Government and Regulations

WASHINGTON (IMNG) – In 2013 and going forward, employers are likely to increasingly rely on direct contracting with physicians and using other means to steer patients to certain physicians in an effort to bring employee benefit costs in line, according to a new survey.

Besides direct contracting, employers say they will use additional ways to get patients to use particular providers, such as reimbursing less for higher-cost providers and encouraging use of work-site health clinics, according to the National Business Group on Health.

The nonprofit NBGH surveyed its members in June, after the employers had finalized benefit plans for 2013, but before the Supreme Court issued its decision upholding the Affordable Care Act.

The Supreme Court ruling means that employers are facing slightly less uncertainty about the future, but costs were still an overriding concern, said Helen Darling, CEO of the NBGH. "Employers are very concerned about the severe cost pressures from providing comprehensive health services and health benefits," she said.

The 82 members that responded to the survey said that they expected the cost of benefits to rise 7% next year. While that is in keeping with the past several years’ increases, it comes during a time when revenues for many are flat or decreasing.

As a result, employers are exploring a variety of ways to control costs and improve quality. Eleven percent of respondents said they were using direct contracting with surgical centers of excellence to control costs, improve quality, and ensure appropriate care. Twenty-one percent said they were considering it. Fully 11% indicated that they were currently using direct contracting with patient-centered medical homes, and 18% said they were thinking about doing so in the future.

Making employees aware of the cost of their health care is another tactic being used by employers. Seventy-nine percent said they give their workers access to an online database showing the price of various services.

Employers also have begun to use "reference pricing" for health care services. The employer sets a price for a service, and if a worker wants something that is more expensive, he or she will have to pay the difference. Reference pricing is largely used with pharmaceuticals, but 4% said they use it for lab services and the same proportion do so for imaging.

Ms. Darling said she expects reference pricing to be applied to physician services in the near future.

Overall, employers said that using consumer-directed health plans – such as high-deductible plans – and wellness initiatives were proving to be more effective than shifting costs directly to workers through higher premiums or deductibles. Even so, 60% said they would ask employees to pay a larger percentage of the premium in 2013. More than a third also said they would increase in-network deductibles, out-of-network deductibles, and out-of-pocket maximums.

Employees will be influenced in other ways, too. Some 46% of the respondents said they have on-site health clinics in at least one of their locations, providing primarily acute care, but also health improvement programs and occupational health services. More than half of those clinics also offer primary care services.

In addition, companies are increasingly offering financial incentives for participating in weight management or tobacco cessation programs, or for meeting particular health outcomes. Almost half said they offer incentives just for participating, with a median payout of $450 per worker – a 50% increase from 2012.

WASHINGTON (IMNG) – In 2013 and going forward, employers are likely to increasingly rely on direct contracting with physicians and using other means to steer patients to certain physicians in an effort to bring employee benefit costs in line, according to a new survey.

Besides direct contracting, employers say they will use additional ways to get patients to use particular providers, such as reimbursing less for higher-cost providers and encouraging use of work-site health clinics, according to the National Business Group on Health.

The nonprofit NBGH surveyed its members in June, after the employers had finalized benefit plans for 2013, but before the Supreme Court issued its decision upholding the Affordable Care Act.

The Supreme Court ruling means that employers are facing slightly less uncertainty about the future, but costs were still an overriding concern, said Helen Darling, CEO of the NBGH. "Employers are very concerned about the severe cost pressures from providing comprehensive health services and health benefits," she said.

The 82 members that responded to the survey said that they expected the cost of benefits to rise 7% next year. While that is in keeping with the past several years’ increases, it comes during a time when revenues for many are flat or decreasing.

As a result, employers are exploring a variety of ways to control costs and improve quality. Eleven percent of respondents said they were using direct contracting with surgical centers of excellence to control costs, improve quality, and ensure appropriate care. Twenty-one percent said they were considering it. Fully 11% indicated that they were currently using direct contracting with patient-centered medical homes, and 18% said they were thinking about doing so in the future.

Making employees aware of the cost of their health care is another tactic being used by employers. Seventy-nine percent said they give their workers access to an online database showing the price of various services.

Employers also have begun to use "reference pricing" for health care services. The employer sets a price for a service, and if a worker wants something that is more expensive, he or she will have to pay the difference. Reference pricing is largely used with pharmaceuticals, but 4% said they use it for lab services and the same proportion do so for imaging.

Ms. Darling said she expects reference pricing to be applied to physician services in the near future.

Overall, employers said that using consumer-directed health plans – such as high-deductible plans – and wellness initiatives were proving to be more effective than shifting costs directly to workers through higher premiums or deductibles. Even so, 60% said they would ask employees to pay a larger percentage of the premium in 2013. More than a third also said they would increase in-network deductibles, out-of-network deductibles, and out-of-pocket maximums.

Employees will be influenced in other ways, too. Some 46% of the respondents said they have on-site health clinics in at least one of their locations, providing primarily acute care, but also health improvement programs and occupational health services. More than half of those clinics also offer primary care services.

In addition, companies are increasingly offering financial incentives for participating in weight management or tobacco cessation programs, or for meeting particular health outcomes. Almost half said they offer incentives just for participating, with a median payout of $450 per worker – a 50% increase from 2012.

WASHINGTON (IMNG) – In 2013 and going forward, employers are likely to increasingly rely on direct contracting with physicians and using other means to steer patients to certain physicians in an effort to bring employee benefit costs in line, according to a new survey.

Besides direct contracting, employers say they will use additional ways to get patients to use particular providers, such as reimbursing less for higher-cost providers and encouraging use of work-site health clinics, according to the National Business Group on Health.

The nonprofit NBGH surveyed its members in June, after the employers had finalized benefit plans for 2013, but before the Supreme Court issued its decision upholding the Affordable Care Act.

The Supreme Court ruling means that employers are facing slightly less uncertainty about the future, but costs were still an overriding concern, said Helen Darling, CEO of the NBGH. "Employers are very concerned about the severe cost pressures from providing comprehensive health services and health benefits," she said.

The 82 members that responded to the survey said that they expected the cost of benefits to rise 7% next year. While that is in keeping with the past several years’ increases, it comes during a time when revenues for many are flat or decreasing.

As a result, employers are exploring a variety of ways to control costs and improve quality. Eleven percent of respondents said they were using direct contracting with surgical centers of excellence to control costs, improve quality, and ensure appropriate care. Twenty-one percent said they were considering it. Fully 11% indicated that they were currently using direct contracting with patient-centered medical homes, and 18% said they were thinking about doing so in the future.

Making employees aware of the cost of their health care is another tactic being used by employers. Seventy-nine percent said they give their workers access to an online database showing the price of various services.

Employers also have begun to use "reference pricing" for health care services. The employer sets a price for a service, and if a worker wants something that is more expensive, he or she will have to pay the difference. Reference pricing is largely used with pharmaceuticals, but 4% said they use it for lab services and the same proportion do so for imaging.

Ms. Darling said she expects reference pricing to be applied to physician services in the near future.

Overall, employers said that using consumer-directed health plans – such as high-deductible plans – and wellness initiatives were proving to be more effective than shifting costs directly to workers through higher premiums or deductibles. Even so, 60% said they would ask employees to pay a larger percentage of the premium in 2013. More than a third also said they would increase in-network deductibles, out-of-network deductibles, and out-of-pocket maximums.

Employees will be influenced in other ways, too. Some 46% of the respondents said they have on-site health clinics in at least one of their locations, providing primarily acute care, but also health improvement programs and occupational health services. More than half of those clinics also offer primary care services.

In addition, companies are increasingly offering financial incentives for participating in weight management or tobacco cessation programs, or for meeting particular health outcomes. Almost half said they offer incentives just for participating, with a median payout of $450 per worker – a 50% increase from 2012.

Doctors who want to earn Medicare and Medicaid incentives for the meaningful use of electronic health records will not have to meet so-called stage 2 requirements until 2014, under final federal regulations that were released on Aug. 23.

More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to receive such incentive payments under stage 1 of meaningful use, which requires physicians to certify that EHRs can capture and report data, among other issues, according to the Health and Human Services department.

Under stage 2, users must show that they can exchange data with other providers and that they can give patients secure online access to their health information.

Original federal proposals required providers to meet stage 2 requirements next year. The delay was hailed by at least one group of physicians.

"MGMA is pleased that the Centers for Medicare and Medicaid Services responded to our concerns regarding several of the proposed stage 2 meaningful use requirements," said Dr. Susan Turney, president and CEO of MGMA-ACMPE, the merged entity of the Medical Group Management Association (MGMA) and the American College of Medical Practice Executives (ACMPE), in a statement."Extending the start for stage 2 until 2014 was a necessary step to permit medical groups sufficient time to implement new software," she added.

Dr. Turney also said that MGMA-ACMPE members applauded some other changes to the proposal, including "lowering the thresholds for achieving certain measures such as mandatory online access and electronic exchange of summary of care documents."

Other important provisions in the final rule exempt certain physicians from the penalties that will be assessed come 2015 on those providers who do not adopt EHRs.

Physicians or hospitals will be exempt from the 1% reduction in Medicare reimbursement if they can show that the following apply to them:

• They lack Internet access, or face barriers to obtaining health information technology infrastructure.

• They are newly practicing.

• They have to contend with unforeseen circumstances, such as natural disasters.

The rule also makes exceptions for physicians who have limited interaction with patients, who practice at multiple locations, or who have no control over the availability of EHRs at locations that make up more than half of their patient encounters.

"These exclusions will allow physicians to achieve meaningful use with fewer hurdles," said Dr. Turney.

The American Medical Association took a more cautious approach, at least in an initial statement by board chair Steven J. Stack. "In a comment letter submitted by the AMA and 100 state and specialty medical societies in May, recommendations were outlined to eliminate physician roadblocks and encourage greater physician participation," said Dr. Stack. "We will carefully review the final rule and hope to see the changes we advocated for to promote widespread adoption and meaningful use of EHRs by physicians."

The rule also further clarifies certification criteria for EHRs, and modifies the certification program to "cut red tape and make the certification process more efficient," according to an HHS statement. All EHRs that have been certified under the 2011 rules can be used until 2014.

"The changes we’re announcing today will lead to more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests and greater patient engagement in their own care," said HHS Secretary Kathleen Sebelius in the statement.

Doctors who want to earn Medicare and Medicaid incentives for the meaningful use of electronic health records will not have to meet so-called stage 2 requirements until 2014, under final federal regulations that were released on Aug. 23.

More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to receive such incentive payments under stage 1 of meaningful use, which requires physicians to certify that EHRs can capture and report data, among other issues, according to the Health and Human Services department.

Under stage 2, users must show that they can exchange data with other providers and that they can give patients secure online access to their health information.

Original federal proposals required providers to meet stage 2 requirements next year. The delay was hailed by at least one group of physicians.

"MGMA is pleased that the Centers for Medicare and Medicaid Services responded to our concerns regarding several of the proposed stage 2 meaningful use requirements," said Dr. Susan Turney, president and CEO of MGMA-ACMPE, the merged entity of the Medical Group Management Association (MGMA) and the American College of Medical Practice Executives (ACMPE), in a statement."Extending the start for stage 2 until 2014 was a necessary step to permit medical groups sufficient time to implement new software," she added.

Dr. Turney also said that MGMA-ACMPE members applauded some other changes to the proposal, including "lowering the thresholds for achieving certain measures such as mandatory online access and electronic exchange of summary of care documents."

Other important provisions in the final rule exempt certain physicians from the penalties that will be assessed come 2015 on those providers who do not adopt EHRs.

Physicians or hospitals will be exempt from the 1% reduction in Medicare reimbursement if they can show that the following apply to them:

• They lack Internet access, or face barriers to obtaining health information technology infrastructure.

• They are newly practicing.

• They have to contend with unforeseen circumstances, such as natural disasters.

The rule also makes exceptions for physicians who have limited interaction with patients, who practice at multiple locations, or who have no control over the availability of EHRs at locations that make up more than half of their patient encounters.

"These exclusions will allow physicians to achieve meaningful use with fewer hurdles," said Dr. Turney.

The American Medical Association took a more cautious approach, at least in an initial statement by board chair Steven J. Stack. "In a comment letter submitted by the AMA and 100 state and specialty medical societies in May, recommendations were outlined to eliminate physician roadblocks and encourage greater physician participation," said Dr. Stack. "We will carefully review the final rule and hope to see the changes we advocated for to promote widespread adoption and meaningful use of EHRs by physicians."

The rule also further clarifies certification criteria for EHRs, and modifies the certification program to "cut red tape and make the certification process more efficient," according to an HHS statement. All EHRs that have been certified under the 2011 rules can be used until 2014.

"The changes we’re announcing today will lead to more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests and greater patient engagement in their own care," said HHS Secretary Kathleen Sebelius in the statement.

Doctors who want to earn Medicare and Medicaid incentives for the meaningful use of electronic health records will not have to meet so-called stage 2 requirements until 2014, under final federal regulations that were released on Aug. 23.

More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to receive such incentive payments under stage 1 of meaningful use, which requires physicians to certify that EHRs can capture and report data, among other issues, according to the Health and Human Services department.

Under stage 2, users must show that they can exchange data with other providers and that they can give patients secure online access to their health information.

Original federal proposals required providers to meet stage 2 requirements next year. The delay was hailed by at least one group of physicians.

"MGMA is pleased that the Centers for Medicare and Medicaid Services responded to our concerns regarding several of the proposed stage 2 meaningful use requirements," said Dr. Susan Turney, president and CEO of MGMA-ACMPE, the merged entity of the Medical Group Management Association (MGMA) and the American College of Medical Practice Executives (ACMPE), in a statement."Extending the start for stage 2 until 2014 was a necessary step to permit medical groups sufficient time to implement new software," she added.

Dr. Turney also said that MGMA-ACMPE members applauded some other changes to the proposal, including "lowering the thresholds for achieving certain measures such as mandatory online access and electronic exchange of summary of care documents."

Other important provisions in the final rule exempt certain physicians from the penalties that will be assessed come 2015 on those providers who do not adopt EHRs.

Physicians or hospitals will be exempt from the 1% reduction in Medicare reimbursement if they can show that the following apply to them:

• They lack Internet access, or face barriers to obtaining health information technology infrastructure.

• They are newly practicing.

• They have to contend with unforeseen circumstances, such as natural disasters.

The rule also makes exceptions for physicians who have limited interaction with patients, who practice at multiple locations, or who have no control over the availability of EHRs at locations that make up more than half of their patient encounters.

"These exclusions will allow physicians to achieve meaningful use with fewer hurdles," said Dr. Turney.

The American Medical Association took a more cautious approach, at least in an initial statement by board chair Steven J. Stack. "In a comment letter submitted by the AMA and 100 state and specialty medical societies in May, recommendations were outlined to eliminate physician roadblocks and encourage greater physician participation," said Dr. Stack. "We will carefully review the final rule and hope to see the changes we advocated for to promote widespread adoption and meaningful use of EHRs by physicians."

The rule also further clarifies certification criteria for EHRs, and modifies the certification program to "cut red tape and make the certification process more efficient," according to an HHS statement. All EHRs that have been certified under the 2011 rules can be used until 2014.

"The changes we’re announcing today will lead to more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests and greater patient engagement in their own care," said HHS Secretary Kathleen Sebelius in the statement.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

Implementation of the diagnosis and procedure codes in the 10th edition of the International Classification of Diseases has been put off for another year, the Centers for Medicare and Medicaid Services announced Aug. 24.

Many hospitals and physicians have expressed deep concern that they would not be able to meet the Oct. 1, 2013, deadline for using ICD-10. In April, the federal agency said in a proposed rule that it would delay compliance by a year; the final decision was announced in a rule that primarily establishes a standard unique identifier for health plans to help smooth payment transactions for hospitals and physicians.

"We believe the change in the compliance date for ICD-10 gives covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition by all covered entities," CMS officials wrote.

SAN FRANCISCO – Elderly patients with preexisting Do Not Resuscitate directives appear to be less likely to pursue rescue from complications following emergency surgery than similar patients without such orders, according to an analysis of data from the National Surgical Quality Improvement Program.

When patients with preoperative DNRs were propensity-matched with non-DNR patients, major complication rates were similar – 42% for the DNR group and 41% for the non-DNR group. However, 37% of DNR patients died, compared with 22% of non-DNR patients, Dr. John E. Scarborough reported at the meeting. The investigators adjusted for baseline differences in level of illness to create a propensity-matched cohort of 1,053 patients in each group.

"While we called this outcome failure-to-rescue, we believe that term to be misleading. The term implies that rescue from complications is attempted but is unsuccessful. ... We had no reason to believe that the DNR patients in this well-matched cohort were any less capable of being rescued than non-DNR patients," Dr. Scarborough said. "Instead, we believe that the DNR patients in the matched cohort were less likely than non-DNR patients to pursue rescue from complications."

This conclusion is supported by the finding that DNR patients were significantly less likely to undergo reoperation within 30 days of the index procedure (odds ratio, 0.67).

The authors used participant files from the National Surgical Quality Improvement Program (NSQIP) for 2005-2010, involving medical records for 25,558 patients. These patients were at least 65 years old and underwent an emergency operation for one of 10 common surgical diagnoses. The primary predictor variable was preoperative DNR status, which was defined as "an order signed or cosigned by an attending physician in the 30 days prior to surgery ... regardless of whether the DNR order was subsequently rescinded immediately before the index operation." Other predictor variables included patient demographics, chronic comorbid disease burden, acute physical condition at presentation, and complexity of the emergency operation.

Outcome variables included the 30-day postoperative mortality rate and the 30-day major complication rate – organ/space surgical site infection, wound dehiscence, deep vein thrombosis, pulmonary embolism, pneumonia, reintubation, ventilator use longer than 48 hours, cardiac arrest, myocardial infarction, sepsis, shock, coma longer than 24 hours, prosthetic/graft failure, and bleeding. The failure-to-rescue rate was defined as the mortality rate among patients who had one or more major complications.

A total of 1,061 patients had DNR orders, and 24,497 patients did not. The overall 30-day mortality rate for patients with a DNR order was 37% (395/1,061). The overall 30-day morbidity for patients with a DNR was 42% (446/1,061).

Patients with DNR orders were older: 22% were at least 90 years of age, compared with 5% of the non-DNR patients. They were also sicker, with significantly greater rates of non–independent functional status, cognitive dysfunction, known malignancy, congestive heart failure, chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status class 4, preoperative hypoalbuminemia, and septic shock.

"Although the DNR patients were sicker, we did not find any overt evidence that they were treated less aggressively than non-DNR patients in the preoperative period," said Dr. Scarborough, of the department of surgery at Duke University in Durham, N.C. There was no significant difference between DNR and non-DNR patients in terms of preoperative mechanical ventilation (6% vs. 5%, respectively); and DNR patients were significantly more likely to receive a preoperative transfusion.

There was also no indication that DNR patients were treated less aggressively in the operating room. Operative time was significantly longer for DNR patients, and DNR patients underwent procedures at least as complex as, if not more than, procedures for non-DNR patients.

Invited discussant Dr. Ronnie A. Rosenthal asked how these data could be used to improve the way families are counseled before operations involving elderly patients with DNRs. Dr. Rosenthal is surgeon-in-chief at the VA Connecticut Healthcare System in New Haven.

"What we hope this study provides is a more reliable and sturdy resource for surgeons to counsel such patients than merely explaining to them what the average outcomes are," said Dr. Scarborough. He noted that the oncology literature suggests that patients who better understand their prognosis are in a better position to evaluate whether they want to pursue more aggressive treatment or treatments that have a lot of side effects.

Dr. Norman Estes, chair of the surgery department at the University of Illinois in Peoria, questioned how much of a role surgeons should play in advance planning. "I think that sometimes the advance directive creates a self-fulfilling prophecy for the patient."

Dr. Scarborough noted that advance directives need to be signed by the attending physician. "As to whether the surgeon should be more engaged in the conversation, I guess I would say that it depends on the surgeon. This is a very delicate conversation and obviously one that requires a fair amount of time," he said. Other physicians – such as geriatricians and palliative care physicians – are often more skilled at handling these conversations.

However, it is important for surgeons to have a greater understanding of the patient’s intent with regard to DNR directives, he concluded.

The authors reported that they had no financial disclosures.

SAN FRANCISCO – Elderly patients with preexisting Do Not Resuscitate directives appear to be less likely to pursue rescue from complications following emergency surgery than similar patients without such orders, according to an analysis of data from the National Surgical Quality Improvement Program.

When patients with preoperative DNRs were propensity-matched with non-DNR patients, major complication rates were similar – 42% for the DNR group and 41% for the non-DNR group. However, 37% of DNR patients died, compared with 22% of non-DNR patients, Dr. John E. Scarborough reported at the meeting. The investigators adjusted for baseline differences in level of illness to create a propensity-matched cohort of 1,053 patients in each group.

"While we called this outcome failure-to-rescue, we believe that term to be misleading. The term implies that rescue from complications is attempted but is unsuccessful. ... We had no reason to believe that the DNR patients in this well-matched cohort were any less capable of being rescued than non-DNR patients," Dr. Scarborough said. "Instead, we believe that the DNR patients in the matched cohort were less likely than non-DNR patients to pursue rescue from complications."

This conclusion is supported by the finding that DNR patients were significantly less likely to undergo reoperation within 30 days of the index procedure (odds ratio, 0.67).

The authors used participant files from the National Surgical Quality Improvement Program (NSQIP) for 2005-2010, involving medical records for 25,558 patients. These patients were at least 65 years old and underwent an emergency operation for one of 10 common surgical diagnoses. The primary predictor variable was preoperative DNR status, which was defined as "an order signed or cosigned by an attending physician in the 30 days prior to surgery ... regardless of whether the DNR order was subsequently rescinded immediately before the index operation." Other predictor variables included patient demographics, chronic comorbid disease burden, acute physical condition at presentation, and complexity of the emergency operation.

Outcome variables included the 30-day postoperative mortality rate and the 30-day major complication rate – organ/space surgical site infection, wound dehiscence, deep vein thrombosis, pulmonary embolism, pneumonia, reintubation, ventilator use longer than 48 hours, cardiac arrest, myocardial infarction, sepsis, shock, coma longer than 24 hours, prosthetic/graft failure, and bleeding. The failure-to-rescue rate was defined as the mortality rate among patients who had one or more major complications.

A total of 1,061 patients had DNR orders, and 24,497 patients did not. The overall 30-day mortality rate for patients with a DNR order was 37% (395/1,061). The overall 30-day morbidity for patients with a DNR was 42% (446/1,061).

Patients with DNR orders were older: 22% were at least 90 years of age, compared with 5% of the non-DNR patients. They were also sicker, with significantly greater rates of non–independent functional status, cognitive dysfunction, known malignancy, congestive heart failure, chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status class 4, preoperative hypoalbuminemia, and septic shock.

"Although the DNR patients were sicker, we did not find any overt evidence that they were treated less aggressively than non-DNR patients in the preoperative period," said Dr. Scarborough, of the department of surgery at Duke University in Durham, N.C. There was no significant difference between DNR and non-DNR patients in terms of preoperative mechanical ventilation (6% vs. 5%, respectively); and DNR patients were significantly more likely to receive a preoperative transfusion.

There was also no indication that DNR patients were treated less aggressively in the operating room. Operative time was significantly longer for DNR patients, and DNR patients underwent procedures at least as complex as, if not more than, procedures for non-DNR patients.

Invited discussant Dr. Ronnie A. Rosenthal asked how these data could be used to improve the way families are counseled before operations involving elderly patients with DNRs. Dr. Rosenthal is surgeon-in-chief at the VA Connecticut Healthcare System in New Haven.

"What we hope this study provides is a more reliable and sturdy resource for surgeons to counsel such patients than merely explaining to them what the average outcomes are," said Dr. Scarborough. He noted that the oncology literature suggests that patients who better understand their prognosis are in a better position to evaluate whether they want to pursue more aggressive treatment or treatments that have a lot of side effects.

Dr. Norman Estes, chair of the surgery department at the University of Illinois in Peoria, questioned how much of a role surgeons should play in advance planning. "I think that sometimes the advance directive creates a self-fulfilling prophecy for the patient."

Dr. Scarborough noted that advance directives need to be signed by the attending physician. "As to whether the surgeon should be more engaged in the conversation, I guess I would say that it depends on the surgeon. This is a very delicate conversation and obviously one that requires a fair amount of time," he said. Other physicians – such as geriatricians and palliative care physicians – are often more skilled at handling these conversations.

However, it is important for surgeons to have a greater understanding of the patient’s intent with regard to DNR directives, he concluded.

The authors reported that they had no financial disclosures.

SAN FRANCISCO – Elderly patients with preexisting Do Not Resuscitate directives appear to be less likely to pursue rescue from complications following emergency surgery than similar patients without such orders, according to an analysis of data from the National Surgical Quality Improvement Program.

When patients with preoperative DNRs were propensity-matched with non-DNR patients, major complication rates were similar – 42% for the DNR group and 41% for the non-DNR group. However, 37% of DNR patients died, compared with 22% of non-DNR patients, Dr. John E. Scarborough reported at the meeting. The investigators adjusted for baseline differences in level of illness to create a propensity-matched cohort of 1,053 patients in each group.

"While we called this outcome failure-to-rescue, we believe that term to be misleading. The term implies that rescue from complications is attempted but is unsuccessful. ... We had no reason to believe that the DNR patients in this well-matched cohort were any less capable of being rescued than non-DNR patients," Dr. Scarborough said. "Instead, we believe that the DNR patients in the matched cohort were less likely than non-DNR patients to pursue rescue from complications."

This conclusion is supported by the finding that DNR patients were significantly less likely to undergo reoperation within 30 days of the index procedure (odds ratio, 0.67).

The authors used participant files from the National Surgical Quality Improvement Program (NSQIP) for 2005-2010, involving medical records for 25,558 patients. These patients were at least 65 years old and underwent an emergency operation for one of 10 common surgical diagnoses. The primary predictor variable was preoperative DNR status, which was defined as "an order signed or cosigned by an attending physician in the 30 days prior to surgery ... regardless of whether the DNR order was subsequently rescinded immediately before the index operation." Other predictor variables included patient demographics, chronic comorbid disease burden, acute physical condition at presentation, and complexity of the emergency operation.

Outcome variables included the 30-day postoperative mortality rate and the 30-day major complication rate – organ/space surgical site infection, wound dehiscence, deep vein thrombosis, pulmonary embolism, pneumonia, reintubation, ventilator use longer than 48 hours, cardiac arrest, myocardial infarction, sepsis, shock, coma longer than 24 hours, prosthetic/graft failure, and bleeding. The failure-to-rescue rate was defined as the mortality rate among patients who had one or more major complications.

A total of 1,061 patients had DNR orders, and 24,497 patients did not. The overall 30-day mortality rate for patients with a DNR order was 37% (395/1,061). The overall 30-day morbidity for patients with a DNR was 42% (446/1,061).

Patients with DNR orders were older: 22% were at least 90 years of age, compared with 5% of the non-DNR patients. They were also sicker, with significantly greater rates of non–independent functional status, cognitive dysfunction, known malignancy, congestive heart failure, chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status class 4, preoperative hypoalbuminemia, and septic shock.

"Although the DNR patients were sicker, we did not find any overt evidence that they were treated less aggressively than non-DNR patients in the preoperative period," said Dr. Scarborough, of the department of surgery at Duke University in Durham, N.C. There was no significant difference between DNR and non-DNR patients in terms of preoperative mechanical ventilation (6% vs. 5%, respectively); and DNR patients were significantly more likely to receive a preoperative transfusion.

There was also no indication that DNR patients were treated less aggressively in the operating room. Operative time was significantly longer for DNR patients, and DNR patients underwent procedures at least as complex as, if not more than, procedures for non-DNR patients.

Invited discussant Dr. Ronnie A. Rosenthal asked how these data could be used to improve the way families are counseled before operations involving elderly patients with DNRs. Dr. Rosenthal is surgeon-in-chief at the VA Connecticut Healthcare System in New Haven.

"What we hope this study provides is a more reliable and sturdy resource for surgeons to counsel such patients than merely explaining to them what the average outcomes are," said Dr. Scarborough. He noted that the oncology literature suggests that patients who better understand their prognosis are in a better position to evaluate whether they want to pursue more aggressive treatment or treatments that have a lot of side effects.

Dr. Norman Estes, chair of the surgery department at the University of Illinois in Peoria, questioned how much of a role surgeons should play in advance planning. "I think that sometimes the advance directive creates a self-fulfilling prophecy for the patient."

Dr. Scarborough noted that advance directives need to be signed by the attending physician. "As to whether the surgeon should be more engaged in the conversation, I guess I would say that it depends on the surgeon. This is a very delicate conversation and obviously one that requires a fair amount of time," he said. Other physicians – such as geriatricians and palliative care physicians – are often more skilled at handling these conversations.

However, it is important for surgeons to have a greater understanding of the patient’s intent with regard to DNR directives, he concluded.

The authors reported that they had no financial disclosures.

The federal government is requiring health plans to make it easier for physicians to get paid electronically.

On Aug. 7, the Department of Health and Human Services released new rules for health care electronic funds transfers (EFT) and electronic remittance advice (ERA). Starting Jan. 1, 2014, health plans must offer a standardized, online form for physicians and hospitals to enroll to electronically receive payments, as well as notices about claims adjustments and denials. The new rules are required under the Affordable Care Act.

"These new rules will cut red tape, save money, and ensure doctors spend more time seeing patients and less time filling out forms," HHS Secretary Kathleen Sebelius said in a statement.

The requirements could help shift more physician practices away from paper billing. About 70% of health care claim payments are still made in paper check form, according to HHS.

The interim final rule from HHS does not require physicians and hospitals to accept electronic payments. However, if they do, the agency estimates that they will save time and money. For example, practices will save time in handling payment denials since health plans are required to simplify the codes used to explain whether a claim is paid and why.

The net savings to the health care industry from the new electronic standards will be between $300 million and $3.3 billion over 10 years, according to the final rule. HHS officials predicted that most of the implementation cost would be borne by health plans, but most of the benefits would go to providers.

The interim final rule with comment period will be published in the Federal Register on Aug. 10. The public comment period closes on Oct. 9.

The federal government is requiring health plans to make it easier for physicians to get paid electronically.

On Aug. 7, the Department of Health and Human Services released new rules for health care electronic funds transfers (EFT) and electronic remittance advice (ERA). Starting Jan. 1, 2014, health plans must offer a standardized, online form for physicians and hospitals to enroll to electronically receive payments, as well as notices about claims adjustments and denials. The new rules are required under the Affordable Care Act.

"These new rules will cut red tape, save money, and ensure doctors spend more time seeing patients and less time filling out forms," HHS Secretary Kathleen Sebelius said in a statement.

The requirements could help shift more physician practices away from paper billing. About 70% of health care claim payments are still made in paper check form, according to HHS.

The interim final rule from HHS does not require physicians and hospitals to accept electronic payments. However, if they do, the agency estimates that they will save time and money. For example, practices will save time in handling payment denials since health plans are required to simplify the codes used to explain whether a claim is paid and why.

The net savings to the health care industry from the new electronic standards will be between $300 million and $3.3 billion over 10 years, according to the final rule. HHS officials predicted that most of the implementation cost would be borne by health plans, but most of the benefits would go to providers.

The interim final rule with comment period will be published in the Federal Register on Aug. 10. The public comment period closes on Oct. 9.

The federal government is requiring health plans to make it easier for physicians to get paid electronically.

On Aug. 7, the Department of Health and Human Services released new rules for health care electronic funds transfers (EFT) and electronic remittance advice (ERA). Starting Jan. 1, 2014, health plans must offer a standardized, online form for physicians and hospitals to enroll to electronically receive payments, as well as notices about claims adjustments and denials. The new rules are required under the Affordable Care Act.

"These new rules will cut red tape, save money, and ensure doctors spend more time seeing patients and less time filling out forms," HHS Secretary Kathleen Sebelius said in a statement.

The requirements could help shift more physician practices away from paper billing. About 70% of health care claim payments are still made in paper check form, according to HHS.

The interim final rule from HHS does not require physicians and hospitals to accept electronic payments. However, if they do, the agency estimates that they will save time and money. For example, practices will save time in handling payment denials since health plans are required to simplify the codes used to explain whether a claim is paid and why.

The net savings to the health care industry from the new electronic standards will be between $300 million and $3.3 billion over 10 years, according to the final rule. HHS officials predicted that most of the implementation cost would be borne by health plans, but most of the benefits would go to providers.

The interim final rule with comment period will be published in the Federal Register on Aug. 10. The public comment period closes on Oct. 9.

After years of state governments, universities, and professional societies all tightening their restrictions around gift-giving to physicians, Massachusetts has gone in the other direction.

In 2008, Massachusetts lawmakers passed one of the nation’s strictest gift bans, which limited gifts, meals, and entertainment from the drug and device industry and imposed public disclosure requirements. But on July 8, Gov. Deval Patrick (D) loosened things up.

The revisions, which were part of a state budget bill, now allow drug and device makers to pay for "modest" meals and refreshments for physicians in connection with informational sessions. Pitches can be made anywhere that is "conducive to information communication," so modest meals could occur in restaurants, not just hospital conference rooms. Still, these turkey sandwiches and the like will need to be reported to the state. The changes do not apply to continuing medical education.

The new law will also allow device companies to offer technical training to physicians before they buy the equipment.

Not everyone is pleased. Health Care For All, AARP Massachusetts, the American Medical Student Association, and the National Physicians Alliance all condemned the move, saying it would be a boon for the restaurant industry and drug companies, but would undermine the trust between doctors and patients.

But device group AdvaMed defended the law, saying it would provide more flexibility so that physicians could learn to use the latest technology.

–Mary Ellen Schneider (on twitter @MaryEllenNY)

After years of state governments, universities, and professional societies all tightening their restrictions around gift-giving to physicians, Massachusetts has gone in the other direction.

In 2008, Massachusetts lawmakers passed one of the nation’s strictest gift bans, which limited gifts, meals, and entertainment from the drug and device industry and imposed public disclosure requirements. But on July 8, Gov. Deval Patrick (D) loosened things up.

The revisions, which were part of a state budget bill, now allow drug and device makers to pay for "modest" meals and refreshments for physicians in connection with informational sessions. Pitches can be made anywhere that is "conducive to information communication," so modest meals could occur in restaurants, not just hospital conference rooms. Still, these turkey sandwiches and the like will need to be reported to the state. The changes do not apply to continuing medical education.

The new law will also allow device companies to offer technical training to physicians before they buy the equipment.

Not everyone is pleased. Health Care For All, AARP Massachusetts, the American Medical Student Association, and the National Physicians Alliance all condemned the move, saying it would be a boon for the restaurant industry and drug companies, but would undermine the trust between doctors and patients.

But device group AdvaMed defended the law, saying it would provide more flexibility so that physicians could learn to use the latest technology.

–Mary Ellen Schneider (on twitter @MaryEllenNY)

After years of state governments, universities, and professional societies all tightening their restrictions around gift-giving to physicians, Massachusetts has gone in the other direction.

In 2008, Massachusetts lawmakers passed one of the nation’s strictest gift bans, which limited gifts, meals, and entertainment from the drug and device industry and imposed public disclosure requirements. But on July 8, Gov. Deval Patrick (D) loosened things up.

The revisions, which were part of a state budget bill, now allow drug and device makers to pay for "modest" meals and refreshments for physicians in connection with informational sessions. Pitches can be made anywhere that is "conducive to information communication," so modest meals could occur in restaurants, not just hospital conference rooms. Still, these turkey sandwiches and the like will need to be reported to the state. The changes do not apply to continuing medical education.

The new law will also allow device companies to offer technical training to physicians before they buy the equipment.

Not everyone is pleased. Health Care For All, AARP Massachusetts, the American Medical Student Association, and the National Physicians Alliance all condemned the move, saying it would be a boon for the restaurant industry and drug companies, but would undermine the trust between doctors and patients.

But device group AdvaMed defended the law, saying it would provide more flexibility so that physicians could learn to use the latest technology.

–Mary Ellen Schneider (on twitter @MaryEllenNY)

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

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

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

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

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

The news that CMS will pay physicians specifically for providing these non face-to-face postdischarge services is "very encouraging," said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians. CMS is projecting that most internists will see about a 5% increase in Medicare payments due to the policy change. Ms. Erickson said the amount will vary based on how often different types of physicians bill for the codes.

The rule does not specify which physicians can use the new G code but Medicare will only pay one physician to perform the service. Ms. Erickson said most of the time it will likely be a primary care physician.

The ACP is now waiting to see how the CMS proposal aligns with work already underway by the American Medical Association’s CPT Editorial Panel and its Specialty Society Relative Value Scale Update Committee (RUC) to develop codes for these services.

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

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

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

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

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

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

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients. "This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

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

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

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance.

Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

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

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

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

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

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

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

The news that CMS will pay physicians specifically for providing these non face-to-face postdischarge services is "very encouraging," said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians. CMS is projecting that most internists will see about a 5% increase in Medicare payments due to the policy change. Ms. Erickson said the amount will vary based on how often different types of physicians bill for the codes.

The rule does not specify which physicians can use the new G code but Medicare will only pay one physician to perform the service. Ms. Erickson said most of the time it will likely be a primary care physician.

The ACP is now waiting to see how the CMS proposal aligns with work already underway by the American Medical Association’s CPT Editorial Panel and its Specialty Society Relative Value Scale Update Committee (RUC) to develop codes for these services.

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

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

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

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

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

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

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients. "This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

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

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

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance.

Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

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

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

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

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

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

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

The news that CMS will pay physicians specifically for providing these non face-to-face postdischarge services is "very encouraging," said Shari Erickson, director of regulatory and insurer affairs at the American College of Physicians. CMS is projecting that most internists will see about a 5% increase in Medicare payments due to the policy change. Ms. Erickson said the amount will vary based on how often different types of physicians bill for the codes.

The rule does not specify which physicians can use the new G code but Medicare will only pay one physician to perform the service. Ms. Erickson said most of the time it will likely be a primary care physician.

The ACP is now waiting to see how the CMS proposal aligns with work already underway by the American Medical Association’s CPT Editorial Panel and its Specialty Society Relative Value Scale Update Committee (RUC) to develop codes for these services.

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

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

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

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

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

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

Dr. William Zoghbi, president of the American College of Cardiology, said the planned reductions in cardiology diagnostic test fees would be bad for both physicians and patients. "This policy disadvantages physicians who aim for efficiency, and reduces payments based on a misguided understanding of how different services, such as echocardiology and SPECT imaging, are from one another," Dr. Zoghbi said in a statement. "Furthermore, it would lead to a major inconvenience to patients."

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

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

Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance.

Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS.

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

The Supreme Court's decision to largely uphold the Affordable Care Act in essence preserved the status quo for the health system and took away some uncertainty - but only in the short term. The congressional and presidential elections in November could bring further changes to the law.

For now, though, the nation's physicians are pondering the court's ruling and how it will affect their practices. Concerns remain regarding some aspects of the law, and there is uncertainty on what the justices' Medicaid decision means.

Christian Shalgian, director of the division of advocacy and health policy at the American College of Surgeons, said he was surprised by the ruling, adding that surgeons are more concerned about what the law doesn't do than what it does.

"The biggest issue in my mind [with] the Affordable Care Act is what's not included in the [law]," said Mr. Shalgian. "The Medicare physician payment issue is one that's driving health care costs, and it needs to be fixed."

However, many other physician groups praised the court's opinions, noting that keeping the law in place would increase health care coverage and maintain the ACA's enhanced preventive care benefits.

"We are pleased that this decision means millions of Americans can look forward to the coverage they need to get healthy and stay healthy," said Dr. Jeremy Lazarus, president of the American Medical Association, in a statement. "This decision protects important improvements, such as ending coverage denials due to preexisting conditions and lifetime caps on insurance and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents' health insurance policies."

Dr. David L. Bronson, president of the American College of Physicians, noted in a statement that although the group did not take a position on the constitutional issues, "we believe that the individual insurance mandate, combined with the ACA's subsidies to buy qualified coverage through state marketplaces (exchanges), Medicaid expansion to more low-income persons, and consumer protections against insurance practices that deny or limit coverage, are the most effective ways to expand coverage to nearly all Americans."

The American Academy of Family Physicians said that keeping the law in place will also allow the continuation of efforts to boost the breadth and depth of primary care.

"The Supreme Court decision maintains already-launched initiatives that support wider implementation of the patient-centered medical home and that value primary medical care through payment incentives for primary care physicians," said Dr. Glen Stream, AAFP president, in a statement.

Oncologists noted that they were pleased that many provisions that protect cancer patients would continue to stay intact, such as coverage for preventive screenings like colonoscopies and mammograms, the elimination of lifetime caps and preexisting condition exclusions for insurance plans, and the requirement that private insurers cover the cost of participating in clinical trials.

Cardiologists also applauded the fact that provisions ensuring preventive care and coverage of preexisting conditions would stay in place. American College of Cardiology president William Zoghbi said in a statement that the organization "favors provisions in the law that support preventive care, access to care, elimination of waste, and a payment system that encourages quality." However, the transformation is not complete. "Hard work remains ahead before we arrive at a sustainable payment system that emphasizes value and a strong patient-doctor relationship," said Dr. Zoghbi.

Because the law basically remains the same - for now - the 2.3% excise tax on medical devices will still go into effect on Jan. 1, 2013. AdvaMed, an industry lobbying group, said that it will continue to try to overturn that tax, which could end up driving up the cost of devices such as pacemakers.

The largely positive statements from organized medicine did not hide the fact that many individual physicians are still fearful of the law's effect on their practice.

In a survey of 644 primary care physicians that was conducted the day the Supreme Court ruled, 66% of respondents said that they did not believe the law could achieve health care coverage for all Americans. The poll was conducted by MDLinx, a Web-based information provider for doctors. "The survey showed a surprisingly high level of skepticism among primary care physicians," said Stephen Smith, chief marketing officer for MDLinx, in a statement. The poll also found that only 21% said that increased patient volume would have an "extremely positive" impact on their medical practice. Almost half said it would have an "extremely negative" impact. Respondents expressed concerns about the shortage of primary care doctors.

And most physician organizations indicated their continuing dissatisfaction with some parts of the law, including the Independent Payment Advisory Board, or IPAB, and the lack of any concrete malpractice reform.

The American Association of Clinical Urologists (AACU), the American Urological Association (AUA), and the Large Urology Group Practice Association (LUGPA) issued a joint statement, noting that "we are concerned that there are key aspects to this law that will, ultimately, hurt this nation's ability to provide widespread care for its citizens," including the IPAB. Mr. Shalgian said that the IPAB has been an issue for the ACS since it was first proposed.

At a press briefing called by the Republican Doctors Caucus, Rep. Phil Gingrey (R-Ga.), an ob.gyn., said that he and his fellow caucus members would work to overturn most if not all of the ACA, starting with the IPAB.

Some of Rep. Gingrey's colleagues were adamant that they'd do everything possible to overturn the law. Rep. Tom Price (R-Ga.), an orthopedic surgeon, said that the ACA "violates accessibility, violates affordability, violates quality, violates choices."

Rep. Paul Broun (R-Ga.) called the Act a "destroyer." He said it would "destroy a patient's ability to go to see a doctor and get the quality care they desperately need." Added Dr. Broun, "Obamacare must be repealed. It must be replaced with some policy that will make health care cheaper for everyone, provide coverage for all Americans, and save Medicare from going broke."

With the Supreme Court's efforts in the rear-view mirror, Republicans renewed their vow to repeal all or part of the ACA; however, that's unlikely to happen as long as Democrats maintain control of the Senate and the White House.

If Republicans win a majority in the Senate in November, and if Mitt Romney wins the presidential election, there could be major change.

In the meantime, most physician groups said they would work to fix the parts of the law that were objectionable.

Mr. Shalgian said that the ACS will be exploring options for medical liability reform during the annual Clinical Congress in Chicago.

Dr. Stream of the AAFP said that such reform is essential. "The [ACA] provides a foundation for reforming our health care system, but much work still lies ahead including a permanent replacement for the Sustainable Growth Rate formula and meaningful medical liability reform," he said.

Dr. Bronson of the ACP said that the organization realizes that "even with the Supreme Court's ruling, the political debate over the ACA continues and that its future is a major issue in the 2012 election."

He added, "We hope that a day will come when the debate will no longer be polarized between repeal on one hand, or keeping the law exactly as it is on the other, but on preserving all of the good things that it does while making needed improvements," among which would be "meaningful reforms to the medical liability system."

The Supreme Court's decision to largely uphold the Affordable Care Act in essence preserved the status quo for the health system and took away some uncertainty - but only in the short term. The congressional and presidential elections in November could bring further changes to the law.

For now, though, the nation's physicians are pondering the court's ruling and how it will affect their practices. Concerns remain regarding some aspects of the law, and there is uncertainty on what the justices' Medicaid decision means.

Christian Shalgian, director of the division of advocacy and health policy at the American College of Surgeons, said he was surprised by the ruling, adding that surgeons are more concerned about what the law doesn't do than what it does.

"The biggest issue in my mind [with] the Affordable Care Act is what's not included in the [law]," said Mr. Shalgian. "The Medicare physician payment issue is one that's driving health care costs, and it needs to be fixed."

However, many other physician groups praised the court's opinions, noting that keeping the law in place would increase health care coverage and maintain the ACA's enhanced preventive care benefits.

"We are pleased that this decision means millions of Americans can look forward to the coverage they need to get healthy and stay healthy," said Dr. Jeremy Lazarus, president of the American Medical Association, in a statement. "This decision protects important improvements, such as ending coverage denials due to preexisting conditions and lifetime caps on insurance and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents' health insurance policies."

Dr. David L. Bronson, president of the American College of Physicians, noted in a statement that although the group did not take a position on the constitutional issues, "we believe that the individual insurance mandate, combined with the ACA's subsidies to buy qualified coverage through state marketplaces (exchanges), Medicaid expansion to more low-income persons, and consumer protections against insurance practices that deny or limit coverage, are the most effective ways to expand coverage to nearly all Americans."

The American Academy of Family Physicians said that keeping the law in place will also allow the continuation of efforts to boost the breadth and depth of primary care.

"The Supreme Court decision maintains already-launched initiatives that support wider implementation of the patient-centered medical home and that value primary medical care through payment incentives for primary care physicians," said Dr. Glen Stream, AAFP president, in a statement.

Oncologists noted that they were pleased that many provisions that protect cancer patients would continue to stay intact, such as coverage for preventive screenings like colonoscopies and mammograms, the elimination of lifetime caps and preexisting condition exclusions for insurance plans, and the requirement that private insurers cover the cost of participating in clinical trials.

Cardiologists also applauded the fact that provisions ensuring preventive care and coverage of preexisting conditions would stay in place. American College of Cardiology president William Zoghbi said in a statement that the organization "favors provisions in the law that support preventive care, access to care, elimination of waste, and a payment system that encourages quality." However, the transformation is not complete. "Hard work remains ahead before we arrive at a sustainable payment system that emphasizes value and a strong patient-doctor relationship," said Dr. Zoghbi.

Because the law basically remains the same - for now - the 2.3% excise tax on medical devices will still go into effect on Jan. 1, 2013. AdvaMed, an industry lobbying group, said that it will continue to try to overturn that tax, which could end up driving up the cost of devices such as pacemakers.

The largely positive statements from organized medicine did not hide the fact that many individual physicians are still fearful of the law's effect on their practice.

In a survey of 644 primary care physicians that was conducted the day the Supreme Court ruled, 66% of respondents said that they did not believe the law could achieve health care coverage for all Americans. The poll was conducted by MDLinx, a Web-based information provider for doctors. "The survey showed a surprisingly high level of skepticism among primary care physicians," said Stephen Smith, chief marketing officer for MDLinx, in a statement. The poll also found that only 21% said that increased patient volume would have an "extremely positive" impact on their medical practice. Almost half said it would have an "extremely negative" impact. Respondents expressed concerns about the shortage of primary care doctors.

And most physician organizations indicated their continuing dissatisfaction with some parts of the law, including the Independent Payment Advisory Board, or IPAB, and the lack of any concrete malpractice reform.

The American Association of Clinical Urologists (AACU), the American Urological Association (AUA), and the Large Urology Group Practice Association (LUGPA) issued a joint statement, noting that "we are concerned that there are key aspects to this law that will, ultimately, hurt this nation's ability to provide widespread care for its citizens," including the IPAB. Mr. Shalgian said that the IPAB has been an issue for the ACS since it was first proposed.

At a press briefing called by the Republican Doctors Caucus, Rep. Phil Gingrey (R-Ga.), an ob.gyn., said that he and his fellow caucus members would work to overturn most if not all of the ACA, starting with the IPAB.

Some of Rep. Gingrey's colleagues were adamant that they'd do everything possible to overturn the law. Rep. Tom Price (R-Ga.), an orthopedic surgeon, said that the ACA "violates accessibility, violates affordability, violates quality, violates choices."

Rep. Paul Broun (R-Ga.) called the Act a "destroyer." He said it would "destroy a patient's ability to go to see a doctor and get the quality care they desperately need." Added Dr. Broun, "Obamacare must be repealed. It must be replaced with some policy that will make health care cheaper for everyone, provide coverage for all Americans, and save Medicare from going broke."

With the Supreme Court's efforts in the rear-view mirror, Republicans renewed their vow to repeal all or part of the ACA; however, that's unlikely to happen as long as Democrats maintain control of the Senate and the White House.

If Republicans win a majority in the Senate in November, and if Mitt Romney wins the presidential election, there could be major change.

In the meantime, most physician groups said they would work to fix the parts of the law that were objectionable.

Mr. Shalgian said that the ACS will be exploring options for medical liability reform during the annual Clinical Congress in Chicago.

Dr. Stream of the AAFP said that such reform is essential. "The [ACA] provides a foundation for reforming our health care system, but much work still lies ahead including a permanent replacement for the Sustainable Growth Rate formula and meaningful medical liability reform," he said.

Dr. Bronson of the ACP said that the organization realizes that "even with the Supreme Court's ruling, the political debate over the ACA continues and that its future is a major issue in the 2012 election."

He added, "We hope that a day will come when the debate will no longer be polarized between repeal on one hand, or keeping the law exactly as it is on the other, but on preserving all of the good things that it does while making needed improvements," among which would be "meaningful reforms to the medical liability system."

The Supreme Court's decision to largely uphold the Affordable Care Act in essence preserved the status quo for the health system and took away some uncertainty - but only in the short term. The congressional and presidential elections in November could bring further changes to the law.

For now, though, the nation's physicians are pondering the court's ruling and how it will affect their practices. Concerns remain regarding some aspects of the law, and there is uncertainty on what the justices' Medicaid decision means.

Christian Shalgian, director of the division of advocacy and health policy at the American College of Surgeons, said he was surprised by the ruling, adding that surgeons are more concerned about what the law doesn't do than what it does.

"The biggest issue in my mind [with] the Affordable Care Act is what's not included in the [law]," said Mr. Shalgian. "The Medicare physician payment issue is one that's driving health care costs, and it needs to be fixed."

However, many other physician groups praised the court's opinions, noting that keeping the law in place would increase health care coverage and maintain the ACA's enhanced preventive care benefits.

"We are pleased that this decision means millions of Americans can look forward to the coverage they need to get healthy and stay healthy," said Dr. Jeremy Lazarus, president of the American Medical Association, in a statement. "This decision protects important improvements, such as ending coverage denials due to preexisting conditions and lifetime caps on insurance and allowing the 2.5 million young adults up to age 26 who gained coverage under the law to stay on their parents' health insurance policies."

Dr. David L. Bronson, president of the American College of Physicians, noted in a statement that although the group did not take a position on the constitutional issues, "we believe that the individual insurance mandate, combined with the ACA's subsidies to buy qualified coverage through state marketplaces (exchanges), Medicaid expansion to more low-income persons, and consumer protections against insurance practices that deny or limit coverage, are the most effective ways to expand coverage to nearly all Americans."

The American Academy of Family Physicians said that keeping the law in place will also allow the continuation of efforts to boost the breadth and depth of primary care.

"The Supreme Court decision maintains already-launched initiatives that support wider implementation of the patient-centered medical home and that value primary medical care through payment incentives for primary care physicians," said Dr. Glen Stream, AAFP president, in a statement.

Oncologists noted that they were pleased that many provisions that protect cancer patients would continue to stay intact, such as coverage for preventive screenings like colonoscopies and mammograms, the elimination of lifetime caps and preexisting condition exclusions for insurance plans, and the requirement that private insurers cover the cost of participating in clinical trials.

Cardiologists also applauded the fact that provisions ensuring preventive care and coverage of preexisting conditions would stay in place. American College of Cardiology president William Zoghbi said in a statement that the organization "favors provisions in the law that support preventive care, access to care, elimination of waste, and a payment system that encourages quality." However, the transformation is not complete. "Hard work remains ahead before we arrive at a sustainable payment system that emphasizes value and a strong patient-doctor relationship," said Dr. Zoghbi.

Because the law basically remains the same - for now - the 2.3% excise tax on medical devices will still go into effect on Jan. 1, 2013. AdvaMed, an industry lobbying group, said that it will continue to try to overturn that tax, which could end up driving up the cost of devices such as pacemakers.

The largely positive statements from organized medicine did not hide the fact that many individual physicians are still fearful of the law's effect on their practice.

In a survey of 644 primary care physicians that was conducted the day the Supreme Court ruled, 66% of respondents said that they did not believe the law could achieve health care coverage for all Americans. The poll was conducted by MDLinx, a Web-based information provider for doctors. "The survey showed a surprisingly high level of skepticism among primary care physicians," said Stephen Smith, chief marketing officer for MDLinx, in a statement. The poll also found that only 21% said that increased patient volume would have an "extremely positive" impact on their medical practice. Almost half said it would have an "extremely negative" impact. Respondents expressed concerns about the shortage of primary care doctors.

And most physician organizations indicated their continuing dissatisfaction with some parts of the law, including the Independent Payment Advisory Board, or IPAB, and the lack of any concrete malpractice reform.

The American Association of Clinical Urologists (AACU), the American Urological Association (AUA), and the Large Urology Group Practice Association (LUGPA) issued a joint statement, noting that "we are concerned that there are key aspects to this law that will, ultimately, hurt this nation's ability to provide widespread care for its citizens," including the IPAB. Mr. Shalgian said that the IPAB has been an issue for the ACS since it was first proposed.

At a press briefing called by the Republican Doctors Caucus, Rep. Phil Gingrey (R-Ga.), an ob.gyn., said that he and his fellow caucus members would work to overturn most if not all of the ACA, starting with the IPAB.

Some of Rep. Gingrey's colleagues were adamant that they'd do everything possible to overturn the law. Rep. Tom Price (R-Ga.), an orthopedic surgeon, said that the ACA "violates accessibility, violates affordability, violates quality, violates choices."

Rep. Paul Broun (R-Ga.) called the Act a "destroyer." He said it would "destroy a patient's ability to go to see a doctor and get the quality care they desperately need." Added Dr. Broun, "Obamacare must be repealed. It must be replaced with some policy that will make health care cheaper for everyone, provide coverage for all Americans, and save Medicare from going broke."

With the Supreme Court's efforts in the rear-view mirror, Republicans renewed their vow to repeal all or part of the ACA; however, that's unlikely to happen as long as Democrats maintain control of the Senate and the White House.

If Republicans win a majority in the Senate in November, and if Mitt Romney wins the presidential election, there could be major change.

In the meantime, most physician groups said they would work to fix the parts of the law that were objectionable.

Mr. Shalgian said that the ACS will be exploring options for medical liability reform during the annual Clinical Congress in Chicago.

Dr. Stream of the AAFP said that such reform is essential. "The [ACA] provides a foundation for reforming our health care system, but much work still lies ahead including a permanent replacement for the Sustainable Growth Rate formula and meaningful medical liability reform," he said.

Dr. Bronson of the ACP said that the organization realizes that "even with the Supreme Court's ruling, the political debate over the ACA continues and that its future is a major issue in the 2012 election."

He added, "We hope that a day will come when the debate will no longer be polarized between repeal on one hand, or keeping the law exactly as it is on the other, but on preserving all of the good things that it does while making needed improvements," among which would be "meaningful reforms to the medical liability system."