proposed rule. A rheumatologist or a pediatric cardiologist, for instance, would qualify for the increased payment if he or she delivered certain primary care services.

Some nonphysician providers also will be eligible for increased payments. For instance, nurse practitioners who provide primary care services would be able to receive the higher payment if they work under the supervision of a qualifying physician and bill under that physician’s Medicaid provider number.

The payment policy applies to Medicaid fee-for-service patients and those enrolled in managed care plans, according to CMS.

The federal government will cover the full cost of the increase in provider payments, at an estimated cost of $11 billion over 2 years. That estimate does not take into account the potential savings to the Medicaid program from beneficiaries having increased access to preventive care, CMS officials said.

The National Committee for Quality Assurance, along with several partners, released a draft set of six new quality measures for adolescent well-care related to chlamydia identification, tobacco use, and depression.

Once finalized, the measures will be submitted to the federal government for inclusion in the Children’s Improved Core Set, used by states in reporting quality of care for children enrolled in the Children’s Health Insurance Program and Medicaid.

The measures were developed by the National Collaborative for Innovation in Quality Measurement (NCINQ), a group led by the National Committee for Quality Assurance (NCQA). Other participants in the NCINQ include Nationwide Children’s Hospital, New York University, the National Partnership for Women and Families, the American Academy of Pediatrics, health plans, physician groups, and consumers.

Three of the proposed measures relate to chlamydia identification and follow-up. The measures include documenting the sexual activity of adolescent patients, performing chlamydia screening with results for female adolescents, and prescribing antibiotics for female adolescents who have a positive test result.

The draft measure set also includes two measures on tobacco use, including documentation of tobacco use among adolescents and cessation treatment for adolescent tobacco users. The consortium also drafted a measure on depression screening of adolescents.

Physicians and other members of the public have until 5 p.m. ET on May 29 to comment on the draft measure set.

The National Committee for Quality Assurance, along with several partners, released a draft set of six new quality measures for adolescent well-care related to chlamydia identification, tobacco use, and depression.

Once finalized, the measures will be submitted to the federal government for inclusion in the Children’s Improved Core Set, used by states in reporting quality of care for children enrolled in the Children’s Health Insurance Program and Medicaid.

The measures were developed by the National Collaborative for Innovation in Quality Measurement (NCINQ), a group led by the National Committee for Quality Assurance (NCQA). Other participants in the NCINQ include Nationwide Children’s Hospital, New York University, the National Partnership for Women and Families, the American Academy of Pediatrics, health plans, physician groups, and consumers.

Three of the proposed measures relate to chlamydia identification and follow-up. The measures include documenting the sexual activity of adolescent patients, performing chlamydia screening with results for female adolescents, and prescribing antibiotics for female adolescents who have a positive test result.

The draft measure set also includes two measures on tobacco use, including documentation of tobacco use among adolescents and cessation treatment for adolescent tobacco users. The consortium also drafted a measure on depression screening of adolescents.

Physicians and other members of the public have until 5 p.m. ET on May 29 to comment on the draft measure set.

The National Committee for Quality Assurance, along with several partners, released a draft set of six new quality measures for adolescent well-care related to chlamydia identification, tobacco use, and depression.

Once finalized, the measures will be submitted to the federal government for inclusion in the Children’s Improved Core Set, used by states in reporting quality of care for children enrolled in the Children’s Health Insurance Program and Medicaid.

The measures were developed by the National Collaborative for Innovation in Quality Measurement (NCINQ), a group led by the National Committee for Quality Assurance (NCQA). Other participants in the NCINQ include Nationwide Children’s Hospital, New York University, the National Partnership for Women and Families, the American Academy of Pediatrics, health plans, physician groups, and consumers.

Three of the proposed measures relate to chlamydia identification and follow-up. The measures include documenting the sexual activity of adolescent patients, performing chlamydia screening with results for female adolescents, and prescribing antibiotics for female adolescents who have a positive test result.

The draft measure set also includes two measures on tobacco use, including documentation of tobacco use among adolescents and cessation treatment for adolescent tobacco users. The consortium also drafted a measure on depression screening of adolescents.

Physicians and other members of the public have until 5 p.m. ET on May 29 to comment on the draft measure set.