Government and Regulations

As physicians and hospitals gear up to implement electronic health records and other health information technology products, the federal government should increase its scrutiny of these products to ensure that they don’t actually contribute to medical errors.

That was the conclusion of an Institute of Medicine panel, which called on the Health and Human Services Department to assess potential safety risks associated with health IT and come up with a plan to minimize those risks. The plan should be published in 2012, with new reports each year, according to the panel’s recommendations.

But if the HHS secretary determines that the industry is falling short of the safety goals, the Food and Drug Administration should be tasked with regulating electronic health records, personal health records, and health information exchanges, the IOM committee recommended. The IOM study was sponsored by HHS.

The report http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx comes as physicians and hospitals strive to qualify for federal incentive payments for the use of health IT products to meet certain quality benchmarks. The program includes bonus payments in the early years, followed later by penalties if they fail to adopt health IT.

"Based on the literature, HIT certainly has clear and demonstrated potential to improve the safety and the quality of patient care, but it also can cause harm. We’ve heard about that," said Dr. Paul C. Tang, a member of the IOM committee and vice president and chief innovation and technology officer at Palo Alto (Calif.) Medical Foundation.

Although evidence demonstrates that health IT systems have helped to improve medication safety in some places, the literature is inconclusive about IT’s safety benefits in other areas, Dr. Tang said. And there are reports of harm associated with using these systems, from dosing errors to delays in treatment, according to the report.

But right now it’s difficult to quantify the safety issues because unlike drugs or devices, health IT software is installed and used differently from institution to institution, said Dr. Tang, who also serves as the vice chair on the HIT Policy Committee, which advises the federal government on the development of a nationwide health information infrastructure.

In addition, there is a wide array of different types of health IT products on the market. There are also contractual issues, such as confidentiality clauses, that may make it difficult for users to share safety concerns about the products, according to the IOM report. The IOM panel made a series of recommendations aimed at improving the information available on the safety risks and benefits associated with health IT use.

For instance, the panel called on HHS to develop a way for health IT users and vendors to report adverse events related to health IT. And the panel members urged Congress to establish an independent federal entity charged with investigating those adverse events. The body could be modeled on the National Transportation Safety Board, he said. ☐

As physicians and hospitals gear up to implement electronic health records and other health information technology products, the federal government should increase its scrutiny of these products to ensure that they don’t actually contribute to medical errors.

That was the conclusion of an Institute of Medicine panel, which called on the Health and Human Services Department to assess potential safety risks associated with health IT and come up with a plan to minimize those risks. The plan should be published in 2012, with new reports each year, according to the panel’s recommendations.

But if the HHS secretary determines that the industry is falling short of the safety goals, the Food and Drug Administration should be tasked with regulating electronic health records, personal health records, and health information exchanges, the IOM committee recommended. The IOM study was sponsored by HHS.

The report http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx comes as physicians and hospitals strive to qualify for federal incentive payments for the use of health IT products to meet certain quality benchmarks. The program includes bonus payments in the early years, followed later by penalties if they fail to adopt health IT.

"Based on the literature, HIT certainly has clear and demonstrated potential to improve the safety and the quality of patient care, but it also can cause harm. We’ve heard about that," said Dr. Paul C. Tang, a member of the IOM committee and vice president and chief innovation and technology officer at Palo Alto (Calif.) Medical Foundation.

Although evidence demonstrates that health IT systems have helped to improve medication safety in some places, the literature is inconclusive about IT’s safety benefits in other areas, Dr. Tang said. And there are reports of harm associated with using these systems, from dosing errors to delays in treatment, according to the report.

But right now it’s difficult to quantify the safety issues because unlike drugs or devices, health IT software is installed and used differently from institution to institution, said Dr. Tang, who also serves as the vice chair on the HIT Policy Committee, which advises the federal government on the development of a nationwide health information infrastructure.

In addition, there is a wide array of different types of health IT products on the market. There are also contractual issues, such as confidentiality clauses, that may make it difficult for users to share safety concerns about the products, according to the IOM report. The IOM panel made a series of recommendations aimed at improving the information available on the safety risks and benefits associated with health IT use.

For instance, the panel called on HHS to develop a way for health IT users and vendors to report adverse events related to health IT. And the panel members urged Congress to establish an independent federal entity charged with investigating those adverse events. The body could be modeled on the National Transportation Safety Board, he said. ☐

As physicians and hospitals gear up to implement electronic health records and other health information technology products, the federal government should increase its scrutiny of these products to ensure that they don’t actually contribute to medical errors.

That was the conclusion of an Institute of Medicine panel, which called on the Health and Human Services Department to assess potential safety risks associated with health IT and come up with a plan to minimize those risks. The plan should be published in 2012, with new reports each year, according to the panel’s recommendations.

But if the HHS secretary determines that the industry is falling short of the safety goals, the Food and Drug Administration should be tasked with regulating electronic health records, personal health records, and health information exchanges, the IOM committee recommended. The IOM study was sponsored by HHS.

The report http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx comes as physicians and hospitals strive to qualify for federal incentive payments for the use of health IT products to meet certain quality benchmarks. The program includes bonus payments in the early years, followed later by penalties if they fail to adopt health IT.

"Based on the literature, HIT certainly has clear and demonstrated potential to improve the safety and the quality of patient care, but it also can cause harm. We’ve heard about that," said Dr. Paul C. Tang, a member of the IOM committee and vice president and chief innovation and technology officer at Palo Alto (Calif.) Medical Foundation.

Although evidence demonstrates that health IT systems have helped to improve medication safety in some places, the literature is inconclusive about IT’s safety benefits in other areas, Dr. Tang said. And there are reports of harm associated with using these systems, from dosing errors to delays in treatment, according to the report.

But right now it’s difficult to quantify the safety issues because unlike drugs or devices, health IT software is installed and used differently from institution to institution, said Dr. Tang, who also serves as the vice chair on the HIT Policy Committee, which advises the federal government on the development of a nationwide health information infrastructure.

In addition, there is a wide array of different types of health IT products on the market. There are also contractual issues, such as confidentiality clauses, that may make it difficult for users to share safety concerns about the products, according to the IOM report. The IOM panel made a series of recommendations aimed at improving the information available on the safety risks and benefits associated with health IT use.

For instance, the panel called on HHS to develop a way for health IT users and vendors to report adverse events related to health IT. And the panel members urged Congress to establish an independent federal entity charged with investigating those adverse events. The body could be modeled on the National Transportation Safety Board, he said. ☐

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system can compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, he said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, he said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adopting the new policy.

The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

Dr. Campbell, a transplantation surgeon, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during handoff. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

Dr. Campbell reported he had no relevant conflicts.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system can compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, he said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, he said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adopting the new policy.

The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

Dr. Campbell, a transplantation surgeon, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during handoff. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

Dr. Campbell reported he had no relevant conflicts.

SAN FRANCISCO – Changing the clinical culture so that physicians were more willing to talk with patients about medical and surgical errors increased the number of errors reported, decreased lawsuits and legal costs, and improved safety at one institution.

"It used to be a ‘defend and deny’ culture," said Dr. Darrell A. Campbell Jr., professor of surgery and chief of clinical affairs at the University of Michigan, Ann Arbor. "Now it’s ‘disclose and discuss.’ "

The University of Michigan Health System’s "Disclosure of Unanticipated Outcomes" policy requires physicians to give patients "full disclosure of results, including results that differ significantly from what was anticipated" to allow patients to make informed decisions about future medical care, he said at the annual clinical congress of the American College of Surgeons.

Under the policy’s driving principles, the health system will defend medically appropriate care vigorously but will compensate quickly and fairly when inappropriate medical care causes injury and will learn from mistakes to improve patient safety and communication. The health system can compensate quickly and fairly because it is a closed-staff model covered by a captive insurance company, he said.

Reports of errors and "risk management events" more than doubled since full implementation of the policy in February 2004, from 6,706 in 2004 to 15,650 in 2007, he said. "I think people feel much more comfortable reporting errors" now.

A comparison of data from 2001 (before the policy) and 2005 (after the policy) found that the number of claims and lawsuits fell from 262 to 114, the average time to resolve claims and lawsuits decreased from 21 months to 10 months, and annual litigation costs declined from $3 million to $1 million, he said.

A retrospective study by other investigators looked at the university’s experience from 1995 to 2007 and reported similar findings. The average monthly rate of new legal claims decreased from seven per 100,000 patient encounters to less than five per 100,000 patient encounters after adopting the new policy.

The median time to resolve claims decreased from 1.36 to 0.95 years, and costs decreased for total liability, patient compensation, and legal costs not related to compensation (Ann. Intern. Med. 2010;153:213-21).

Dr. Campbell, a transplantation surgeon, described a case that went awry to illustrate possible responses to the situation. A 9-month-old girl undergoing a liver transplant had a small-diameter hepatic artery. Although the surgeon communicated to the anesthesiologist that the patient should not be overtransfused, the message may have been lost during handoff. The first postoperative hematocrit was 50%, the hepatic artery thrombosed, and the patient required retransplantation.

Prior to the full-disclosure policy, it might have been tempting to tell the patient’s parents, "These things happen," he said. While this is true, and it may avoid litigation, it’s not the whole truth. Caregivers would feel bad about it, the clinical safety culture would suffer, nothing would be learned, and the same problem could happen again.

If the physician instead says to the parents, "I’m concerned about what just happened. Let’s talk," the conversation is more difficult and could lead to litigation, but it’s an honest approach that augments doctor-patient trust and the culture of safety, which should make caregivers feel better, he said.

"Let’s talk" does not mean the surgeon should make reckless comments, Dr. Campbell stressed. It would not be helpful to say, "Anesthesia is incompetent," or "The fellow dropped the ball," or "I should have been notified earlier," or "I did a perfect operation," or "Somebody’s head will roll," for example.

Disclosing an unanticipated outcome should sound something like the following, he suggested: "This was an unexpected result. I am going to investigate fully. You have the right to know the whole story – the facts. I will tell you what I learn, but not right now."

That provides a window for exploring other possible complications in the case he described, he said. There may have been a laboratory or transcription error. An artery may have been open at the time of reexploration and not seen on relatively insensitive ultrasound. A technical error could have been made, or the patient may have had a humorally mediated rejection of the organ.

Dr. Campbell reported he had no relevant conflicts.

SAN FRANCISCO – The medical community has long debated whether surgeons need to disclose their operative volumes and outcomes to patients when obtaining informed consent, and legal rulings in court cases offer mixed opinions.

Recent surveys administered to patients and attending surgeons have indicated that although patients want to know about their surgeon’s expertise and surgical outcomes during preoperative discussions for informed consent, attendings are significantly less likely to think that such information is important to disclose, Dr. Susan Lee Char said at the annual clinical congress of the American College of Surgeons.

Dr. Char and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey, which presented a hypothetical case of a patient’s undergoing elective partial hepatectomy, asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale (with a score of 1 indicating "completely unimportant" and a score of 6 indicating "extremely important").

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt that this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosing such information may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients, as compared with 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively.

A total of 41% of patients and 5% of surgeons said the patient should be told the number of times that the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed. A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training obtained by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential, Dr. Char added. Patients who were scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than were those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure.

And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

The study was limited because it used a hypothetical case scenario rather than real informed-consent discussions, and it included only one type of surgery. Because most of the patients were well-educated women, the results may not be generalizable.

Dr. Char said she had no conflicts.

SAN FRANCISCO – The medical community has long debated whether surgeons need to disclose their operative volumes and outcomes to patients when obtaining informed consent, and legal rulings in court cases offer mixed opinions.

Recent surveys administered to patients and attending surgeons have indicated that although patients want to know about their surgeon’s expertise and surgical outcomes during preoperative discussions for informed consent, attendings are significantly less likely to think that such information is important to disclose, Dr. Susan Lee Char said at the annual clinical congress of the American College of Surgeons.

Dr. Char and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey, which presented a hypothetical case of a patient’s undergoing elective partial hepatectomy, asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale (with a score of 1 indicating "completely unimportant" and a score of 6 indicating "extremely important").

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt that this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosing such information may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients, as compared with 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively.

A total of 41% of patients and 5% of surgeons said the patient should be told the number of times that the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed. A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training obtained by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential, Dr. Char added. Patients who were scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than were those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure.

And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

The study was limited because it used a hypothetical case scenario rather than real informed-consent discussions, and it included only one type of surgery. Because most of the patients were well-educated women, the results may not be generalizable.

Dr. Char said she had no conflicts.

SAN FRANCISCO – The medical community has long debated whether surgeons need to disclose their operative volumes and outcomes to patients when obtaining informed consent, and legal rulings in court cases offer mixed opinions.

Recent surveys administered to patients and attending surgeons have indicated that although patients want to know about their surgeon’s expertise and surgical outcomes during preoperative discussions for informed consent, attendings are significantly less likely to think that such information is important to disclose, Dr. Susan Lee Char said at the annual clinical congress of the American College of Surgeons.

Dr. Char and her associates surveyed 353 adult patients at their first postoperative clinic visit and 85 attending surgeons at hospitals affiliated with the University of California, San Francisco. The survey, which presented a hypothetical case of a patient’s undergoing elective partial hepatectomy, asked respondents to rate the importance of receiving or conveying various items of information on a 6-point Likert scale (with a score of 1 indicating "completely unimportant" and a score of 6 indicating "extremely important").

In all, 79% of patients said it’s essential to know if their surgeon would be doing a procedure for the first time on them, but only 55% of attending surgeons felt that this was important information to disclose. A total of 63% of patients considered it essential to know the number of times a surgeon had performed a particular procedure and the outcomes in those cases, compared with just 25% and 20% of surgeons, respectively.

"The data suggest that surgeons do have an ethical obligation to disclose volumes and outcomes and if it’s the first time [they’re] doing a procedure," said Dr. Char, a surgical resident at the university who is also a lawyer. "This has possible legal implications."

The main barrier to surgeons’ disclosing such information may be a practical one, she added. Surgeons often don’t have data on the volumes and outcomes of their procedures.

Patients’ and attending surgeons’ perceptions of the importance of other types of information also differed significantly. A general description of the procedure was rated as important by 65% of patients vs. 58% of surgeons, and technical details of the procedure were important to 48% of patients, as compared with 13% of surgeons. Disclosure of risks and benefits of the procedure were deemed essential by 77% and 71% of patients, respectively, compared with 72% and 65% of surgeons, respectively.

A total of 41% of patients and 5% of surgeons said the patient should be told the number of times that the procedure has been done by other surgeons, and 44% of patients and 20% of surgeons said other surgeons’ outcomes should be disclosed. A total of 64% of patients and 31% of surgeons believed it was important to discuss any special training obtained by the surgeon doing the procedure. Some 64% of patients said they would want to be informed about the surgeon’s special training for a standard procedure, compared with 68% for a laparoscopic procedure and 71% for a robotic procedure.

Technological innovation made a difference in whether patients deemed certain information essential, Dr. Char added. Patients who were scheduled for a laparoscopic or robotic procedure were significantly more likely to want information than were those undergoing a standard operation.

In all, 63% of patients said they would want to know the number of times that a standard procedure had been done by their surgeon. That percentage rose to 66% for a laparoscopic procedure and to 68% for a robotic procedure. Outcomes information was considered important by 63% of patients for a standard procedure, 66% for a laparoscopic procedure, and 67% for a robotic procedure.

And 24% of patients, compared with 6% of surgeons, said the patient should be told if the surgeon planned to publish an article including the case. Disclosing whether a surgeon is a paid consultant was less important to patients (5%) than to surgeons (40%).

The study was limited because it used a hypothetical case scenario rather than real informed-consent discussions, and it included only one type of surgery. Because most of the patients were well-educated women, the results may not be generalizable.

Dr. Char said she had no conflicts.

Physicians are once again waiting for Congress to avert a 27% Medicare physician fee cut scheduled to take effect on March 1.

The pay cut was originally scheduled to begin Jan. 1, but after much back-and-forth in Congress, the House and Senate passed the Temporary Payroll Tax Cut Continuation Act of 2011 on Dec. 23, which included an extension of 2011 Medicare physician-payment rates through the end of February. President Obama quickly signed the bill into law.

Lawmakers also agreed to appoint a 20-member House-Senate conference committee to work on a longer-term plan to address the Medicare physician pay issue, along with a full-year extension of the Social Security payroll tax holiday and federally funded unemployment insurance benefits.

The agreement followed several days of brinksmanship by leaders in the House and Senate. It started on Dec. 13, when the House passed a bill that would have replaced the 27% Medicare fee cut with a 1% pay raise for physicians for 2 years. Despite bipartisan support for the so-called doc fix, other controversial provisions in the bill kept it from gaining traction in the Senate. A few days later, the Senate approved their own version of the bill, which extended the payroll tax holiday and unemployment benefits for 2 months and postponed any Medicare pay cuts until the end of February.

The House initially rejected the idea of a short-term fix, and even passed a resolution to formally disagree with the legislation passed by the Senate. But intense public criticism led House leaders to agree to the short-term plan and use the first 2 months of this year to negotiate a compromise.

"There’s a tremendous degree of frustration out there," said Robert Doherty, senior vice president for government affairs and public policy at the American College of Physicians. "If Congress is expecting physicians to applaud them for agreeing to a 2-month extension, they’re going to find a lot of silence from the physician community."

Frustration is especially high because members of Congress had signaled early in 2011 that they were interested in crafting a long-term solution to replace the Sustainable Growth Rate formula, the statutory formula that ties spending on physicians’ services to the Gross Domestic Product. In March 2011, leaders in the House Energy and Commerce Committee wrote to several physicians’ groups asking for proposals on how to reform the physician payment system and move to a new system that "reduces spending, pays providers fairly, and pays for services according to their value to the beneficiary."

The letter emphasized the need to act quickly in developing a long-term solution, or risk the "unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care" for Medicare beneficiaries. "We cannot let either happen," the lawmakers wrote.

It’s too soon to tell what Congress will do next, but a long-term solution that would replace the SGR is unlikely now.

In a worse-case scenario, physicians could be facing a situation similar to what happened in 2010, when Congress passed a series of temporary patches during the first half of the year, Mr. Doherty said. That situation could become a reality if lawmakers once again are deadlocked on the larger legislative package. "To a great extent, we’re once again going to be held hostage to negotiations over a broader package on issues that really have nothing to do with the SGR."☐

Physicians are once again waiting for Congress to avert a 27% Medicare physician fee cut scheduled to take effect on March 1.

The pay cut was originally scheduled to begin Jan. 1, but after much back-and-forth in Congress, the House and Senate passed the Temporary Payroll Tax Cut Continuation Act of 2011 on Dec. 23, which included an extension of 2011 Medicare physician-payment rates through the end of February. President Obama quickly signed the bill into law.

Lawmakers also agreed to appoint a 20-member House-Senate conference committee to work on a longer-term plan to address the Medicare physician pay issue, along with a full-year extension of the Social Security payroll tax holiday and federally funded unemployment insurance benefits.

The agreement followed several days of brinksmanship by leaders in the House and Senate. It started on Dec. 13, when the House passed a bill that would have replaced the 27% Medicare fee cut with a 1% pay raise for physicians for 2 years. Despite bipartisan support for the so-called doc fix, other controversial provisions in the bill kept it from gaining traction in the Senate. A few days later, the Senate approved their own version of the bill, which extended the payroll tax holiday and unemployment benefits for 2 months and postponed any Medicare pay cuts until the end of February.

The House initially rejected the idea of a short-term fix, and even passed a resolution to formally disagree with the legislation passed by the Senate. But intense public criticism led House leaders to agree to the short-term plan and use the first 2 months of this year to negotiate a compromise.

"There’s a tremendous degree of frustration out there," said Robert Doherty, senior vice president for government affairs and public policy at the American College of Physicians. "If Congress is expecting physicians to applaud them for agreeing to a 2-month extension, they’re going to find a lot of silence from the physician community."

Frustration is especially high because members of Congress had signaled early in 2011 that they were interested in crafting a long-term solution to replace the Sustainable Growth Rate formula, the statutory formula that ties spending on physicians’ services to the Gross Domestic Product. In March 2011, leaders in the House Energy and Commerce Committee wrote to several physicians’ groups asking for proposals on how to reform the physician payment system and move to a new system that "reduces spending, pays providers fairly, and pays for services according to their value to the beneficiary."

The letter emphasized the need to act quickly in developing a long-term solution, or risk the "unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care" for Medicare beneficiaries. "We cannot let either happen," the lawmakers wrote.

It’s too soon to tell what Congress will do next, but a long-term solution that would replace the SGR is unlikely now.

In a worse-case scenario, physicians could be facing a situation similar to what happened in 2010, when Congress passed a series of temporary patches during the first half of the year, Mr. Doherty said. That situation could become a reality if lawmakers once again are deadlocked on the larger legislative package. "To a great extent, we’re once again going to be held hostage to negotiations over a broader package on issues that really have nothing to do with the SGR."☐

Physicians are once again waiting for Congress to avert a 27% Medicare physician fee cut scheduled to take effect on March 1.

The pay cut was originally scheduled to begin Jan. 1, but after much back-and-forth in Congress, the House and Senate passed the Temporary Payroll Tax Cut Continuation Act of 2011 on Dec. 23, which included an extension of 2011 Medicare physician-payment rates through the end of February. President Obama quickly signed the bill into law.

Lawmakers also agreed to appoint a 20-member House-Senate conference committee to work on a longer-term plan to address the Medicare physician pay issue, along with a full-year extension of the Social Security payroll tax holiday and federally funded unemployment insurance benefits.

The agreement followed several days of brinksmanship by leaders in the House and Senate. It started on Dec. 13, when the House passed a bill that would have replaced the 27% Medicare fee cut with a 1% pay raise for physicians for 2 years. Despite bipartisan support for the so-called doc fix, other controversial provisions in the bill kept it from gaining traction in the Senate. A few days later, the Senate approved their own version of the bill, which extended the payroll tax holiday and unemployment benefits for 2 months and postponed any Medicare pay cuts until the end of February.

The House initially rejected the idea of a short-term fix, and even passed a resolution to formally disagree with the legislation passed by the Senate. But intense public criticism led House leaders to agree to the short-term plan and use the first 2 months of this year to negotiate a compromise.

"There’s a tremendous degree of frustration out there," said Robert Doherty, senior vice president for government affairs and public policy at the American College of Physicians. "If Congress is expecting physicians to applaud them for agreeing to a 2-month extension, they’re going to find a lot of silence from the physician community."

Frustration is especially high because members of Congress had signaled early in 2011 that they were interested in crafting a long-term solution to replace the Sustainable Growth Rate formula, the statutory formula that ties spending on physicians’ services to the Gross Domestic Product. In March 2011, leaders in the House Energy and Commerce Committee wrote to several physicians’ groups asking for proposals on how to reform the physician payment system and move to a new system that "reduces spending, pays providers fairly, and pays for services according to their value to the beneficiary."

The letter emphasized the need to act quickly in developing a long-term solution, or risk the "unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care" for Medicare beneficiaries. "We cannot let either happen," the lawmakers wrote.

It’s too soon to tell what Congress will do next, but a long-term solution that would replace the SGR is unlikely now.

In a worse-case scenario, physicians could be facing a situation similar to what happened in 2010, when Congress passed a series of temporary patches during the first half of the year, Mr. Doherty said. That situation could become a reality if lawmakers once again are deadlocked on the larger legislative package. "To a great extent, we’re once again going to be held hostage to negotiations over a broader package on issues that really have nothing to do with the SGR."☐

As hospitals face increasing pressure to prevent surgical site infections, the American College of Surgeons National Surgical Quality Improvement Program offers one way to rapidly identify potential problems and track improvement efforts.

That was the experience at Huntington Memorial Hospital in Pasadena, Calif., where surgeons were able to significantly reduce the number of vascular surgical site infections by using the NSQIP to guide their quality improvement efforts. The NSQIP, which is operated by the American College of Surgeons (ACS), is a risk-adjusted data collection tool that captures and analyzes clinical outcomes data. The program sends periodic and real-time data to participating hospitals.

Between January 2009 and December 2010, the rate of vascular surgical site infections at the 650-bed community hospital dropped from 4.16% to 0.85% among 478 vascular surgeries performed during the 2-year period. In 2009, 10 vascular surgical site infections (SSis) were diagnosed. Seven were categorized as "superficial" and three were considered "deep." But in 2010, only two superficial vascular SSIs were diagnosed. There were no deep infections identified at the hospital that year. Surgeons from Huntington Memorial Hospital shared their data at the Western Surgical Association annual meeting in Tucson, Ariz.

Huntington Memorial Hospital joined the NSQIP in 2007. Hospital officials reviewed their data in 2008, and found that that the number of vascular surgical site infections was unacceptably high, Dr. Steven Katz, professor of surgery at the University of Southern California in Los Angeles and the director of surgical education at Huntington, said in an interview. The early NSQIP data showed that the observed to expected (O/E) ratio for vascular surgical site infections was 1.97 in 2008. The O/E ratio is a risk-adjusted outcome for a specific surgical site. An O/E ratio of less than 1 means that the site is performing better than expected, but a ratio greater than 1 means an excess of adverse events, according to the ACS.

The hospital convened a multidisciplinary committee with representatives from vascular surgery, anesthesiology, infection control, quality improvement, and nursing. The group then got to work looking for places where their practices fell short of best practices.

As a result, the hospital made a series of changes in perioperative patient management, including changing the surgical preparation solution and handwashing brushes from povidone-iodine to chlorhexidine, increasing the preoperative dose of cefazolin from 1 g to 2 g for patients not on dialysis, and intraoperative redosing of antibiotics in cases where the operative time was 4 hours or more. They also discontinued prophylactic antibiotics within 24 hours of surgery, used supplemental oxygen at an FiO₂ of 80% intraoperatively and immediately after surgery, and routinely used patient warming devices to maintain a core temperature of 37° C. The changes were phased in starting in August 2009, and were fully implemented by the beginning of 2010.

The new protocols reduced infections. Between January 2008 and December 2010, the O/E ratio for vascular SSIs fell from 1.97 to 0.93.

The NSQIP was important to the hospital’s success, said Dr. Katz. The real-time benchmarking reports provided by the program helped to initially identify the problem of high infection rates and later helped to track the success of the interventions, he said. Although the NSQIP doesn’t instruct hospitals on how to make quality improvements, the systems-based data it provides is especially helpful in developing a multidisciplinary approach to tackling the problems, Dr. Katz said.

The NSQIP database is quickly becoming the standard for measuring surgical quality, and the data from Huntington Memorial Hospital lends the program even more credibility, Dr. Richard Keen, chair of surgery at Cook County Hospital in Chicago, said in an interview. The experience at Huntington is "exactly how it’s supposed to work," Dr. Keen said. The NSQIP should help hospitals identify problems they otherwise might not have known about, and help them track whether their interventions have been effective, he said.

But despite recognition by the Joint Commission and others, the NSQIP still isn’t in use in a majority of hospitals around the country. The major stumbling block, Dr. Keen said, is the issue of return on investment. The annual fee for the program is between $10,000 and $24,000, depending on the hospital size, but the larger costs come with the full-time employee needed to work with the data.

But Dr. Keen said he expects to see an "explosion" in participation in the NSQIP in the next few years, driven in part by pressures from payers. The recent moves by Medicare to link payments to quality will make the NSQIP an important tool for hospitals to show that they are making progress in meeting quality goals, he said.

As hospitals face increasing pressure to prevent surgical site infections, the American College of Surgeons National Surgical Quality Improvement Program offers one way to rapidly identify potential problems and track improvement efforts.

That was the experience at Huntington Memorial Hospital in Pasadena, Calif., where surgeons were able to significantly reduce the number of vascular surgical site infections by using the NSQIP to guide their quality improvement efforts. The NSQIP, which is operated by the American College of Surgeons (ACS), is a risk-adjusted data collection tool that captures and analyzes clinical outcomes data. The program sends periodic and real-time data to participating hospitals.

Between January 2009 and December 2010, the rate of vascular surgical site infections at the 650-bed community hospital dropped from 4.16% to 0.85% among 478 vascular surgeries performed during the 2-year period. In 2009, 10 vascular surgical site infections (SSis) were diagnosed. Seven were categorized as "superficial" and three were considered "deep." But in 2010, only two superficial vascular SSIs were diagnosed. There were no deep infections identified at the hospital that year. Surgeons from Huntington Memorial Hospital shared their data at the Western Surgical Association annual meeting in Tucson, Ariz.

Huntington Memorial Hospital joined the NSQIP in 2007. Hospital officials reviewed their data in 2008, and found that that the number of vascular surgical site infections was unacceptably high, Dr. Steven Katz, professor of surgery at the University of Southern California in Los Angeles and the director of surgical education at Huntington, said in an interview. The early NSQIP data showed that the observed to expected (O/E) ratio for vascular surgical site infections was 1.97 in 2008. The O/E ratio is a risk-adjusted outcome for a specific surgical site. An O/E ratio of less than 1 means that the site is performing better than expected, but a ratio greater than 1 means an excess of adverse events, according to the ACS.

The hospital convened a multidisciplinary committee with representatives from vascular surgery, anesthesiology, infection control, quality improvement, and nursing. The group then got to work looking for places where their practices fell short of best practices.

As a result, the hospital made a series of changes in perioperative patient management, including changing the surgical preparation solution and handwashing brushes from povidone-iodine to chlorhexidine, increasing the preoperative dose of cefazolin from 1 g to 2 g for patients not on dialysis, and intraoperative redosing of antibiotics in cases where the operative time was 4 hours or more. They also discontinued prophylactic antibiotics within 24 hours of surgery, used supplemental oxygen at an FiO₂ of 80% intraoperatively and immediately after surgery, and routinely used patient warming devices to maintain a core temperature of 37° C. The changes were phased in starting in August 2009, and were fully implemented by the beginning of 2010.

The new protocols reduced infections. Between January 2008 and December 2010, the O/E ratio for vascular SSIs fell from 1.97 to 0.93.

The NSQIP was important to the hospital’s success, said Dr. Katz. The real-time benchmarking reports provided by the program helped to initially identify the problem of high infection rates and later helped to track the success of the interventions, he said. Although the NSQIP doesn’t instruct hospitals on how to make quality improvements, the systems-based data it provides is especially helpful in developing a multidisciplinary approach to tackling the problems, Dr. Katz said.

The NSQIP database is quickly becoming the standard for measuring surgical quality, and the data from Huntington Memorial Hospital lends the program even more credibility, Dr. Richard Keen, chair of surgery at Cook County Hospital in Chicago, said in an interview. The experience at Huntington is "exactly how it’s supposed to work," Dr. Keen said. The NSQIP should help hospitals identify problems they otherwise might not have known about, and help them track whether their interventions have been effective, he said.

But despite recognition by the Joint Commission and others, the NSQIP still isn’t in use in a majority of hospitals around the country. The major stumbling block, Dr. Keen said, is the issue of return on investment. The annual fee for the program is between $10,000 and $24,000, depending on the hospital size, but the larger costs come with the full-time employee needed to work with the data.

But Dr. Keen said he expects to see an "explosion" in participation in the NSQIP in the next few years, driven in part by pressures from payers. The recent moves by Medicare to link payments to quality will make the NSQIP an important tool for hospitals to show that they are making progress in meeting quality goals, he said.

As hospitals face increasing pressure to prevent surgical site infections, the American College of Surgeons National Surgical Quality Improvement Program offers one way to rapidly identify potential problems and track improvement efforts.

That was the experience at Huntington Memorial Hospital in Pasadena, Calif., where surgeons were able to significantly reduce the number of vascular surgical site infections by using the NSQIP to guide their quality improvement efforts. The NSQIP, which is operated by the American College of Surgeons (ACS), is a risk-adjusted data collection tool that captures and analyzes clinical outcomes data. The program sends periodic and real-time data to participating hospitals.

Between January 2009 and December 2010, the rate of vascular surgical site infections at the 650-bed community hospital dropped from 4.16% to 0.85% among 478 vascular surgeries performed during the 2-year period. In 2009, 10 vascular surgical site infections (SSis) were diagnosed. Seven were categorized as "superficial" and three were considered "deep." But in 2010, only two superficial vascular SSIs were diagnosed. There were no deep infections identified at the hospital that year. Surgeons from Huntington Memorial Hospital shared their data at the Western Surgical Association annual meeting in Tucson, Ariz.

Huntington Memorial Hospital joined the NSQIP in 2007. Hospital officials reviewed their data in 2008, and found that that the number of vascular surgical site infections was unacceptably high, Dr. Steven Katz, professor of surgery at the University of Southern California in Los Angeles and the director of surgical education at Huntington, said in an interview. The early NSQIP data showed that the observed to expected (O/E) ratio for vascular surgical site infections was 1.97 in 2008. The O/E ratio is a risk-adjusted outcome for a specific surgical site. An O/E ratio of less than 1 means that the site is performing better than expected, but a ratio greater than 1 means an excess of adverse events, according to the ACS.

The hospital convened a multidisciplinary committee with representatives from vascular surgery, anesthesiology, infection control, quality improvement, and nursing. The group then got to work looking for places where their practices fell short of best practices.

As a result, the hospital made a series of changes in perioperative patient management, including changing the surgical preparation solution and handwashing brushes from povidone-iodine to chlorhexidine, increasing the preoperative dose of cefazolin from 1 g to 2 g for patients not on dialysis, and intraoperative redosing of antibiotics in cases where the operative time was 4 hours or more. They also discontinued prophylactic antibiotics within 24 hours of surgery, used supplemental oxygen at an FiO₂ of 80% intraoperatively and immediately after surgery, and routinely used patient warming devices to maintain a core temperature of 37° C. The changes were phased in starting in August 2009, and were fully implemented by the beginning of 2010.

The new protocols reduced infections. Between January 2008 and December 2010, the O/E ratio for vascular SSIs fell from 1.97 to 0.93.

The NSQIP was important to the hospital’s success, said Dr. Katz. The real-time benchmarking reports provided by the program helped to initially identify the problem of high infection rates and later helped to track the success of the interventions, he said. Although the NSQIP doesn’t instruct hospitals on how to make quality improvements, the systems-based data it provides is especially helpful in developing a multidisciplinary approach to tackling the problems, Dr. Katz said.

The NSQIP database is quickly becoming the standard for measuring surgical quality, and the data from Huntington Memorial Hospital lends the program even more credibility, Dr. Richard Keen, chair of surgery at Cook County Hospital in Chicago, said in an interview. The experience at Huntington is "exactly how it’s supposed to work," Dr. Keen said. The NSQIP should help hospitals identify problems they otherwise might not have known about, and help them track whether their interventions have been effective, he said.

But despite recognition by the Joint Commission and others, the NSQIP still isn’t in use in a majority of hospitals around the country. The major stumbling block, Dr. Keen said, is the issue of return on investment. The annual fee for the program is between $10,000 and $24,000, depending on the hospital size, but the larger costs come with the full-time employee needed to work with the data.

But Dr. Keen said he expects to see an "explosion" in participation in the NSQIP in the next few years, driven in part by pressures from payers. The recent moves by Medicare to link payments to quality will make the NSQIP an important tool for hospitals to show that they are making progress in meeting quality goals, he said.

NEW ORLEANS – The American Medical Association’s policy-making body wrapped up 2 and a half days of meetings Nov. 15 by calling for a delay in implementation of the ICD-10 coding system, and reiterating its intention to seek the ability to privately broker fees with Medicare patients.

Physicians have long sought to be allowed to engage in so-called "private contracting" with Medicare patients. Under that scenario, Medicare patients could use their benefits to see a physician that does not accept Medicare. Currently, patients have to pay for the entire visit out of pocket if their physician does not accept Medicare.

The AMA says private contracting will empower patients – and, the group is supporting legislation sponsored by Rep. Tom Price (R-Ga.) that would allow such private contracting. The Medicare Patient Empowerment Act (H.R. 1700) was introduced last May; a companion bill was introduced in the Senate by Lisa Murkowski (R-Alaska).

The AMA House of Delegates reaffirmed support of the legislation, but also called upon the AMA to start a grassroots campaign to get patients involved.

Alabama delegate Dr. Jeff Terry and president of the Medical Association of the State of Alabama said, "A grassroots campaign will allow our politicians to do the right thing." Such a campaign will let politicians know "that we don’t want our congressmen to walk out on a political limb not supported by the public."

The emphasis on private contracting was in part a symptom of the high-pressure environment physicians find themselves in, facing a potential 27% cut in Medicare payments as well as high-cost requirements to implement electronic medical records, said Dr. Robert Wah, chairman of the AMA Board of Trustees.

"The fact that patients may be able to take their benefit where they’d like to, to see the doctors they want to see, is a potential safety valve to all this pressure being exerted on physician practices and patients in the Medicare system," Dr. Wah said in an interview. "So we’re actively pushing at the local level for people to go to their congressmen and ask them to sign on to this legislation."

The push back against the coming implementation of the new ICD-10 coding system in 2013 is also a symptom of physicians feeling overwhelmed by their changing practice environment, Dr. Wah said. The House approved a resolution sponsored by the Alabama and Mississippi delegations, to take action to stop the implementation.

The ICD-10 will consist of 69,000 codes, as compared with the 14,000 in ICD-9, currently in use. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel said in a statement.

The ICD-10 system has been in development for 10 years but has been delayed several times already. The House of Delegates called on the AMA to mount "a vigorous campaign to seek delay of the implementation date," according to Dr. Wah. ☐

NEW ORLEANS – The American Medical Association’s policy-making body wrapped up 2 and a half days of meetings Nov. 15 by calling for a delay in implementation of the ICD-10 coding system, and reiterating its intention to seek the ability to privately broker fees with Medicare patients.

Physicians have long sought to be allowed to engage in so-called "private contracting" with Medicare patients. Under that scenario, Medicare patients could use their benefits to see a physician that does not accept Medicare. Currently, patients have to pay for the entire visit out of pocket if their physician does not accept Medicare.

The AMA says private contracting will empower patients – and, the group is supporting legislation sponsored by Rep. Tom Price (R-Ga.) that would allow such private contracting. The Medicare Patient Empowerment Act (H.R. 1700) was introduced last May; a companion bill was introduced in the Senate by Lisa Murkowski (R-Alaska).

The AMA House of Delegates reaffirmed support of the legislation, but also called upon the AMA to start a grassroots campaign to get patients involved.

Alabama delegate Dr. Jeff Terry and president of the Medical Association of the State of Alabama said, "A grassroots campaign will allow our politicians to do the right thing." Such a campaign will let politicians know "that we don’t want our congressmen to walk out on a political limb not supported by the public."

The emphasis on private contracting was in part a symptom of the high-pressure environment physicians find themselves in, facing a potential 27% cut in Medicare payments as well as high-cost requirements to implement electronic medical records, said Dr. Robert Wah, chairman of the AMA Board of Trustees.

"The fact that patients may be able to take their benefit where they’d like to, to see the doctors they want to see, is a potential safety valve to all this pressure being exerted on physician practices and patients in the Medicare system," Dr. Wah said in an interview. "So we’re actively pushing at the local level for people to go to their congressmen and ask them to sign on to this legislation."

The push back against the coming implementation of the new ICD-10 coding system in 2013 is also a symptom of physicians feeling overwhelmed by their changing practice environment, Dr. Wah said. The House approved a resolution sponsored by the Alabama and Mississippi delegations, to take action to stop the implementation.

The ICD-10 will consist of 69,000 codes, as compared with the 14,000 in ICD-9, currently in use. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel said in a statement.

The ICD-10 system has been in development for 10 years but has been delayed several times already. The House of Delegates called on the AMA to mount "a vigorous campaign to seek delay of the implementation date," according to Dr. Wah. ☐

NEW ORLEANS – The American Medical Association’s policy-making body wrapped up 2 and a half days of meetings Nov. 15 by calling for a delay in implementation of the ICD-10 coding system, and reiterating its intention to seek the ability to privately broker fees with Medicare patients.

Physicians have long sought to be allowed to engage in so-called "private contracting" with Medicare patients. Under that scenario, Medicare patients could use their benefits to see a physician that does not accept Medicare. Currently, patients have to pay for the entire visit out of pocket if their physician does not accept Medicare.

The AMA says private contracting will empower patients – and, the group is supporting legislation sponsored by Rep. Tom Price (R-Ga.) that would allow such private contracting. The Medicare Patient Empowerment Act (H.R. 1700) was introduced last May; a companion bill was introduced in the Senate by Lisa Murkowski (R-Alaska).

The AMA House of Delegates reaffirmed support of the legislation, but also called upon the AMA to start a grassroots campaign to get patients involved.

Alabama delegate Dr. Jeff Terry and president of the Medical Association of the State of Alabama said, "A grassroots campaign will allow our politicians to do the right thing." Such a campaign will let politicians know "that we don’t want our congressmen to walk out on a political limb not supported by the public."

The emphasis on private contracting was in part a symptom of the high-pressure environment physicians find themselves in, facing a potential 27% cut in Medicare payments as well as high-cost requirements to implement electronic medical records, said Dr. Robert Wah, chairman of the AMA Board of Trustees.

"The fact that patients may be able to take their benefit where they’d like to, to see the doctors they want to see, is a potential safety valve to all this pressure being exerted on physician practices and patients in the Medicare system," Dr. Wah said in an interview. "So we’re actively pushing at the local level for people to go to their congressmen and ask them to sign on to this legislation."

The push back against the coming implementation of the new ICD-10 coding system in 2013 is also a symptom of physicians feeling overwhelmed by their changing practice environment, Dr. Wah said. The House approved a resolution sponsored by the Alabama and Mississippi delegations, to take action to stop the implementation.

The ICD-10 will consist of 69,000 codes, as compared with the 14,000 in ICD-9, currently in use. "At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions," AMA President Peter W. Carmel said in a statement.

The ICD-10 system has been in development for 10 years but has been delayed several times already. The House of Delegates called on the AMA to mount "a vigorous campaign to seek delay of the implementation date," according to Dr. Wah. ☐

SAN FRANCISCO – Societal trends will trump health reform in changing the health care system, and surgeons need to do their part to decrease costs, leaders in the American College of Surgeons said at their annual clinical congress.

"Change is happening in spite of, alongside, and with the Affordable Care Act [ACA]," said Thomas Ricketts, Ph.D., codirector of the American College of Surgeons Health Policy Research Institute. Change is being driven as much as or more by the economy along with institutional and professional decisions, he said.

Those forces are shifting the health care system from one that is dominated by independent physicians and surgeons to one in which physicians will be employees. Health insurers are linking up with clinician groups. Instead of community-based hospitals responsive to local needs, institutions are aggregating in large, geographically spread "empires" that are learning how to manage themselves, said Dr. Ricketts, professor of health policy and management at the University of North Carolina at Chapel Hill.

The pace of mergers accelerated after passage of the ACA in March 2010. In the first two quarters of 2011 there were 139 mergers or acquisitions involving hospitals, compared with 37-82 in each of the years from 2001 to 2010, he said.

The ACA will make health coverage accessible to an estimated 32 million currently uninsured Americans. Seven in 10 hospitals and health systems in the United States plan to hire more physicians in the next 1-3 years, but it’s unclear whether there will be enough physicians. "It’s a huge problem," Dr. Ricketts said.

Physicians and patients should brace themselves for what he called "simple complexity" in the evolving health system, which will define the individual roles of providers with specificity, yet add complexity as system structures evolve.

Major provisions of the ACA will roll out over time, but many of the provisions of particular concern to surgeons kick in by 2014, Dr. Don E. Detmer said in a separate presentation during the same session. Enactment began with 13 components in 2010 involving payment reform, workforce and quality-of-care improvements, access to care, and new insurance rules. Eight major provisions in 2011 affected physician quality reporting, new approaches to payment and delivery of care, and more, said Dr. Detmer, medical director of the ACS Division of Advocacy and Health Policy.

In 2012, four provisions kick in that involve reduced payments for preventable hospital readmissions, launch of Accountable Care Organizations, higher Medicare payments to hospitals with high-quality and outcomes data, and required reporting of data on health disparities.

Five major provisions starting in 2013 include bundled payments for episodes of postacute care, limits on flexible spending accounts, increased payroll taxes for Medicare, expansion of preventive services in Medicaid, and electronic simplification of some administrative functions.

The top four of nine provisions that start in 2014 include creation of an essential benefits package for insurers to offer, the start of insurance exchanges through employers or states to offer insurance to people who have no coverage, a requirement for uninsured individuals to buy coverage or pay a penalty, and creation of an independent payment advisory board to identify potentially wasteful spending in Medicare.

As enacted, the ACA is unlikely to produce sufficient reforms to significantly alter the curve of ever-increasing costs through overall system performance, "but the ACA plus physician payment reforms just might," predicted Dr. Detmer, professor emeritus at the University of Virginia, Charlottesville.

Another player besides the ACA could have had a drastic effect – the Congressional Joint Select Committee on Deficit Reduction (also called the Super Committee) was charged with decreasing federal budget deficits by $1.2 trillion between 2012 and 2021. They failed to agree on a plan, so, that will likely trigger massive, widespread cuts in federal spending starting in January 2013.

Policy-driven changes in health care make many physicians nervous, but any resulting changes are "probably not as scary as what we’ve got now," Dr. Detmer said.

A separate federal commission on government spending, known as the Debt Commission, has recommended a number of reductions in health care spending, including cutting $54 billion from graduate and indirect medical education between 2012 and 2020, Dr. George F. Sheldon said in a separate presentation during the session. Fifteen new U.S. medical schools currently are planned with no federal support, which may help supply the physicians and surgeons needed to meet growing demand for care, but the schools alone will not be sufficient, said Dr. Sheldon, codirector of the ACS Health Policy Research Institute.

Of the 26,769 active general surgeons in the United States, 42% are aged 55 years or older, 2008 data show. The number of active general surgeons decreased by 2% between 1996 and 2006, especially in rural areas, other studies report.

The regionalization of health systems offers an opportunity for different models of surgical care, he suggested. Surgeons and high-technology equipment may locate more in regional centers than individual practices.

Government programs could do more to increase the supply of surgeons, added Dr. Sheldon, professor of surgery at the University of North Carolina at Chapel Hill. The National Health Service Corps doesn’t include surgeons, "but it would be great if they did," he said.

Creating new medical schools – and somehow finding the residency programs to train the extra graduates – is a good long-term plan, but it doesn’t solve immediate workforce shortages, said Dr. Andrew L. Warshaw, chair of the ACS Health Policy Advisory Group. "If we have shortages now, it will be worse" as the ACA is implemented, he said in a presentation during the session. He noted that such shortages occurred in Massachusetts after the state adopted universal health care coverage.

Greater use of mid-level providers may help extend physicians’ reach, and regionalization models can either put more physicians where they’re needed or bring patients to physicians’ locations, he suggested.

But physicians need to tackle costs of health care, added Dr. Warshaw, of Harvard Medical School, Boston. If any solutions include a fix of the Sustainable Growth Rate (SGR) formula as requested by physicians, $1.6 trillion instead of $1.2 trillion would have to be cut from the federal deficit – cuts that could come from other parts of health care.

"What can surgeons do?" Dr. Warshaw said. "Every person in this room needs to do something, somewhere, somehow within your own practice to figure out what’s the right kind of care to give your patients. There’s good evidence that that can go a long way toward paying down the SGR."

If postoperative complications cost an average of $10,000, preventing just one postoperative complication per day at every U.S. hospital would reduce costs by $125-$250 billion over 10 years, he estimated.

Surgeons also need to figure out optimal care for patients and demand that other specialties do the same. One study at Massachusetts General Hospital found that physicians ordered between 1 and 30 CAT scans for patients seen in the emergency department for head trauma. Such a wide range in practices is "wrong," he said. "It’s our job to figure this out." Medical liability reform potentially could save another $62 billion in health care costs over 10 years, he added.

"I don’t think we can count on the ACA to reduce costs. We have to do a lot more," Dr. Warshaw said. "There’s a huge amount going on, and it’s way ahead of the Affordable Care Act in many ways."

Dr. Detmer has consulted for CS Placement. Dr. Ricketts, Dr. Sheldon, and Dr. Warshaw said that they had no financial conflicts. ☐

SAN FRANCISCO – Societal trends will trump health reform in changing the health care system, and surgeons need to do their part to decrease costs, leaders in the American College of Surgeons said at their annual clinical congress.

"Change is happening in spite of, alongside, and with the Affordable Care Act [ACA]," said Thomas Ricketts, Ph.D., codirector of the American College of Surgeons Health Policy Research Institute. Change is being driven as much as or more by the economy along with institutional and professional decisions, he said.

Those forces are shifting the health care system from one that is dominated by independent physicians and surgeons to one in which physicians will be employees. Health insurers are linking up with clinician groups. Instead of community-based hospitals responsive to local needs, institutions are aggregating in large, geographically spread "empires" that are learning how to manage themselves, said Dr. Ricketts, professor of health policy and management at the University of North Carolina at Chapel Hill.

The pace of mergers accelerated after passage of the ACA in March 2010. In the first two quarters of 2011 there were 139 mergers or acquisitions involving hospitals, compared with 37-82 in each of the years from 2001 to 2010, he said.

The ACA will make health coverage accessible to an estimated 32 million currently uninsured Americans. Seven in 10 hospitals and health systems in the United States plan to hire more physicians in the next 1-3 years, but it’s unclear whether there will be enough physicians. "It’s a huge problem," Dr. Ricketts said.

Physicians and patients should brace themselves for what he called "simple complexity" in the evolving health system, which will define the individual roles of providers with specificity, yet add complexity as system structures evolve.

Major provisions of the ACA will roll out over time, but many of the provisions of particular concern to surgeons kick in by 2014, Dr. Don E. Detmer said in a separate presentation during the same session. Enactment began with 13 components in 2010 involving payment reform, workforce and quality-of-care improvements, access to care, and new insurance rules. Eight major provisions in 2011 affected physician quality reporting, new approaches to payment and delivery of care, and more, said Dr. Detmer, medical director of the ACS Division of Advocacy and Health Policy.

In 2012, four provisions kick in that involve reduced payments for preventable hospital readmissions, launch of Accountable Care Organizations, higher Medicare payments to hospitals with high-quality and outcomes data, and required reporting of data on health disparities.

Five major provisions starting in 2013 include bundled payments for episodes of postacute care, limits on flexible spending accounts, increased payroll taxes for Medicare, expansion of preventive services in Medicaid, and electronic simplification of some administrative functions.

The top four of nine provisions that start in 2014 include creation of an essential benefits package for insurers to offer, the start of insurance exchanges through employers or states to offer insurance to people who have no coverage, a requirement for uninsured individuals to buy coverage or pay a penalty, and creation of an independent payment advisory board to identify potentially wasteful spending in Medicare.

As enacted, the ACA is unlikely to produce sufficient reforms to significantly alter the curve of ever-increasing costs through overall system performance, "but the ACA plus physician payment reforms just might," predicted Dr. Detmer, professor emeritus at the University of Virginia, Charlottesville.

Another player besides the ACA could have had a drastic effect – the Congressional Joint Select Committee on Deficit Reduction (also called the Super Committee) was charged with decreasing federal budget deficits by $1.2 trillion between 2012 and 2021. They failed to agree on a plan, so, that will likely trigger massive, widespread cuts in federal spending starting in January 2013.

Policy-driven changes in health care make many physicians nervous, but any resulting changes are "probably not as scary as what we’ve got now," Dr. Detmer said.

A separate federal commission on government spending, known as the Debt Commission, has recommended a number of reductions in health care spending, including cutting $54 billion from graduate and indirect medical education between 2012 and 2020, Dr. George F. Sheldon said in a separate presentation during the session. Fifteen new U.S. medical schools currently are planned with no federal support, which may help supply the physicians and surgeons needed to meet growing demand for care, but the schools alone will not be sufficient, said Dr. Sheldon, codirector of the ACS Health Policy Research Institute.

Of the 26,769 active general surgeons in the United States, 42% are aged 55 years or older, 2008 data show. The number of active general surgeons decreased by 2% between 1996 and 2006, especially in rural areas, other studies report.

The regionalization of health systems offers an opportunity for different models of surgical care, he suggested. Surgeons and high-technology equipment may locate more in regional centers than individual practices.

Government programs could do more to increase the supply of surgeons, added Dr. Sheldon, professor of surgery at the University of North Carolina at Chapel Hill. The National Health Service Corps doesn’t include surgeons, "but it would be great if they did," he said.

Creating new medical schools – and somehow finding the residency programs to train the extra graduates – is a good long-term plan, but it doesn’t solve immediate workforce shortages, said Dr. Andrew L. Warshaw, chair of the ACS Health Policy Advisory Group. "If we have shortages now, it will be worse" as the ACA is implemented, he said in a presentation during the session. He noted that such shortages occurred in Massachusetts after the state adopted universal health care coverage.

Greater use of mid-level providers may help extend physicians’ reach, and regionalization models can either put more physicians where they’re needed or bring patients to physicians’ locations, he suggested.

But physicians need to tackle costs of health care, added Dr. Warshaw, of Harvard Medical School, Boston. If any solutions include a fix of the Sustainable Growth Rate (SGR) formula as requested by physicians, $1.6 trillion instead of $1.2 trillion would have to be cut from the federal deficit – cuts that could come from other parts of health care.

"What can surgeons do?" Dr. Warshaw said. "Every person in this room needs to do something, somewhere, somehow within your own practice to figure out what’s the right kind of care to give your patients. There’s good evidence that that can go a long way toward paying down the SGR."

If postoperative complications cost an average of $10,000, preventing just one postoperative complication per day at every U.S. hospital would reduce costs by $125-$250 billion over 10 years, he estimated.

Surgeons also need to figure out optimal care for patients and demand that other specialties do the same. One study at Massachusetts General Hospital found that physicians ordered between 1 and 30 CAT scans for patients seen in the emergency department for head trauma. Such a wide range in practices is "wrong," he said. "It’s our job to figure this out." Medical liability reform potentially could save another $62 billion in health care costs over 10 years, he added.

"I don’t think we can count on the ACA to reduce costs. We have to do a lot more," Dr. Warshaw said. "There’s a huge amount going on, and it’s way ahead of the Affordable Care Act in many ways."

Dr. Detmer has consulted for CS Placement. Dr. Ricketts, Dr. Sheldon, and Dr. Warshaw said that they had no financial conflicts. ☐

SAN FRANCISCO – Societal trends will trump health reform in changing the health care system, and surgeons need to do their part to decrease costs, leaders in the American College of Surgeons said at their annual clinical congress.

"Change is happening in spite of, alongside, and with the Affordable Care Act [ACA]," said Thomas Ricketts, Ph.D., codirector of the American College of Surgeons Health Policy Research Institute. Change is being driven as much as or more by the economy along with institutional and professional decisions, he said.

Those forces are shifting the health care system from one that is dominated by independent physicians and surgeons to one in which physicians will be employees. Health insurers are linking up with clinician groups. Instead of community-based hospitals responsive to local needs, institutions are aggregating in large, geographically spread "empires" that are learning how to manage themselves, said Dr. Ricketts, professor of health policy and management at the University of North Carolina at Chapel Hill.

The pace of mergers accelerated after passage of the ACA in March 2010. In the first two quarters of 2011 there were 139 mergers or acquisitions involving hospitals, compared with 37-82 in each of the years from 2001 to 2010, he said.

The ACA will make health coverage accessible to an estimated 32 million currently uninsured Americans. Seven in 10 hospitals and health systems in the United States plan to hire more physicians in the next 1-3 years, but it’s unclear whether there will be enough physicians. "It’s a huge problem," Dr. Ricketts said.

Physicians and patients should brace themselves for what he called "simple complexity" in the evolving health system, which will define the individual roles of providers with specificity, yet add complexity as system structures evolve.

Major provisions of the ACA will roll out over time, but many of the provisions of particular concern to surgeons kick in by 2014, Dr. Don E. Detmer said in a separate presentation during the same session. Enactment began with 13 components in 2010 involving payment reform, workforce and quality-of-care improvements, access to care, and new insurance rules. Eight major provisions in 2011 affected physician quality reporting, new approaches to payment and delivery of care, and more, said Dr. Detmer, medical director of the ACS Division of Advocacy and Health Policy.

In 2012, four provisions kick in that involve reduced payments for preventable hospital readmissions, launch of Accountable Care Organizations, higher Medicare payments to hospitals with high-quality and outcomes data, and required reporting of data on health disparities.

Five major provisions starting in 2013 include bundled payments for episodes of postacute care, limits on flexible spending accounts, increased payroll taxes for Medicare, expansion of preventive services in Medicaid, and electronic simplification of some administrative functions.

The top four of nine provisions that start in 2014 include creation of an essential benefits package for insurers to offer, the start of insurance exchanges through employers or states to offer insurance to people who have no coverage, a requirement for uninsured individuals to buy coverage or pay a penalty, and creation of an independent payment advisory board to identify potentially wasteful spending in Medicare.

As enacted, the ACA is unlikely to produce sufficient reforms to significantly alter the curve of ever-increasing costs through overall system performance, "but the ACA plus physician payment reforms just might," predicted Dr. Detmer, professor emeritus at the University of Virginia, Charlottesville.

Another player besides the ACA could have had a drastic effect – the Congressional Joint Select Committee on Deficit Reduction (also called the Super Committee) was charged with decreasing federal budget deficits by $1.2 trillion between 2012 and 2021. They failed to agree on a plan, so, that will likely trigger massive, widespread cuts in federal spending starting in January 2013.

Policy-driven changes in health care make many physicians nervous, but any resulting changes are "probably not as scary as what we’ve got now," Dr. Detmer said.

A separate federal commission on government spending, known as the Debt Commission, has recommended a number of reductions in health care spending, including cutting $54 billion from graduate and indirect medical education between 2012 and 2020, Dr. George F. Sheldon said in a separate presentation during the session. Fifteen new U.S. medical schools currently are planned with no federal support, which may help supply the physicians and surgeons needed to meet growing demand for care, but the schools alone will not be sufficient, said Dr. Sheldon, codirector of the ACS Health Policy Research Institute.

Of the 26,769 active general surgeons in the United States, 42% are aged 55 years or older, 2008 data show. The number of active general surgeons decreased by 2% between 1996 and 2006, especially in rural areas, other studies report.

The regionalization of health systems offers an opportunity for different models of surgical care, he suggested. Surgeons and high-technology equipment may locate more in regional centers than individual practices.

Government programs could do more to increase the supply of surgeons, added Dr. Sheldon, professor of surgery at the University of North Carolina at Chapel Hill. The National Health Service Corps doesn’t include surgeons, "but it would be great if they did," he said.

Creating new medical schools – and somehow finding the residency programs to train the extra graduates – is a good long-term plan, but it doesn’t solve immediate workforce shortages, said Dr. Andrew L. Warshaw, chair of the ACS Health Policy Advisory Group. "If we have shortages now, it will be worse" as the ACA is implemented, he said in a presentation during the session. He noted that such shortages occurred in Massachusetts after the state adopted universal health care coverage.

Greater use of mid-level providers may help extend physicians’ reach, and regionalization models can either put more physicians where they’re needed or bring patients to physicians’ locations, he suggested.

But physicians need to tackle costs of health care, added Dr. Warshaw, of Harvard Medical School, Boston. If any solutions include a fix of the Sustainable Growth Rate (SGR) formula as requested by physicians, $1.6 trillion instead of $1.2 trillion would have to be cut from the federal deficit – cuts that could come from other parts of health care.

"What can surgeons do?" Dr. Warshaw said. "Every person in this room needs to do something, somewhere, somehow within your own practice to figure out what’s the right kind of care to give your patients. There’s good evidence that that can go a long way toward paying down the SGR."

If postoperative complications cost an average of $10,000, preventing just one postoperative complication per day at every U.S. hospital would reduce costs by $125-$250 billion over 10 years, he estimated.

Surgeons also need to figure out optimal care for patients and demand that other specialties do the same. One study at Massachusetts General Hospital found that physicians ordered between 1 and 30 CAT scans for patients seen in the emergency department for head trauma. Such a wide range in practices is "wrong," he said. "It’s our job to figure this out." Medical liability reform potentially could save another $62 billion in health care costs over 10 years, he added.

"I don’t think we can count on the ACA to reduce costs. We have to do a lot more," Dr. Warshaw said. "There’s a huge amount going on, and it’s way ahead of the Affordable Care Act in many ways."

Dr. Detmer has consulted for CS Placement. Dr. Ricketts, Dr. Sheldon, and Dr. Warshaw said that they had no financial conflicts. ☐