Mary Ellen Schneider

SAN FRANCISCO – When a pregnant woman presents with a complaint of itching, consider a range of causes, not just those triggered by pregnancy, Dr. Bethanee J. Schlosser advised.

Although some dermatoses of pregnancy are common, a pregnant woman's itching may have nothing to do with her pregnancy and could be the result of contact dermatitis, drug eruption, scabies, folliculitis, or another cause, Dr. Schlosser said at the meeting sponsored by Skin Disease Education Foundation (SDEF).

“Just because they're pregnant doesn't mean they only have to fit in the pregnancy dermatoses box,” Dr. Schlosser of the department of dermatology, and director of the women's skin health program, at Northwestern University in Chicago, said in an interview.

With that said, the two most prominent dermatoses of pregnancy are pruritic urticarial papules and plaques of pregnancy, a condition now known under the umbrella term polymorphic eruption of pregnancy, and pemphigoid gestationis, previously called herpes gestationis.

Polymorphic eruption of pregnancy occurs in about 1 in 300 pregnancies and is generally associated with multiple gestations and increased maternal weight gain. It is also more common in women having their first child. The mean onset is at about 35 weeks, but in about 15% of cases, the onset can be post partum, according to Dr. Schlosser.

Pemphigoid gestationis is a rare acquired autoimmune blistering disease unique to pregnancy. It occurs in 1 in 50,000 pregnancies and is probably the least common dermatosis of pregnancy. The onset is usually in the second or third trimester, but in about 14% of cases, the onset can occur post partum. With pemphigoid gestationis, there is no change in maternal outcome, but there are risks to the fetus including being small for gestational age, preterm delivery, and neonatal pemphigoid disease.

Typically, patients with the polymorphic eruption present with “hivelike” or urticarial papules and plaques, but no blisters, while women with pemphigoid gestationis often have more blistering. However, the clinical presentations and the routine histopathology can be identical, she explained. “I've seen patients with both entities, with both kinds of clinical features,” she noted. “If it's in your differential diagnosis and you can't distinguish 100% clinically, then that's where the utility of biopsy comes in.”

Cutaneous biopsy is a common procedure and is low risk, she reported, even in the context of pregnancy. Routine histopathology and direct immunofluorescence are essential in terms of differentiating between pemphigoid gestationis and polymorphic eruption.

The first-line treatment for both conditions is topical corticosteroids and oral antihistamines when the condition is mild or localized and systemic corticosteroids in severe cases. Although the treatments are generally the same, the difference between the two conditions is not academic, she said, because the potential sequelae and considerations for mother and child are different.

Dr. Schlosser also recommended that dermatologists make it a priority to communicate with the referring physician, specifically to review the risks to both the mother and child that may be associated with a particular skin condition or its treatments. For example, polymorphic eruption of pregnancy is generally nonthreatening to the mother and child. But Dr. Schlosser said she has seen patients with widespread, severe polymorphic eruptions who have needed treatment with systemic corticosteroids. That's essential information for the ob.gyn.; if the patient has a cesarean delivery, the patient will likely require stress-dose corticosteroids. Similarly, the newborn would need to be monitored for hypoglycemia during the immediate after-birth period.

“That doesn't mean that dermatologists shouldn't treat pregnant women aggressively, when appropriate,” she said. “But the entire multidisciplinary care team needs to be kept informed so that the risks can be managed.”

Dr. Schlosser said she had no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Classic umbilical sparing is seen in this case of polymorphic eruption of pregnancy.

Erythematous edematous papules and vesicles are evident on the palm in in this case of pemphigoid gestationis.

Source Photos courtesy Dr. Bethanee J. Schlosser

SAN FRANCISCO – When a pregnant woman presents with a complaint of itching, consider a range of causes, not just those triggered by pregnancy, Dr. Bethanee J. Schlosser advised.

Although some dermatoses of pregnancy are common, a pregnant woman's itching may have nothing to do with her pregnancy and could be the result of contact dermatitis, drug eruption, scabies, folliculitis, or another cause, Dr. Schlosser said at the meeting sponsored by Skin Disease Education Foundation (SDEF).

“Just because they're pregnant doesn't mean they only have to fit in the pregnancy dermatoses box,” Dr. Schlosser of the department of dermatology, and director of the women's skin health program, at Northwestern University in Chicago, said in an interview.

With that said, the two most prominent dermatoses of pregnancy are pruritic urticarial papules and plaques of pregnancy, a condition now known under the umbrella term polymorphic eruption of pregnancy, and pemphigoid gestationis, previously called herpes gestationis.

Polymorphic eruption of pregnancy occurs in about 1 in 300 pregnancies and is generally associated with multiple gestations and increased maternal weight gain. It is also more common in women having their first child. The mean onset is at about 35 weeks, but in about 15% of cases, the onset can be post partum, according to Dr. Schlosser.

Pemphigoid gestationis is a rare acquired autoimmune blistering disease unique to pregnancy. It occurs in 1 in 50,000 pregnancies and is probably the least common dermatosis of pregnancy. The onset is usually in the second or third trimester, but in about 14% of cases, the onset can occur post partum. With pemphigoid gestationis, there is no change in maternal outcome, but there are risks to the fetus including being small for gestational age, preterm delivery, and neonatal pemphigoid disease.

Typically, patients with the polymorphic eruption present with “hivelike” or urticarial papules and plaques, but no blisters, while women with pemphigoid gestationis often have more blistering. However, the clinical presentations and the routine histopathology can be identical, she explained. “I've seen patients with both entities, with both kinds of clinical features,” she noted. “If it's in your differential diagnosis and you can't distinguish 100% clinically, then that's where the utility of biopsy comes in.”

Cutaneous biopsy is a common procedure and is low risk, she reported, even in the context of pregnancy. Routine histopathology and direct immunofluorescence are essential in terms of differentiating between pemphigoid gestationis and polymorphic eruption.

The first-line treatment for both conditions is topical corticosteroids and oral antihistamines when the condition is mild or localized and systemic corticosteroids in severe cases. Although the treatments are generally the same, the difference between the two conditions is not academic, she said, because the potential sequelae and considerations for mother and child are different.

Dr. Schlosser also recommended that dermatologists make it a priority to communicate with the referring physician, specifically to review the risks to both the mother and child that may be associated with a particular skin condition or its treatments. For example, polymorphic eruption of pregnancy is generally nonthreatening to the mother and child. But Dr. Schlosser said she has seen patients with widespread, severe polymorphic eruptions who have needed treatment with systemic corticosteroids. That's essential information for the ob.gyn.; if the patient has a cesarean delivery, the patient will likely require stress-dose corticosteroids. Similarly, the newborn would need to be monitored for hypoglycemia during the immediate after-birth period.

“That doesn't mean that dermatologists shouldn't treat pregnant women aggressively, when appropriate,” she said. “But the entire multidisciplinary care team needs to be kept informed so that the risks can be managed.”

Dr. Schlosser said she had no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Classic umbilical sparing is seen in this case of polymorphic eruption of pregnancy.

Erythematous edematous papules and vesicles are evident on the palm in in this case of pemphigoid gestationis.

Source Photos courtesy Dr. Bethanee J. Schlosser

SAN FRANCISCO – When a pregnant woman presents with a complaint of itching, consider a range of causes, not just those triggered by pregnancy, Dr. Bethanee J. Schlosser advised.

Although some dermatoses of pregnancy are common, a pregnant woman's itching may have nothing to do with her pregnancy and could be the result of contact dermatitis, drug eruption, scabies, folliculitis, or another cause, Dr. Schlosser said at the meeting sponsored by Skin Disease Education Foundation (SDEF).

“Just because they're pregnant doesn't mean they only have to fit in the pregnancy dermatoses box,” Dr. Schlosser of the department of dermatology, and director of the women's skin health program, at Northwestern University in Chicago, said in an interview.

With that said, the two most prominent dermatoses of pregnancy are pruritic urticarial papules and plaques of pregnancy, a condition now known under the umbrella term polymorphic eruption of pregnancy, and pemphigoid gestationis, previously called herpes gestationis.

Polymorphic eruption of pregnancy occurs in about 1 in 300 pregnancies and is generally associated with multiple gestations and increased maternal weight gain. It is also more common in women having their first child. The mean onset is at about 35 weeks, but in about 15% of cases, the onset can be post partum, according to Dr. Schlosser.

Pemphigoid gestationis is a rare acquired autoimmune blistering disease unique to pregnancy. It occurs in 1 in 50,000 pregnancies and is probably the least common dermatosis of pregnancy. The onset is usually in the second or third trimester, but in about 14% of cases, the onset can occur post partum. With pemphigoid gestationis, there is no change in maternal outcome, but there are risks to the fetus including being small for gestational age, preterm delivery, and neonatal pemphigoid disease.

Typically, patients with the polymorphic eruption present with “hivelike” or urticarial papules and plaques, but no blisters, while women with pemphigoid gestationis often have more blistering. However, the clinical presentations and the routine histopathology can be identical, she explained. “I've seen patients with both entities, with both kinds of clinical features,” she noted. “If it's in your differential diagnosis and you can't distinguish 100% clinically, then that's where the utility of biopsy comes in.”

Cutaneous biopsy is a common procedure and is low risk, she reported, even in the context of pregnancy. Routine histopathology and direct immunofluorescence are essential in terms of differentiating between pemphigoid gestationis and polymorphic eruption.

The first-line treatment for both conditions is topical corticosteroids and oral antihistamines when the condition is mild or localized and systemic corticosteroids in severe cases. Although the treatments are generally the same, the difference between the two conditions is not academic, she said, because the potential sequelae and considerations for mother and child are different.

Dr. Schlosser also recommended that dermatologists make it a priority to communicate with the referring physician, specifically to review the risks to both the mother and child that may be associated with a particular skin condition or its treatments. For example, polymorphic eruption of pregnancy is generally nonthreatening to the mother and child. But Dr. Schlosser said she has seen patients with widespread, severe polymorphic eruptions who have needed treatment with systemic corticosteroids. That's essential information for the ob.gyn.; if the patient has a cesarean delivery, the patient will likely require stress-dose corticosteroids. Similarly, the newborn would need to be monitored for hypoglycemia during the immediate after-birth period.

“That doesn't mean that dermatologists shouldn't treat pregnant women aggressively, when appropriate,” she said. “But the entire multidisciplinary care team needs to be kept informed so that the risks can be managed.”

Dr. Schlosser said she had no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Classic umbilical sparing is seen in this case of polymorphic eruption of pregnancy.

Erythematous edematous papules and vesicles are evident on the palm in in this case of pemphigoid gestationis.

Source Photos courtesy Dr. Bethanee J. Schlosser

Physicians and hospitals now have the chance to test out bundled payments on a range of conditions under a new Medicare initiative.

In August, officials at the Centers for Medicare and Medicaid Services released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers a variety of options for bundling payments for a hospital stay, for postdischarge services, or for both the hospital stay and the postdischarge care.

The move toward bundled payments is a major shift in how the government pays for medical care. Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to incentivize clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

“Today, Medicare pays for care the wrong way,” Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. “Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy.”

The new bundling program offers four ways that health care providers can receive a bundled payment, three of which provide payment retrospectively, and one that offers a prospective payment. For example, under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2%–3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

The prospective payment model would work differently. Under that option, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit “no pay” claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

Organizations interested in applying for Model 1 had to submit a letter of intent by Sept. 22. Nov. 4 is the deadline for those interested in Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. CMS will consider a number of factors in choosing participants for the program including the best proposals for care improvement, the number of patients involved, and the conditions addressed, and the price discounts offered, he said.

The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior adviser to the CMS Innovation Center and past president of the American Medical Association. “I do believe that both physicians and hospitals will find this [to be] an opportunity that's flexible enough to give them the opportunity to begin to learn how to get paid for care differently,” she said.

The AMA praised CMS for making the program flexible. Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects.

“For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that's organizing these,” he said.

“We think those are important as well, but we also think it's important that physicians be a part of that leadership.”

Physicians and hospitals now have the chance to test out bundled payments on a range of conditions under a new Medicare initiative.

In August, officials at the Centers for Medicare and Medicaid Services released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers a variety of options for bundling payments for a hospital stay, for postdischarge services, or for both the hospital stay and the postdischarge care.

The move toward bundled payments is a major shift in how the government pays for medical care. Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to incentivize clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

“Today, Medicare pays for care the wrong way,” Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. “Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy.”

The new bundling program offers four ways that health care providers can receive a bundled payment, three of which provide payment retrospectively, and one that offers a prospective payment. For example, under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2%–3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

The prospective payment model would work differently. Under that option, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit “no pay” claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

Organizations interested in applying for Model 1 had to submit a letter of intent by Sept. 22. Nov. 4 is the deadline for those interested in Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. CMS will consider a number of factors in choosing participants for the program including the best proposals for care improvement, the number of patients involved, and the conditions addressed, and the price discounts offered, he said.

The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior adviser to the CMS Innovation Center and past president of the American Medical Association. “I do believe that both physicians and hospitals will find this [to be] an opportunity that's flexible enough to give them the opportunity to begin to learn how to get paid for care differently,” she said.

The AMA praised CMS for making the program flexible. Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects.

“For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that's organizing these,” he said.

“We think those are important as well, but we also think it's important that physicians be a part of that leadership.”

Physicians and hospitals now have the chance to test out bundled payments on a range of conditions under a new Medicare initiative.

In August, officials at the Centers for Medicare and Medicaid Services released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers a variety of options for bundling payments for a hospital stay, for postdischarge services, or for both the hospital stay and the postdischarge care.

The move toward bundled payments is a major shift in how the government pays for medical care. Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to incentivize clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

“Today, Medicare pays for care the wrong way,” Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. “Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy.”

The new bundling program offers four ways that health care providers can receive a bundled payment, three of which provide payment retrospectively, and one that offers a prospective payment. For example, under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2%–3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

The prospective payment model would work differently. Under that option, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit “no pay” claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

Organizations interested in applying for Model 1 had to submit a letter of intent by Sept. 22. Nov. 4 is the deadline for those interested in Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. CMS will consider a number of factors in choosing participants for the program including the best proposals for care improvement, the number of patients involved, and the conditions addressed, and the price discounts offered, he said.

The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior adviser to the CMS Innovation Center and past president of the American Medical Association. “I do believe that both physicians and hospitals will find this [to be] an opportunity that's flexible enough to give them the opportunity to begin to learn how to get paid for care differently,” she said.

The AMA praised CMS for making the program flexible. Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects.

“For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that's organizing these,” he said.

“We think those are important as well, but we also think it's important that physicians be a part of that leadership.”

Supporters of the Affordable Care Act scored a legal victory as a federal appeals court dismissed a pair of lawsuits challenging the constitutionality of the so-called individual mandate to buy health insurance.

On Sept. 8, a three-judge panel of the Fourth Circuit Court of Appeals in Richmond, Va., tossed out a suit brought by Virginia's Attorney General Ken Cuccinelli. They concluded that Virginia did not have the legal standing to challenge the individual mandate because it will affect individuals, not the state.

Mr. Cuccinelli argued that the individual mandate violated the Virginia Health Care Freedom Act, a state law that says no resident can be required to obtain insurance. The judges rejected that argument, writing that the Virginia law, signed after the Affordable Care Act was enacted, was a ploy to set up a legal challenge to the health reform law. The appeals court did not address whether the individual mandate was constitutional.

In the second ruling on Sept. 8, the same three-judge panel dismissed a challenge brought by Liberty University, a Christian college in Lynchburg, Va. In that case, the university charged that the law's tax penalties for individuals and employers were unconstitutional. The appeals court ruled that the university also lacked standing because it cannot challenge the provisions until they take effect in 2014.

Both cases were sent back to district court with instructions that they be dismissed.

There are currently more than 25 active legal challenges to the Affordable Care Act working their way through courthouses around the country. One of those cases is expected to reach the Supreme Court in the next few years.

Supporters of the Affordable Care Act scored a legal victory as a federal appeals court dismissed a pair of lawsuits challenging the constitutionality of the so-called individual mandate to buy health insurance.

On Sept. 8, a three-judge panel of the Fourth Circuit Court of Appeals in Richmond, Va., tossed out a suit brought by Virginia's Attorney General Ken Cuccinelli. They concluded that Virginia did not have the legal standing to challenge the individual mandate because it will affect individuals, not the state.

Mr. Cuccinelli argued that the individual mandate violated the Virginia Health Care Freedom Act, a state law that says no resident can be required to obtain insurance. The judges rejected that argument, writing that the Virginia law, signed after the Affordable Care Act was enacted, was a ploy to set up a legal challenge to the health reform law. The appeals court did not address whether the individual mandate was constitutional.

In the second ruling on Sept. 8, the same three-judge panel dismissed a challenge brought by Liberty University, a Christian college in Lynchburg, Va. In that case, the university charged that the law's tax penalties for individuals and employers were unconstitutional. The appeals court ruled that the university also lacked standing because it cannot challenge the provisions until they take effect in 2014.

Both cases were sent back to district court with instructions that they be dismissed.

There are currently more than 25 active legal challenges to the Affordable Care Act working their way through courthouses around the country. One of those cases is expected to reach the Supreme Court in the next few years.

Supporters of the Affordable Care Act scored a legal victory as a federal appeals court dismissed a pair of lawsuits challenging the constitutionality of the so-called individual mandate to buy health insurance.

On Sept. 8, a three-judge panel of the Fourth Circuit Court of Appeals in Richmond, Va., tossed out a suit brought by Virginia's Attorney General Ken Cuccinelli. They concluded that Virginia did not have the legal standing to challenge the individual mandate because it will affect individuals, not the state.

Mr. Cuccinelli argued that the individual mandate violated the Virginia Health Care Freedom Act, a state law that says no resident can be required to obtain insurance. The judges rejected that argument, writing that the Virginia law, signed after the Affordable Care Act was enacted, was a ploy to set up a legal challenge to the health reform law. The appeals court did not address whether the individual mandate was constitutional.

In the second ruling on Sept. 8, the same three-judge panel dismissed a challenge brought by Liberty University, a Christian college in Lynchburg, Va. In that case, the university charged that the law's tax penalties for individuals and employers were unconstitutional. The appeals court ruled that the university also lacked standing because it cannot challenge the provisions until they take effect in 2014.

Both cases were sent back to district court with instructions that they be dismissed.

There are currently more than 25 active legal challenges to the Affordable Care Act working their way through courthouses around the country. One of those cases is expected to reach the Supreme Court in the next few years.

A federal appeals court in Atlanta has struck down the Affordable Care Act's requirement that individuals purchase health insurance.

In a 2-1 ruling issued Aug. 12, the court declared that the so-called individual mandate violates the Commerce Clause of the U.S. Constitution and that Congress overstepped its authority in creating the requirement to buy insurance. The lawsuit was brought by a coalition of 26 states that oppose the ACA on the grounds that the mandate infringes on the constitutional rights of individuals not to purchase insurance, and that the expansion of Medicaid will create an undue burden on state governments.

The appeals court affirms in part a ruling issued by U.S. District Court Judge Roger Vinson of Pensacola, Fla., in January. The appeals court disagreed with Judge Vinson's decision to declare the entire ACA unconstitutional. The higher court concluded that the individual mandate could be stripped out, allowing the rest of the law to stand.

Stephanie Cutter, deputy senior adviser to President Obama, wrote in a blog post Aug. 12 that the White House was disappointed in the ruling but confident that it would be overturned.

“The individual responsibility provision … is constitutional,” Ms. Cutter wrote. “Those who claim this provision exceeds Congress' power to regulate interstate commerce are incorrect. Individuals who choose to go without health insurance are making an economic decision that affects all of us – when people without insurance obtain health care they cannot pay for, those with insurance and taxpayers are often left to pick up the tab.”

A federal appeals court in Atlanta has struck down the Affordable Care Act's requirement that individuals purchase health insurance.

In a 2-1 ruling issued Aug. 12, the court declared that the so-called individual mandate violates the Commerce Clause of the U.S. Constitution and that Congress overstepped its authority in creating the requirement to buy insurance. The lawsuit was brought by a coalition of 26 states that oppose the ACA on the grounds that the mandate infringes on the constitutional rights of individuals not to purchase insurance, and that the expansion of Medicaid will create an undue burden on state governments.

The appeals court affirms in part a ruling issued by U.S. District Court Judge Roger Vinson of Pensacola, Fla., in January. The appeals court disagreed with Judge Vinson's decision to declare the entire ACA unconstitutional. The higher court concluded that the individual mandate could be stripped out, allowing the rest of the law to stand.

Stephanie Cutter, deputy senior adviser to President Obama, wrote in a blog post Aug. 12 that the White House was disappointed in the ruling but confident that it would be overturned.

“The individual responsibility provision … is constitutional,” Ms. Cutter wrote. “Those who claim this provision exceeds Congress' power to regulate interstate commerce are incorrect. Individuals who choose to go without health insurance are making an economic decision that affects all of us – when people without insurance obtain health care they cannot pay for, those with insurance and taxpayers are often left to pick up the tab.”

A federal appeals court in Atlanta has struck down the Affordable Care Act's requirement that individuals purchase health insurance.

In a 2-1 ruling issued Aug. 12, the court declared that the so-called individual mandate violates the Commerce Clause of the U.S. Constitution and that Congress overstepped its authority in creating the requirement to buy insurance. The lawsuit was brought by a coalition of 26 states that oppose the ACA on the grounds that the mandate infringes on the constitutional rights of individuals not to purchase insurance, and that the expansion of Medicaid will create an undue burden on state governments.

The appeals court affirms in part a ruling issued by U.S. District Court Judge Roger Vinson of Pensacola, Fla., in January. The appeals court disagreed with Judge Vinson's decision to declare the entire ACA unconstitutional. The higher court concluded that the individual mandate could be stripped out, allowing the rest of the law to stand.

Stephanie Cutter, deputy senior adviser to President Obama, wrote in a blog post Aug. 12 that the White House was disappointed in the ruling but confident that it would be overturned.

“The individual responsibility provision … is constitutional,” Ms. Cutter wrote. “Those who claim this provision exceeds Congress' power to regulate interstate commerce are incorrect. Individuals who choose to go without health insurance are making an economic decision that affects all of us – when people without insurance obtain health care they cannot pay for, those with insurance and taxpayers are often left to pick up the tab.”

A federal judge in Harrisburg, Pa., ruled Sept. 13 that the Affordable Care Act's requirement that individuals purchase health insurance is unconstitutional.

U.S. District Judge Christopher Conner struck down the so-called individual mandate, saying that the government overstepped its constitutional authority to regulate interstate commerce by requiring that individuals buy health insurance.

This is the fourth time in a month that the courts have ruled on the individual mandate. In August, a federal appeals court in Atlanta struck down the individual mandate saying it violated the Commerce clause.

And on Sept. 8, a three-judge panel of the Fourth Circuit Court of Appeals in Richmond, Va., dismissed two separate lawsuits challenging the Affordable Care Act's individual mandate, both on procedural grounds. Legal experts predict that the constitutionality of the individual mandate will ultimately be decided by the Supreme Court.

The Harrisburg case was brought by Barbara Goudy-Bachman and Gregory Bachman, a married couple from Etters, Pa., who argued they would be adversely affected by the requirement to purchase insurance in 2014. The couple is self-employed and do not have health insurance.

In court documents, the Bachmans said that if they were required to purchase health insurance, they would not be able to afford the payments on a new car they want to purchase.

A federal judge in Harrisburg, Pa., ruled Sept. 13 that the Affordable Care Act's requirement that individuals purchase health insurance is unconstitutional.

U.S. District Judge Christopher Conner struck down the so-called individual mandate, saying that the government overstepped its constitutional authority to regulate interstate commerce by requiring that individuals buy health insurance.

This is the fourth time in a month that the courts have ruled on the individual mandate. In August, a federal appeals court in Atlanta struck down the individual mandate saying it violated the Commerce clause.

And on Sept. 8, a three-judge panel of the Fourth Circuit Court of Appeals in Richmond, Va., dismissed two separate lawsuits challenging the Affordable Care Act's individual mandate, both on procedural grounds. Legal experts predict that the constitutionality of the individual mandate will ultimately be decided by the Supreme Court.

The Harrisburg case was brought by Barbara Goudy-Bachman and Gregory Bachman, a married couple from Etters, Pa., who argued they would be adversely affected by the requirement to purchase insurance in 2014. The couple is self-employed and do not have health insurance.

In court documents, the Bachmans said that if they were required to purchase health insurance, they would not be able to afford the payments on a new car they want to purchase.

A federal judge in Harrisburg, Pa., ruled Sept. 13 that the Affordable Care Act's requirement that individuals purchase health insurance is unconstitutional.

U.S. District Judge Christopher Conner struck down the so-called individual mandate, saying that the government overstepped its constitutional authority to regulate interstate commerce by requiring that individuals buy health insurance.

This is the fourth time in a month that the courts have ruled on the individual mandate. In August, a federal appeals court in Atlanta struck down the individual mandate saying it violated the Commerce clause.

And on Sept. 8, a three-judge panel of the Fourth Circuit Court of Appeals in Richmond, Va., dismissed two separate lawsuits challenging the Affordable Care Act's individual mandate, both on procedural grounds. Legal experts predict that the constitutionality of the individual mandate will ultimately be decided by the Supreme Court.

The Harrisburg case was brought by Barbara Goudy-Bachman and Gregory Bachman, a married couple from Etters, Pa., who argued they would be adversely affected by the requirement to purchase insurance in 2014. The couple is self-employed and do not have health insurance.

In court documents, the Bachmans said that if they were required to purchase health insurance, they would not be able to afford the payments on a new car they want to purchase.

Nearly 50 million people in the United States lacked health insurance in 2010, up almost a million from the year before, according to statistics released by the Census Bureau.

While the number of uninsured people rose to 49.9 million in 2010 from 49 million the year before, there was no statistically significant change in the uninsurance rate, which was 16.3% in 2010.

A similar trend was seen among youngsters: 9.8% of children (7.3 million) were uninsured in 2010, a rate not significantly different from the rate of 9.7% in 2009.

Other age groups did experience significant changes. Among those aged 65 years and older, the uninsurance rate in 2010 increased to 2.0%, up from 1.7% in 2009. During a press briefing, Census Bureau officials said they could not offer an explanation for the increase in this age group, which traditionally has very low uninsurance rates because of Medicare coverage.

The uninsurance rate also rose among people aged 35-64 years. However, more young adults aged 18-24 years became insured in 2010. The uninsurance rate for that group dropped to 27.2% in 2010 from 29.3% the year before. A provision of the Affordable Care Act that allows parents to keep children on their health insurance policy up to age 26 could be a factor in the increase in coverage in this age group, Brett O'Hara, Ph.D., chief of the Health and Disability Statistics Branch at the Census Bureau, said during a press briefing.

The report also showed that once again, private insurance coverage in the United States is declining while public coverage is increasing. Employment-based insurance dropped to 55.3% in 2010 from 56.1% in 2009. The number of people who received their health insurance through their employer fell from 170.8 million to 169.3 million.

At the same time, the number of people covered by government-sponsored health insurance increased by nearly 2 million, bringing the total number to 95 million in 2010.

Vitals

Source Elsevier Global Medical News

Nearly 50 million people in the United States lacked health insurance in 2010, up almost a million from the year before, according to statistics released by the Census Bureau.

While the number of uninsured people rose to 49.9 million in 2010 from 49 million the year before, there was no statistically significant change in the uninsurance rate, which was 16.3% in 2010.

A similar trend was seen among youngsters: 9.8% of children (7.3 million) were uninsured in 2010, a rate not significantly different from the rate of 9.7% in 2009.

Other age groups did experience significant changes. Among those aged 65 years and older, the uninsurance rate in 2010 increased to 2.0%, up from 1.7% in 2009. During a press briefing, Census Bureau officials said they could not offer an explanation for the increase in this age group, which traditionally has very low uninsurance rates because of Medicare coverage.

The uninsurance rate also rose among people aged 35-64 years. However, more young adults aged 18-24 years became insured in 2010. The uninsurance rate for that group dropped to 27.2% in 2010 from 29.3% the year before. A provision of the Affordable Care Act that allows parents to keep children on their health insurance policy up to age 26 could be a factor in the increase in coverage in this age group, Brett O'Hara, Ph.D., chief of the Health and Disability Statistics Branch at the Census Bureau, said during a press briefing.

The report also showed that once again, private insurance coverage in the United States is declining while public coverage is increasing. Employment-based insurance dropped to 55.3% in 2010 from 56.1% in 2009. The number of people who received their health insurance through their employer fell from 170.8 million to 169.3 million.

At the same time, the number of people covered by government-sponsored health insurance increased by nearly 2 million, bringing the total number to 95 million in 2010.

Vitals

Source Elsevier Global Medical News

Nearly 50 million people in the United States lacked health insurance in 2010, up almost a million from the year before, according to statistics released by the Census Bureau.

While the number of uninsured people rose to 49.9 million in 2010 from 49 million the year before, there was no statistically significant change in the uninsurance rate, which was 16.3% in 2010.

A similar trend was seen among youngsters: 9.8% of children (7.3 million) were uninsured in 2010, a rate not significantly different from the rate of 9.7% in 2009.

Other age groups did experience significant changes. Among those aged 65 years and older, the uninsurance rate in 2010 increased to 2.0%, up from 1.7% in 2009. During a press briefing, Census Bureau officials said they could not offer an explanation for the increase in this age group, which traditionally has very low uninsurance rates because of Medicare coverage.

The uninsurance rate also rose among people aged 35-64 years. However, more young adults aged 18-24 years became insured in 2010. The uninsurance rate for that group dropped to 27.2% in 2010 from 29.3% the year before. A provision of the Affordable Care Act that allows parents to keep children on their health insurance policy up to age 26 could be a factor in the increase in coverage in this age group, Brett O'Hara, Ph.D., chief of the Health and Disability Statistics Branch at the Census Bureau, said during a press briefing.

The report also showed that once again, private insurance coverage in the United States is declining while public coverage is increasing. Employment-based insurance dropped to 55.3% in 2010 from 56.1% in 2009. The number of people who received their health insurance through their employer fell from 170.8 million to 169.3 million.

At the same time, the number of people covered by government-sponsored health insurance increased by nearly 2 million, bringing the total number to 95 million in 2010.

Vitals

Source Elsevier Global Medical News

DMARDs Get Some Support

There is “moderate” evidence that disease-modifying antirheumatic drugs are more effective than conventional treatments for juvenile idiopathic arthritis, according to a comparative-effectiveness review released by the federal Agency for Healthcare Research and Quality. The Duke Evidence-Based Practice Center in Durham, N.C., analyzed studies that compared DMARDs – biologics and nonbiologics – with conventional arthritis treatments and each other. While DMARDs generally performed better than therapies such as non-steroidal anti-inflammatory drugs, there was insufficient evidence about their long-term safety and effectiveness, the researchers found. The studies also failed to determine whether any type of DMARD is more effective than another against juvenile idiopathic arthritis.

Drugs, Biologics in Debt Plan

President Obama's latest plan to reduce the deficit, by about $4 trillion, includes two proposals to get generic drugs and follow-on biologics onto the market faster. One would give the Federal Trade Commission the authority to stop “pay for delay” agreements between brand name companies and generic manufacturers. The administration said that such a ban would save federal health programs about $2.7 billion over 10 years by increasing their access to lower-cost drugs. The second proposal would shorten the exclusivity period for brand-name biologics from 12 to 7 years. It would also eliminate some brand manufacturers' practice of “evergreening” market exclusivity by making minor changes to product formulations. The administration estimated savings of $3.5 billion over 10 years for federal health programs from the market exclusivity changes.

Stem Cell Challenge Goes On

The fate of federal funding for stem cell research continues to be in the hands of the courts. Plaintiffs challenging federal funding of human embryonic stem cell research have appealed the July U.S. District Court dismissal of their case. The plaintiffs say that the stem cell policy issued by the National Institutes of Health in 2009 is illegal because federal funding for research involving the destruction of human embryos is banned by the Dickey-Wicker amendment. But the Obama administration has countered that the policy does not fund destruction of embryos but rather supports the research done on stem cells from embryos. Federal funding for embryonic stem cell research will continue as the court reviews the case.

Lower Managed Care Cost

Seniors enrolling this fall in Medicare Advantage managed care plans for 2012 will likely see lower premiums for the same benefits, officials at the Centers for Medicare and Medicaid Services announced. They predicted an average premium that is 4% less than this year's, due in part to greater negotiating authority granted to the CMS under the Affordable Care Act. For example, the CMS can now deny what it sees as unreasonable premium and cost sharing increases, CMS Deputy Administrator Jonathan Blum said. Nevertheless, he and his colleagues predicted 10% more enrollment in the plans over 2011. The estimate conflicts with a Congressional Budget Office projection that enrollment will decline in response to health reform changes.

Information Rules Proposed

A proposed federal rule designed to expand patients' rights to their health records would allow people to receive test results directly from laboratories. Open for public comment through mid-November, the new rule would amend regulations governing clinical laboratories, which are currently barred from providing results directly to patients. That precludes people from being as active as possible in their own health care decision making, the U.S. Department of Health and Human Services said in its proposal. The notice added that “while individuals can obtain test results through the ordering provider, we believe that the advent of certain health reform concepts … would be best served” by lifting some disclosure limitations.

Patients Think Newer Is Better

Patients are more likely to choose newer drugs over older when they're not provided information about the products' safety and effectiveness, according to a study published in Archives of Internal Medicine. The researchers gave participants a choice between two fictitious drugs for heartburn and two for high cholesterol. More people chose a drug described as older if they were also told the newer drug many not be as safe and effective. But for the heartburn drug, most people who were not given that warning chose the newer drug. In their Internet survey, the researchers also found that 39% of respondents believed that the Food and Drug Administration approves only “extremely effective” drugs and 25% believed the FDA approves only drugs without serious side effects.

DMARDs Get Some Support

There is “moderate” evidence that disease-modifying antirheumatic drugs are more effective than conventional treatments for juvenile idiopathic arthritis, according to a comparative-effectiveness review released by the federal Agency for Healthcare Research and Quality. The Duke Evidence-Based Practice Center in Durham, N.C., analyzed studies that compared DMARDs – biologics and nonbiologics – with conventional arthritis treatments and each other. While DMARDs generally performed better than therapies such as non-steroidal anti-inflammatory drugs, there was insufficient evidence about their long-term safety and effectiveness, the researchers found. The studies also failed to determine whether any type of DMARD is more effective than another against juvenile idiopathic arthritis.

Drugs, Biologics in Debt Plan

President Obama's latest plan to reduce the deficit, by about $4 trillion, includes two proposals to get generic drugs and follow-on biologics onto the market faster. One would give the Federal Trade Commission the authority to stop “pay for delay” agreements between brand name companies and generic manufacturers. The administration said that such a ban would save federal health programs about $2.7 billion over 10 years by increasing their access to lower-cost drugs. The second proposal would shorten the exclusivity period for brand-name biologics from 12 to 7 years. It would also eliminate some brand manufacturers' practice of “evergreening” market exclusivity by making minor changes to product formulations. The administration estimated savings of $3.5 billion over 10 years for federal health programs from the market exclusivity changes.

Stem Cell Challenge Goes On

The fate of federal funding for stem cell research continues to be in the hands of the courts. Plaintiffs challenging federal funding of human embryonic stem cell research have appealed the July U.S. District Court dismissal of their case. The plaintiffs say that the stem cell policy issued by the National Institutes of Health in 2009 is illegal because federal funding for research involving the destruction of human embryos is banned by the Dickey-Wicker amendment. But the Obama administration has countered that the policy does not fund destruction of embryos but rather supports the research done on stem cells from embryos. Federal funding for embryonic stem cell research will continue as the court reviews the case.

Lower Managed Care Cost

Seniors enrolling this fall in Medicare Advantage managed care plans for 2012 will likely see lower premiums for the same benefits, officials at the Centers for Medicare and Medicaid Services announced. They predicted an average premium that is 4% less than this year's, due in part to greater negotiating authority granted to the CMS under the Affordable Care Act. For example, the CMS can now deny what it sees as unreasonable premium and cost sharing increases, CMS Deputy Administrator Jonathan Blum said. Nevertheless, he and his colleagues predicted 10% more enrollment in the plans over 2011. The estimate conflicts with a Congressional Budget Office projection that enrollment will decline in response to health reform changes.

Information Rules Proposed

A proposed federal rule designed to expand patients' rights to their health records would allow people to receive test results directly from laboratories. Open for public comment through mid-November, the new rule would amend regulations governing clinical laboratories, which are currently barred from providing results directly to patients. That precludes people from being as active as possible in their own health care decision making, the U.S. Department of Health and Human Services said in its proposal. The notice added that “while individuals can obtain test results through the ordering provider, we believe that the advent of certain health reform concepts … would be best served” by lifting some disclosure limitations.

Patients Think Newer Is Better

Patients are more likely to choose newer drugs over older when they're not provided information about the products' safety and effectiveness, according to a study published in Archives of Internal Medicine. The researchers gave participants a choice between two fictitious drugs for heartburn and two for high cholesterol. More people chose a drug described as older if they were also told the newer drug many not be as safe and effective. But for the heartburn drug, most people who were not given that warning chose the newer drug. In their Internet survey, the researchers also found that 39% of respondents believed that the Food and Drug Administration approves only “extremely effective” drugs and 25% believed the FDA approves only drugs without serious side effects.

DMARDs Get Some Support

There is “moderate” evidence that disease-modifying antirheumatic drugs are more effective than conventional treatments for juvenile idiopathic arthritis, according to a comparative-effectiveness review released by the federal Agency for Healthcare Research and Quality. The Duke Evidence-Based Practice Center in Durham, N.C., analyzed studies that compared DMARDs – biologics and nonbiologics – with conventional arthritis treatments and each other. While DMARDs generally performed better than therapies such as non-steroidal anti-inflammatory drugs, there was insufficient evidence about their long-term safety and effectiveness, the researchers found. The studies also failed to determine whether any type of DMARD is more effective than another against juvenile idiopathic arthritis.

Drugs, Biologics in Debt Plan

President Obama's latest plan to reduce the deficit, by about $4 trillion, includes two proposals to get generic drugs and follow-on biologics onto the market faster. One would give the Federal Trade Commission the authority to stop “pay for delay” agreements between brand name companies and generic manufacturers. The administration said that such a ban would save federal health programs about $2.7 billion over 10 years by increasing their access to lower-cost drugs. The second proposal would shorten the exclusivity period for brand-name biologics from 12 to 7 years. It would also eliminate some brand manufacturers' practice of “evergreening” market exclusivity by making minor changes to product formulations. The administration estimated savings of $3.5 billion over 10 years for federal health programs from the market exclusivity changes.

Stem Cell Challenge Goes On

The fate of federal funding for stem cell research continues to be in the hands of the courts. Plaintiffs challenging federal funding of human embryonic stem cell research have appealed the July U.S. District Court dismissal of their case. The plaintiffs say that the stem cell policy issued by the National Institutes of Health in 2009 is illegal because federal funding for research involving the destruction of human embryos is banned by the Dickey-Wicker amendment. But the Obama administration has countered that the policy does not fund destruction of embryos but rather supports the research done on stem cells from embryos. Federal funding for embryonic stem cell research will continue as the court reviews the case.

Lower Managed Care Cost

Seniors enrolling this fall in Medicare Advantage managed care plans for 2012 will likely see lower premiums for the same benefits, officials at the Centers for Medicare and Medicaid Services announced. They predicted an average premium that is 4% less than this year's, due in part to greater negotiating authority granted to the CMS under the Affordable Care Act. For example, the CMS can now deny what it sees as unreasonable premium and cost sharing increases, CMS Deputy Administrator Jonathan Blum said. Nevertheless, he and his colleagues predicted 10% more enrollment in the plans over 2011. The estimate conflicts with a Congressional Budget Office projection that enrollment will decline in response to health reform changes.

Information Rules Proposed

A proposed federal rule designed to expand patients' rights to their health records would allow people to receive test results directly from laboratories. Open for public comment through mid-November, the new rule would amend regulations governing clinical laboratories, which are currently barred from providing results directly to patients. That precludes people from being as active as possible in their own health care decision making, the U.S. Department of Health and Human Services said in its proposal. The notice added that “while individuals can obtain test results through the ordering provider, we believe that the advent of certain health reform concepts … would be best served” by lifting some disclosure limitations.

Patients Think Newer Is Better

Patients are more likely to choose newer drugs over older when they're not provided information about the products' safety and effectiveness, according to a study published in Archives of Internal Medicine. The researchers gave participants a choice between two fictitious drugs for heartburn and two for high cholesterol. More people chose a drug described as older if they were also told the newer drug many not be as safe and effective. But for the heartburn drug, most people who were not given that warning chose the newer drug. In their Internet survey, the researchers also found that 39% of respondents believed that the Food and Drug Administration approves only “extremely effective” drugs and 25% believed the FDA approves only drugs without serious side effects.

Hospital employment of physicians continues to rise rapidly around the country, but the trend could drive up costs at least in the short term, according to a report from the Center for Studying Health System Change.

Physicians who are employed by hospitals are often paid based on their productivity, which is an incentive to increase the volume of services. In some cases, physicians are under pressure from their hospitals to order more expensive tests, according to the report released in August.

Researchers from the CSHSC based their analysis on interviews with nearly 550 physicians, hospital executives, health plan officials, and others, in 12 nationally representative metropolitan communities (Findings From HSC 2011 August [Issue Brief No. 13]). The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

In one area, at least two cardiologists said they declined job offers from a local hospital because they believed the pressure to drive up volume would be stronger there than in their independent cardiology practices, according to the report.

“The acceleration in hospital employment of physicians risks raising costs and not improving quality of care unless payment reforms shift provider incentives away from volume toward higher quality and efficiency,” said Dr. Ann S. O'Malley, a senior health researcher at the CSHSC and a coauthor of the study.

The trend toward hospitals' employing more physicians can also drive up costs for the health system because hospitals are able to charge hospital facility fees for office visits and procedures, even when those services are administered in a physician's office. That means that Medicare – and in some cases private insurers – are paying significantly more for the same services simply because the physician is employed by the hospital.

Hospital employment of physicians does have the potential to improve quality through better integration of care and communication between physicians. But the researchers noted that integration and communication can be slow to improve just because physicians get their paychecks from the hospital. respondents from the 12 communities said that the hospital employment model is generally helpful in coordinating care for a single diagnosis, such as heart failure. But integration across all of a patient's medical needs requires more time and effort, they said.

The research was funded by the Robert Wood Johnson Foundation and the National Institute for Health Care Reform.

Hospital employment of physicians continues to rise rapidly around the country, but the trend could drive up costs at least in the short term, according to a report from the Center for Studying Health System Change.

Physicians who are employed by hospitals are often paid based on their productivity, which is an incentive to increase the volume of services. In some cases, physicians are under pressure from their hospitals to order more expensive tests, according to the report released in August.

Researchers from the CSHSC based their analysis on interviews with nearly 550 physicians, hospital executives, health plan officials, and others, in 12 nationally representative metropolitan communities (Findings From HSC 2011 August [Issue Brief No. 13]). The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

In one area, at least two cardiologists said they declined job offers from a local hospital because they believed the pressure to drive up volume would be stronger there than in their independent cardiology practices, according to the report.

“The acceleration in hospital employment of physicians risks raising costs and not improving quality of care unless payment reforms shift provider incentives away from volume toward higher quality and efficiency,” said Dr. Ann S. O'Malley, a senior health researcher at the CSHSC and a coauthor of the study.

The trend toward hospitals' employing more physicians can also drive up costs for the health system because hospitals are able to charge hospital facility fees for office visits and procedures, even when those services are administered in a physician's office. That means that Medicare – and in some cases private insurers – are paying significantly more for the same services simply because the physician is employed by the hospital.

Hospital employment of physicians does have the potential to improve quality through better integration of care and communication between physicians. But the researchers noted that integration and communication can be slow to improve just because physicians get their paychecks from the hospital. respondents from the 12 communities said that the hospital employment model is generally helpful in coordinating care for a single diagnosis, such as heart failure. But integration across all of a patient's medical needs requires more time and effort, they said.

The research was funded by the Robert Wood Johnson Foundation and the National Institute for Health Care Reform.

Hospital employment of physicians continues to rise rapidly around the country, but the trend could drive up costs at least in the short term, according to a report from the Center for Studying Health System Change.

Physicians who are employed by hospitals are often paid based on their productivity, which is an incentive to increase the volume of services. In some cases, physicians are under pressure from their hospitals to order more expensive tests, according to the report released in August.

Researchers from the CSHSC based their analysis on interviews with nearly 550 physicians, hospital executives, health plan officials, and others, in 12 nationally representative metropolitan communities (Findings From HSC 2011 August [Issue Brief No. 13]). The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

In one area, at least two cardiologists said they declined job offers from a local hospital because they believed the pressure to drive up volume would be stronger there than in their independent cardiology practices, according to the report.

“The acceleration in hospital employment of physicians risks raising costs and not improving quality of care unless payment reforms shift provider incentives away from volume toward higher quality and efficiency,” said Dr. Ann S. O'Malley, a senior health researcher at the CSHSC and a coauthor of the study.

The trend toward hospitals' employing more physicians can also drive up costs for the health system because hospitals are able to charge hospital facility fees for office visits and procedures, even when those services are administered in a physician's office. That means that Medicare – and in some cases private insurers – are paying significantly more for the same services simply because the physician is employed by the hospital.

Hospital employment of physicians does have the potential to improve quality through better integration of care and communication between physicians. But the researchers noted that integration and communication can be slow to improve just because physicians get their paychecks from the hospital. respondents from the 12 communities said that the hospital employment model is generally helpful in coordinating care for a single diagnosis, such as heart failure. But integration across all of a patient's medical needs requires more time and effort, they said.

The research was funded by the Robert Wood Johnson Foundation and the National Institute for Health Care Reform.

Officials at the Centers for Medicare and Medicaid Services in August released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers options for bundling payments for a hospital stay, for post-discharge services, or for both the hospital stay and the post-discharge care.

Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to encourage clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

"Today, Medicare pays for care the wrong way," Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. "Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy."

The new bundling program offers three ways for health care providers to receive payment retrospectively, and one way to receive a prospective payment. Under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2% to 3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

Under prospective payment model, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit "no pay" claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

The American College of Surgeons General Surgery Coding and Reimbursement Committee (GSCRC) has been actively studying how bundled payments could be applied in surgery. The ACS believes that critical to the success of any bundling initiative is ensuring that the bundle is clinically coherent. The ACS GSCRC will continue this work and their discussions with the administration, CMS, and other stakeholders to ensure that any possible bundled payments in surgery will improve patient care.

Organizations interested in applying must submit a letter of intent by Sept. 22 for Model 1 and by Nov. 4 for Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html.

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior advisor to the CMS Innovation Center and past president of the American Medical Association.

The AMA was still reviewing the bundled payment details at press time, but Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects. "For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that’s organizing these," he said. "We think those are important as well, but we also think it’s important that physicians be a part of that leadership."

Health care consultant Robert Minkin urged physicians to seriously consider applying for the bundling program. The program is a sentinel event in the move from fee for service to more centralized, coordinated care model, he said.

Officials at the Centers for Medicare and Medicaid Services in August released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers options for bundling payments for a hospital stay, for post-discharge services, or for both the hospital stay and the post-discharge care.

Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to encourage clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

"Today, Medicare pays for care the wrong way," Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. "Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy."

The new bundling program offers three ways for health care providers to receive payment retrospectively, and one way to receive a prospective payment. Under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2% to 3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

Under prospective payment model, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit "no pay" claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

The American College of Surgeons General Surgery Coding and Reimbursement Committee (GSCRC) has been actively studying how bundled payments could be applied in surgery. The ACS believes that critical to the success of any bundling initiative is ensuring that the bundle is clinically coherent. The ACS GSCRC will continue this work and their discussions with the administration, CMS, and other stakeholders to ensure that any possible bundled payments in surgery will improve patient care.

Organizations interested in applying must submit a letter of intent by Sept. 22 for Model 1 and by Nov. 4 for Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html.

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior advisor to the CMS Innovation Center and past president of the American Medical Association.

The AMA was still reviewing the bundled payment details at press time, but Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects. "For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that’s organizing these," he said. "We think those are important as well, but we also think it’s important that physicians be a part of that leadership."

Health care consultant Robert Minkin urged physicians to seriously consider applying for the bundling program. The program is a sentinel event in the move from fee for service to more centralized, coordinated care model, he said.

Officials at the Centers for Medicare and Medicaid Services in August released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers options for bundling payments for a hospital stay, for post-discharge services, or for both the hospital stay and the post-discharge care.

Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to encourage clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

"Today, Medicare pays for care the wrong way," Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. "Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy."

The new bundling program offers three ways for health care providers to receive payment retrospectively, and one way to receive a prospective payment. Under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2% to 3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

Under prospective payment model, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit "no pay" claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

The American College of Surgeons General Surgery Coding and Reimbursement Committee (GSCRC) has been actively studying how bundled payments could be applied in surgery. The ACS believes that critical to the success of any bundling initiative is ensuring that the bundle is clinically coherent. The ACS GSCRC will continue this work and their discussions with the administration, CMS, and other stakeholders to ensure that any possible bundled payments in surgery will improve patient care.

Organizations interested in applying must submit a letter of intent by Sept. 22 for Model 1 and by Nov. 4 for Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html.

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior advisor to the CMS Innovation Center and past president of the American Medical Association.

The AMA was still reviewing the bundled payment details at press time, but Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects. "For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that’s organizing these," he said. "We think those are important as well, but we also think it’s important that physicians be a part of that leadership."

Health care consultant Robert Minkin urged physicians to seriously consider applying for the bundling program. The program is a sentinel event in the move from fee for service to more centralized, coordinated care model, he said.

Many hospitals may be unprepared for a new Medicare requirement to lower readmissions, and could face resulting financial penalties over the next few years, according to a new report from the Dartmouth Atlas Project.

Over a 5-year period, hospitals made little progress in reducing readmissions among Medicare beneficiaries aged 65 years and older. The Dartmouth Atlas researchers found that surgical 30-day readmission rates were 12.7% in both 2004 and 2009, and medical 30-day readmission rates rose from 15.9% in 2004 to 16.1% in 2009.

They found similar trends when they looked at specific conditions. For example, the national readmission rates for hip fractures were 14.3% in 2004, compared with 14.5% in 2009. The rates were also relatively unchanged for congestive heart failure (20.9% vs. 21.2%) and pneumonia (15.1% vs. 15.3%). However, U.S. hospitals showed some improvement in acute myocardial infarctions, reducing 30-day readmissions from 19.4% in 2004 to 18.5% in 2009.

"For a long-standing and well-recognized problem, not much progress has been made," Dr. David C. Goodman, the study’s lead author and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said during a press conference to release the findings.

The researchers analyzed data for fee-for-service Medicare beneficiaries aged 65 years and older who lived in 306 Dartmouth Atlas hospital referral regions and had both Part A and Part B Medicare coverage.

Hospital readmissions have garnered significant attention in the health care community since the passage of the Affordable Care Act. The new health law calls on the Centers for Medicare and Medicaid Services to start measuring 30-day hospital readmission rates and to penalize poor performers. In October 2012, hospitals with high readmission rates will face penalties of 1% of their total Medicare billings. The penalty increases to 2% the following year.

Part of the solution to reducing hospital readmissions is good discharge planning, Dr. Goodman said. "This sounds simple but often doesn’t happen."

That planning should include having the care team in the hospital develop a care plan and communicate that plan to the patient and their family. It also means ensuring that the patient has all the necessary prescriptions, understands what medications to take and when, and can get their prescriptions. And health care providers in the hospital should also help patients set up follow-up appointments with their primary care physician, Dr. Goodman said.

But aside from discharge planning, there are also "hidden" factors such as how local patterns of hospital use affect readmission rates. Dr. Goodman and his colleagues found that communities and health care systems with higher underlying admission rates also tended to have higher rates of hospital readmission.

The Dartmouth Atlas Project receives most of its funding from the Robert Wood Johnson Foundation, the National Institute on Aging, the California Healthcare Foundation, the United Healthcare Foundation, and the WellPoint Foundation. The researchers reported no financial conflicts.

Many hospitals may be unprepared for a new Medicare requirement to lower readmissions, and could face resulting financial penalties over the next few years, according to a new report from the Dartmouth Atlas Project.

Over a 5-year period, hospitals made little progress in reducing readmissions among Medicare beneficiaries aged 65 years and older. The Dartmouth Atlas researchers found that surgical 30-day readmission rates were 12.7% in both 2004 and 2009, and medical 30-day readmission rates rose from 15.9% in 2004 to 16.1% in 2009.

They found similar trends when they looked at specific conditions. For example, the national readmission rates for hip fractures were 14.3% in 2004, compared with 14.5% in 2009. The rates were also relatively unchanged for congestive heart failure (20.9% vs. 21.2%) and pneumonia (15.1% vs. 15.3%). However, U.S. hospitals showed some improvement in acute myocardial infarctions, reducing 30-day readmissions from 19.4% in 2004 to 18.5% in 2009.

"For a long-standing and well-recognized problem, not much progress has been made," Dr. David C. Goodman, the study’s lead author and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said during a press conference to release the findings.

The researchers analyzed data for fee-for-service Medicare beneficiaries aged 65 years and older who lived in 306 Dartmouth Atlas hospital referral regions and had both Part A and Part B Medicare coverage.

Hospital readmissions have garnered significant attention in the health care community since the passage of the Affordable Care Act. The new health law calls on the Centers for Medicare and Medicaid Services to start measuring 30-day hospital readmission rates and to penalize poor performers. In October 2012, hospitals with high readmission rates will face penalties of 1% of their total Medicare billings. The penalty increases to 2% the following year.

Part of the solution to reducing hospital readmissions is good discharge planning, Dr. Goodman said. "This sounds simple but often doesn’t happen."

That planning should include having the care team in the hospital develop a care plan and communicate that plan to the patient and their family. It also means ensuring that the patient has all the necessary prescriptions, understands what medications to take and when, and can get their prescriptions. And health care providers in the hospital should also help patients set up follow-up appointments with their primary care physician, Dr. Goodman said.

But aside from discharge planning, there are also "hidden" factors such as how local patterns of hospital use affect readmission rates. Dr. Goodman and his colleagues found that communities and health care systems with higher underlying admission rates also tended to have higher rates of hospital readmission.

The Dartmouth Atlas Project receives most of its funding from the Robert Wood Johnson Foundation, the National Institute on Aging, the California Healthcare Foundation, the United Healthcare Foundation, and the WellPoint Foundation. The researchers reported no financial conflicts.

Many hospitals may be unprepared for a new Medicare requirement to lower readmissions, and could face resulting financial penalties over the next few years, according to a new report from the Dartmouth Atlas Project.

Over a 5-year period, hospitals made little progress in reducing readmissions among Medicare beneficiaries aged 65 years and older. The Dartmouth Atlas researchers found that surgical 30-day readmission rates were 12.7% in both 2004 and 2009, and medical 30-day readmission rates rose from 15.9% in 2004 to 16.1% in 2009.

They found similar trends when they looked at specific conditions. For example, the national readmission rates for hip fractures were 14.3% in 2004, compared with 14.5% in 2009. The rates were also relatively unchanged for congestive heart failure (20.9% vs. 21.2%) and pneumonia (15.1% vs. 15.3%). However, U.S. hospitals showed some improvement in acute myocardial infarctions, reducing 30-day readmissions from 19.4% in 2004 to 18.5% in 2009.

"For a long-standing and well-recognized problem, not much progress has been made," Dr. David C. Goodman, the study’s lead author and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said during a press conference to release the findings.

The researchers analyzed data for fee-for-service Medicare beneficiaries aged 65 years and older who lived in 306 Dartmouth Atlas hospital referral regions and had both Part A and Part B Medicare coverage.

Hospital readmissions have garnered significant attention in the health care community since the passage of the Affordable Care Act. The new health law calls on the Centers for Medicare and Medicaid Services to start measuring 30-day hospital readmission rates and to penalize poor performers. In October 2012, hospitals with high readmission rates will face penalties of 1% of their total Medicare billings. The penalty increases to 2% the following year.

Part of the solution to reducing hospital readmissions is good discharge planning, Dr. Goodman said. "This sounds simple but often doesn’t happen."

That planning should include having the care team in the hospital develop a care plan and communicate that plan to the patient and their family. It also means ensuring that the patient has all the necessary prescriptions, understands what medications to take and when, and can get their prescriptions. And health care providers in the hospital should also help patients set up follow-up appointments with their primary care physician, Dr. Goodman said.

But aside from discharge planning, there are also "hidden" factors such as how local patterns of hospital use affect readmission rates. Dr. Goodman and his colleagues found that communities and health care systems with higher underlying admission rates also tended to have higher rates of hospital readmission.

The Dartmouth Atlas Project receives most of its funding from the Robert Wood Johnson Foundation, the National Institute on Aging, the California Healthcare Foundation, the United Healthcare Foundation, and the WellPoint Foundation. The researchers reported no financial conflicts.