Alicia Ault

The Centers for Medicare and Medicaid Services has proposed an overall 3% increase in payments for outpatient hospital care in 2009, almost a full percentage point below the update for 2008. As expected, reporting on quality of care is being tied to the amount of increase hospitals and other outpatient providers will receive.

For the first time, hospitals and other recipients of payments under the outpatient system that do not report data on seven quality measures of emergency and perioperative care will see only a 1% increase.

The proposed rule also outlines changes for ambulatory surgery centers (ASCs) that are part of a 4-year transition to a new payment system that began this year. In 2009, as was the case this year, ASCs would be paid 65% of the rate paid for the same service in an outpatient hospital department.

The agency estimates it will spend $29 billion in 2009 on payments to acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute-care hospitals, community mental health centers, children's hospitals, and cancer hospitals. That's a $2 billion increase from the estimated $27 billion CMS will spend on outpatient services this year, said the agency. Payments to ambulatory surgery centers will increase from an estimated $3.5 billion in 2008 to $3.9 billion in 2009, according to CMS.

CMS is proposing to more aggressively penalize hospitals and other outpatient providers that do not report quality data. Providers must report on 7 measures in 2008 and on 11 in 2009, including 4 imaging efficiency measures. In addition, the agency is seeking to reduce copayments for beneficiaries who are treated at hospitals that do not report quality data.

By law, Medicare is gradually changing the payment system so that beneficiaries will be liable for only 20% of a covered service. The coinsurance rate has varied widely over the last 8–10 years. In 2009, about 25% of services will be subject to the 20% coinsurance, from 23% in 2008, said CMS.

For imaging—a huge and growing portion of Medicare expenditures—CMS would make a single payment for multiple imaging procedures performed in a single hospital session, including ultrasound, computed tomography, and magnetic resonance imaging.

CMS also proposes reducing pay for some device-oriented procedures: a 48% reduction for the placing of left ventricular pacing add-on leads; a 3% decrease for replacing pacemakers, electrodes, or pulse generators; 4% for stent placement; and 1% for drug-eluting stents.

A small increase is proposed for most neurology devices and drug infusion devices, but placement of neurostimulator electrodes would be slashed by 52%.

For ASCs, reimbursement would decrease for 92 procedures, but increase for 2,475, according to the Ambulatory Surgery Center Association. Nervous system procedures and pain management would be reduced by 3%, according to Washington Analysis, a firm that advises investors on health policy developments.

CMS proposes adding nine surgical procedures to the list of services covered at an ASC. Three have new Current Procedural Terminology (CPT) codes, and six—nasal/sinus endoscopy surgery; removal of vein clot; blood exchange/transfuse, non-nb; laparoscopic insertion of a permanent intraperitoneal catheter; laparoscopic revision of a permanent intraperitoneal catheter; and laparoscopy with omentopexy add-on—were previously excluded from coverage. Five procedures will be added to the list of office-based procedures, paid at either the ASC rate or the office practice expense payment rate, whichever is lower.

Finally, the agency is proposing to create four new ambulatory payment classifications for type B emergency departments (EDs that are not open 24 hours a day, 7 days a week). According to data collected by CMS, most type B visits are more expensive than a clinic visit, but less expensive than a visit to a traditional ED. The goal is to make payment for the type B centers more reflective of actual costs. The four payment groups will be based on claims data from the type B providers.

CMS will issue the final rule Nov. 1.

The Centers for Medicare and Medicaid Services has proposed an overall 3% increase in payments for outpatient hospital care in 2009, almost a full percentage point below the update for 2008. As expected, reporting on quality of care is being tied to the amount of increase hospitals and other outpatient providers will receive.

For the first time, hospitals and other recipients of payments under the outpatient system that do not report data on seven quality measures of emergency and perioperative care will see only a 1% increase.

The proposed rule also outlines changes for ambulatory surgery centers (ASCs) that are part of a 4-year transition to a new payment system that began this year. In 2009, as was the case this year, ASCs would be paid 65% of the rate paid for the same service in an outpatient hospital department.

The agency estimates it will spend $29 billion in 2009 on payments to acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute-care hospitals, community mental health centers, children's hospitals, and cancer hospitals. That's a $2 billion increase from the estimated $27 billion CMS will spend on outpatient services this year, said the agency. Payments to ambulatory surgery centers will increase from an estimated $3.5 billion in 2008 to $3.9 billion in 2009, according to CMS.

CMS is proposing to more aggressively penalize hospitals and other outpatient providers that do not report quality data. Providers must report on 7 measures in 2008 and on 11 in 2009, including 4 imaging efficiency measures. In addition, the agency is seeking to reduce copayments for beneficiaries who are treated at hospitals that do not report quality data.

By law, Medicare is gradually changing the payment system so that beneficiaries will be liable for only 20% of a covered service. The coinsurance rate has varied widely over the last 8–10 years. In 2009, about 25% of services will be subject to the 20% coinsurance, from 23% in 2008, said CMS.

For imaging—a huge and growing portion of Medicare expenditures—CMS would make a single payment for multiple imaging procedures performed in a single hospital session, including ultrasound, computed tomography, and magnetic resonance imaging.

CMS also proposes reducing pay for some device-oriented procedures: a 48% reduction for the placing of left ventricular pacing add-on leads; a 3% decrease for replacing pacemakers, electrodes, or pulse generators; 4% for stent placement; and 1% for drug-eluting stents.

A small increase is proposed for most neurology devices and drug infusion devices, but placement of neurostimulator electrodes would be slashed by 52%.

For ASCs, reimbursement would decrease for 92 procedures, but increase for 2,475, according to the Ambulatory Surgery Center Association. Nervous system procedures and pain management would be reduced by 3%, according to Washington Analysis, a firm that advises investors on health policy developments.

CMS proposes adding nine surgical procedures to the list of services covered at an ASC. Three have new Current Procedural Terminology (CPT) codes, and six—nasal/sinus endoscopy surgery; removal of vein clot; blood exchange/transfuse, non-nb; laparoscopic insertion of a permanent intraperitoneal catheter; laparoscopic revision of a permanent intraperitoneal catheter; and laparoscopy with omentopexy add-on—were previously excluded from coverage. Five procedures will be added to the list of office-based procedures, paid at either the ASC rate or the office practice expense payment rate, whichever is lower.

Finally, the agency is proposing to create four new ambulatory payment classifications for type B emergency departments (EDs that are not open 24 hours a day, 7 days a week). According to data collected by CMS, most type B visits are more expensive than a clinic visit, but less expensive than a visit to a traditional ED. The goal is to make payment for the type B centers more reflective of actual costs. The four payment groups will be based on claims data from the type B providers.

CMS will issue the final rule Nov. 1.

The Centers for Medicare and Medicaid Services has proposed an overall 3% increase in payments for outpatient hospital care in 2009, almost a full percentage point below the update for 2008. As expected, reporting on quality of care is being tied to the amount of increase hospitals and other outpatient providers will receive.

For the first time, hospitals and other recipients of payments under the outpatient system that do not report data on seven quality measures of emergency and perioperative care will see only a 1% increase.

The proposed rule also outlines changes for ambulatory surgery centers (ASCs) that are part of a 4-year transition to a new payment system that began this year. In 2009, as was the case this year, ASCs would be paid 65% of the rate paid for the same service in an outpatient hospital department.

The agency estimates it will spend $29 billion in 2009 on payments to acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute-care hospitals, community mental health centers, children's hospitals, and cancer hospitals. That's a $2 billion increase from the estimated $27 billion CMS will spend on outpatient services this year, said the agency. Payments to ambulatory surgery centers will increase from an estimated $3.5 billion in 2008 to $3.9 billion in 2009, according to CMS.

CMS is proposing to more aggressively penalize hospitals and other outpatient providers that do not report quality data. Providers must report on 7 measures in 2008 and on 11 in 2009, including 4 imaging efficiency measures. In addition, the agency is seeking to reduce copayments for beneficiaries who are treated at hospitals that do not report quality data.

By law, Medicare is gradually changing the payment system so that beneficiaries will be liable for only 20% of a covered service. The coinsurance rate has varied widely over the last 8–10 years. In 2009, about 25% of services will be subject to the 20% coinsurance, from 23% in 2008, said CMS.

For imaging—a huge and growing portion of Medicare expenditures—CMS would make a single payment for multiple imaging procedures performed in a single hospital session, including ultrasound, computed tomography, and magnetic resonance imaging.

CMS also proposes reducing pay for some device-oriented procedures: a 48% reduction for the placing of left ventricular pacing add-on leads; a 3% decrease for replacing pacemakers, electrodes, or pulse generators; 4% for stent placement; and 1% for drug-eluting stents.

A small increase is proposed for most neurology devices and drug infusion devices, but placement of neurostimulator electrodes would be slashed by 52%.

For ASCs, reimbursement would decrease for 92 procedures, but increase for 2,475, according to the Ambulatory Surgery Center Association. Nervous system procedures and pain management would be reduced by 3%, according to Washington Analysis, a firm that advises investors on health policy developments.

CMS proposes adding nine surgical procedures to the list of services covered at an ASC. Three have new Current Procedural Terminology (CPT) codes, and six—nasal/sinus endoscopy surgery; removal of vein clot; blood exchange/transfuse, non-nb; laparoscopic insertion of a permanent intraperitoneal catheter; laparoscopic revision of a permanent intraperitoneal catheter; and laparoscopy with omentopexy add-on—were previously excluded from coverage. Five procedures will be added to the list of office-based procedures, paid at either the ASC rate or the office practice expense payment rate, whichever is lower.

Finally, the agency is proposing to create four new ambulatory payment classifications for type B emergency departments (EDs that are not open 24 hours a day, 7 days a week). According to data collected by CMS, most type B visits are more expensive than a clinic visit, but less expensive than a visit to a traditional ED. The goal is to make payment for the type B centers more reflective of actual costs. The four payment groups will be based on claims data from the type B providers.

CMS will issue the final rule Nov. 1.

The Government Accountability Office is urging Congress to require Medicare to adopt prior authorization procedures for outpatient imaging services, saying that the federal health program's current approach has allowed costs to balloon.

According to the GAO, from 2000 to 2006, Medicare Part B spending on imaging services more than doubled to $14 billion. In particular, spending on more technically demanding imaging studies, such as CT, MRI, and nuclear medicine, rose 17% a year, compared with 9% annual growth for less complex studies such as x-rays. Imaging studies have increasingly shifted to the outpatient sector and the proportion of physician income from imaging is steadily rising, said the GAO in its report, “Medicare Part B Imaging Services.”

Shortly after the report was issued, Sen. Charles Grassley (R-Iowa), introduced legislation (S. 3343) that would require physicians making referrals for MRIs, CTs, positron-emission tomography scans, and potentially other modalities, to disclose to patients in writing if they have ownership in the imaging facility.

The proposal was initially included in the bill that canceled Medicare physician fee cuts but was dropped in the final package.

The GAO analyzed Medicare claims data and also interviewed health plans and radiology benefit management companies to compile its report, which was requested by Sen. Jay Rockefeller (D-W.Va.).

Because of the rapid growth in imaging, the GAO said, “we recommend that [the Centers for Medicare and Medicaid Services] examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

The proportion of Medicare Part B spending on imaging conducted in a physician office setting, which was 58% in 2000, rose to 64% in 2006, according to the GAO, which noted that physician-directed imaging has grown. (See Policy & Practice, p. 19.)

“The rise in testing and therefore in cost for outpatient imaging is a symptom of our broken health care system,” said Dr. Elaine Jones, a neurologist in private practice in Bristol, R.I, and a member of the legislative affairs committee of the American Association of Neurology.

“Instituting prior authorization is just a cost-shifting measure. It shifts cost to patients and risks to physicians. Most of these measures do not include reward systems, only regulations. Insurance companies, including Medicare, are looking for ways to save money,” she said.

The American College of Cardiology also criticized the GAO study, noting that the agency did not use data showing a decline in imaging growth in 2007. (See also p. 19.)

“We are disappointed that the GAO chose to ignore the work that physicians and specialty societies are doing to ensure the most appropriate use of these technologies,” the college's CEO, Dr. Jack Lewin, said in a statement. “Prior authorization is a Band-Aid to the utilization issue and not a viable solution. Medicare should look to accreditation, appropriate use criteria, and improved communication to lower utilization and improve quality.”

Dr. Jones said that, as always, “the response is 'if costs are increasing, we need to stop paying.' If a patient comes to me with pain, I don't just give them a pain pill. I try to find the cause of the pain and address that. In the same way, we need to look at why costs are rising, and not just refuse to pay.”

The Medical Imaging Technology Alliance (MITA) issued a similar critique, and noted that the GAO report did not take into account appropriateness and accreditation criteria that were part of the recently passed Medicare bill that eliminated a scheduled reduction in physician fees. The law will require imaging facilities to be accredited starting in 2012.

Appropriateness and accreditation will “ensure that an image is taken at the right time by the right person and in an appropriate manner,” MITA vice president Andrew Whitman said in an interview. MITA is the medical technology trade association of the National Electrical Manufacturers Association.

He also criticized the GAO's support of radiology benefit management companies (RBMs), which the private sector has used to implement prior authorization and other tools to rein in costs. RBMs do not readily share guidelines and appropriateness criteria and are not well regulated, he said.

In response to the GAO report, the Health and Human Services Department said it also had concerns about the “administrative burden” of using RBMs, and it pointed out that there were no independent data showing that RBMs could successfully manage imaging costs. It added that proprietary guidelines in use by RBMs might conflict with those being promoted by federal health authorities, meaning that the RBM recommendations could present a conflict for Medicare in the consideration of payment.

One RBM, MedSolutions, praised the GAO study and refuted assertions that the companies added a layer of cost or bureaucratic burden. The Nashville, Tenn.-based company also said that its clients have found its approach to be successful.

“Our administrative costs are typically a small fraction of documented savings, and it is standard practice for us to operate with complete transparency with physicians and patients,” MedSolutions CEO Curt Thorne said in a statement.

Accreditation and appropriate use criteria would be more effective in reducing imaging, say some physicians. ©Stockbyte/Getty Images

The Government Accountability Office is urging Congress to require Medicare to adopt prior authorization procedures for outpatient imaging services, saying that the federal health program's current approach has allowed costs to balloon.

According to the GAO, from 2000 to 2006, Medicare Part B spending on imaging services more than doubled to $14 billion. In particular, spending on more technically demanding imaging studies, such as CT, MRI, and nuclear medicine, rose 17% a year, compared with 9% annual growth for less complex studies such as x-rays. Imaging studies have increasingly shifted to the outpatient sector and the proportion of physician income from imaging is steadily rising, said the GAO in its report, “Medicare Part B Imaging Services.”

Shortly after the report was issued, Sen. Charles Grassley (R-Iowa), introduced legislation (S. 3343) that would require physicians making referrals for MRIs, CTs, positron-emission tomography scans, and potentially other modalities, to disclose to patients in writing if they have ownership in the imaging facility.

The proposal was initially included in the bill that canceled Medicare physician fee cuts but was dropped in the final package.

The GAO analyzed Medicare claims data and also interviewed health plans and radiology benefit management companies to compile its report, which was requested by Sen. Jay Rockefeller (D-W.Va.).

Because of the rapid growth in imaging, the GAO said, “we recommend that [the Centers for Medicare and Medicaid Services] examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

The proportion of Medicare Part B spending on imaging conducted in a physician office setting, which was 58% in 2000, rose to 64% in 2006, according to the GAO, which noted that physician-directed imaging has grown. (See Policy & Practice, p. 19.)

“The rise in testing and therefore in cost for outpatient imaging is a symptom of our broken health care system,” said Dr. Elaine Jones, a neurologist in private practice in Bristol, R.I, and a member of the legislative affairs committee of the American Association of Neurology.

“Instituting prior authorization is just a cost-shifting measure. It shifts cost to patients and risks to physicians. Most of these measures do not include reward systems, only regulations. Insurance companies, including Medicare, are looking for ways to save money,” she said.

The American College of Cardiology also criticized the GAO study, noting that the agency did not use data showing a decline in imaging growth in 2007. (See also p. 19.)

“We are disappointed that the GAO chose to ignore the work that physicians and specialty societies are doing to ensure the most appropriate use of these technologies,” the college's CEO, Dr. Jack Lewin, said in a statement. “Prior authorization is a Band-Aid to the utilization issue and not a viable solution. Medicare should look to accreditation, appropriate use criteria, and improved communication to lower utilization and improve quality.”

Dr. Jones said that, as always, “the response is 'if costs are increasing, we need to stop paying.' If a patient comes to me with pain, I don't just give them a pain pill. I try to find the cause of the pain and address that. In the same way, we need to look at why costs are rising, and not just refuse to pay.”

The Medical Imaging Technology Alliance (MITA) issued a similar critique, and noted that the GAO report did not take into account appropriateness and accreditation criteria that were part of the recently passed Medicare bill that eliminated a scheduled reduction in physician fees. The law will require imaging facilities to be accredited starting in 2012.

Appropriateness and accreditation will “ensure that an image is taken at the right time by the right person and in an appropriate manner,” MITA vice president Andrew Whitman said in an interview. MITA is the medical technology trade association of the National Electrical Manufacturers Association.

He also criticized the GAO's support of radiology benefit management companies (RBMs), which the private sector has used to implement prior authorization and other tools to rein in costs. RBMs do not readily share guidelines and appropriateness criteria and are not well regulated, he said.

In response to the GAO report, the Health and Human Services Department said it also had concerns about the “administrative burden” of using RBMs, and it pointed out that there were no independent data showing that RBMs could successfully manage imaging costs. It added that proprietary guidelines in use by RBMs might conflict with those being promoted by federal health authorities, meaning that the RBM recommendations could present a conflict for Medicare in the consideration of payment.

One RBM, MedSolutions, praised the GAO study and refuted assertions that the companies added a layer of cost or bureaucratic burden. The Nashville, Tenn.-based company also said that its clients have found its approach to be successful.

“Our administrative costs are typically a small fraction of documented savings, and it is standard practice for us to operate with complete transparency with physicians and patients,” MedSolutions CEO Curt Thorne said in a statement.

Accreditation and appropriate use criteria would be more effective in reducing imaging, say some physicians. ©Stockbyte/Getty Images

The Government Accountability Office is urging Congress to require Medicare to adopt prior authorization procedures for outpatient imaging services, saying that the federal health program's current approach has allowed costs to balloon.

According to the GAO, from 2000 to 2006, Medicare Part B spending on imaging services more than doubled to $14 billion. In particular, spending on more technically demanding imaging studies, such as CT, MRI, and nuclear medicine, rose 17% a year, compared with 9% annual growth for less complex studies such as x-rays. Imaging studies have increasingly shifted to the outpatient sector and the proportion of physician income from imaging is steadily rising, said the GAO in its report, “Medicare Part B Imaging Services.”

Shortly after the report was issued, Sen. Charles Grassley (R-Iowa), introduced legislation (S. 3343) that would require physicians making referrals for MRIs, CTs, positron-emission tomography scans, and potentially other modalities, to disclose to patients in writing if they have ownership in the imaging facility.

The proposal was initially included in the bill that canceled Medicare physician fee cuts but was dropped in the final package.

The GAO analyzed Medicare claims data and also interviewed health plans and radiology benefit management companies to compile its report, which was requested by Sen. Jay Rockefeller (D-W.Va.).

Because of the rapid growth in imaging, the GAO said, “we recommend that [the Centers for Medicare and Medicaid Services] examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

The proportion of Medicare Part B spending on imaging conducted in a physician office setting, which was 58% in 2000, rose to 64% in 2006, according to the GAO, which noted that physician-directed imaging has grown. (See Policy & Practice, p. 19.)

“The rise in testing and therefore in cost for outpatient imaging is a symptom of our broken health care system,” said Dr. Elaine Jones, a neurologist in private practice in Bristol, R.I, and a member of the legislative affairs committee of the American Association of Neurology.

“Instituting prior authorization is just a cost-shifting measure. It shifts cost to patients and risks to physicians. Most of these measures do not include reward systems, only regulations. Insurance companies, including Medicare, are looking for ways to save money,” she said.

The American College of Cardiology also criticized the GAO study, noting that the agency did not use data showing a decline in imaging growth in 2007. (See also p. 19.)

“We are disappointed that the GAO chose to ignore the work that physicians and specialty societies are doing to ensure the most appropriate use of these technologies,” the college's CEO, Dr. Jack Lewin, said in a statement. “Prior authorization is a Band-Aid to the utilization issue and not a viable solution. Medicare should look to accreditation, appropriate use criteria, and improved communication to lower utilization and improve quality.”

Dr. Jones said that, as always, “the response is 'if costs are increasing, we need to stop paying.' If a patient comes to me with pain, I don't just give them a pain pill. I try to find the cause of the pain and address that. In the same way, we need to look at why costs are rising, and not just refuse to pay.”

The Medical Imaging Technology Alliance (MITA) issued a similar critique, and noted that the GAO report did not take into account appropriateness and accreditation criteria that were part of the recently passed Medicare bill that eliminated a scheduled reduction in physician fees. The law will require imaging facilities to be accredited starting in 2012.

Appropriateness and accreditation will “ensure that an image is taken at the right time by the right person and in an appropriate manner,” MITA vice president Andrew Whitman said in an interview. MITA is the medical technology trade association of the National Electrical Manufacturers Association.

He also criticized the GAO's support of radiology benefit management companies (RBMs), which the private sector has used to implement prior authorization and other tools to rein in costs. RBMs do not readily share guidelines and appropriateness criteria and are not well regulated, he said.

In response to the GAO report, the Health and Human Services Department said it also had concerns about the “administrative burden” of using RBMs, and it pointed out that there were no independent data showing that RBMs could successfully manage imaging costs. It added that proprietary guidelines in use by RBMs might conflict with those being promoted by federal health authorities, meaning that the RBM recommendations could present a conflict for Medicare in the consideration of payment.

One RBM, MedSolutions, praised the GAO study and refuted assertions that the companies added a layer of cost or bureaucratic burden. The Nashville, Tenn.-based company also said that its clients have found its approach to be successful.

“Our administrative costs are typically a small fraction of documented savings, and it is standard practice for us to operate with complete transparency with physicians and patients,” MedSolutions CEO Curt Thorne said in a statement.

Accreditation and appropriate use criteria would be more effective in reducing imaging, say some physicians. ©Stockbyte/Getty Images

WASHINGTON — Without pharmaceutical funding, continuing medical education could falter, judging from comments at a forum of CME providers and physicians. The forum was sponsored by the Center for Medicine in the Public Interest, a New York-based nonprofit organization, and the Coalition for Healthcare Communication, an umbrella group for advertising agencies and medical journal publishers.

The meeting was called in response to numerous efforts from legislators and accrediting organizations for greater accountability for CME funding. In July, a task force of the Association of American Medical Colleges said that academic medical centers should discourage faculty participation in industry-sponsored speakers bureaus. A month earlier, the Accreditation Council for CME proposed tightening restrictions on commercial support of CME, and possibly banning industry funding.

“CME in the U.S. is a great success story,” said Dr. George Lundberg, a former editor of JAMA and current editor-in-chief at Medscape. CME changes knowledge, skills, and patient outcomes, he said, adding that surveys have shown that physicians are in favor of industry support.

Dr. Michael Weber, a professor of medicine at the State University of New York, Brooklyn, said that he views pharmaceutical funding of CME as a mandate, “not a luxury.” Manufacturers must educate clinicians on how to use their products, he said.

Dr. Jack Lewin, CEO of the American College of Cardiology, said that without industry funding, it would cost the ACC $2,000–$3,000 more per attendee at its annual meeting. The ACC already removes conflicts of interest from its professional and educational programs, and discloses industry funding on its Web site.

About a third of that organization's $97 million annual budget comes from outside sources ($35 million), and 21% of that is from charitable contributions, he said.

Public Citizen's Health Research Group, in comments sent to the ACCME on its proposal to limit or ban industry support of CME, said, “Despite a quadrupling of commercial support for CME over the past 10 years, in 2007, the percentage of CME income provided by commercial interests actually decreased to 2002 levels.”

Public Citizen advocates an end to commercially funded CME. “Shifting the burden of funding toward physicians (not exactly a group occupying the lower rungs of the earning ladder) would attenuate the effect of lost revenue.”

Drugmakers to Disclose Doctor Payments

Two pharmaceutical companies will begin publicly disclosing how much each pays physicians.

Eli Lilly & Co. was the first company to step forward, followed a day later by Merck & Co.

Lilly is starting a registry that will compile payments to physicians who have served as speakers or advisers for the company. It will be available to the public on the company's Web site as early as the second half of 2009, Lilly officials said in a statement. The registry will be updated each year to reflect the previous year's payments.

Lilly said that by 2011, it aims to report whatever is required under the proposed Physician Payments Sunshine Act. That bill (S. 2029) was introduced by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.) in November 2007. As currently written, it would require manufacturers of pharmaceuticals, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, and travel. Product samples for patients would be excluded.

The bill was endorsed by several major drug companies, including Lilly and Merck; the Pharmaceutical Research and Manufacturers of America; the Advanced Medical Technology Association; and the Association of American Medical Colleges, among others. But it has not had any movement since its introduction.

In a statement, Sen. Kohl congratulated Lilly, saying the company was “fulfilling the obligations of the Physician Payments Sunshine Act before it has been enacted.”

Merck said that it will start disclosing the grants to patient organizations, professional societies, and others for “independent professional education initiatives,” which would include continuing medical education. Next year, it will include other grants made by the Merck Company Foundation and the Merck Office of Corporate Contributions. The information will be posted on its Web site.

In 2009, Merck will also start disclosing payments to physicians on its speakers bureau.

WASHINGTON — Without pharmaceutical funding, continuing medical education could falter, judging from comments at a forum of CME providers and physicians. The forum was sponsored by the Center for Medicine in the Public Interest, a New York-based nonprofit organization, and the Coalition for Healthcare Communication, an umbrella group for advertising agencies and medical journal publishers.

The meeting was called in response to numerous efforts from legislators and accrediting organizations for greater accountability for CME funding. In July, a task force of the Association of American Medical Colleges said that academic medical centers should discourage faculty participation in industry-sponsored speakers bureaus. A month earlier, the Accreditation Council for CME proposed tightening restrictions on commercial support of CME, and possibly banning industry funding.

“CME in the U.S. is a great success story,” said Dr. George Lundberg, a former editor of JAMA and current editor-in-chief at Medscape. CME changes knowledge, skills, and patient outcomes, he said, adding that surveys have shown that physicians are in favor of industry support.

Dr. Michael Weber, a professor of medicine at the State University of New York, Brooklyn, said that he views pharmaceutical funding of CME as a mandate, “not a luxury.” Manufacturers must educate clinicians on how to use their products, he said.

Dr. Jack Lewin, CEO of the American College of Cardiology, said that without industry funding, it would cost the ACC $2,000–$3,000 more per attendee at its annual meeting. The ACC already removes conflicts of interest from its professional and educational programs, and discloses industry funding on its Web site.

About a third of that organization's $97 million annual budget comes from outside sources ($35 million), and 21% of that is from charitable contributions, he said.

Public Citizen's Health Research Group, in comments sent to the ACCME on its proposal to limit or ban industry support of CME, said, “Despite a quadrupling of commercial support for CME over the past 10 years, in 2007, the percentage of CME income provided by commercial interests actually decreased to 2002 levels.”

Public Citizen advocates an end to commercially funded CME. “Shifting the burden of funding toward physicians (not exactly a group occupying the lower rungs of the earning ladder) would attenuate the effect of lost revenue.”

Drugmakers to Disclose Doctor Payments

Two pharmaceutical companies will begin publicly disclosing how much each pays physicians.

Eli Lilly & Co. was the first company to step forward, followed a day later by Merck & Co.

Lilly is starting a registry that will compile payments to physicians who have served as speakers or advisers for the company. It will be available to the public on the company's Web site as early as the second half of 2009, Lilly officials said in a statement. The registry will be updated each year to reflect the previous year's payments.

Lilly said that by 2011, it aims to report whatever is required under the proposed Physician Payments Sunshine Act. That bill (S. 2029) was introduced by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.) in November 2007. As currently written, it would require manufacturers of pharmaceuticals, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, and travel. Product samples for patients would be excluded.

The bill was endorsed by several major drug companies, including Lilly and Merck; the Pharmaceutical Research and Manufacturers of America; the Advanced Medical Technology Association; and the Association of American Medical Colleges, among others. But it has not had any movement since its introduction.

In a statement, Sen. Kohl congratulated Lilly, saying the company was “fulfilling the obligations of the Physician Payments Sunshine Act before it has been enacted.”

Merck said that it will start disclosing the grants to patient organizations, professional societies, and others for “independent professional education initiatives,” which would include continuing medical education. Next year, it will include other grants made by the Merck Company Foundation and the Merck Office of Corporate Contributions. The information will be posted on its Web site.

In 2009, Merck will also start disclosing payments to physicians on its speakers bureau.

WASHINGTON — Without pharmaceutical funding, continuing medical education could falter, judging from comments at a forum of CME providers and physicians. The forum was sponsored by the Center for Medicine in the Public Interest, a New York-based nonprofit organization, and the Coalition for Healthcare Communication, an umbrella group for advertising agencies and medical journal publishers.

The meeting was called in response to numerous efforts from legislators and accrediting organizations for greater accountability for CME funding. In July, a task force of the Association of American Medical Colleges said that academic medical centers should discourage faculty participation in industry-sponsored speakers bureaus. A month earlier, the Accreditation Council for CME proposed tightening restrictions on commercial support of CME, and possibly banning industry funding.

“CME in the U.S. is a great success story,” said Dr. George Lundberg, a former editor of JAMA and current editor-in-chief at Medscape. CME changes knowledge, skills, and patient outcomes, he said, adding that surveys have shown that physicians are in favor of industry support.

Dr. Michael Weber, a professor of medicine at the State University of New York, Brooklyn, said that he views pharmaceutical funding of CME as a mandate, “not a luxury.” Manufacturers must educate clinicians on how to use their products, he said.

Dr. Jack Lewin, CEO of the American College of Cardiology, said that without industry funding, it would cost the ACC $2,000–$3,000 more per attendee at its annual meeting. The ACC already removes conflicts of interest from its professional and educational programs, and discloses industry funding on its Web site.

About a third of that organization's $97 million annual budget comes from outside sources ($35 million), and 21% of that is from charitable contributions, he said.

Public Citizen's Health Research Group, in comments sent to the ACCME on its proposal to limit or ban industry support of CME, said, “Despite a quadrupling of commercial support for CME over the past 10 years, in 2007, the percentage of CME income provided by commercial interests actually decreased to 2002 levels.”

Public Citizen advocates an end to commercially funded CME. “Shifting the burden of funding toward physicians (not exactly a group occupying the lower rungs of the earning ladder) would attenuate the effect of lost revenue.”

Drugmakers to Disclose Doctor Payments

Two pharmaceutical companies will begin publicly disclosing how much each pays physicians.

Eli Lilly & Co. was the first company to step forward, followed a day later by Merck & Co.

Lilly is starting a registry that will compile payments to physicians who have served as speakers or advisers for the company. It will be available to the public on the company's Web site as early as the second half of 2009, Lilly officials said in a statement. The registry will be updated each year to reflect the previous year's payments.

Lilly said that by 2011, it aims to report whatever is required under the proposed Physician Payments Sunshine Act. That bill (S. 2029) was introduced by Sen. Chuck Grassley (R-Iowa) and Sen. Herb Kohl (D-Wis.) in November 2007. As currently written, it would require manufacturers of pharmaceuticals, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, and travel. Product samples for patients would be excluded.

The bill was endorsed by several major drug companies, including Lilly and Merck; the Pharmaceutical Research and Manufacturers of America; the Advanced Medical Technology Association; and the Association of American Medical Colleges, among others. But it has not had any movement since its introduction.

In a statement, Sen. Kohl congratulated Lilly, saying the company was “fulfilling the obligations of the Physician Payments Sunshine Act before it has been enacted.”

Merck said that it will start disclosing the grants to patient organizations, professional societies, and others for “independent professional education initiatives,” which would include continuing medical education. Next year, it will include other grants made by the Merck Company Foundation and the Merck Office of Corporate Contributions. The information will be posted on its Web site.

In 2009, Merck will also start disclosing payments to physicians on its speakers bureau.

The Food and Drug Administration said last month it would not allow generic drugs made by Ranbaxy Laboratories Ltd. at two of its Indian manufacturing plants to cross U.S. borders, citing an extensive history of manufacturing violations at those facilities.

According to the FDA the “import alert” covers 30 drugs made at Ranbaxy's Dewas and Paonta Sahib manufacturing plants, including simvastatin, fenofibrate, gabapentin, metformin HCl, ranitidine, and acyclovir.

Such a wide-ranging shutdown is not common for violations of “good manufacturing practices.” But in a teleconference with reporters, Deborah M. Autor, director at the FDA's Center for Drug Evaluation and Research Office of Compliance, said the alert and two warnings letters were issued because of the seriousness of the manufacturing violations and the company's lack of quick and appropriate actions.

Consumers were advised not to discontinue any generic medication, even if it was manufactured by Ranbaxy, because of the agency's testing and the lack of adverse event reports relating to the products, said Douglas Throckmorton, deputy director of the CDER, in the teleconference.

The FDA began investigating in 2005 after it received reports of manufacturing violations and allegations of potential fraudulent activity at the Dewas and Paonta Sahib plants, said Ms. Autor. The agency documented significant violations of its good manufacturing practices (GMP) rules during inspections conducted in 2006.

Inspections of both plants early this year once again found significant violations. At the Dewas plant, the FDA cited the potential for cross-contamination from the facility's ?-lactam manufacturing process, inadequate batch production and control records, inadequate failure investigations, and inadequate aseptic (sterile) processing operations.

The agency cited the Paonta Sahib plant for a lack of assurance that responsible individuals were present to determine the firm was following GMP rules, inaccurate written records of the cleaning and use of major equipment, incomplete batch production and control records, and inadequate procedures for the review and approval of production and control records.

Ranbaxy has also been under criminal investigation by the U.S. Department of Justice for alleged fraud relating to several of its FDA approvals.

The Food and Drug Administration said last month it would not allow generic drugs made by Ranbaxy Laboratories Ltd. at two of its Indian manufacturing plants to cross U.S. borders, citing an extensive history of manufacturing violations at those facilities.

According to the FDA the “import alert” covers 30 drugs made at Ranbaxy's Dewas and Paonta Sahib manufacturing plants, including simvastatin, fenofibrate, gabapentin, metformin HCl, ranitidine, and acyclovir.

Such a wide-ranging shutdown is not common for violations of “good manufacturing practices.” But in a teleconference with reporters, Deborah M. Autor, director at the FDA's Center for Drug Evaluation and Research Office of Compliance, said the alert and two warnings letters were issued because of the seriousness of the manufacturing violations and the company's lack of quick and appropriate actions.

Consumers were advised not to discontinue any generic medication, even if it was manufactured by Ranbaxy, because of the agency's testing and the lack of adverse event reports relating to the products, said Douglas Throckmorton, deputy director of the CDER, in the teleconference.

The FDA began investigating in 2005 after it received reports of manufacturing violations and allegations of potential fraudulent activity at the Dewas and Paonta Sahib plants, said Ms. Autor. The agency documented significant violations of its good manufacturing practices (GMP) rules during inspections conducted in 2006.

Inspections of both plants early this year once again found significant violations. At the Dewas plant, the FDA cited the potential for cross-contamination from the facility's ?-lactam manufacturing process, inadequate batch production and control records, inadequate failure investigations, and inadequate aseptic (sterile) processing operations.

The agency cited the Paonta Sahib plant for a lack of assurance that responsible individuals were present to determine the firm was following GMP rules, inaccurate written records of the cleaning and use of major equipment, incomplete batch production and control records, and inadequate procedures for the review and approval of production and control records.

Ranbaxy has also been under criminal investigation by the U.S. Department of Justice for alleged fraud relating to several of its FDA approvals.

The Food and Drug Administration said last month it would not allow generic drugs made by Ranbaxy Laboratories Ltd. at two of its Indian manufacturing plants to cross U.S. borders, citing an extensive history of manufacturing violations at those facilities.

According to the FDA the “import alert” covers 30 drugs made at Ranbaxy's Dewas and Paonta Sahib manufacturing plants, including simvastatin, fenofibrate, gabapentin, metformin HCl, ranitidine, and acyclovir.

Such a wide-ranging shutdown is not common for violations of “good manufacturing practices.” But in a teleconference with reporters, Deborah M. Autor, director at the FDA's Center for Drug Evaluation and Research Office of Compliance, said the alert and two warnings letters were issued because of the seriousness of the manufacturing violations and the company's lack of quick and appropriate actions.

Consumers were advised not to discontinue any generic medication, even if it was manufactured by Ranbaxy, because of the agency's testing and the lack of adverse event reports relating to the products, said Douglas Throckmorton, deputy director of the CDER, in the teleconference.

The FDA began investigating in 2005 after it received reports of manufacturing violations and allegations of potential fraudulent activity at the Dewas and Paonta Sahib plants, said Ms. Autor. The agency documented significant violations of its good manufacturing practices (GMP) rules during inspections conducted in 2006.

Inspections of both plants early this year once again found significant violations. At the Dewas plant, the FDA cited the potential for cross-contamination from the facility's ?-lactam manufacturing process, inadequate batch production and control records, inadequate failure investigations, and inadequate aseptic (sterile) processing operations.

The agency cited the Paonta Sahib plant for a lack of assurance that responsible individuals were present to determine the firm was following GMP rules, inaccurate written records of the cleaning and use of major equipment, incomplete batch production and control records, and inadequate procedures for the review and approval of production and control records.

Ranbaxy has also been under criminal investigation by the U.S. Department of Justice for alleged fraud relating to several of its FDA approvals.

ACC Says Quality Is Job #1

The American College of Cardiology has launched a preemptive strike in the likely upcoming battle for health reform. The organization and 300 member-cardiologists spent a day last month lobbying Capitol Hill, armed with ACC's new QualityFirst campaign and evidence that cardiologists are already collecting quality data and crunching numbers to improve care. The QualityFirst campaign, which will be focused inside the Beltway, backs cost-effective, quality care; payment incentives; increased transparency; and coordination across care sites. “The current system and its focus on quantity, not quality, is unsustainable,” said Dr. W. Douglas Weaver, ACC president, at a press briefing. The ACC also shared results of a poll of 1,003 likely voters conducted for the organization. Eighty-six percent of respondents said they'd trust physicians or medical or patient advocacy groups to set quality standards. In addition, 83% agreed that ACC's QualityFirst objectives were extremely or very important, and 64% said the organization's top priority should be setting new standards for health reform.

CMS Proposes Denial of CAS

The Centers for Medicare and Medicaid Services has proposed to keep the status quo—no coverage—of percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting. The ACC, the Society for Vascular Medicine, and the Society of Vascular Interventional Neurology had asked the agency to reconsider and add coverage for patients who are at high risk for carotid endarterectomy because of defined anatomic factors, and who have symptomatic carotid artery stenosis of 50%-90% or greater or asymptomatic carotid artery stenosis of at least 80%. In comments on the proposed decision, the organizations again argued for coverage, citing “compelling scientific evidence” that revascularization prevents stroke, compared with medical therapy. “CMS should not require that CAS be superior to [carotid endarterectomy] to consider it a valid treatment option,” according to the groups.

CMS Alters Overpayment Policy

CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the agency can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect Sept. 29, apply to most Part A and Part B claims for which a demand letter has been issued. The changes do not affect the appeal process or the normal debt collection and referral process, according to the CMS.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

ACC Says Quality Is Job #1

The American College of Cardiology has launched a preemptive strike in the likely upcoming battle for health reform. The organization and 300 member-cardiologists spent a day last month lobbying Capitol Hill, armed with ACC's new QualityFirst campaign and evidence that cardiologists are already collecting quality data and crunching numbers to improve care. The QualityFirst campaign, which will be focused inside the Beltway, backs cost-effective, quality care; payment incentives; increased transparency; and coordination across care sites. “The current system and its focus on quantity, not quality, is unsustainable,” said Dr. W. Douglas Weaver, ACC president, at a press briefing. The ACC also shared results of a poll of 1,003 likely voters conducted for the organization. Eighty-six percent of respondents said they'd trust physicians or medical or patient advocacy groups to set quality standards. In addition, 83% agreed that ACC's QualityFirst objectives were extremely or very important, and 64% said the organization's top priority should be setting new standards for health reform.

CMS Proposes Denial of CAS

The Centers for Medicare and Medicaid Services has proposed to keep the status quo—no coverage—of percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting. The ACC, the Society for Vascular Medicine, and the Society of Vascular Interventional Neurology had asked the agency to reconsider and add coverage for patients who are at high risk for carotid endarterectomy because of defined anatomic factors, and who have symptomatic carotid artery stenosis of 50%-90% or greater or asymptomatic carotid artery stenosis of at least 80%. In comments on the proposed decision, the organizations again argued for coverage, citing “compelling scientific evidence” that revascularization prevents stroke, compared with medical therapy. “CMS should not require that CAS be superior to [carotid endarterectomy] to consider it a valid treatment option,” according to the groups.

CMS Alters Overpayment Policy

CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the agency can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect Sept. 29, apply to most Part A and Part B claims for which a demand letter has been issued. The changes do not affect the appeal process or the normal debt collection and referral process, according to the CMS.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

ACC Says Quality Is Job #1

The American College of Cardiology has launched a preemptive strike in the likely upcoming battle for health reform. The organization and 300 member-cardiologists spent a day last month lobbying Capitol Hill, armed with ACC's new QualityFirst campaign and evidence that cardiologists are already collecting quality data and crunching numbers to improve care. The QualityFirst campaign, which will be focused inside the Beltway, backs cost-effective, quality care; payment incentives; increased transparency; and coordination across care sites. “The current system and its focus on quantity, not quality, is unsustainable,” said Dr. W. Douglas Weaver, ACC president, at a press briefing. The ACC also shared results of a poll of 1,003 likely voters conducted for the organization. Eighty-six percent of respondents said they'd trust physicians or medical or patient advocacy groups to set quality standards. In addition, 83% agreed that ACC's QualityFirst objectives were extremely or very important, and 64% said the organization's top priority should be setting new standards for health reform.

CMS Proposes Denial of CAS

The Centers for Medicare and Medicaid Services has proposed to keep the status quo—no coverage—of percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting. The ACC, the Society for Vascular Medicine, and the Society of Vascular Interventional Neurology had asked the agency to reconsider and add coverage for patients who are at high risk for carotid endarterectomy because of defined anatomic factors, and who have symptomatic carotid artery stenosis of 50%-90% or greater or asymptomatic carotid artery stenosis of at least 80%. In comments on the proposed decision, the organizations again argued for coverage, citing “compelling scientific evidence” that revascularization prevents stroke, compared with medical therapy. “CMS should not require that CAS be superior to [carotid endarterectomy] to consider it a valid treatment option,” according to the groups.

CMS Alters Overpayment Policy

CMS will no longer seek payment from a physician for an overpayment while the physician is seeking a reconsideration of the overpayment determination by a qualified independent contractor. Under the new policy, which was mandated by the 2003 Medicare Modernization Act, the agency can only seek to recoup the payment after a decision has been made on the reconsideration. The changes, which went into effect Sept. 29, apply to most Part A and Part B claims for which a demand letter has been issued. The changes do not affect the appeal process or the normal debt collection and referral process, according to the CMS.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

The Government Accountability Office is urging Congress to require Medicare to adopt prior authorization procedures for outpatient imaging services, saying that the federal health program's current approach has allowed costs to balloon.

According to the GAO, from 2000 to 2006, Medicare Part B spending on imaging services more than doubled to $14 billion. In particular, spending on more technically demanding imaging studies, such as computed tomography, magnetic resonance imaging, and nuclear medicine, rose 17% a year, compared with 9% annual growth for less complex studies such as x-rays. Imaging studies have increasingly shifted to the outpatient sector and the proportion of physician income from imaging is steadily rising, said the GAO in its report, “Medicare Part B Imaging Services.”

Shortly after the report was issued, Sen. Charles Grassley (R-Iowa), introduced legislation (S. 3343) that would require physicians making referrals for MRIs, CTs, PET scans, and potentially other modalities, to disclose to patients in writing if they have ownership in the imaging facility. The proposal was initially included in the bill that canceled Medicare physician fee cuts but was dropped in the final package.

The GAO analyzed Medicare claims data and also interviewed health plans and radiology benefit management companies to compile its report, which was requested by Sen. Jay Rockefeller (D-W.Va.).

Because of the rapid growth in imaging, the GAO said, “we recommend that [the Centers for Medicare and Medicaid Services] examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

The proportion of Medicare Part B spending on imaging conducted in a physician office setting, which was 58% in 2000, rose to 64% in 2006, according to the GAO. Physician-directed imaging has grown especially in cardiology, according to the GAO report. “In 2006, cardiologists obtained 36% of their total Medicare revenue from in-office imaging, compared with 23% in 2000.”

By comparison, the proportion of income coming from use of imaging by vascular surgeons—who had the second-highest growth rate—increased from 10% in 2000 to 19% in 2006.

The American College of Cardiology criticized the GAO study, noting that “the agency did not take into account physician input, nor did it use data from 2007 showing a decline in imaging growth.”

“While the American College of Cardiology does not dispute the rapid growth in medical imaging, we are disappointed that the GAO chose to ignore the work that physicians and specialty societies are doing to ensure the most appropriate use of these technologies,” the college's CEO, Dr. Jack Lewin, said in a statement. “Prior authorization is a Band-Aid to the utilization issue and not a viable solution. Medicare should look to accreditation, appropriate use criteria, and improved communication to lower utilization and improve quality.”

The Medical Imaging Technology Alliance (MITA) issued a similar critique, and noted that the GAO report did not take into account appropriateness and accreditation criteria that were part of the just-passed Medicare bill that eliminated a scheduled reduction in physician fees. The law will require imaging facilities to be accredited starting in 2012.

Appropriateness and accreditation will “ensure that an image is taken at the right time by the right person and in an appropriate manner,” MITA vice president Andrew Whitman said in an interview. MITA is the medical technology trade association of the National Electrical Manufacturers Association.

Mr. Whitman also criticized the GAO's support of radiology benefit management companies (RBMs), which the private sector has used to implement prior authorization and other tools to rein in costs. RBMs do not readily share guidelines and appropriateness criteria and are not well regulated, Mr. Whitman said.

In response to the GAO report, the Health and Human Services department said it, too, had concerns about the “administrative burden” of using RBMs, “as well as the advisability of prior authorization for the Medicare program,” according to the report. HHS pointed out that there were no independent data showing that RBMs could successfully manage imaging costs. The agency also said that proprietary guidelines in use by RBMs might conflict with those being promoted by federal health authorities. Thus the RBM recommendations could present a conflict for Medicare when considering payment, said HHS.

“We do not dispute HHS's reservations about prior authorization, and agree that these concerns will require careful examination within the context of Medicare statutes and regulations,” said the GAO report.

The GAO ignored the work of physicians' groups in developing appropriate use criteria, said the ACC. ©Stockbyte/Getty Images

The Government Accountability Office is urging Congress to require Medicare to adopt prior authorization procedures for outpatient imaging services, saying that the federal health program's current approach has allowed costs to balloon.

According to the GAO, from 2000 to 2006, Medicare Part B spending on imaging services more than doubled to $14 billion. In particular, spending on more technically demanding imaging studies, such as computed tomography, magnetic resonance imaging, and nuclear medicine, rose 17% a year, compared with 9% annual growth for less complex studies such as x-rays. Imaging studies have increasingly shifted to the outpatient sector and the proportion of physician income from imaging is steadily rising, said the GAO in its report, “Medicare Part B Imaging Services.”

Shortly after the report was issued, Sen. Charles Grassley (R-Iowa), introduced legislation (S. 3343) that would require physicians making referrals for MRIs, CTs, PET scans, and potentially other modalities, to disclose to patients in writing if they have ownership in the imaging facility. The proposal was initially included in the bill that canceled Medicare physician fee cuts but was dropped in the final package.

The GAO analyzed Medicare claims data and also interviewed health plans and radiology benefit management companies to compile its report, which was requested by Sen. Jay Rockefeller (D-W.Va.).

Because of the rapid growth in imaging, the GAO said, “we recommend that [the Centers for Medicare and Medicaid Services] examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

The proportion of Medicare Part B spending on imaging conducted in a physician office setting, which was 58% in 2000, rose to 64% in 2006, according to the GAO. Physician-directed imaging has grown especially in cardiology, according to the GAO report. “In 2006, cardiologists obtained 36% of their total Medicare revenue from in-office imaging, compared with 23% in 2000.”

By comparison, the proportion of income coming from use of imaging by vascular surgeons—who had the second-highest growth rate—increased from 10% in 2000 to 19% in 2006.

The American College of Cardiology criticized the GAO study, noting that “the agency did not take into account physician input, nor did it use data from 2007 showing a decline in imaging growth.”

“While the American College of Cardiology does not dispute the rapid growth in medical imaging, we are disappointed that the GAO chose to ignore the work that physicians and specialty societies are doing to ensure the most appropriate use of these technologies,” the college's CEO, Dr. Jack Lewin, said in a statement. “Prior authorization is a Band-Aid to the utilization issue and not a viable solution. Medicare should look to accreditation, appropriate use criteria, and improved communication to lower utilization and improve quality.”

The Medical Imaging Technology Alliance (MITA) issued a similar critique, and noted that the GAO report did not take into account appropriateness and accreditation criteria that were part of the just-passed Medicare bill that eliminated a scheduled reduction in physician fees. The law will require imaging facilities to be accredited starting in 2012.

Appropriateness and accreditation will “ensure that an image is taken at the right time by the right person and in an appropriate manner,” MITA vice president Andrew Whitman said in an interview. MITA is the medical technology trade association of the National Electrical Manufacturers Association.

Mr. Whitman also criticized the GAO's support of radiology benefit management companies (RBMs), which the private sector has used to implement prior authorization and other tools to rein in costs. RBMs do not readily share guidelines and appropriateness criteria and are not well regulated, Mr. Whitman said.

In response to the GAO report, the Health and Human Services department said it, too, had concerns about the “administrative burden” of using RBMs, “as well as the advisability of prior authorization for the Medicare program,” according to the report. HHS pointed out that there were no independent data showing that RBMs could successfully manage imaging costs. The agency also said that proprietary guidelines in use by RBMs might conflict with those being promoted by federal health authorities. Thus the RBM recommendations could present a conflict for Medicare when considering payment, said HHS.

“We do not dispute HHS's reservations about prior authorization, and agree that these concerns will require careful examination within the context of Medicare statutes and regulations,” said the GAO report.

The GAO ignored the work of physicians' groups in developing appropriate use criteria, said the ACC. ©Stockbyte/Getty Images

The Government Accountability Office is urging Congress to require Medicare to adopt prior authorization procedures for outpatient imaging services, saying that the federal health program's current approach has allowed costs to balloon.

According to the GAO, from 2000 to 2006, Medicare Part B spending on imaging services more than doubled to $14 billion. In particular, spending on more technically demanding imaging studies, such as computed tomography, magnetic resonance imaging, and nuclear medicine, rose 17% a year, compared with 9% annual growth for less complex studies such as x-rays. Imaging studies have increasingly shifted to the outpatient sector and the proportion of physician income from imaging is steadily rising, said the GAO in its report, “Medicare Part B Imaging Services.”

Shortly after the report was issued, Sen. Charles Grassley (R-Iowa), introduced legislation (S. 3343) that would require physicians making referrals for MRIs, CTs, PET scans, and potentially other modalities, to disclose to patients in writing if they have ownership in the imaging facility. The proposal was initially included in the bill that canceled Medicare physician fee cuts but was dropped in the final package.

The GAO analyzed Medicare claims data and also interviewed health plans and radiology benefit management companies to compile its report, which was requested by Sen. Jay Rockefeller (D-W.Va.).

Because of the rapid growth in imaging, the GAO said, “we recommend that [the Centers for Medicare and Medicaid Services] examine the feasibility of expanding its payment safeguard mechanisms by adding more front-end approaches to managing imaging services, such as using privileging and prior authorization.”

The proportion of Medicare Part B spending on imaging conducted in a physician office setting, which was 58% in 2000, rose to 64% in 2006, according to the GAO. Physician-directed imaging has grown especially in cardiology, according to the GAO report. “In 2006, cardiologists obtained 36% of their total Medicare revenue from in-office imaging, compared with 23% in 2000.”

By comparison, the proportion of income coming from use of imaging by vascular surgeons—who had the second-highest growth rate—increased from 10% in 2000 to 19% in 2006.

The American College of Cardiology criticized the GAO study, noting that “the agency did not take into account physician input, nor did it use data from 2007 showing a decline in imaging growth.”

“While the American College of Cardiology does not dispute the rapid growth in medical imaging, we are disappointed that the GAO chose to ignore the work that physicians and specialty societies are doing to ensure the most appropriate use of these technologies,” the college's CEO, Dr. Jack Lewin, said in a statement. “Prior authorization is a Band-Aid to the utilization issue and not a viable solution. Medicare should look to accreditation, appropriate use criteria, and improved communication to lower utilization and improve quality.”

The Medical Imaging Technology Alliance (MITA) issued a similar critique, and noted that the GAO report did not take into account appropriateness and accreditation criteria that were part of the just-passed Medicare bill that eliminated a scheduled reduction in physician fees. The law will require imaging facilities to be accredited starting in 2012.

Appropriateness and accreditation will “ensure that an image is taken at the right time by the right person and in an appropriate manner,” MITA vice president Andrew Whitman said in an interview. MITA is the medical technology trade association of the National Electrical Manufacturers Association.

Mr. Whitman also criticized the GAO's support of radiology benefit management companies (RBMs), which the private sector has used to implement prior authorization and other tools to rein in costs. RBMs do not readily share guidelines and appropriateness criteria and are not well regulated, Mr. Whitman said.

In response to the GAO report, the Health and Human Services department said it, too, had concerns about the “administrative burden” of using RBMs, “as well as the advisability of prior authorization for the Medicare program,” according to the report. HHS pointed out that there were no independent data showing that RBMs could successfully manage imaging costs. The agency also said that proprietary guidelines in use by RBMs might conflict with those being promoted by federal health authorities. Thus the RBM recommendations could present a conflict for Medicare when considering payment, said HHS.

“We do not dispute HHS's reservations about prior authorization, and agree that these concerns will require careful examination within the context of Medicare statutes and regulations,” said the GAO report.

The GAO ignored the work of physicians' groups in developing appropriate use criteria, said the ACC. ©Stockbyte/Getty Images

Psychologists OK Anti-Torture Policy

The American Psychological Association's membership has approved a resolution to prohibit psychologists from participating in interrogations. Once the policy becomes official at the APA's next annual meeting in August 2009, members will be restricted to working directly for detainees, for an independent third party to protect human rights, or to provide treatment to military personnel. The resolution was approved by 8,792 members; 6,157 voted against the measure. The American Civil Liberties Union and many psychologists had sought such a resolution for years. At the association's 2007 annual meeting, its membership adopted a weaker resolution that called on the U.S. government to ban 19 specific interrogation techniques. But it did not bar participation in those interrogations by psychologists.

Teva Loses Risperidone Exclusivity

Earlier this year, Teva Pharmaceutical Industries became the first company to sell generic risperidone, leading it to revise its sales and earnings estimates greatly upwards. But the U.S. Court of Appeals for the District of Columbia has vacated an April 2008 ruling that granted the company 6 months of marketing exclusivity for the generic, paving the way for other generic companies to release their versions. Mylan Inc., Par Pharmaceutical, Roxane, Ranbaxy Pharmaceuticals, Apotex Inc., and Pliva all have received tentative approval from the Food and Drug Administration for a generic formulation. Teva said it was seeking a stay of the decision, pending further appeals. The branded formation, Risperdal, had sales of just over $2 billion in 2007.

Media Influences Tobacco Use

Media communications–including movies, advertising, and news–play a key role in shaping tobacco use, according to a lengthy report from the National Cancer Institute. The report noted that cigarettes are among the most heavily marketed products in the United States, and that most of the cigarette industry's marketing budget is allocated to promotional activities, especially for price discounts, which accounted for 75% of the industry's $10 billion in total marketing expenditures in 2005. Depictions of cigarette smoking are pervasive in movies; they occur in three-quarters or more of contemporary box office hits, the NCI report said, adding that the weight of evidence indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. The report provides the government's strongest conclusion to date on the media's powerful and causal effect on tobacco use, Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, said in a statement.

Tobacco Control Support Drops

Budgets for tobacco control programs in most states are either staying level or declining despite increases in payments from the 1997 Tobacco Master Settlement Agreement, which was designed to compensate states for some of the cost of smoking-related illnesses, the American Lung Association reported. The passage of smoke-free air laws also has slowed down in most states, the ALA found. Only two states this year–Iowa and Nebraska–have approved legislation to strengthen existing laws. Activity on cigarette tax increases in 2008 also has been slower than in previous years, with only two states and the District of Columbia approving increases, according to the report. New York's increase in the cigarette tax is the highest, at $1.25 a pack, the ALA said.

CSPI Tries to Dampen Sparks

The Center for Science in the Public Interest has sued MillerCoors LLC to have its Sparks caffeinated alcoholic beverage taken off the market. In a suit filed in the Superior Court of the District of Columbia, the group said that at 6%-7% alcohol by volume, Sparks has more alcohol than beer (generally 4%-5% by volume) and that it contains unapproved additives such as caffeine and guarana, all wrapped in a sweet citrusy flavor that appeals to young people. “MillerCoors is trying to hook teens and tweens on a dangerous drink,” CSPI litigation director Steve Gardner in a statement. CSPI has won this battle before. In June, the group and 11 state attorneys general got Anheuser-Busch to agree to remove caffeine and other unapproved additives from its alcoholic energy drinks.

Pfizer Touts Its Drug Safety Site

Pfizer has launched a drug safety Web site for patients and physicians that is accessible through the company's home page,

www.pfizer.com

Grants to MDs in Hurricanes

The American Medical Association Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricanes Gustav and Ike, which hit parts of Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore medical practices in those locations, according to the AMA.

Psychologists OK Anti-Torture Policy

The American Psychological Association's membership has approved a resolution to prohibit psychologists from participating in interrogations. Once the policy becomes official at the APA's next annual meeting in August 2009, members will be restricted to working directly for detainees, for an independent third party to protect human rights, or to provide treatment to military personnel. The resolution was approved by 8,792 members; 6,157 voted against the measure. The American Civil Liberties Union and many psychologists had sought such a resolution for years. At the association's 2007 annual meeting, its membership adopted a weaker resolution that called on the U.S. government to ban 19 specific interrogation techniques. But it did not bar participation in those interrogations by psychologists.

Teva Loses Risperidone Exclusivity

Earlier this year, Teva Pharmaceutical Industries became the first company to sell generic risperidone, leading it to revise its sales and earnings estimates greatly upwards. But the U.S. Court of Appeals for the District of Columbia has vacated an April 2008 ruling that granted the company 6 months of marketing exclusivity for the generic, paving the way for other generic companies to release their versions. Mylan Inc., Par Pharmaceutical, Roxane, Ranbaxy Pharmaceuticals, Apotex Inc., and Pliva all have received tentative approval from the Food and Drug Administration for a generic formulation. Teva said it was seeking a stay of the decision, pending further appeals. The branded formation, Risperdal, had sales of just over $2 billion in 2007.

Media Influences Tobacco Use

Media communications–including movies, advertising, and news–play a key role in shaping tobacco use, according to a lengthy report from the National Cancer Institute. The report noted that cigarettes are among the most heavily marketed products in the United States, and that most of the cigarette industry's marketing budget is allocated to promotional activities, especially for price discounts, which accounted for 75% of the industry's $10 billion in total marketing expenditures in 2005. Depictions of cigarette smoking are pervasive in movies; they occur in three-quarters or more of contemporary box office hits, the NCI report said, adding that the weight of evidence indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. The report provides the government's strongest conclusion to date on the media's powerful and causal effect on tobacco use, Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, said in a statement.

Tobacco Control Support Drops

Budgets for tobacco control programs in most states are either staying level or declining despite increases in payments from the 1997 Tobacco Master Settlement Agreement, which was designed to compensate states for some of the cost of smoking-related illnesses, the American Lung Association reported. The passage of smoke-free air laws also has slowed down in most states, the ALA found. Only two states this year–Iowa and Nebraska–have approved legislation to strengthen existing laws. Activity on cigarette tax increases in 2008 also has been slower than in previous years, with only two states and the District of Columbia approving increases, according to the report. New York's increase in the cigarette tax is the highest, at $1.25 a pack, the ALA said.

CSPI Tries to Dampen Sparks

The Center for Science in the Public Interest has sued MillerCoors LLC to have its Sparks caffeinated alcoholic beverage taken off the market. In a suit filed in the Superior Court of the District of Columbia, the group said that at 6%-7% alcohol by volume, Sparks has more alcohol than beer (generally 4%-5% by volume) and that it contains unapproved additives such as caffeine and guarana, all wrapped in a sweet citrusy flavor that appeals to young people. “MillerCoors is trying to hook teens and tweens on a dangerous drink,” CSPI litigation director Steve Gardner in a statement. CSPI has won this battle before. In June, the group and 11 state attorneys general got Anheuser-Busch to agree to remove caffeine and other unapproved additives from its alcoholic energy drinks.

Pfizer Touts Its Drug Safety Site

Pfizer has launched a drug safety Web site for patients and physicians that is accessible through the company's home page,

www.pfizer.com

Grants to MDs in Hurricanes

The American Medical Association Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricanes Gustav and Ike, which hit parts of Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore medical practices in those locations, according to the AMA.

Psychologists OK Anti-Torture Policy

The American Psychological Association's membership has approved a resolution to prohibit psychologists from participating in interrogations. Once the policy becomes official at the APA's next annual meeting in August 2009, members will be restricted to working directly for detainees, for an independent third party to protect human rights, or to provide treatment to military personnel. The resolution was approved by 8,792 members; 6,157 voted against the measure. The American Civil Liberties Union and many psychologists had sought such a resolution for years. At the association's 2007 annual meeting, its membership adopted a weaker resolution that called on the U.S. government to ban 19 specific interrogation techniques. But it did not bar participation in those interrogations by psychologists.

Teva Loses Risperidone Exclusivity

Earlier this year, Teva Pharmaceutical Industries became the first company to sell generic risperidone, leading it to revise its sales and earnings estimates greatly upwards. But the U.S. Court of Appeals for the District of Columbia has vacated an April 2008 ruling that granted the company 6 months of marketing exclusivity for the generic, paving the way for other generic companies to release their versions. Mylan Inc., Par Pharmaceutical, Roxane, Ranbaxy Pharmaceuticals, Apotex Inc., and Pliva all have received tentative approval from the Food and Drug Administration for a generic formulation. Teva said it was seeking a stay of the decision, pending further appeals. The branded formation, Risperdal, had sales of just over $2 billion in 2007.

Media Influences Tobacco Use

Media communications–including movies, advertising, and news–play a key role in shaping tobacco use, according to a lengthy report from the National Cancer Institute. The report noted that cigarettes are among the most heavily marketed products in the United States, and that most of the cigarette industry's marketing budget is allocated to promotional activities, especially for price discounts, which accounted for 75% of the industry's $10 billion in total marketing expenditures in 2005. Depictions of cigarette smoking are pervasive in movies; they occur in three-quarters or more of contemporary box office hits, the NCI report said, adding that the weight of evidence indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. The report provides the government's strongest conclusion to date on the media's powerful and causal effect on tobacco use, Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, said in a statement.

Tobacco Control Support Drops

Budgets for tobacco control programs in most states are either staying level or declining despite increases in payments from the 1997 Tobacco Master Settlement Agreement, which was designed to compensate states for some of the cost of smoking-related illnesses, the American Lung Association reported. The passage of smoke-free air laws also has slowed down in most states, the ALA found. Only two states this year–Iowa and Nebraska–have approved legislation to strengthen existing laws. Activity on cigarette tax increases in 2008 also has been slower than in previous years, with only two states and the District of Columbia approving increases, according to the report. New York's increase in the cigarette tax is the highest, at $1.25 a pack, the ALA said.

CSPI Tries to Dampen Sparks

The Center for Science in the Public Interest has sued MillerCoors LLC to have its Sparks caffeinated alcoholic beverage taken off the market. In a suit filed in the Superior Court of the District of Columbia, the group said that at 6%-7% alcohol by volume, Sparks has more alcohol than beer (generally 4%-5% by volume) and that it contains unapproved additives such as caffeine and guarana, all wrapped in a sweet citrusy flavor that appeals to young people. “MillerCoors is trying to hook teens and tweens on a dangerous drink,” CSPI litigation director Steve Gardner in a statement. CSPI has won this battle before. In June, the group and 11 state attorneys general got Anheuser-Busch to agree to remove caffeine and other unapproved additives from its alcoholic energy drinks.

Pfizer Touts Its Drug Safety Site

Pfizer has launched a drug safety Web site for patients and physicians that is accessible through the company's home page,

www.pfizer.com

Grants to MDs in Hurricanes

The American Medical Association Foundation's Health Care Recovery Fund will provide grants of up to $2,500 to physicians in places that have been declared disaster areas by the Federal Emergency Management Agency, and the foundation currently is accepting donations to help physicians who have been directly affected by Hurricanes Gustav and Ike, which hit parts of Louisiana, Mississippi, and Texas. The foundation provides the grants to physicians in FEMA-declared disaster areas to help them rebuild or restore medical practices in those locations, according to the AMA.

Standardizing criteria across hospitals could help reduce the practice of ambulance diversion, as could reductions in emergency department boarding and increased coverage of uninsured patients, a new report suggests.

Currently, hospitals in most areas decide on their own when and how often to go on diversion, which leads to a chaotic system and poses health risks to patients who may be delayed in getting needed care, said Dr. Guy Clifton, professor of neurosurgery at the University of Texas, Houston.

Dr. Clifton coauthored the report, “Ambulance Diversions: What They Are, Why We Care, and What to Do,” for the New America Foundation, a Washington, D.C.-based public policy institute.

Covering uninsured patients also would help curb diversion, because it would reduce the number of nonurgent cases contributing to emergency department crowding, he said in an interview.

Before joining the foundation, Dr. Clifton was a Robert Wood Johnson Foundation Health Policy Fellow in the office of Sen. Orrin Hatch (R-Utah). He also wrote the forthcoming book “Flatlined: Resuscitating American Medicine” (Piscataway, N.J.: Rutgers University Press, 2009), which takes on the issues raised by the huge number of uninsured Americans.

According to the report, about half of hospitals and 70% of urban hospitals reported at least some time on diversion in 2004. The diversion picture is a bit fuzzy, he said.

Dr. Clifton said that because there is a shortage of primary care providers, many people, even those with insurance, are receiving less preventive care. When they come to the emergency department, they are not seeking nonurgent help, and are often sick enough that they require admission.

Diversion standards, data collection, and public reporting should be instituted nationally, he said.

For a copy of the report, visit www.newamerica.net/files/Ambulance%20Diversions.pdf

Standardizing criteria across hospitals could help reduce the practice of ambulance diversion, as could reductions in emergency department boarding and increased coverage of uninsured patients, a new report suggests.

Currently, hospitals in most areas decide on their own when and how often to go on diversion, which leads to a chaotic system and poses health risks to patients who may be delayed in getting needed care, said Dr. Guy Clifton, professor of neurosurgery at the University of Texas, Houston.

Dr. Clifton coauthored the report, “Ambulance Diversions: What They Are, Why We Care, and What to Do,” for the New America Foundation, a Washington, D.C.-based public policy institute.

Covering uninsured patients also would help curb diversion, because it would reduce the number of nonurgent cases contributing to emergency department crowding, he said in an interview.

Before joining the foundation, Dr. Clifton was a Robert Wood Johnson Foundation Health Policy Fellow in the office of Sen. Orrin Hatch (R-Utah). He also wrote the forthcoming book “Flatlined: Resuscitating American Medicine” (Piscataway, N.J.: Rutgers University Press, 2009), which takes on the issues raised by the huge number of uninsured Americans.

According to the report, about half of hospitals and 70% of urban hospitals reported at least some time on diversion in 2004. The diversion picture is a bit fuzzy, he said.

Dr. Clifton said that because there is a shortage of primary care providers, many people, even those with insurance, are receiving less preventive care. When they come to the emergency department, they are not seeking nonurgent help, and are often sick enough that they require admission.

Diversion standards, data collection, and public reporting should be instituted nationally, he said.

For a copy of the report, visit www.newamerica.net/files/Ambulance%20Diversions.pdf

Standardizing criteria across hospitals could help reduce the practice of ambulance diversion, as could reductions in emergency department boarding and increased coverage of uninsured patients, a new report suggests.

Currently, hospitals in most areas decide on their own when and how often to go on diversion, which leads to a chaotic system and poses health risks to patients who may be delayed in getting needed care, said Dr. Guy Clifton, professor of neurosurgery at the University of Texas, Houston.

Dr. Clifton coauthored the report, “Ambulance Diversions: What They Are, Why We Care, and What to Do,” for the New America Foundation, a Washington, D.C.-based public policy institute.

Covering uninsured patients also would help curb diversion, because it would reduce the number of nonurgent cases contributing to emergency department crowding, he said in an interview.

Before joining the foundation, Dr. Clifton was a Robert Wood Johnson Foundation Health Policy Fellow in the office of Sen. Orrin Hatch (R-Utah). He also wrote the forthcoming book “Flatlined: Resuscitating American Medicine” (Piscataway, N.J.: Rutgers University Press, 2009), which takes on the issues raised by the huge number of uninsured Americans.

According to the report, about half of hospitals and 70% of urban hospitals reported at least some time on diversion in 2004. The diversion picture is a bit fuzzy, he said.

Dr. Clifton said that because there is a shortage of primary care providers, many people, even those with insurance, are receiving less preventive care. When they come to the emergency department, they are not seeking nonurgent help, and are often sick enough that they require admission.

Diversion standards, data collection, and public reporting should be instituted nationally, he said.

For a copy of the report, visit www.newamerica.net/files/Ambulance%20Diversions.pdf

SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.

A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.

In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.

Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.

At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.

“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.

Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.

Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.

Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.

With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.

The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.

Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.

The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.

The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.

The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.

In either case, going without sedation appears to be acceptable for an increasing number of patients, he said.

Dr. Sidney J. Winawer noted after Dr. Leung spoke that the United States is unusual in its preference for sedated colonoscopy. This can be attributed largely to deep-rooted fears that go back to the old days of rigid sigmoidoscopy and poor sedation practices with colonoscopy, both of which increased discomfort, said Dr. Winawer, Paul Sherlock Chair of the gastroenterology and nutrition service at Memorial Sloan-Kettering Cancer Center in New York.

“We have to overcome this old fear that people have had,” he said. “It's very hard to try to reeducate the public that colonoscopy can be a very comfortable procedure, usually with adequate sedation, and they should not be afraid of it,” Dr. Winawer said.

Dr. Leung and Dr. Winawer disclosed no conflicts of interest.

SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.

A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.

In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.

Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.

At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.

“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.

Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.

Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.

Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.

With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.

The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.

Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.

The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.

The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.

The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.

In either case, going without sedation appears to be acceptable for an increasing number of patients, he said.

Dr. Sidney J. Winawer noted after Dr. Leung spoke that the United States is unusual in its preference for sedated colonoscopy. This can be attributed largely to deep-rooted fears that go back to the old days of rigid sigmoidoscopy and poor sedation practices with colonoscopy, both of which increased discomfort, said Dr. Winawer, Paul Sherlock Chair of the gastroenterology and nutrition service at Memorial Sloan-Kettering Cancer Center in New York.

“We have to overcome this old fear that people have had,” he said. “It's very hard to try to reeducate the public that colonoscopy can be a very comfortable procedure, usually with adequate sedation, and they should not be afraid of it,” Dr. Winawer said.

Dr. Leung and Dr. Winawer disclosed no conflicts of interest.

SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.

A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.

In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.

Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.

At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.

“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.

Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.

Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.

Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.

With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.

The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.

Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.

The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.

The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.

The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.

In either case, going without sedation appears to be acceptable for an increasing number of patients, he said.

Dr. Sidney J. Winawer noted after Dr. Leung spoke that the United States is unusual in its preference for sedated colonoscopy. This can be attributed largely to deep-rooted fears that go back to the old days of rigid sigmoidoscopy and poor sedation practices with colonoscopy, both of which increased discomfort, said Dr. Winawer, Paul Sherlock Chair of the gastroenterology and nutrition service at Memorial Sloan-Kettering Cancer Center in New York.

“We have to overcome this old fear that people have had,” he said. “It's very hard to try to reeducate the public that colonoscopy can be a very comfortable procedure, usually with adequate sedation, and they should not be afraid of it,” Dr. Winawer said.

Dr. Leung and Dr. Winawer disclosed no conflicts of interest.

MedSpa Bill Fails in California

A bill that could have shuttered a huge number of medical spas in California essentially expired after a failed floor vote in the state Senate and protracted negotiations over a competing bill in the Assembly. Introduced in February, AB 2398 made its way through the legislature with the support of the American Society for Dermatologic Surgery Association, the California Society of Dermatology and Dermatologic Surgery, and other groups. The bill would have revoked the licenses of any physician who practiced for a "business organization" that provided outpatient cosmetic procedures, because it would be considered a violation of the prohibition against the corporate practice of medicine. The California Medspa Management Association, the International Medical Spa Association (IMSA), and the Manufacturers of Equipment for Light-Based Aesthetics said the law would amount to restraint of trade and would "undermine a physician's right to make a living," according to a letter sent to Gov. Arnold Schwarzenegger by IMSA.

FDA Warns on Laser Brush

The Food and Drug Administration has warned Sunetics International Corp. of Las Vegas that it is illegally marketing its Laser Hair Brush and Laser Skin Brush. The company advertises the products as laser devices that can grow hair and treat skin conditions such as acne and dyspigmentation, according to the FDA. The devices have not received premarket approval, which is required for any product making a claim to affect a structure or function in the body, according to the agency's warning letter. Sunetics did submit an approval application in January of this year, but it is still being reviewed, the agency said.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

Genomics Collaboration

Pharmacy benefit manager Medco Health Solutions Inc. and the FDA have partnered to study genetic testing and the effect of genetics on prescription drug efficacy, according to Medco. The agreement extends to Aug. 31, 2010. Over the next 2 years, Medco will deliver a series of reports to the FDA that will address the safety of prescription drugs, physician participation in pharmacogenomics testing, the usefulness of the tests in prescribing, and the quantifying of prescription information that contains genetic information. Medco said its reports will be derived from clinical settings, including one that will examine whether physicians are willing to change the dose of a prescription based on a genetic test result. "Studying this field can advance pharmacy care to remove some of the trial and error in how medications are prescribed," Dr. Robert Epstein, Medco chief medical officer, said in a statement.

Uninsured Spend $30B on Care

Americans who lack health insurance for any part of 2008 will spend $30 billion out of pocket for health services, and also will receive $56 billion in uncompensated care while uninsured, according to a study in the journal Health Affairs. Government programs will pay about $43 billion for the uncompensated care, the researchers reported. Compared with people who have full-year private health care coverage, people who are uninsured for a full year receive less than half as much care but pay a larger share out of pocket, the authors reported. Someone who is uninsured all year would pay 35% (or $583 on average) out of pocket toward average annual medical costs of $1,686, the study said. In contrast, the annual medical costs of the privately insured average $3,915, with 17% (or $681 on average) paid out of pocket, according to the study.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people (66% of all adults and 81% of those who have online access) said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, as opposed to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the pollsters called "cybercondriacs"—which indicates that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

MedSpa Bill Fails in California

A bill that could have shuttered a huge number of medical spas in California essentially expired after a failed floor vote in the state Senate and protracted negotiations over a competing bill in the Assembly. Introduced in February, AB 2398 made its way through the legislature with the support of the American Society for Dermatologic Surgery Association, the California Society of Dermatology and Dermatologic Surgery, and other groups. The bill would have revoked the licenses of any physician who practiced for a "business organization" that provided outpatient cosmetic procedures, because it would be considered a violation of the prohibition against the corporate practice of medicine. The California Medspa Management Association, the International Medical Spa Association (IMSA), and the Manufacturers of Equipment for Light-Based Aesthetics said the law would amount to restraint of trade and would "undermine a physician's right to make a living," according to a letter sent to Gov. Arnold Schwarzenegger by IMSA.

FDA Warns on Laser Brush

The Food and Drug Administration has warned Sunetics International Corp. of Las Vegas that it is illegally marketing its Laser Hair Brush and Laser Skin Brush. The company advertises the products as laser devices that can grow hair and treat skin conditions such as acne and dyspigmentation, according to the FDA. The devices have not received premarket approval, which is required for any product making a claim to affect a structure or function in the body, according to the agency's warning letter. Sunetics did submit an approval application in January of this year, but it is still being reviewed, the agency said.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

Genomics Collaboration

Pharmacy benefit manager Medco Health Solutions Inc. and the FDA have partnered to study genetic testing and the effect of genetics on prescription drug efficacy, according to Medco. The agreement extends to Aug. 31, 2010. Over the next 2 years, Medco will deliver a series of reports to the FDA that will address the safety of prescription drugs, physician participation in pharmacogenomics testing, the usefulness of the tests in prescribing, and the quantifying of prescription information that contains genetic information. Medco said its reports will be derived from clinical settings, including one that will examine whether physicians are willing to change the dose of a prescription based on a genetic test result. "Studying this field can advance pharmacy care to remove some of the trial and error in how medications are prescribed," Dr. Robert Epstein, Medco chief medical officer, said in a statement.

Uninsured Spend $30B on Care

Americans who lack health insurance for any part of 2008 will spend $30 billion out of pocket for health services, and also will receive $56 billion in uncompensated care while uninsured, according to a study in the journal Health Affairs. Government programs will pay about $43 billion for the uncompensated care, the researchers reported. Compared with people who have full-year private health care coverage, people who are uninsured for a full year receive less than half as much care but pay a larger share out of pocket, the authors reported. Someone who is uninsured all year would pay 35% (or $583 on average) out of pocket toward average annual medical costs of $1,686, the study said. In contrast, the annual medical costs of the privately insured average $3,915, with 17% (or $681 on average) paid out of pocket, according to the study.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people (66% of all adults and 81% of those who have online access) said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, as opposed to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the pollsters called "cybercondriacs"—which indicates that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.

MedSpa Bill Fails in California

A bill that could have shuttered a huge number of medical spas in California essentially expired after a failed floor vote in the state Senate and protracted negotiations over a competing bill in the Assembly. Introduced in February, AB 2398 made its way through the legislature with the support of the American Society for Dermatologic Surgery Association, the California Society of Dermatology and Dermatologic Surgery, and other groups. The bill would have revoked the licenses of any physician who practiced for a "business organization" that provided outpatient cosmetic procedures, because it would be considered a violation of the prohibition against the corporate practice of medicine. The California Medspa Management Association, the International Medical Spa Association (IMSA), and the Manufacturers of Equipment for Light-Based Aesthetics said the law would amount to restraint of trade and would "undermine a physician's right to make a living," according to a letter sent to Gov. Arnold Schwarzenegger by IMSA.

FDA Warns on Laser Brush

The Food and Drug Administration has warned Sunetics International Corp. of Las Vegas that it is illegally marketing its Laser Hair Brush and Laser Skin Brush. The company advertises the products as laser devices that can grow hair and treat skin conditions such as acne and dyspigmentation, according to the FDA. The devices have not received premarket approval, which is required for any product making a claim to affect a structure or function in the body, according to the agency's warning letter. Sunetics did submit an approval application in January of this year, but it is still being reviewed, the agency said.

PQRI Frustrating, But Not Costly

A total of 90% of physicians answering a Medical Group Management Association survey said that they had trouble accessing their confidential 2007 Physician Quality Reporting Initiative (PQRI) reports from the Centers for Medicare and Medicaid's secure Web site. Overall, 70% sought CMS help in getting the reports; of those, 11% rated the help as not satisfactory. The PQRI reports received average marks for clarity and slightly lower ratings for providing guidance on improving outcomes. Even so, 90% of the practices said they would participate in the 2008 PQRI program. Survey responses were taken from 295 practices who said they had reported on PQRI measures from July to December 2007. When asked why they participated, the largest weight was given to preparing for the future, when quality reporting is anticipated to play a bigger role in Medicare reimbursement. Overall, 61% of practices earned a bonus from 2007. Most practices said that participation had not led to the need for more staff or higher expenses.

Genomics Collaboration

Pharmacy benefit manager Medco Health Solutions Inc. and the FDA have partnered to study genetic testing and the effect of genetics on prescription drug efficacy, according to Medco. The agreement extends to Aug. 31, 2010. Over the next 2 years, Medco will deliver a series of reports to the FDA that will address the safety of prescription drugs, physician participation in pharmacogenomics testing, the usefulness of the tests in prescribing, and the quantifying of prescription information that contains genetic information. Medco said its reports will be derived from clinical settings, including one that will examine whether physicians are willing to change the dose of a prescription based on a genetic test result. "Studying this field can advance pharmacy care to remove some of the trial and error in how medications are prescribed," Dr. Robert Epstein, Medco chief medical officer, said in a statement.

Uninsured Spend $30B on Care

Americans who lack health insurance for any part of 2008 will spend $30 billion out of pocket for health services, and also will receive $56 billion in uncompensated care while uninsured, according to a study in the journal Health Affairs. Government programs will pay about $43 billion for the uncompensated care, the researchers reported. Compared with people who have full-year private health care coverage, people who are uninsured for a full year receive less than half as much care but pay a larger share out of pocket, the authors reported. Someone who is uninsured all year would pay 35% (or $583 on average) out of pocket toward average annual medical costs of $1,686, the study said. In contrast, the annual medical costs of the privately insured average $3,915, with 17% (or $681 on average) paid out of pocket, according to the study.

Health Searches Level Off

The number of adults going online for health information has plateaued or declined, according to a Harris Interactive poll. According to the pollster, a total of 150 million people (66% of all adults and 81% of those who have online access) said they obtained health information from the Internet in 2008. That represents a slight drop from 2007, when the poll found that 160 million people reported obtaining health information online. The researchers noted that the slight differences from 2007 to 2008 are within the possible sampling error. But they pointed out that, as opposed to other years, it appears that there has been no increase in the total number of people with Internet access or in the number of people searching for health information—those the pollsters called "cybercondriacs"—which indicates that a plateau or even a slight decline was underway. Just under half of cybercondriacs said that they had discussed the information they obtained online with their doctors, and 49% had gone online to look for information as a result of discussions with their doctors, the survey found.