Alicia Ault

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and otherwise flat payments for rheumatologists.

Dr. Charles King, a rheumatologist in Tupelo, Miss., and chair of the American College of Rheumatology’s Committee on Rheumatologic Care, said that even if the SGR formula cut is averted, the 0% change in reimbursement based on 2013 coding changes is essentially a pay cut since Medicare officials are simultaneously asking physicians to make investments in health information technology.

"It is a salary cut by default," Dr. King said.

In more bad news for rheumatologists, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rulealso includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

Dr. King urged rheumatologists to pay close attention to the value-based modifier program since all physicians will be subject to the program by 2017, regardless of the size of their practice. He also advised physicians to begin participating in the Physician Quality Reporting System, since the Centers for Medicare and Medicaid Services (CMS) will use that program as the basis for the quality reporting in the value-based modifier program.

In the meantime, the ACR is asking CMS to slow down its implementation until there are better quality measures across a wider spectrum of conditions.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

The rule was published in the Federal Register on Nov. 16, and comments will close on Dec. 31. It will take effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and otherwise flat payments for rheumatologists.

Dr. Charles King, a rheumatologist in Tupelo, Miss., and chair of the American College of Rheumatology’s Committee on Rheumatologic Care, said that even if the SGR formula cut is averted, the 0% change in reimbursement based on 2013 coding changes is essentially a pay cut since Medicare officials are simultaneously asking physicians to make investments in health information technology.

"It is a salary cut by default," Dr. King said.

In more bad news for rheumatologists, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rulealso includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

Dr. King urged rheumatologists to pay close attention to the value-based modifier program since all physicians will be subject to the program by 2017, regardless of the size of their practice. He also advised physicians to begin participating in the Physician Quality Reporting System, since the Centers for Medicare and Medicaid Services (CMS) will use that program as the basis for the quality reporting in the value-based modifier program.

In the meantime, the ACR is asking CMS to slow down its implementation until there are better quality measures across a wider spectrum of conditions.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

The rule was published in the Federal Register on Nov. 16, and comments will close on Dec. 31. It will take effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and otherwise flat payments for rheumatologists.

Dr. Charles King, a rheumatologist in Tupelo, Miss., and chair of the American College of Rheumatology’s Committee on Rheumatologic Care, said that even if the SGR formula cut is averted, the 0% change in reimbursement based on 2013 coding changes is essentially a pay cut since Medicare officials are simultaneously asking physicians to make investments in health information technology.

"It is a salary cut by default," Dr. King said.

In more bad news for rheumatologists, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rulealso includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

Dr. King urged rheumatologists to pay close attention to the value-based modifier program since all physicians will be subject to the program by 2017, regardless of the size of their practice. He also advised physicians to begin participating in the Physician Quality Reporting System, since the Centers for Medicare and Medicaid Services (CMS) will use that program as the basis for the quality reporting in the value-based modifier program.

In the meantime, the ACR is asking CMS to slow down its implementation until there are better quality measures across a wider spectrum of conditions.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

The rule was published in the Federal Register on Nov. 16, and comments will close on Dec. 31. It will take effect Jan. 1, 2013.

A St. Louis dermatologist and several colleagues have succeeded in convincing the American Academy of Dermatology to vote at its March annual meeting on whether to change the organization’s name to the American Academy of Dermatology and Dermatologic Surgery.

Dr. Lee Portnoff, who is in private practice and is an assistant professor of clinical medicine at Washington University in St. Louis, said in an interview that he and his colleagues were calling for the change because "it is important that our largest dermatology umbrella organization has a name that represents and promotes the surgical aspect of our practices."

In a position paper submitted to the AAD, Dr. Portnoff and the three signatories – Dr. Harold J. Brody, Dr. William P. Coleman III, and Dr. Raymond L. Cornelison Jr. – noted that a simple majority of AAD members approved just such a name change 14 years ago at an annual meeting but that a two-thirds majority was required for passage.

In addition, even though the AAD Advisory Board backed resolutions over the past 2 years urging the AAD Board of Directors to add "dermatologic surgery" to the academy’s name, the Board of Directors declined to have such a change considered at the annual meeting, saying that it would be too expensive to change and that it would mean establishing a new "brand" for dermatology. Dr. Portnoff said, however, that many specialties are now performing dermatologic surgery and that dermatology should reclaim the distinction.

The position paper calling for the change also says that "we do not see how the addition of the surgical name will alter the branding that exists." Instead, it could make the branding more successful, and also "enhance our specialty tremendously."

The AAD will be taking comments on the proposal until Dec. 1, according to a spokeswoman for the organization.

Members who want to comment can do so via the AAD website, by e-mail, or by mail to the attention of the Secretary Treasurer, Bylaws Statements, 930 E. Woodfield Road, Schaumburg, IL 60173-4729.

Statements cannot be any longer than two typewritten, double-spaced pages.

If the academy votes to change the name, it would take effect 12 months later, unless the Board of Directors and the AAD voted to change the effective date.

A St. Louis dermatologist and several colleagues have succeeded in convincing the American Academy of Dermatology to vote at its March annual meeting on whether to change the organization’s name to the American Academy of Dermatology and Dermatologic Surgery.

Dr. Lee Portnoff, who is in private practice and is an assistant professor of clinical medicine at Washington University in St. Louis, said in an interview that he and his colleagues were calling for the change because "it is important that our largest dermatology umbrella organization has a name that represents and promotes the surgical aspect of our practices."

In a position paper submitted to the AAD, Dr. Portnoff and the three signatories – Dr. Harold J. Brody, Dr. William P. Coleman III, and Dr. Raymond L. Cornelison Jr. – noted that a simple majority of AAD members approved just such a name change 14 years ago at an annual meeting but that a two-thirds majority was required for passage.

In addition, even though the AAD Advisory Board backed resolutions over the past 2 years urging the AAD Board of Directors to add "dermatologic surgery" to the academy’s name, the Board of Directors declined to have such a change considered at the annual meeting, saying that it would be too expensive to change and that it would mean establishing a new "brand" for dermatology. Dr. Portnoff said, however, that many specialties are now performing dermatologic surgery and that dermatology should reclaim the distinction.

The position paper calling for the change also says that "we do not see how the addition of the surgical name will alter the branding that exists." Instead, it could make the branding more successful, and also "enhance our specialty tremendously."

The AAD will be taking comments on the proposal until Dec. 1, according to a spokeswoman for the organization.

Members who want to comment can do so via the AAD website, by e-mail, or by mail to the attention of the Secretary Treasurer, Bylaws Statements, 930 E. Woodfield Road, Schaumburg, IL 60173-4729.

Statements cannot be any longer than two typewritten, double-spaced pages.

If the academy votes to change the name, it would take effect 12 months later, unless the Board of Directors and the AAD voted to change the effective date.

A St. Louis dermatologist and several colleagues have succeeded in convincing the American Academy of Dermatology to vote at its March annual meeting on whether to change the organization’s name to the American Academy of Dermatology and Dermatologic Surgery.

Dr. Lee Portnoff, who is in private practice and is an assistant professor of clinical medicine at Washington University in St. Louis, said in an interview that he and his colleagues were calling for the change because "it is important that our largest dermatology umbrella organization has a name that represents and promotes the surgical aspect of our practices."

In a position paper submitted to the AAD, Dr. Portnoff and the three signatories – Dr. Harold J. Brody, Dr. William P. Coleman III, and Dr. Raymond L. Cornelison Jr. – noted that a simple majority of AAD members approved just such a name change 14 years ago at an annual meeting but that a two-thirds majority was required for passage.

In addition, even though the AAD Advisory Board backed resolutions over the past 2 years urging the AAD Board of Directors to add "dermatologic surgery" to the academy’s name, the Board of Directors declined to have such a change considered at the annual meeting, saying that it would be too expensive to change and that it would mean establishing a new "brand" for dermatology. Dr. Portnoff said, however, that many specialties are now performing dermatologic surgery and that dermatology should reclaim the distinction.

The position paper calling for the change also says that "we do not see how the addition of the surgical name will alter the branding that exists." Instead, it could make the branding more successful, and also "enhance our specialty tremendously."

The AAD will be taking comments on the proposal until Dec. 1, according to a spokeswoman for the organization.

Members who want to comment can do so via the AAD website, by e-mail, or by mail to the attention of the Secretary Treasurer, Bylaws Statements, 930 E. Woodfield Road, Schaumburg, IL 60173-4729.

Statements cannot be any longer than two typewritten, double-spaced pages.

If the academy votes to change the name, it would take effect 12 months later, unless the Board of Directors and the AAD voted to change the effective date.

As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.

Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.

The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.

"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.

Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.

"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.

Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.

Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.

The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.

"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.

According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."

The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.

The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.

As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.

Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.

The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.

"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.

Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.

"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.

Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.

Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.

The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.

"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.

According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."

The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.

The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.

As the sensitivity of troponin testing improves, so must clinicians refine the way they order and interpret such tests, according to a new consensus statement issued by seven professional societies.

Clinicians have used troponin as a biomarker for myocardial infarction since the early 1990s. However, while an elevated level indicates myocardial necrosis, it does not necessarily mean that a myocardial infarction has occurred. There can be other myriad reasons for an increase in troponin.

The consensus statement – written by a 14-member group of experts – reviews the most recent research on troponin testing and its clinical applications. It also addresses frequently asked questions on what an elevated troponin level means, when the test should be ordered, and prognosis with a positive test. The statement also gives a schematic look at potential causes of a positive troponin test. The schematic is divided into ischemic and nonischemic causes, and then further broken down.

"We need to be thinking about why we are ordering the troponin test before we order it," said Dr. L. Kristin Newby, cochair of the writing committee for the ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. "We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results," said Dr. Newby, who is a professor of medicine in the division of cardiovascular medicine at Duke University Medical Center, Durham, N.C.

Troponin may be elevated because of heart failure, surgery, trauma, kidney disease, or pulmonary embolism, among other conditions. The biomarker may also show up in patients with sepsis or those taking certain chemotherapies, such as anthracyclines and cyclophosphamide, which are known to cause cardiac damage.

"If we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important," said Dr. Newby.

Further complicating testing, the statement warns clinicians that "all troponin assays are not created equal," and that there "is a wide spectrum of assay quality in practice." The measurement of cardiac troponin is also not standardized, though there have been recommendations by the National Academy of Clinical Biochemistry on how to do so.

Most assays, however, are "able to selectively detect cardiac troponin to the exclusion of troponin from other tissues," according to the statement.

The statement also documents that elevated troponin deserves investigation because it is associated with worse outcomes.

"If you have a pulmonary embolism or end-stage renal disease and your troponin is elevated, your prognosis – how you are expected to do – is worse," said Dr. Newby.

According to the statement, for clinicians, the "best value of troponin testing remains in the diagnosis of MI." But even with that use, "it is important to understand the clinical context as treatment may vary considerably."

The 37-page statement was developed by the American College of Cardiology Foundation, the American Association for Clinical Chemistry, the American College of Chest Physicians, the American College of Emergency Physicians, the American College of Physicians, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions.

The statement was published online (JACC 2012;60) and will also be available on the ACC’s website.

BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.

The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.

Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.

MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.

In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.

Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.

While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.

A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.

The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.

If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.

Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.

The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.

As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.

Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.

Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.

The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.

Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.

The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.

About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.

As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.

Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.

Maryland will contract with certain entities who will then hire individual navigators. Those navigators will not be employees of the exchange. The aim is to have a full cadre of navigators by late spring and to have them completely trained by late summer, said Danielle Davis, director of communications and outreach for the Maryland Health Connection.

What Will Plans Look Like in Maryland?

The ACA requires each state health insurance exchange to establish an essential benefits package; every plan for sale in the exchange must offer these benefits. In Maryland, plans must offer:

• Ambulatory services.

• Emergency services.

• Hospitalization.

• Maternity and newborn care.

• Mental health and substance use disorder services.

• Prescription drugs.

• Rehabilitative and habilitative services and devices.

• Laboratory services.

• Preventive and wellness services and chronic disease management.

• Pediatric services, including oral and vision care.

Each state exchange must choose a benchmark plan that covers the essential benefits; insurance carriers build upon that plan. Maryland chose its state employees’ health benefits plan as its benchmark.

So far, all 12 insurers in Maryland’s small group and individual markets have indicated they want to participate in the exchange, Ms. Pearce said. Consumers can begin enrolling on Oct. 1, 2013; coverage starts on Jan. 1, 2014.

For physicians, the transition should be seamless, said Ms. Pearce. Patients who gain coverage through the exchange will have benefits and identification cards from insurance carriers, just like every insured patient.

BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.

The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.

Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.

MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.

In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.

Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.

While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.

A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.

The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.

If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.

Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.

The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.

As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.

Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.

Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.

The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.

Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.

The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.

About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.

As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.

Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.

Maryland will contract with certain entities who will then hire individual navigators. Those navigators will not be employees of the exchange. The aim is to have a full cadre of navigators by late spring and to have them completely trained by late summer, said Danielle Davis, director of communications and outreach for the Maryland Health Connection.

What Will Plans Look Like in Maryland?

The ACA requires each state health insurance exchange to establish an essential benefits package; every plan for sale in the exchange must offer these benefits. In Maryland, plans must offer:

• Ambulatory services.

• Emergency services.

• Hospitalization.

• Maternity and newborn care.

• Mental health and substance use disorder services.

• Prescription drugs.

• Rehabilitative and habilitative services and devices.

• Laboratory services.

• Preventive and wellness services and chronic disease management.

• Pediatric services, including oral and vision care.

Each state exchange must choose a benchmark plan that covers the essential benefits; insurance carriers build upon that plan. Maryland chose its state employees’ health benefits plan as its benchmark.

So far, all 12 insurers in Maryland’s small group and individual markets have indicated they want to participate in the exchange, Ms. Pearce said. Consumers can begin enrolling on Oct. 1, 2013; coverage starts on Jan. 1, 2014.

For physicians, the transition should be seamless, said Ms. Pearce. Patients who gain coverage through the exchange will have benefits and identification cards from insurance carriers, just like every insured patient.

BALTIMORE – As the Nov. 16 deadline draws near for states to determine whether and how they will run their own health insurance exchange, Maryland has no doubt about where it stands.

The state moved quickly to set up its Maryland Health Benefit Exchange so that will be ready when open enrollment starts in October 2013, as required under the Affordable Care Act.

Physicians have been involved in creating the exchange and will have an ongoing say in how it operates, according to Gene M. Ransom, CEO of MedChi, the Maryland State Medical Society.

MedChi has been watching closely the exchange’s development in part because the society wants to ensure that protections currently in place – such as those restricting how prior authorization is used by insurers – will not be overturned or altered as part of the new insurance framework, Mr. Ransom said in an interview.

In addition, many Maryland physicians are very likely to purchase employee health coverage through the state exchange, Mr. Ransom said, noting that as small businesses, the rates available through the exchange might be more attractive than those currently available on the open market.

Doctors also may end up helping to fund the exchange’s ongoing operations, although how – and how much they will be asked to pony up – is not entirely clear yet, according to Rebecca Pearce, executive director of the Maryland Health Benefit Exchange.

While the Maryland exchange is fully funded via federal grants through 2014, it is required by law to become self-sustaining after that.

A task force is formulating funding recommendations for the state legislature. Based on past work, possible funding mechanisms include a transaction-based fee on providers; a fee attached to licensure; or a special assessment on insurers or hospitals, Ms. Pearce said.

The notion of physicians being asked to help fund the exchange does not sit well with MedChi, said Mr. Ransom, who added that such an idea has not been mentioned publicly during exchange board meetings or exchange committee meetings. Nor has it been broached privately with any MedChi lobbyists or staff, he added.

If such a fee were levied, "We would be adamantly opposed," Mr. Ransom said.

Health insurance exchanges, a major feature of the Affordable Care Act, are supposed to create an open marketplace for individuals and small groups to buy health insurance coverage and help to bring them some of the economies of scale enjoyed by large groups.

The marketplaces have been likened to an Orbitz or Travelocity for health insurance. Under the ACA, a state can either run its own exchange, have the federal government run it, partner with the federal government, or opt out.

As of early November, 16 states said they would go solo, 3 wanted partnerships, 16 were studying options, 8 were silent, and 8 said they would not create an exchange, according to the Kaiser Family Foundation.

Five states -- Connecticut, Maryland, Nevada, Rhode Island, and Vermont – as well as Washington, D.C., have received advanced (level 2) funding from Health and Human Services department.

Maryland has been certain of its plans since the passage of the ACA. In September 2011, Gov. Martin O’Malley (D) appointed Ms. Pearce. The Maryland Health Benefit Exchange has received $157 million through four planning and establishment grants from the HHS.

The exchange is lead by a board of trustees chaired by Dr. Joshua M. Sharfstein, state secretary of health and mental hygiene. Dr. Georges C. Benjamin, executive director of the American Public Health Association, also is on the board.

Physicians – many of them active MedChi members, according to Mr. Ransom – as well as advocates, insurance carriers, consumers, business leaders, and community leaders, also serve on the five committees the exchange has established. Those committees address navigators, continuity of care, plan management, finances, and implementation.

The exchange has also set up a website for the Maryland Health Connection, through which consumers will find and select insurance.

About 14% (730,000) of Maryland’s population is uninsured, but only 40% of them are thought to be eligible for the exchange coverage, Ms. Pearce said in an interview. In the first year, an estimated 145,000-180,000 will enroll for coverage through the Connection, she said. By 2020, some 250,000 will likely be purchasing coverage through the exchange.

As required by the ACA, the Maryland exchange will use navigators to reach special populations, such as non-English speakers, or the disabled. Navigators will offer in-person assistance to walk people through their choices and the enrollment process.

Navigators also are tasked with helping individuals and small employers apply for tax credits as well as linking individuals to other programs for which they might be eligible for, such as Medicaid or the Children’s Health Insurance Program. Navigators may not have conflicts of interest, although independent insurance agents and brokers may serve as navigators.

Maryland will contract with certain entities who will then hire individual navigators. Those navigators will not be employees of the exchange. The aim is to have a full cadre of navigators by late spring and to have them completely trained by late summer, said Danielle Davis, director of communications and outreach for the Maryland Health Connection.

What Will Plans Look Like in Maryland?

The ACA requires each state health insurance exchange to establish an essential benefits package; every plan for sale in the exchange must offer these benefits. In Maryland, plans must offer:

• Ambulatory services.

• Emergency services.

• Hospitalization.

• Maternity and newborn care.

• Mental health and substance use disorder services.

• Prescription drugs.

• Rehabilitative and habilitative services and devices.

• Laboratory services.

• Preventive and wellness services and chronic disease management.

• Pediatric services, including oral and vision care.

Each state exchange must choose a benchmark plan that covers the essential benefits; insurance carriers build upon that plan. Maryland chose its state employees’ health benefits plan as its benchmark.

So far, all 12 insurers in Maryland’s small group and individual markets have indicated they want to participate in the exchange, Ms. Pearce said. Consumers can begin enrolling on Oct. 1, 2013; coverage starts on Jan. 1, 2014.

For physicians, the transition should be seamless, said Ms. Pearce. Patients who gain coverage through the exchange will have benefits and identification cards from insurance carriers, just like every insured patient.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

Courtesy AMA

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.

Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.

ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.

"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."

The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.

The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

Courtesy AMA

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.

Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.

ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.

"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."

The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.

The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.

Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

Courtesy AMA

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.

The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.

Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.

ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.

"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."

The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.

For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.

The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and pay increases for care coordination and for primary care provided under Medicaid.

Under current law, the Sustainable Growth Rate (SGR) formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.*

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.

As called for under the Affordable Care Act, the CMS will pay Medicare rates for evaluation and management codes between 99201 and 99499 when they are used by physicians who are board certified by the American Board of Medical Specialties, the American Osteopathic Association, and the American Board of Physician Specialties.

The codes cover not just primary care, but also hospital observation and consultation for inpatient services provided by nonadmitting physicians, emergency department services, and critical care services.

The final rule does not, however, allow emergency physicians or obstetricians to be compensated at the Medicare level for services under Medicaid, according to the consulting firm Washington Analysis.

The CMS estimated that increasing the Medicaid pay will cost $5.6 billion in 2013 and $5.7 billion in 2014.

Dr. Thomas K. McInerny, president of the American Academy of Pediatrics, said that pay parity between Medicaid and Medicare was "a monumental victory for children’s access to quality health care." He noted that children make up more than half of all recipients of Medicaid services, and that pediatricians provide almost two-thirds of the office visits for those children.

The American Academy of Family Physicians also praised the rule. Dr. Jeffrey Cain, AAFP president, agreed that pay parity would increase access to care.

"More than 6 in 10 (64%) family physicians accept new Medicaid patients, and these beneficiaries comprise 15% of the average family physician’s patient panel," he said in a statement. "However, increasingly inadequate Medicaid payment has forced nearly 2 in 10 family physicians to stop accepting new Medicaid patients."

The rules will be published in the Federal Register on Nov. 16 and comments will close on Dec. 31. Both rules take effect Jan. 1, 2013.

*Correction, 11/6/2012: An earlier version of this story mischaracterized Dr. Hoven's position within the AMA.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and pay increases for care coordination and for primary care provided under Medicaid.

Under current law, the Sustainable Growth Rate (SGR) formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.*

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.

As called for under the Affordable Care Act, the CMS will pay Medicare rates for evaluation and management codes between 99201 and 99499 when they are used by physicians who are board certified by the American Board of Medical Specialties, the American Osteopathic Association, and the American Board of Physician Specialties.

The codes cover not just primary care, but also hospital observation and consultation for inpatient services provided by nonadmitting physicians, emergency department services, and critical care services.

The final rule does not, however, allow emergency physicians or obstetricians to be compensated at the Medicare level for services under Medicaid, according to the consulting firm Washington Analysis.

The CMS estimated that increasing the Medicaid pay will cost $5.6 billion in 2013 and $5.7 billion in 2014.

Dr. Thomas K. McInerny, president of the American Academy of Pediatrics, said that pay parity between Medicaid and Medicare was "a monumental victory for children’s access to quality health care." He noted that children make up more than half of all recipients of Medicaid services, and that pediatricians provide almost two-thirds of the office visits for those children.

The American Academy of Family Physicians also praised the rule. Dr. Jeffrey Cain, AAFP president, agreed that pay parity would increase access to care.

"More than 6 in 10 (64%) family physicians accept new Medicaid patients, and these beneficiaries comprise 15% of the average family physician’s patient panel," he said in a statement. "However, increasingly inadequate Medicaid payment has forced nearly 2 in 10 family physicians to stop accepting new Medicaid patients."

The rules will be published in the Federal Register on Nov. 16 and comments will close on Dec. 31. Both rules take effect Jan. 1, 2013.

*Correction, 11/6/2012: An earlier version of this story mischaracterized Dr. Hoven's position within the AMA.

Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and pay increases for care coordination and for primary care provided under Medicaid.

Under current law, the Sustainable Growth Rate (SGR) formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.

In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.

The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."

The American Medical Association decried the SGR cut.

"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.*

The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.

In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.

In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and email communications.

In another final rule issued Nov. 1, the CMS announced that, as expected, it will pay certain providers the Medicare pay rate for certain primary care services provided under Medicaid in 2013 and 2014.

As called for under the Affordable Care Act, the CMS will pay Medicare rates for evaluation and management codes between 99201 and 99499 when they are used by physicians who are board certified by the American Board of Medical Specialties, the American Osteopathic Association, and the American Board of Physician Specialties.

The codes cover not just primary care, but also hospital observation and consultation for inpatient services provided by nonadmitting physicians, emergency department services, and critical care services.

The final rule does not, however, allow emergency physicians or obstetricians to be compensated at the Medicare level for services under Medicaid, according to the consulting firm Washington Analysis.

The CMS estimated that increasing the Medicaid pay will cost $5.6 billion in 2013 and $5.7 billion in 2014.

Dr. Thomas K. McInerny, president of the American Academy of Pediatrics, said that pay parity between Medicaid and Medicare was "a monumental victory for children’s access to quality health care." He noted that children make up more than half of all recipients of Medicaid services, and that pediatricians provide almost two-thirds of the office visits for those children.

The American Academy of Family Physicians also praised the rule. Dr. Jeffrey Cain, AAFP president, agreed that pay parity would increase access to care.

"More than 6 in 10 (64%) family physicians accept new Medicaid patients, and these beneficiaries comprise 15% of the average family physician’s patient panel," he said in a statement. "However, increasingly inadequate Medicaid payment has forced nearly 2 in 10 family physicians to stop accepting new Medicaid patients."

The rules will be published in the Federal Register on Nov. 16 and comments will close on Dec. 31. Both rules take effect Jan. 1, 2013.

*Correction, 11/6/2012: An earlier version of this story mischaracterized Dr. Hoven's position within the AMA.

PHILADELPHIA – The American Academy of Family Physicians concluded its 3-day Congress of Delegates meeting with a bold move forward – but it was probably not in an area that most members were expecting.

Debate among the 223 delegates and alternates regarding the academy’s participation in the American Medical Association’s Relative Value Scale Update Committee (RUC) ended up taking a backseat to controversy over resolutions urging the organization to endorse same-sex civil marriage*. In the end, delegates decided to maintain the status quo on the AAFP’s RUC efforts, but ended a 3-year gridlock over same-sex civil marriage by endorsing it by a vote of 75 to 44.

Alicia Ault/IMNG Medical Media

Debate over civil marriage for same-sex couples was intense and heated, with at least an hour of impassioned discussion at the Reference Committee on Advocacy, and close to that on the floor before the delegates voted to close debate.

Many supporters testified that their own same-sex partnerships had suffered as a result of their being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that his cousin's son Christopher committed suicide at age 19 because he felt persecuted about his homosexuality.**

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that the AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans*.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP policy will now state that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

That language was crafted in two resolutions brought forward by the resident and student sections. The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same-sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get the same legal rights as married heterosexuals.

Staying the Course on RUC

Many AAFP members have been dissatisfied with the RUC’s handling of primary care valuations and family medicine valuations in particular. Several resolutions were put forward at the congress to create a family medicine–specific set of codes and to make the AAFP the exclusive body for establishing billing codes for preventive and primary care services for Medicare.

The resolutions fostered some discussion – but most of it was fairly muted. The delegates, in the end, decided to instruct the organization to continue its efforts to seek higher valuations for primary care.

"This congress is very familiar with family medicine’s frustration with the RUC," said Dr. Glen Stream, whose term as AAFP president ended at the meeting. But he said that for the moment, "remaining in the RUC allows the opportunity to advocate and press for [the] changes" that the AAFP has requested.

Among those: creating primary care–specific E&M codes, valuing the codes to reflect the intensity and complexity of primary care, and paying for certain non-face-to-face services.

The AAFP has also hired Avalere Health to come up with data to support higher valuations, which the academy will take to the Centers for Medicare and Medicaid Services to use as a basis for the 2014 Medicare Physician Fee Schedule, said Dr. Stream, who now serves as AAFP board chair.

In Other Issues

The Congress of Delegates also approved a controversial resolution to end age restrictions on over-the-counter emergency contraception (EC). Under current law, women under age 16 must get a prescription to get EC. Supporters said that there is no scientific basis to prohibit younger women from getting the drug over the counter, and that it could help avert many abortions. Opponents, however, said that OTC availability would lead to fewer counseling opportunities with those young patients, and might lead to even greater sexual activity.

Among other resolutions, a proposal to oppose telemedicine when it is provided in the absence of a preexisting physician-patient relationship, was referred to the board of directors for study.

The board will also report back to the congress next year on developing model legislation that would exempt primary physicians from antitrust laws so they can collectively negotiate with health insurers. The goal is to help independent practices survive in the changing health delivery system.

Much discussion also centered on how to advance the patient-centered medical home model of care, including which, or how many organizations should certify the entities.

Dr. Douglas Henley, AAFP executive vice president, said that the medical home is the perfect environment to help control health costs and improve quality of care. The family physician can help prevent patients from becoming victims of unnecessary care, he said. Dr. Henley coined a new acronym to describe those patients: VOMIT, or "victims of multiple interventional technologies."

Finally, the AAFP leadership said that the board had given approval to generate a new report on what family medicine should look like over the next decade. The AAFP developed just such a blueprint 8 years ago; however, the research supporting that paper has become dated, said Dr. Henley.

"Now is a critical time to begin a discussion and perhaps revisit research or even initiate new research about what comprehensive primary care means in 2012 and into the future," said Dr. Henley.

That process has begun, he said, adding that AAFP members should expect to hear more in January.

*Correction, 11/06/12: A previous version of this story misstated the number of delegates and alternates at the meeting and misstated Dr. Erica Swegler's last name. The photo caption also misstated the name of the governing body.

**Correction, 12/10/12: A previous version of this story misstated Dr. Van Winkle's relation to Christopher.

PHILADELPHIA – The American Academy of Family Physicians concluded its 3-day Congress of Delegates meeting with a bold move forward – but it was probably not in an area that most members were expecting.

Debate among the 223 delegates and alternates regarding the academy’s participation in the American Medical Association’s Relative Value Scale Update Committee (RUC) ended up taking a backseat to controversy over resolutions urging the organization to endorse same-sex civil marriage*. In the end, delegates decided to maintain the status quo on the AAFP’s RUC efforts, but ended a 3-year gridlock over same-sex civil marriage by endorsing it by a vote of 75 to 44.

Alicia Ault/IMNG Medical Media

Debate over civil marriage for same-sex couples was intense and heated, with at least an hour of impassioned discussion at the Reference Committee on Advocacy, and close to that on the floor before the delegates voted to close debate.

Many supporters testified that their own same-sex partnerships had suffered as a result of their being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that his cousin's son Christopher committed suicide at age 19 because he felt persecuted about his homosexuality.**

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that the AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans*.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP policy will now state that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

That language was crafted in two resolutions brought forward by the resident and student sections. The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same-sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get the same legal rights as married heterosexuals.

Staying the Course on RUC

Many AAFP members have been dissatisfied with the RUC’s handling of primary care valuations and family medicine valuations in particular. Several resolutions were put forward at the congress to create a family medicine–specific set of codes and to make the AAFP the exclusive body for establishing billing codes for preventive and primary care services for Medicare.

The resolutions fostered some discussion – but most of it was fairly muted. The delegates, in the end, decided to instruct the organization to continue its efforts to seek higher valuations for primary care.

"This congress is very familiar with family medicine’s frustration with the RUC," said Dr. Glen Stream, whose term as AAFP president ended at the meeting. But he said that for the moment, "remaining in the RUC allows the opportunity to advocate and press for [the] changes" that the AAFP has requested.

Among those: creating primary care–specific E&M codes, valuing the codes to reflect the intensity and complexity of primary care, and paying for certain non-face-to-face services.

The AAFP has also hired Avalere Health to come up with data to support higher valuations, which the academy will take to the Centers for Medicare and Medicaid Services to use as a basis for the 2014 Medicare Physician Fee Schedule, said Dr. Stream, who now serves as AAFP board chair.

In Other Issues

The Congress of Delegates also approved a controversial resolution to end age restrictions on over-the-counter emergency contraception (EC). Under current law, women under age 16 must get a prescription to get EC. Supporters said that there is no scientific basis to prohibit younger women from getting the drug over the counter, and that it could help avert many abortions. Opponents, however, said that OTC availability would lead to fewer counseling opportunities with those young patients, and might lead to even greater sexual activity.

Among other resolutions, a proposal to oppose telemedicine when it is provided in the absence of a preexisting physician-patient relationship, was referred to the board of directors for study.

The board will also report back to the congress next year on developing model legislation that would exempt primary physicians from antitrust laws so they can collectively negotiate with health insurers. The goal is to help independent practices survive in the changing health delivery system.

Much discussion also centered on how to advance the patient-centered medical home model of care, including which, or how many organizations should certify the entities.

Dr. Douglas Henley, AAFP executive vice president, said that the medical home is the perfect environment to help control health costs and improve quality of care. The family physician can help prevent patients from becoming victims of unnecessary care, he said. Dr. Henley coined a new acronym to describe those patients: VOMIT, or "victims of multiple interventional technologies."

Finally, the AAFP leadership said that the board had given approval to generate a new report on what family medicine should look like over the next decade. The AAFP developed just such a blueprint 8 years ago; however, the research supporting that paper has become dated, said Dr. Henley.

"Now is a critical time to begin a discussion and perhaps revisit research or even initiate new research about what comprehensive primary care means in 2012 and into the future," said Dr. Henley.

That process has begun, he said, adding that AAFP members should expect to hear more in January.

*Correction, 11/06/12: A previous version of this story misstated the number of delegates and alternates at the meeting and misstated Dr. Erica Swegler's last name. The photo caption also misstated the name of the governing body.

**Correction, 12/10/12: A previous version of this story misstated Dr. Van Winkle's relation to Christopher.

PHILADELPHIA – The American Academy of Family Physicians concluded its 3-day Congress of Delegates meeting with a bold move forward – but it was probably not in an area that most members were expecting.

Debate among the 223 delegates and alternates regarding the academy’s participation in the American Medical Association’s Relative Value Scale Update Committee (RUC) ended up taking a backseat to controversy over resolutions urging the organization to endorse same-sex civil marriage*. In the end, delegates decided to maintain the status quo on the AAFP’s RUC efforts, but ended a 3-year gridlock over same-sex civil marriage by endorsing it by a vote of 75 to 44.

Alicia Ault/IMNG Medical Media

Debate over civil marriage for same-sex couples was intense and heated, with at least an hour of impassioned discussion at the Reference Committee on Advocacy, and close to that on the floor before the delegates voted to close debate.

Many supporters testified that their own same-sex partnerships had suffered as a result of their being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that his cousin's son Christopher committed suicide at age 19 because he felt persecuted about his homosexuality.**

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that the AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans*.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP policy will now state that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

That language was crafted in two resolutions brought forward by the resident and student sections. The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same-sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get the same legal rights as married heterosexuals.

Staying the Course on RUC

Many AAFP members have been dissatisfied with the RUC’s handling of primary care valuations and family medicine valuations in particular. Several resolutions were put forward at the congress to create a family medicine–specific set of codes and to make the AAFP the exclusive body for establishing billing codes for preventive and primary care services for Medicare.

The resolutions fostered some discussion – but most of it was fairly muted. The delegates, in the end, decided to instruct the organization to continue its efforts to seek higher valuations for primary care.

"This congress is very familiar with family medicine’s frustration with the RUC," said Dr. Glen Stream, whose term as AAFP president ended at the meeting. But he said that for the moment, "remaining in the RUC allows the opportunity to advocate and press for [the] changes" that the AAFP has requested.

Among those: creating primary care–specific E&M codes, valuing the codes to reflect the intensity and complexity of primary care, and paying for certain non-face-to-face services.

The AAFP has also hired Avalere Health to come up with data to support higher valuations, which the academy will take to the Centers for Medicare and Medicaid Services to use as a basis for the 2014 Medicare Physician Fee Schedule, said Dr. Stream, who now serves as AAFP board chair.

In Other Issues

The Congress of Delegates also approved a controversial resolution to end age restrictions on over-the-counter emergency contraception (EC). Under current law, women under age 16 must get a prescription to get EC. Supporters said that there is no scientific basis to prohibit younger women from getting the drug over the counter, and that it could help avert many abortions. Opponents, however, said that OTC availability would lead to fewer counseling opportunities with those young patients, and might lead to even greater sexual activity.

Among other resolutions, a proposal to oppose telemedicine when it is provided in the absence of a preexisting physician-patient relationship, was referred to the board of directors for study.

The board will also report back to the congress next year on developing model legislation that would exempt primary physicians from antitrust laws so they can collectively negotiate with health insurers. The goal is to help independent practices survive in the changing health delivery system.

Much discussion also centered on how to advance the patient-centered medical home model of care, including which, or how many organizations should certify the entities.

Dr. Douglas Henley, AAFP executive vice president, said that the medical home is the perfect environment to help control health costs and improve quality of care. The family physician can help prevent patients from becoming victims of unnecessary care, he said. Dr. Henley coined a new acronym to describe those patients: VOMIT, or "victims of multiple interventional technologies."

Finally, the AAFP leadership said that the board had given approval to generate a new report on what family medicine should look like over the next decade. The AAFP developed just such a blueprint 8 years ago; however, the research supporting that paper has become dated, said Dr. Henley.

"Now is a critical time to begin a discussion and perhaps revisit research or even initiate new research about what comprehensive primary care means in 2012 and into the future," said Dr. Henley.

That process has begun, he said, adding that AAFP members should expect to hear more in January.

*Correction, 11/06/12: A previous version of this story misstated the number of delegates and alternates at the meeting and misstated Dr. Erica Swegler's last name. The photo caption also misstated the name of the governing body.

**Correction, 12/10/12: A previous version of this story misstated Dr. Van Winkle's relation to Christopher.

Medicare physician pay would be cut by at least 2% in 2013 while some Affordable Care Act programs would be spared the automatic cuts called for under the Budget Control Act of 2011, according to a report from the federal Office of Management and Budget.

The report provides details on how to cut $1.2 trillion from the federal budget by 2021 and was mandated after the Joint Select Committee on Deficit Reduction failed to do the same. The process – known as sequestration – would cut funding for most federal agencies across the board.

The Office of Management and Budget (OMB) report noted that the estimates are preliminary; the true magnitude of the cuts won’t be known until sequestration actually occurs.

The report also notes that the White House firmly opposes the automatic cuts.

"Sequestration is a blunt and indiscriminate instrument. It is not the responsible way for our nation to achieve deficit reduction," according to the report. OMB called on Congress to avoid sequestration either by passing the President’s budget proposals or otherwise approving "a comprehensive and balanced deficit reduction package."

Under sequestration, there would be a 9.4% cut to defense discretionary funding, 10% to mandatory defense programs, 8.2% reduction to nondefense discretionary funding, and 7.6% to nondefense mandatory programs.

Medicare – including physician and hospital payment – is slated for a 2%, or $11 billion, cut in 2013 alone. The 2% reduction will continue each year through 2021.

The American Hospital Association, American Medical Association, and American Nurses Association in a joint statement said that as many as 766,000 jobs in health care and related fields could be lost by 2021 if the Medicare cuts are allowed to stand, in part because of the reduction in payments to physicians and hospitals. They also predicted a ripple effect, including reduced spending on goods and services by health care providers and organizations, as well as reduced household purchases by health care workers who lose their jobs.

"Hospitals’ ability to maintain the kind of access to services that their communities need is being threatened," AHA President and CEO Rich Umbdenstock said in a statement.

Alicia Ault/IMNG Medical Media

Dr. Jeremy A. Lazarus, president of the AMA, said, "Coupled with the looming 27% Medicare physician payment cut, this 2% sequester will hurt patient access to care and will inject more uncertainty into our Medicare system. We need stability in Medicare physician payment as we work to improve our nation’s Medicare payment and delivery system to promote high-quality, high-value, better-coordinated care to our patients."

Among other programs at the Center for Medicare and Medicaid Services that would take a hit under sequestration: health insurance exchange grants ($66 million); state demonstration grants ($40 million); fraud and abuse ($78 million); the prevention and public health fund ($76 million); the Office of the National Coordinator for Health Information Technology ($1 million); the Office of Inspector General ($5 million); and the Hospital Insurance Trust Fund ($5.6 billion).

Many programs would be exempt from sequestration, however, including the Children’s Health Insurance Program, Medicare and Medicaid incentive payments for participating in health IT programs, and the consumer operated and oriented plan and the pre-existing condition insurance plan, both of which were created by the ACA.

Food and Drug Administration funding would be cut $319 million, and the Centers for Disease Control and Prevention would see at least a $490 million budget reduction, with $14 million of that coming out of the World Trade Center Health Program Fund. Funding for the National Institutes of Health would be cut $2.6 billion.

Medicare physician pay would be cut by at least 2% in 2013 while some Affordable Care Act programs would be spared the automatic cuts called for under the Budget Control Act of 2011, according to a report from the federal Office of Management and Budget.

The report provides details on how to cut $1.2 trillion from the federal budget by 2021 and was mandated after the Joint Select Committee on Deficit Reduction failed to do the same. The process – known as sequestration – would cut funding for most federal agencies across the board.

The Office of Management and Budget (OMB) report noted that the estimates are preliminary; the true magnitude of the cuts won’t be known until sequestration actually occurs.

The report also notes that the White House firmly opposes the automatic cuts.

"Sequestration is a blunt and indiscriminate instrument. It is not the responsible way for our nation to achieve deficit reduction," according to the report. OMB called on Congress to avoid sequestration either by passing the President’s budget proposals or otherwise approving "a comprehensive and balanced deficit reduction package."

Under sequestration, there would be a 9.4% cut to defense discretionary funding, 10% to mandatory defense programs, 8.2% reduction to nondefense discretionary funding, and 7.6% to nondefense mandatory programs.

Medicare – including physician and hospital payment – is slated for a 2%, or $11 billion, cut in 2013 alone. The 2% reduction will continue each year through 2021.

The American Hospital Association, American Medical Association, and American Nurses Association in a joint statement said that as many as 766,000 jobs in health care and related fields could be lost by 2021 if the Medicare cuts are allowed to stand, in part because of the reduction in payments to physicians and hospitals. They also predicted a ripple effect, including reduced spending on goods and services by health care providers and organizations, as well as reduced household purchases by health care workers who lose their jobs.

"Hospitals’ ability to maintain the kind of access to services that their communities need is being threatened," AHA President and CEO Rich Umbdenstock said in a statement.

Alicia Ault/IMNG Medical Media

Dr. Jeremy A. Lazarus, president of the AMA, said, "Coupled with the looming 27% Medicare physician payment cut, this 2% sequester will hurt patient access to care and will inject more uncertainty into our Medicare system. We need stability in Medicare physician payment as we work to improve our nation’s Medicare payment and delivery system to promote high-quality, high-value, better-coordinated care to our patients."

Among other programs at the Center for Medicare and Medicaid Services that would take a hit under sequestration: health insurance exchange grants ($66 million); state demonstration grants ($40 million); fraud and abuse ($78 million); the prevention and public health fund ($76 million); the Office of the National Coordinator for Health Information Technology ($1 million); the Office of Inspector General ($5 million); and the Hospital Insurance Trust Fund ($5.6 billion).

Many programs would be exempt from sequestration, however, including the Children’s Health Insurance Program, Medicare and Medicaid incentive payments for participating in health IT programs, and the consumer operated and oriented plan and the pre-existing condition insurance plan, both of which were created by the ACA.

Food and Drug Administration funding would be cut $319 million, and the Centers for Disease Control and Prevention would see at least a $490 million budget reduction, with $14 million of that coming out of the World Trade Center Health Program Fund. Funding for the National Institutes of Health would be cut $2.6 billion.

Medicare physician pay would be cut by at least 2% in 2013 while some Affordable Care Act programs would be spared the automatic cuts called for under the Budget Control Act of 2011, according to a report from the federal Office of Management and Budget.

The report provides details on how to cut $1.2 trillion from the federal budget by 2021 and was mandated after the Joint Select Committee on Deficit Reduction failed to do the same. The process – known as sequestration – would cut funding for most federal agencies across the board.

The Office of Management and Budget (OMB) report noted that the estimates are preliminary; the true magnitude of the cuts won’t be known until sequestration actually occurs.

The report also notes that the White House firmly opposes the automatic cuts.

"Sequestration is a blunt and indiscriminate instrument. It is not the responsible way for our nation to achieve deficit reduction," according to the report. OMB called on Congress to avoid sequestration either by passing the President’s budget proposals or otherwise approving "a comprehensive and balanced deficit reduction package."

Under sequestration, there would be a 9.4% cut to defense discretionary funding, 10% to mandatory defense programs, 8.2% reduction to nondefense discretionary funding, and 7.6% to nondefense mandatory programs.

Medicare – including physician and hospital payment – is slated for a 2%, or $11 billion, cut in 2013 alone. The 2% reduction will continue each year through 2021.

The American Hospital Association, American Medical Association, and American Nurses Association in a joint statement said that as many as 766,000 jobs in health care and related fields could be lost by 2021 if the Medicare cuts are allowed to stand, in part because of the reduction in payments to physicians and hospitals. They also predicted a ripple effect, including reduced spending on goods and services by health care providers and organizations, as well as reduced household purchases by health care workers who lose their jobs.

"Hospitals’ ability to maintain the kind of access to services that their communities need is being threatened," AHA President and CEO Rich Umbdenstock said in a statement.

Alicia Ault/IMNG Medical Media

Dr. Jeremy A. Lazarus, president of the AMA, said, "Coupled with the looming 27% Medicare physician payment cut, this 2% sequester will hurt patient access to care and will inject more uncertainty into our Medicare system. We need stability in Medicare physician payment as we work to improve our nation’s Medicare payment and delivery system to promote high-quality, high-value, better-coordinated care to our patients."

Among other programs at the Center for Medicare and Medicaid Services that would take a hit under sequestration: health insurance exchange grants ($66 million); state demonstration grants ($40 million); fraud and abuse ($78 million); the prevention and public health fund ($76 million); the Office of the National Coordinator for Health Information Technology ($1 million); the Office of Inspector General ($5 million); and the Hospital Insurance Trust Fund ($5.6 billion).

Many programs would be exempt from sequestration, however, including the Children’s Health Insurance Program, Medicare and Medicaid incentive payments for participating in health IT programs, and the consumer operated and oriented plan and the pre-existing condition insurance plan, both of which were created by the ACA.

Food and Drug Administration funding would be cut $319 million, and the Centers for Disease Control and Prevention would see at least a $490 million budget reduction, with $14 million of that coming out of the World Trade Center Health Program Fund. Funding for the National Institutes of Health would be cut $2.6 billion.

The Food and Drug Administration has expanded approval for the Sapien transcatheter heart valve for patients with aortic valve stenosis who are at high risk for serious surgical complications or death.

It is the second approval for the device, which is made by Edwards Lifesciences Corp. of Irvine, Calif. In November 2011, the FDA approved it for severe aortic valve stenosis in inoperable patients.

Courtesy Edwards Lifesciences

The indication for high-risk patients was reviewed by an FDA advisory panel in July. The majority of the panel indicated that the device was safe and effective in that group.

Both approvals were based on results from the PARTNER trial (N. Engl. J. Med. 2010;363:1597-607).

"Any procedure to replace the aortic valve carries the risk for serious complications, but for some patients with coexisting conditions or diseases, that risk may be especially high," Christy Foreman, director of the office of device evaluation at FDA’s Center for Devices and Radiological Health, said in a statement.

"The THV serves as an alternative for some very high-risk patients."

Larry L. Wood, Edwards’ corporate vice president, transcatheter heart valves, said in a statement: "It is extremely rewarding for us and our clinical partners to know that high-risk patients suffering from this often-debilitating disease will now have access to this life-saving therapy."

The Sapien THV is implanted at the site of the diseased valve using a catheter that is delivered either through a transfemoral or transapical approach. According to the Edwards statement, the transapical approach, which requires insertion through the ribs and myocardium, was not approved outside of clinical trials until now.

Transcatheter aortic valve replacement has become one of the driving forces in the heart valve market, which may hit $1.5 billion by 2016.

The new indication for the Sapien THV is expected to expand that market further. According to the FDA, the approved labeling indicates that a surgeon must determine whether a patient is eligible for the Sapien. But in fact, Edwards, the Centers for Medicare and Medicaid Services, and professional societies such as the American College of Cardiology and the Society of Thoracic Surgeons, have worked together to establish standards and requirements for "Heart Teams" that must be present during the procedure and evaluation of the patient by two cardiac surgeons.

There is an increased risk for major vascular complications and for stroke during the first month post implant. Thus, the device is contraindicated in patients who cannot tolerate anticoagulation/antiplatelet therapy.

Edwards will monitor safety and complication rates through the national Transcatheter Valve Therapy Registry.

The Food and Drug Administration has expanded approval for the Sapien transcatheter heart valve for patients with aortic valve stenosis who are at high risk for serious surgical complications or death.

It is the second approval for the device, which is made by Edwards Lifesciences Corp. of Irvine, Calif. In November 2011, the FDA approved it for severe aortic valve stenosis in inoperable patients.

Courtesy Edwards Lifesciences

The indication for high-risk patients was reviewed by an FDA advisory panel in July. The majority of the panel indicated that the device was safe and effective in that group.

Both approvals were based on results from the PARTNER trial (N. Engl. J. Med. 2010;363:1597-607).

"Any procedure to replace the aortic valve carries the risk for serious complications, but for some patients with coexisting conditions or diseases, that risk may be especially high," Christy Foreman, director of the office of device evaluation at FDA’s Center for Devices and Radiological Health, said in a statement.

"The THV serves as an alternative for some very high-risk patients."

Larry L. Wood, Edwards’ corporate vice president, transcatheter heart valves, said in a statement: "It is extremely rewarding for us and our clinical partners to know that high-risk patients suffering from this often-debilitating disease will now have access to this life-saving therapy."

The Sapien THV is implanted at the site of the diseased valve using a catheter that is delivered either through a transfemoral or transapical approach. According to the Edwards statement, the transapical approach, which requires insertion through the ribs and myocardium, was not approved outside of clinical trials until now.

Transcatheter aortic valve replacement has become one of the driving forces in the heart valve market, which may hit $1.5 billion by 2016.

The new indication for the Sapien THV is expected to expand that market further. According to the FDA, the approved labeling indicates that a surgeon must determine whether a patient is eligible for the Sapien. But in fact, Edwards, the Centers for Medicare and Medicaid Services, and professional societies such as the American College of Cardiology and the Society of Thoracic Surgeons, have worked together to establish standards and requirements for "Heart Teams" that must be present during the procedure and evaluation of the patient by two cardiac surgeons.

There is an increased risk for major vascular complications and for stroke during the first month post implant. Thus, the device is contraindicated in patients who cannot tolerate anticoagulation/antiplatelet therapy.

Edwards will monitor safety and complication rates through the national Transcatheter Valve Therapy Registry.

The Food and Drug Administration has expanded approval for the Sapien transcatheter heart valve for patients with aortic valve stenosis who are at high risk for serious surgical complications or death.

It is the second approval for the device, which is made by Edwards Lifesciences Corp. of Irvine, Calif. In November 2011, the FDA approved it for severe aortic valve stenosis in inoperable patients.

Courtesy Edwards Lifesciences

The indication for high-risk patients was reviewed by an FDA advisory panel in July. The majority of the panel indicated that the device was safe and effective in that group.

Both approvals were based on results from the PARTNER trial (N. Engl. J. Med. 2010;363:1597-607).

"Any procedure to replace the aortic valve carries the risk for serious complications, but for some patients with coexisting conditions or diseases, that risk may be especially high," Christy Foreman, director of the office of device evaluation at FDA’s Center for Devices and Radiological Health, said in a statement.

"The THV serves as an alternative for some very high-risk patients."

Larry L. Wood, Edwards’ corporate vice president, transcatheter heart valves, said in a statement: "It is extremely rewarding for us and our clinical partners to know that high-risk patients suffering from this often-debilitating disease will now have access to this life-saving therapy."

The Sapien THV is implanted at the site of the diseased valve using a catheter that is delivered either through a transfemoral or transapical approach. According to the Edwards statement, the transapical approach, which requires insertion through the ribs and myocardium, was not approved outside of clinical trials until now.

Transcatheter aortic valve replacement has become one of the driving forces in the heart valve market, which may hit $1.5 billion by 2016.

The new indication for the Sapien THV is expected to expand that market further. According to the FDA, the approved labeling indicates that a surgeon must determine whether a patient is eligible for the Sapien. But in fact, Edwards, the Centers for Medicare and Medicaid Services, and professional societies such as the American College of Cardiology and the Society of Thoracic Surgeons, have worked together to establish standards and requirements for "Heart Teams" that must be present during the procedure and evaluation of the patient by two cardiac surgeons.

There is an increased risk for major vascular complications and for stroke during the first month post implant. Thus, the device is contraindicated in patients who cannot tolerate anticoagulation/antiplatelet therapy.

Edwards will monitor safety and complication rates through the national Transcatheter Valve Therapy Registry.

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.

The Sharp Stick of Regulation

Voluntary efforts by hospitals may not be enough, said Dr. Sandra Schneider, former president of the American College of Emergency Physicians. Because hospitals are still paid for the patients who are boarded, they might not see the hidden costs of boarding, she said.

"We have to change that playing field if we want to get serious about [boarding]," Dr. Schneider said.

Among the game changers she cited are the increasing requirements for public reporting on quality measures, including those related to boarding.

Currently, hospitals get paid more by Medicare if they report certain inpatient quality measures. On the outpatient side, emergency departments report on the median time from ED arrival to ED departure for discharged patients and on patients who leave without being seen. In addition, it is now voluntary for hospitals to report on the average time patients spend in the ED before being admitted as an inpatient, and the average time patients spend in the ED after admission but before leaving the ED for their inpatient room.

Data from hospitals that have reported on these measures can be found on the Hospital Compare website.

The Joint Commission is also revisiting its standard on patient flow in the ED, which will go into effect in January 2013. Among other things, the commission is considering defining an episode of boarding as any case in which a patient remains in the ED 4 hours or more after a decision has been made to admit or transfer that patient.

Dr. Pines said that hospital administrators will be motivated both by public reporting imperatives and by Joint Commission standards. Dr. Crane, however, said that "until there are some significant incentives to moving patients upstairs in a timely manner, what’s going to drive senior executives is finance." He thinks that these new standards may help, but more incentives may be needed, such as penalties imposed if boarding limits are exceeded.

Australia, Canada, the United Kingdom, and other developed countries impose such limits and levy penalties.

Hospital Compare data – which will be more fully reported at the end of the first quarter of 2013 – “is going to show us once and for all where the median is and who are the outliers,” Dr. Schneider said. It’s hoped that the outliers will "realize they don’t just have a boarding problem – they have a serious boarding problem," she said.

"If not, then we may have to do what the rest of the world is doing."

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.

The Sharp Stick of Regulation

Voluntary efforts by hospitals may not be enough, said Dr. Sandra Schneider, former president of the American College of Emergency Physicians. Because hospitals are still paid for the patients who are boarded, they might not see the hidden costs of boarding, she said.

"We have to change that playing field if we want to get serious about [boarding]," Dr. Schneider said.

Among the game changers she cited are the increasing requirements for public reporting on quality measures, including those related to boarding.

Currently, hospitals get paid more by Medicare if they report certain inpatient quality measures. On the outpatient side, emergency departments report on the median time from ED arrival to ED departure for discharged patients and on patients who leave without being seen. In addition, it is now voluntary for hospitals to report on the average time patients spend in the ED before being admitted as an inpatient, and the average time patients spend in the ED after admission but before leaving the ED for their inpatient room.

Data from hospitals that have reported on these measures can be found on the Hospital Compare website.

The Joint Commission is also revisiting its standard on patient flow in the ED, which will go into effect in January 2013. Among other things, the commission is considering defining an episode of boarding as any case in which a patient remains in the ED 4 hours or more after a decision has been made to admit or transfer that patient.

Dr. Pines said that hospital administrators will be motivated both by public reporting imperatives and by Joint Commission standards. Dr. Crane, however, said that "until there are some significant incentives to moving patients upstairs in a timely manner, what’s going to drive senior executives is finance." He thinks that these new standards may help, but more incentives may be needed, such as penalties imposed if boarding limits are exceeded.

Australia, Canada, the United Kingdom, and other developed countries impose such limits and levy penalties.

Hospital Compare data – which will be more fully reported at the end of the first quarter of 2013 – “is going to show us once and for all where the median is and who are the outliers,” Dr. Schneider said. It’s hoped that the outliers will "realize they don’t just have a boarding problem – they have a serious boarding problem," she said.

"If not, then we may have to do what the rest of the world is doing."

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.

The Sharp Stick of Regulation

Voluntary efforts by hospitals may not be enough, said Dr. Sandra Schneider, former president of the American College of Emergency Physicians. Because hospitals are still paid for the patients who are boarded, they might not see the hidden costs of boarding, she said.

"We have to change that playing field if we want to get serious about [boarding]," Dr. Schneider said.

Among the game changers she cited are the increasing requirements for public reporting on quality measures, including those related to boarding.

Currently, hospitals get paid more by Medicare if they report certain inpatient quality measures. On the outpatient side, emergency departments report on the median time from ED arrival to ED departure for discharged patients and on patients who leave without being seen. In addition, it is now voluntary for hospitals to report on the average time patients spend in the ED before being admitted as an inpatient, and the average time patients spend in the ED after admission but before leaving the ED for their inpatient room.

Data from hospitals that have reported on these measures can be found on the Hospital Compare website.

The Joint Commission is also revisiting its standard on patient flow in the ED, which will go into effect in January 2013. Among other things, the commission is considering defining an episode of boarding as any case in which a patient remains in the ED 4 hours or more after a decision has been made to admit or transfer that patient.

Dr. Pines said that hospital administrators will be motivated both by public reporting imperatives and by Joint Commission standards. Dr. Crane, however, said that "until there are some significant incentives to moving patients upstairs in a timely manner, what’s going to drive senior executives is finance." He thinks that these new standards may help, but more incentives may be needed, such as penalties imposed if boarding limits are exceeded.

Australia, Canada, the United Kingdom, and other developed countries impose such limits and levy penalties.

Hospital Compare data – which will be more fully reported at the end of the first quarter of 2013 – “is going to show us once and for all where the median is and who are the outliers,” Dr. Schneider said. It’s hoped that the outliers will "realize they don’t just have a boarding problem – they have a serious boarding problem," she said.

"If not, then we may have to do what the rest of the world is doing."