Alicia Ault

The Environmental Working Group has issued its annual ranking of sunscreens, and reported that of more than 1,800 it reviewed, about 25% pass muster. That’s up from 20% in 2011 and 8% in 2010.

According to the group, children’s sunscreens contain the most effective and safest ingredients. Sixty percent of the 180 products marketed for children have ingredients such as minerals, which are considered effective, compared with only 40% of those for the general public. Also, kids’ sunscreens are less likely to contain oxybenzone – which the EWG said is an endocrine-disrupter – or chemicals that might cause allergic reactions.

The group recommends that consumers choose products with zinc oxide, titanium dioxide, or 3% avobenzone and that they avoid oxybenzone and vitamin A (retinyl palmitate). Sunscreen sprays and powders are not as effective as creams or lotions, according to the group. And it found that many manufacturers are selling products with escalating SPF values. More than one in seven have SPF values higher than 50, compared with only one in eight in 2009, according to EWG’s analysis.

In a statement from the EWG, Sen. Jack Reed (D-RI) said the FDA needs to move more quickly on instituting sunscreen standards, but in the meantime, "it is good to know Environmental Working Group is providing consumers with the facts about the effectiveness of sunscreen products that are currently on shelves."

The American Academy of Dermatology refuted much of the EWG claim in a statement, noting that there is no evidence that oxybenzone affects hormones, nor is oxybenzone or vitamin A dangerous in sunscreens, said AAD President Daniel M. Siegel. The AAD continues to back use of a water-resistant, broad-spectrum sunscreen that protects against UVA and UVB, with an SPF 30 or higher, in conjunction with limiting sun exposure and wearing sun-protective clothing.

The Environmental Working Group has issued its annual ranking of sunscreens, and reported that of more than 1,800 it reviewed, about 25% pass muster. That’s up from 20% in 2011 and 8% in 2010.

According to the group, children’s sunscreens contain the most effective and safest ingredients. Sixty percent of the 180 products marketed for children have ingredients such as minerals, which are considered effective, compared with only 40% of those for the general public. Also, kids’ sunscreens are less likely to contain oxybenzone – which the EWG said is an endocrine-disrupter – or chemicals that might cause allergic reactions.

The group recommends that consumers choose products with zinc oxide, titanium dioxide, or 3% avobenzone and that they avoid oxybenzone and vitamin A (retinyl palmitate). Sunscreen sprays and powders are not as effective as creams or lotions, according to the group. And it found that many manufacturers are selling products with escalating SPF values. More than one in seven have SPF values higher than 50, compared with only one in eight in 2009, according to EWG’s analysis.

In a statement from the EWG, Sen. Jack Reed (D-RI) said the FDA needs to move more quickly on instituting sunscreen standards, but in the meantime, "it is good to know Environmental Working Group is providing consumers with the facts about the effectiveness of sunscreen products that are currently on shelves."

The American Academy of Dermatology refuted much of the EWG claim in a statement, noting that there is no evidence that oxybenzone affects hormones, nor is oxybenzone or vitamin A dangerous in sunscreens, said AAD President Daniel M. Siegel. The AAD continues to back use of a water-resistant, broad-spectrum sunscreen that protects against UVA and UVB, with an SPF 30 or higher, in conjunction with limiting sun exposure and wearing sun-protective clothing.

The Environmental Working Group has issued its annual ranking of sunscreens, and reported that of more than 1,800 it reviewed, about 25% pass muster. That’s up from 20% in 2011 and 8% in 2010.

According to the group, children’s sunscreens contain the most effective and safest ingredients. Sixty percent of the 180 products marketed for children have ingredients such as minerals, which are considered effective, compared with only 40% of those for the general public. Also, kids’ sunscreens are less likely to contain oxybenzone – which the EWG said is an endocrine-disrupter – or chemicals that might cause allergic reactions.

The group recommends that consumers choose products with zinc oxide, titanium dioxide, or 3% avobenzone and that they avoid oxybenzone and vitamin A (retinyl palmitate). Sunscreen sprays and powders are not as effective as creams or lotions, according to the group. And it found that many manufacturers are selling products with escalating SPF values. More than one in seven have SPF values higher than 50, compared with only one in eight in 2009, according to EWG’s analysis.

In a statement from the EWG, Sen. Jack Reed (D-RI) said the FDA needs to move more quickly on instituting sunscreen standards, but in the meantime, "it is good to know Environmental Working Group is providing consumers with the facts about the effectiveness of sunscreen products that are currently on shelves."

The American Academy of Dermatology refuted much of the EWG claim in a statement, noting that there is no evidence that oxybenzone affects hormones, nor is oxybenzone or vitamin A dangerous in sunscreens, said AAD President Daniel M. Siegel. The AAD continues to back use of a water-resistant, broad-spectrum sunscreen that protects against UVA and UVB, with an SPF 30 or higher, in conjunction with limiting sun exposure and wearing sun-protective clothing.

The risk of developing progressive multifocal leukoencephalopathy from natalizumab therapy appears to be greater than previously thought, being greatest in multiple sclerosis patients with certain risk factors, according to an updated analysis.

The analysis provides an algorithm that might help clinicians hone in on which patients are least or most likely to develop PML, and give them support in discussing risks and benefits, said Dr. Gary Bloomgren and his coauthors, all of whom work for Biogen Idec, which makes natalizumab (Tysabri).

Courtesy Biogen Idec

The algorithm took into account anti-JC virus antibody status; whether there was prior use of immunosuppressants; and duration of treatment. Positive anti-JC status, prior immunosuppressant use and longer treatment all have been previously identified as PML risk factors. But there has not been a physician-friendly way to stratify risk.

PML is an opportunistic brain infection caused by the JC virus. Previous estimates had put the incidence at about 1 case per 1,000. In April 2011, the Food and Drug Administration reported that 102 cases of PML had been reported among 82,732 patients treated with natalizumab worldwide.

But now that risk is 2.1 per 1,000, given that there have been 212 confirmed cases of PML among the 99,571 patients worldwide who have been treated with natalizumab, Dr. Bloomgren and his colleagues reported May 16 in the New England Journal of Medicine.

The incidence of PML rises to as much as 11.1 per 1,000 in multiple sclerosis patients who are positive for anti-JC virus antibodies, who have taken immunosuppressants before starting natalizumab, and who have taken the drug for 25-48 months.

Although this is a longer period of follow-up than has been reported previously, there were not enough data to calculate the risk beyond 4 years of treatment.

In January of this year, the FDA warned that anti–JC virus–positive status was associated with an increased risk, in addition to the other known risk factors for PML. The agency also estimated the incidence of PML for patients with those risk factors at 11.1 per 1,000.

Dr. Bloomgren and his associates based their calculations on data from Biogen Idec’s safety database, from clinical trials such as the Tysabri Global Observational Program in Safety study (TYGRIS-U.S. and TYGRIS–Rest of World) and from AFFIRM and STRATIFY-1. Data from an independent Swedish registry of patients with multiple sclerosis were also used (N. Engl. J. Med. 2012;366:1870-80).

The algorithm can help stratify risk and assist physicians in deciding whether to use natalizumab, the authors said. Avoiding PML is of great importance. The Biogen Idec researchers said that of the 212 confirmed PML cases, 46 of the patients had died, and that 23 of the 58 survivors for whom data was available had severe disability.

They noted that their risk estimates were limited by several factors, including the assumption that anti–JC-positive status was clearly associated with development of PML. This assumption was based on the fact that all 54 patients identified in the postmarketing setting had been anti–JC-positive before their PML diagnosis. But blood samples were not available for all patients with PML, and the anti-JC virus assay – which is now commercially available – has a small, but perceptible false negative rate.

In a commentary accompanying the study, Dr. Allan H. Ropper said that MS patients who test negative for anti-JC antibodies ostensibly can be reassured that it is safe to take natalizumab. But he noted that there are "basic limitations to serologic tests for JC virus, since there is no standard by which to judge the absence of the virus" (N. Engl. J. Med. 2012;366:1938-9).

Also, the seroprevalance of the virus increases with age, and patients can undergo seroconversion at any time, said Dr. Ropper, a neurologist at Brigham and Women’s Hospital, Boston. He urged retesting for any patients undergoing natalizumab therapy.

While it is not entirely clear why natalizumab is associated with PML, it appears that it may reactivate the JC virus and that it might possibly cause the emergence of a mutation in the virus that leads to the emergency of PML.

Dr. Ropper disclosed no financial conflicts, but reported that he is the associate editor of the New England Journal of Medicine.

Registry to Track PML Scheduled for Fall

With the incidence of progressive multifocal leukoencephalopathy on the rise, the National Institute of Neurological Disorders and Stroke plans to have a registry for the condition up and running by this fall.

The purpose of the registry is to acquire clinical information and biologic material for cases from all over the world, so that researchers can tease out the incidence, prevalence, and potential contributing factors, Eugene O. Major, Ph.D, chief of the laboratory of molecular medicine and neuroscience at the NINDS, said at the annual meeting of the American Academy of Neurology in New Orleans.

The research may also give rise to diagnostics and therapies for the condition, which has up to 50% mortality in the first few months after diagnosis, according to the NINDS.

PML is caused by the reactivation of infection with the JC virus.It is rare, and is most often seen in HIV-infected individuals, but is also seen in people who are undergoing chronic immunosuppression, as with certain cancers. But the disease has also been on the rise in multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus due to biologic therapies that appear to reactivate the JC virus. The NINDS estimates that 5% of HIV patients develop PML.

Much of the data in the registry will be collected through a network of cooperating clinical centers. But the registry, which will be web-based, will have several access points for reporting clinicians and a portal for the public as well, Dr. Major said. The public-facing side of the site will connect patients to the NINDS, its lab site, clinicaltrials.gov, and advocacy groups.

Neurologists and other clinicians will enter cases using a form that will give patients a random identifier. There will be space for narratives and for attaching MRI scans and lab results.

There will also be diagnostic criteria posted, which are currently under review by the AAN, Dr. Major said.

The aim is to conduct a pilot study using five academic medical centers and then have the registry publicly available in the fall, he said.

The risk of developing progressive multifocal leukoencephalopathy from natalizumab therapy appears to be greater than previously thought, being greatest in multiple sclerosis patients with certain risk factors, according to an updated analysis.

The analysis provides an algorithm that might help clinicians hone in on which patients are least or most likely to develop PML, and give them support in discussing risks and benefits, said Dr. Gary Bloomgren and his coauthors, all of whom work for Biogen Idec, which makes natalizumab (Tysabri).

Courtesy Biogen Idec

The algorithm took into account anti-JC virus antibody status; whether there was prior use of immunosuppressants; and duration of treatment. Positive anti-JC status, prior immunosuppressant use and longer treatment all have been previously identified as PML risk factors. But there has not been a physician-friendly way to stratify risk.

PML is an opportunistic brain infection caused by the JC virus. Previous estimates had put the incidence at about 1 case per 1,000. In April 2011, the Food and Drug Administration reported that 102 cases of PML had been reported among 82,732 patients treated with natalizumab worldwide.

But now that risk is 2.1 per 1,000, given that there have been 212 confirmed cases of PML among the 99,571 patients worldwide who have been treated with natalizumab, Dr. Bloomgren and his colleagues reported May 16 in the New England Journal of Medicine.

The incidence of PML rises to as much as 11.1 per 1,000 in multiple sclerosis patients who are positive for anti-JC virus antibodies, who have taken immunosuppressants before starting natalizumab, and who have taken the drug for 25-48 months.

Although this is a longer period of follow-up than has been reported previously, there were not enough data to calculate the risk beyond 4 years of treatment.

In January of this year, the FDA warned that anti–JC virus–positive status was associated with an increased risk, in addition to the other known risk factors for PML. The agency also estimated the incidence of PML for patients with those risk factors at 11.1 per 1,000.

Dr. Bloomgren and his associates based their calculations on data from Biogen Idec’s safety database, from clinical trials such as the Tysabri Global Observational Program in Safety study (TYGRIS-U.S. and TYGRIS–Rest of World) and from AFFIRM and STRATIFY-1. Data from an independent Swedish registry of patients with multiple sclerosis were also used (N. Engl. J. Med. 2012;366:1870-80).

The algorithm can help stratify risk and assist physicians in deciding whether to use natalizumab, the authors said. Avoiding PML is of great importance. The Biogen Idec researchers said that of the 212 confirmed PML cases, 46 of the patients had died, and that 23 of the 58 survivors for whom data was available had severe disability.

They noted that their risk estimates were limited by several factors, including the assumption that anti–JC-positive status was clearly associated with development of PML. This assumption was based on the fact that all 54 patients identified in the postmarketing setting had been anti–JC-positive before their PML diagnosis. But blood samples were not available for all patients with PML, and the anti-JC virus assay – which is now commercially available – has a small, but perceptible false negative rate.

In a commentary accompanying the study, Dr. Allan H. Ropper said that MS patients who test negative for anti-JC antibodies ostensibly can be reassured that it is safe to take natalizumab. But he noted that there are "basic limitations to serologic tests for JC virus, since there is no standard by which to judge the absence of the virus" (N. Engl. J. Med. 2012;366:1938-9).

Also, the seroprevalance of the virus increases with age, and patients can undergo seroconversion at any time, said Dr. Ropper, a neurologist at Brigham and Women’s Hospital, Boston. He urged retesting for any patients undergoing natalizumab therapy.

While it is not entirely clear why natalizumab is associated with PML, it appears that it may reactivate the JC virus and that it might possibly cause the emergence of a mutation in the virus that leads to the emergency of PML.

Dr. Ropper disclosed no financial conflicts, but reported that he is the associate editor of the New England Journal of Medicine.

Registry to Track PML Scheduled for Fall

With the incidence of progressive multifocal leukoencephalopathy on the rise, the National Institute of Neurological Disorders and Stroke plans to have a registry for the condition up and running by this fall.

The purpose of the registry is to acquire clinical information and biologic material for cases from all over the world, so that researchers can tease out the incidence, prevalence, and potential contributing factors, Eugene O. Major, Ph.D, chief of the laboratory of molecular medicine and neuroscience at the NINDS, said at the annual meeting of the American Academy of Neurology in New Orleans.

The research may also give rise to diagnostics and therapies for the condition, which has up to 50% mortality in the first few months after diagnosis, according to the NINDS.

PML is caused by the reactivation of infection with the JC virus.It is rare, and is most often seen in HIV-infected individuals, but is also seen in people who are undergoing chronic immunosuppression, as with certain cancers. But the disease has also been on the rise in multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus due to biologic therapies that appear to reactivate the JC virus. The NINDS estimates that 5% of HIV patients develop PML.

Much of the data in the registry will be collected through a network of cooperating clinical centers. But the registry, which will be web-based, will have several access points for reporting clinicians and a portal for the public as well, Dr. Major said. The public-facing side of the site will connect patients to the NINDS, its lab site, clinicaltrials.gov, and advocacy groups.

Neurologists and other clinicians will enter cases using a form that will give patients a random identifier. There will be space for narratives and for attaching MRI scans and lab results.

There will also be diagnostic criteria posted, which are currently under review by the AAN, Dr. Major said.

The aim is to conduct a pilot study using five academic medical centers and then have the registry publicly available in the fall, he said.

The risk of developing progressive multifocal leukoencephalopathy from natalizumab therapy appears to be greater than previously thought, being greatest in multiple sclerosis patients with certain risk factors, according to an updated analysis.

The analysis provides an algorithm that might help clinicians hone in on which patients are least or most likely to develop PML, and give them support in discussing risks and benefits, said Dr. Gary Bloomgren and his coauthors, all of whom work for Biogen Idec, which makes natalizumab (Tysabri).

Courtesy Biogen Idec

The algorithm took into account anti-JC virus antibody status; whether there was prior use of immunosuppressants; and duration of treatment. Positive anti-JC status, prior immunosuppressant use and longer treatment all have been previously identified as PML risk factors. But there has not been a physician-friendly way to stratify risk.

PML is an opportunistic brain infection caused by the JC virus. Previous estimates had put the incidence at about 1 case per 1,000. In April 2011, the Food and Drug Administration reported that 102 cases of PML had been reported among 82,732 patients treated with natalizumab worldwide.

But now that risk is 2.1 per 1,000, given that there have been 212 confirmed cases of PML among the 99,571 patients worldwide who have been treated with natalizumab, Dr. Bloomgren and his colleagues reported May 16 in the New England Journal of Medicine.

The incidence of PML rises to as much as 11.1 per 1,000 in multiple sclerosis patients who are positive for anti-JC virus antibodies, who have taken immunosuppressants before starting natalizumab, and who have taken the drug for 25-48 months.

Although this is a longer period of follow-up than has been reported previously, there were not enough data to calculate the risk beyond 4 years of treatment.

In January of this year, the FDA warned that anti–JC virus–positive status was associated with an increased risk, in addition to the other known risk factors for PML. The agency also estimated the incidence of PML for patients with those risk factors at 11.1 per 1,000.

Dr. Bloomgren and his associates based their calculations on data from Biogen Idec’s safety database, from clinical trials such as the Tysabri Global Observational Program in Safety study (TYGRIS-U.S. and TYGRIS–Rest of World) and from AFFIRM and STRATIFY-1. Data from an independent Swedish registry of patients with multiple sclerosis were also used (N. Engl. J. Med. 2012;366:1870-80).

The algorithm can help stratify risk and assist physicians in deciding whether to use natalizumab, the authors said. Avoiding PML is of great importance. The Biogen Idec researchers said that of the 212 confirmed PML cases, 46 of the patients had died, and that 23 of the 58 survivors for whom data was available had severe disability.

They noted that their risk estimates were limited by several factors, including the assumption that anti–JC-positive status was clearly associated with development of PML. This assumption was based on the fact that all 54 patients identified in the postmarketing setting had been anti–JC-positive before their PML diagnosis. But blood samples were not available for all patients with PML, and the anti-JC virus assay – which is now commercially available – has a small, but perceptible false negative rate.

In a commentary accompanying the study, Dr. Allan H. Ropper said that MS patients who test negative for anti-JC antibodies ostensibly can be reassured that it is safe to take natalizumab. But he noted that there are "basic limitations to serologic tests for JC virus, since there is no standard by which to judge the absence of the virus" (N. Engl. J. Med. 2012;366:1938-9).

Also, the seroprevalance of the virus increases with age, and patients can undergo seroconversion at any time, said Dr. Ropper, a neurologist at Brigham and Women’s Hospital, Boston. He urged retesting for any patients undergoing natalizumab therapy.

While it is not entirely clear why natalizumab is associated with PML, it appears that it may reactivate the JC virus and that it might possibly cause the emergence of a mutation in the virus that leads to the emergency of PML.

Dr. Ropper disclosed no financial conflicts, but reported that he is the associate editor of the New England Journal of Medicine.

Registry to Track PML Scheduled for Fall

With the incidence of progressive multifocal leukoencephalopathy on the rise, the National Institute of Neurological Disorders and Stroke plans to have a registry for the condition up and running by this fall.

The purpose of the registry is to acquire clinical information and biologic material for cases from all over the world, so that researchers can tease out the incidence, prevalence, and potential contributing factors, Eugene O. Major, Ph.D, chief of the laboratory of molecular medicine and neuroscience at the NINDS, said at the annual meeting of the American Academy of Neurology in New Orleans.

The research may also give rise to diagnostics and therapies for the condition, which has up to 50% mortality in the first few months after diagnosis, according to the NINDS.

PML is caused by the reactivation of infection with the JC virus.It is rare, and is most often seen in HIV-infected individuals, but is also seen in people who are undergoing chronic immunosuppression, as with certain cancers. But the disease has also been on the rise in multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus due to biologic therapies that appear to reactivate the JC virus. The NINDS estimates that 5% of HIV patients develop PML.

Much of the data in the registry will be collected through a network of cooperating clinical centers. But the registry, which will be web-based, will have several access points for reporting clinicians and a portal for the public as well, Dr. Major said. The public-facing side of the site will connect patients to the NINDS, its lab site, clinicaltrials.gov, and advocacy groups.

Neurologists and other clinicians will enter cases using a form that will give patients a random identifier. There will be space for narratives and for attaching MRI scans and lab results.

There will also be diagnostic criteria posted, which are currently under review by the AAN, Dr. Major said.

The aim is to conduct a pilot study using five academic medical centers and then have the registry publicly available in the fall, he said.

The Food and Drug Administration announced in May that it was giving sunscreen manufacturers 6 additional months to comply with the final ruling on product labeling and effectiveness testing.

That final rule was published in June 2011; soon after, the Personal Care Products Council (PCPC) and the Consumer Healthcare Products Association (CHPA) sought a 6-month delay in the deadline, saying that manufacturers needed more time.

The agency agreed and has pushed back compliance dates. Now, products that have sales of less than $25,000 will have until Dec. 17, 2013, to comply; all other products must comply by Dec. 17, 2012. However, the agency is encouraging manufacturers to "introduce individual products bearing the new labeling as it becomes available, even in advance of the revised compliance date."

The American Academy of Dermatology also urged sunscreen makers to comply sooner, rather than later, but said in a statement that the extension "allows manufacturers the necessary time to test their products for broad-spectrum protection and properly label them."

The Environmental Working Group, which publishes a database of sunscreen effectiveness, chided the FDA, saying in a statement that it "has caved to industry pressure every step of the way," of getting the rules finalized – a 30-year process. The group estimates that 90% of sunscreens are already in compliance with what it calls the FDA’s "low-bar regulations on efficacy and safety."

The Food and Drug Administration announced in May that it was giving sunscreen manufacturers 6 additional months to comply with the final ruling on product labeling and effectiveness testing.

That final rule was published in June 2011; soon after, the Personal Care Products Council (PCPC) and the Consumer Healthcare Products Association (CHPA) sought a 6-month delay in the deadline, saying that manufacturers needed more time.

The agency agreed and has pushed back compliance dates. Now, products that have sales of less than $25,000 will have until Dec. 17, 2013, to comply; all other products must comply by Dec. 17, 2012. However, the agency is encouraging manufacturers to "introduce individual products bearing the new labeling as it becomes available, even in advance of the revised compliance date."

The American Academy of Dermatology also urged sunscreen makers to comply sooner, rather than later, but said in a statement that the extension "allows manufacturers the necessary time to test their products for broad-spectrum protection and properly label them."

The Environmental Working Group, which publishes a database of sunscreen effectiveness, chided the FDA, saying in a statement that it "has caved to industry pressure every step of the way," of getting the rules finalized – a 30-year process. The group estimates that 90% of sunscreens are already in compliance with what it calls the FDA’s "low-bar regulations on efficacy and safety."

The Food and Drug Administration announced in May that it was giving sunscreen manufacturers 6 additional months to comply with the final ruling on product labeling and effectiveness testing.

That final rule was published in June 2011; soon after, the Personal Care Products Council (PCPC) and the Consumer Healthcare Products Association (CHPA) sought a 6-month delay in the deadline, saying that manufacturers needed more time.

The agency agreed and has pushed back compliance dates. Now, products that have sales of less than $25,000 will have until Dec. 17, 2013, to comply; all other products must comply by Dec. 17, 2012. However, the agency is encouraging manufacturers to "introduce individual products bearing the new labeling as it becomes available, even in advance of the revised compliance date."

The American Academy of Dermatology also urged sunscreen makers to comply sooner, rather than later, but said in a statement that the extension "allows manufacturers the necessary time to test their products for broad-spectrum protection and properly label them."

The Environmental Working Group, which publishes a database of sunscreen effectiveness, chided the FDA, saying in a statement that it "has caved to industry pressure every step of the way," of getting the rules finalized – a 30-year process. The group estimates that 90% of sunscreens are already in compliance with what it calls the FDA’s "low-bar regulations on efficacy and safety."

NEW ORLEANS – Like many other specialties – particularly cognitive specialties – neurology is under pressure to figure out how best to survive in an environment in which expenses are rising, but income is declining. So what are some strategies for staying in practice, choosing what type of practice is best, ensuring a steady income stream, and staying sane?

At the recent annual meeting of the American Academy of Neurology, several neurologists offered their personal take on preserving the pleasures of practice while maintaining revenues.

Dr. Laurence J. Kinsella, codirector of neurology for SSM Neurosciences Institute, St. Louis, noted that although median income for neurologists had risen fairly steadily since the mid-1990s, a neurologist’s value was very much dependent on what area of the country he or she practices in, whether it is urban or rural, and whether the practice is academic or private, or interventionist or cognitive.*

Choosing where to practice and the best type of practice is dependent on which options offer the best proximity to family or accommodation of a spouse’s needs, as well as the most professional growth, leadership potential, and collegiality, among other factors, said Dr. Kinsella, who is also vice chair of the AAN’s government affairs committee.

In the assessment of a group practice, for instance, be aware that survey data and published research have shown that the average turnover is 7% per year, and 60% of those who leave do so in the first 5 years. The biggest reasons for leaving include practice issues; compensation and location issues; and spousal concerns. Some questions to raise are whether the senior partners are advocates for equity for all partners, and whether the path to partnership is clearly stated, Dr. Kinsella said.

Before signing a contract with any group, it’s worthwhile to consult with an attorney who specializes in health care, he said. Keep in mind that everything is negotiable. Some key components to explore include salary and bonus; productivity scale; call schedule; pension and profit sharing; termination; and malpractice, health, and disability insurance.

"The most important thing is, you have to pay attention and be limber and adjust your models as things change."

Whether you take the academic, private, solo, or group path, the reimbursement challenges will be the same. The elimination of the Medicare consult codes in 2010 have led to a 6%-20% reduction in reimbursement, according to AAN survey data, Dr. Kinsella said.

There is a tool to assess the impact on a practice at www.mitsi.org/. One way to make up for lost revenue is to take a closer look at evaluation and management (E&M) codes, he added. At least 60% of neurologists’ billing is for E&M services. AAN provides templates for determining efficient and appropriate use of E&M codes. Dr. Kinsella said he advocated for the use of prolonged service codes such as 99354 (31-74 minutes) and 99355 (for each additional 30 minutes). "I’d encourage you to get comfortable with these. They are very good to use," he said.

Most neurologists also bill at level 4, then level 5 and level 3 for E&M, and they should be billing primarily level 5, Dr. Kinsella said. A level 5 consult requires more than just a single diagnosis.

Some 40% of neurology practice now comes from neurophysiology, such as sleep studies and electromyography/nerve conduction studies. These procedures pay better than E&M and thus are worth adding into a practice, he said.

Some other revenue-generating ideas include taking on a hospital directorship, such as stroke director; participating in clinical trials; giving botulinum toxin injections and nerve blocks for rotator cuff injuries, for instance; doing skin biopsies for small fiber neuropathy; and doing chart reviews for legal cases and interpretation of images.

Consider also moonlighting as a neurohospitalist. Dr. Kinsella’s practice offered 24/7 coverage to a hospital that suddenly lost a group of neurologists, which worked out well.

"The key is to leverage your scarcity," Dr. Kinsella said, noting that neurologists are in sparse supply and that many hospitals need coverage for call, stroke centers, and telemedicine.

Another avenue is to offer coverage for rural health clinics. Medicare has been assisting rural hospitals and clinics to recruit neurologists. With higher reimbursement in place to help these centers, working for a rural clinic can "cover your windshield cost" to make the drive and take the time away from practice, he said.

His suggestions for keeping practice fun? Get a clinical appointment to teach residents. Or have a different area of practice every day.

Dr. Elaine C. Jones, a colleague of Dr. Kinsella’s on the AAN government affairs committee, has taken a somewhat contrary path to getting satisfaction out of her practice by moving from an academic setting to set up her own solo practice.

She began practicing in the late 1990s at a large multispecialty group based at an academic hospital in Providence, R.I. By 2001, she was chief of neurology, but she felt as if the responsibility was not matched by an equal level of decision-making power. She decided that by going solo she could cut out the middleman on issues concerning staffing decisions, expenses, program development, and office renovations.

She consulted with other physicians in private practice, read up on various publications from the American Medical Association, and relied on her boyfriend, who had banking experience and a law degree, all of which helped her to decide which business model to use. She hired attorneys to help file the necessary paperwork to set up the practice. The hardest decision was naming the practice; she decided on Southern New England Neurology, with an eye on expanding in the future.

In 2005, Dr. Jones opened the practice in Bristol, R.I., renting space in a primary care practice building. Reaching this point had taken $40,000 in personal savings, $50,000 from a home-equity credit line, and a $30,000 equipment loan. Within 6 months, she had covered her costs, and within 18 months she had paid off the loan and was paying down the equity line.

An important initial investment was an electronic health record system, Dr. Jones said.

She began by working just 4 days a week, which gave her time for personal pursuits. But 3 years in, she had outgrown the space and the increased patient volume was taxing her existing staff. Dr. Jones was afraid to leave the bosom of the primary care group and its built-in referrals, but it had no additional room, so she decided to buy a property. She purchased a duplex and invested in extensive renovations, which took about a year to complete.

She has found private practice to be very rewarding because it gives her control over her scheduling, hours, and staffing, and no one is standing behind her pushing for an increase in productivity. But it requires a lot of focus on managing expenses.

In 2010 and 2011, Dr. Jones had a decline in reimbursement, but her patient volume was increasing. There are only so many patients she can see on her own, so she looked for ways to cut expenses and increase income. Accounting, for instance, had gone up to 20% of her expenses. She dismissed her bookkeeper and now does her own books. The health plan cost had increased by 8%, so when the policy came up for renewal, she found state incentives for small businesses, which allowed her to reduce that expense.

Initially, she had an experienced nurse practitioner on staff who helped maintain or increase patient volume. But her salary was more than she could bring in independently, so Dr. Jones decided to let her go.

She’s found ways to bring in new revenue – for instance, by offering botulinum toxin injections for chronic migraines and punch skin biopsies. Dr. Jones said that participating in Medicare’s incentive programs for meaningful use and electronic prescribing have also boosted revenue. "It’s a lot of work, and it changes how you do things, but it is a revenue stream," she said.

With demand outstripping supply, neurologists will continue to be in demand, but the Affordable Care Act and other pressures will still make it hard to practice, Dr. Jones said. She’s considering taking on some coverage with some local hospitals, but added that she’s "not thrilled with working harder" or on more nights and weekends, although she is not ruling out this option.

Nor is she ruling out selling her practice and getting out of medicine all together.

"The most important thing is, you have to pay attention and be limber and adjust your models as things change," said Dr. Jones. But, she acknowledged, "I don’t know if I’ll still be in neurology in 5 years."

Dr. Kinsella disclosed that he owns stock in Rural Healthcare Logistics and is a subcontractor for Premier Service Network. Dr. Jones had no disclosures.

*Correction, 7/13/2012: An earlier version of this story misstated Dr. Kinsella's professional position.

NEW ORLEANS – Like many other specialties – particularly cognitive specialties – neurology is under pressure to figure out how best to survive in an environment in which expenses are rising, but income is declining. So what are some strategies for staying in practice, choosing what type of practice is best, ensuring a steady income stream, and staying sane?

At the recent annual meeting of the American Academy of Neurology, several neurologists offered their personal take on preserving the pleasures of practice while maintaining revenues.

Dr. Laurence J. Kinsella, codirector of neurology for SSM Neurosciences Institute, St. Louis, noted that although median income for neurologists had risen fairly steadily since the mid-1990s, a neurologist’s value was very much dependent on what area of the country he or she practices in, whether it is urban or rural, and whether the practice is academic or private, or interventionist or cognitive.*

Choosing where to practice and the best type of practice is dependent on which options offer the best proximity to family or accommodation of a spouse’s needs, as well as the most professional growth, leadership potential, and collegiality, among other factors, said Dr. Kinsella, who is also vice chair of the AAN’s government affairs committee.

In the assessment of a group practice, for instance, be aware that survey data and published research have shown that the average turnover is 7% per year, and 60% of those who leave do so in the first 5 years. The biggest reasons for leaving include practice issues; compensation and location issues; and spousal concerns. Some questions to raise are whether the senior partners are advocates for equity for all partners, and whether the path to partnership is clearly stated, Dr. Kinsella said.

Before signing a contract with any group, it’s worthwhile to consult with an attorney who specializes in health care, he said. Keep in mind that everything is negotiable. Some key components to explore include salary and bonus; productivity scale; call schedule; pension and profit sharing; termination; and malpractice, health, and disability insurance.

"The most important thing is, you have to pay attention and be limber and adjust your models as things change."

Whether you take the academic, private, solo, or group path, the reimbursement challenges will be the same. The elimination of the Medicare consult codes in 2010 have led to a 6%-20% reduction in reimbursement, according to AAN survey data, Dr. Kinsella said.

There is a tool to assess the impact on a practice at www.mitsi.org/. One way to make up for lost revenue is to take a closer look at evaluation and management (E&M) codes, he added. At least 60% of neurologists’ billing is for E&M services. AAN provides templates for determining efficient and appropriate use of E&M codes. Dr. Kinsella said he advocated for the use of prolonged service codes such as 99354 (31-74 minutes) and 99355 (for each additional 30 minutes). "I’d encourage you to get comfortable with these. They are very good to use," he said.

Most neurologists also bill at level 4, then level 5 and level 3 for E&M, and they should be billing primarily level 5, Dr. Kinsella said. A level 5 consult requires more than just a single diagnosis.

Some 40% of neurology practice now comes from neurophysiology, such as sleep studies and electromyography/nerve conduction studies. These procedures pay better than E&M and thus are worth adding into a practice, he said.

Some other revenue-generating ideas include taking on a hospital directorship, such as stroke director; participating in clinical trials; giving botulinum toxin injections and nerve blocks for rotator cuff injuries, for instance; doing skin biopsies for small fiber neuropathy; and doing chart reviews for legal cases and interpretation of images.

Consider also moonlighting as a neurohospitalist. Dr. Kinsella’s practice offered 24/7 coverage to a hospital that suddenly lost a group of neurologists, which worked out well.

"The key is to leverage your scarcity," Dr. Kinsella said, noting that neurologists are in sparse supply and that many hospitals need coverage for call, stroke centers, and telemedicine.

Another avenue is to offer coverage for rural health clinics. Medicare has been assisting rural hospitals and clinics to recruit neurologists. With higher reimbursement in place to help these centers, working for a rural clinic can "cover your windshield cost" to make the drive and take the time away from practice, he said.

His suggestions for keeping practice fun? Get a clinical appointment to teach residents. Or have a different area of practice every day.

Dr. Elaine C. Jones, a colleague of Dr. Kinsella’s on the AAN government affairs committee, has taken a somewhat contrary path to getting satisfaction out of her practice by moving from an academic setting to set up her own solo practice.

She began practicing in the late 1990s at a large multispecialty group based at an academic hospital in Providence, R.I. By 2001, she was chief of neurology, but she felt as if the responsibility was not matched by an equal level of decision-making power. She decided that by going solo she could cut out the middleman on issues concerning staffing decisions, expenses, program development, and office renovations.

She consulted with other physicians in private practice, read up on various publications from the American Medical Association, and relied on her boyfriend, who had banking experience and a law degree, all of which helped her to decide which business model to use. She hired attorneys to help file the necessary paperwork to set up the practice. The hardest decision was naming the practice; she decided on Southern New England Neurology, with an eye on expanding in the future.

In 2005, Dr. Jones opened the practice in Bristol, R.I., renting space in a primary care practice building. Reaching this point had taken $40,000 in personal savings, $50,000 from a home-equity credit line, and a $30,000 equipment loan. Within 6 months, she had covered her costs, and within 18 months she had paid off the loan and was paying down the equity line.

An important initial investment was an electronic health record system, Dr. Jones said.

She began by working just 4 days a week, which gave her time for personal pursuits. But 3 years in, she had outgrown the space and the increased patient volume was taxing her existing staff. Dr. Jones was afraid to leave the bosom of the primary care group and its built-in referrals, but it had no additional room, so she decided to buy a property. She purchased a duplex and invested in extensive renovations, which took about a year to complete.

She has found private practice to be very rewarding because it gives her control over her scheduling, hours, and staffing, and no one is standing behind her pushing for an increase in productivity. But it requires a lot of focus on managing expenses.

In 2010 and 2011, Dr. Jones had a decline in reimbursement, but her patient volume was increasing. There are only so many patients she can see on her own, so she looked for ways to cut expenses and increase income. Accounting, for instance, had gone up to 20% of her expenses. She dismissed her bookkeeper and now does her own books. The health plan cost had increased by 8%, so when the policy came up for renewal, she found state incentives for small businesses, which allowed her to reduce that expense.

Initially, she had an experienced nurse practitioner on staff who helped maintain or increase patient volume. But her salary was more than she could bring in independently, so Dr. Jones decided to let her go.

She’s found ways to bring in new revenue – for instance, by offering botulinum toxin injections for chronic migraines and punch skin biopsies. Dr. Jones said that participating in Medicare’s incentive programs for meaningful use and electronic prescribing have also boosted revenue. "It’s a lot of work, and it changes how you do things, but it is a revenue stream," she said.

With demand outstripping supply, neurologists will continue to be in demand, but the Affordable Care Act and other pressures will still make it hard to practice, Dr. Jones said. She’s considering taking on some coverage with some local hospitals, but added that she’s "not thrilled with working harder" or on more nights and weekends, although she is not ruling out this option.

Nor is she ruling out selling her practice and getting out of medicine all together.

"The most important thing is, you have to pay attention and be limber and adjust your models as things change," said Dr. Jones. But, she acknowledged, "I don’t know if I’ll still be in neurology in 5 years."

Dr. Kinsella disclosed that he owns stock in Rural Healthcare Logistics and is a subcontractor for Premier Service Network. Dr. Jones had no disclosures.

*Correction, 7/13/2012: An earlier version of this story misstated Dr. Kinsella's professional position.

NEW ORLEANS – Like many other specialties – particularly cognitive specialties – neurology is under pressure to figure out how best to survive in an environment in which expenses are rising, but income is declining. So what are some strategies for staying in practice, choosing what type of practice is best, ensuring a steady income stream, and staying sane?

At the recent annual meeting of the American Academy of Neurology, several neurologists offered their personal take on preserving the pleasures of practice while maintaining revenues.

Dr. Laurence J. Kinsella, codirector of neurology for SSM Neurosciences Institute, St. Louis, noted that although median income for neurologists had risen fairly steadily since the mid-1990s, a neurologist’s value was very much dependent on what area of the country he or she practices in, whether it is urban or rural, and whether the practice is academic or private, or interventionist or cognitive.*

Choosing where to practice and the best type of practice is dependent on which options offer the best proximity to family or accommodation of a spouse’s needs, as well as the most professional growth, leadership potential, and collegiality, among other factors, said Dr. Kinsella, who is also vice chair of the AAN’s government affairs committee.

In the assessment of a group practice, for instance, be aware that survey data and published research have shown that the average turnover is 7% per year, and 60% of those who leave do so in the first 5 years. The biggest reasons for leaving include practice issues; compensation and location issues; and spousal concerns. Some questions to raise are whether the senior partners are advocates for equity for all partners, and whether the path to partnership is clearly stated, Dr. Kinsella said.

Before signing a contract with any group, it’s worthwhile to consult with an attorney who specializes in health care, he said. Keep in mind that everything is negotiable. Some key components to explore include salary and bonus; productivity scale; call schedule; pension and profit sharing; termination; and malpractice, health, and disability insurance.

"The most important thing is, you have to pay attention and be limber and adjust your models as things change."

Whether you take the academic, private, solo, or group path, the reimbursement challenges will be the same. The elimination of the Medicare consult codes in 2010 have led to a 6%-20% reduction in reimbursement, according to AAN survey data, Dr. Kinsella said.

There is a tool to assess the impact on a practice at www.mitsi.org/. One way to make up for lost revenue is to take a closer look at evaluation and management (E&M) codes, he added. At least 60% of neurologists’ billing is for E&M services. AAN provides templates for determining efficient and appropriate use of E&M codes. Dr. Kinsella said he advocated for the use of prolonged service codes such as 99354 (31-74 minutes) and 99355 (for each additional 30 minutes). "I’d encourage you to get comfortable with these. They are very good to use," he said.

Most neurologists also bill at level 4, then level 5 and level 3 for E&M, and they should be billing primarily level 5, Dr. Kinsella said. A level 5 consult requires more than just a single diagnosis.

Some 40% of neurology practice now comes from neurophysiology, such as sleep studies and electromyography/nerve conduction studies. These procedures pay better than E&M and thus are worth adding into a practice, he said.

Some other revenue-generating ideas include taking on a hospital directorship, such as stroke director; participating in clinical trials; giving botulinum toxin injections and nerve blocks for rotator cuff injuries, for instance; doing skin biopsies for small fiber neuropathy; and doing chart reviews for legal cases and interpretation of images.

Consider also moonlighting as a neurohospitalist. Dr. Kinsella’s practice offered 24/7 coverage to a hospital that suddenly lost a group of neurologists, which worked out well.

"The key is to leverage your scarcity," Dr. Kinsella said, noting that neurologists are in sparse supply and that many hospitals need coverage for call, stroke centers, and telemedicine.

Another avenue is to offer coverage for rural health clinics. Medicare has been assisting rural hospitals and clinics to recruit neurologists. With higher reimbursement in place to help these centers, working for a rural clinic can "cover your windshield cost" to make the drive and take the time away from practice, he said.

His suggestions for keeping practice fun? Get a clinical appointment to teach residents. Or have a different area of practice every day.

Dr. Elaine C. Jones, a colleague of Dr. Kinsella’s on the AAN government affairs committee, has taken a somewhat contrary path to getting satisfaction out of her practice by moving from an academic setting to set up her own solo practice.

She began practicing in the late 1990s at a large multispecialty group based at an academic hospital in Providence, R.I. By 2001, she was chief of neurology, but she felt as if the responsibility was not matched by an equal level of decision-making power. She decided that by going solo she could cut out the middleman on issues concerning staffing decisions, expenses, program development, and office renovations.

She consulted with other physicians in private practice, read up on various publications from the American Medical Association, and relied on her boyfriend, who had banking experience and a law degree, all of which helped her to decide which business model to use. She hired attorneys to help file the necessary paperwork to set up the practice. The hardest decision was naming the practice; she decided on Southern New England Neurology, with an eye on expanding in the future.

In 2005, Dr. Jones opened the practice in Bristol, R.I., renting space in a primary care practice building. Reaching this point had taken $40,000 in personal savings, $50,000 from a home-equity credit line, and a $30,000 equipment loan. Within 6 months, she had covered her costs, and within 18 months she had paid off the loan and was paying down the equity line.

An important initial investment was an electronic health record system, Dr. Jones said.

She began by working just 4 days a week, which gave her time for personal pursuits. But 3 years in, she had outgrown the space and the increased patient volume was taxing her existing staff. Dr. Jones was afraid to leave the bosom of the primary care group and its built-in referrals, but it had no additional room, so she decided to buy a property. She purchased a duplex and invested in extensive renovations, which took about a year to complete.

She has found private practice to be very rewarding because it gives her control over her scheduling, hours, and staffing, and no one is standing behind her pushing for an increase in productivity. But it requires a lot of focus on managing expenses.

In 2010 and 2011, Dr. Jones had a decline in reimbursement, but her patient volume was increasing. There are only so many patients she can see on her own, so she looked for ways to cut expenses and increase income. Accounting, for instance, had gone up to 20% of her expenses. She dismissed her bookkeeper and now does her own books. The health plan cost had increased by 8%, so when the policy came up for renewal, she found state incentives for small businesses, which allowed her to reduce that expense.

Initially, she had an experienced nurse practitioner on staff who helped maintain or increase patient volume. But her salary was more than she could bring in independently, so Dr. Jones decided to let her go.

She’s found ways to bring in new revenue – for instance, by offering botulinum toxin injections for chronic migraines and punch skin biopsies. Dr. Jones said that participating in Medicare’s incentive programs for meaningful use and electronic prescribing have also boosted revenue. "It’s a lot of work, and it changes how you do things, but it is a revenue stream," she said.

With demand outstripping supply, neurologists will continue to be in demand, but the Affordable Care Act and other pressures will still make it hard to practice, Dr. Jones said. She’s considering taking on some coverage with some local hospitals, but added that she’s "not thrilled with working harder" or on more nights and weekends, although she is not ruling out this option.

Nor is she ruling out selling her practice and getting out of medicine all together.

"The most important thing is, you have to pay attention and be limber and adjust your models as things change," said Dr. Jones. But, she acknowledged, "I don’t know if I’ll still be in neurology in 5 years."

Dr. Kinsella disclosed that he owns stock in Rural Healthcare Logistics and is a subcontractor for Premier Service Network. Dr. Jones had no disclosures.

*Correction, 7/13/2012: An earlier version of this story misstated Dr. Kinsella's professional position.

It’s time for cardiologists to pay more attention to patients’ needs and to advocate for patient-centered care with insurers and policy makers, according to a new health policy statement from the American College of Cardiology.

The statement outlines a new treatment paradigm of shared decision making with patients, and a systemic approach to care that, for the first time, urges creation of patient-centered medical homes led by cardiovascular specialists.

"In true patient-centered care, the focus is on the patient, not on the disease," Dr. Mary Norine Walsh, chair of the ACC’s patient-centered care committee, said in an interview. "Beyond knowing the technical aspects of the disease, we need to do a better job of understanding patients’ perception of their disease and their goals and life experience, so we can together chart a course for how we are going to manage the disease," said Dr. Walsh, medical director of the heart failure and cardiac transplantation programs at St. Vincent Indianapolis Hospital.

The bottom line is, physicians need to communicate better with patients, at a level that takes into account their health literacy, and patients need to be more actively engaged in their own care, according to the policy statement, which was published in the Journal of the American College of Cardiology (2012, May 14:doi:10.1016/j.jacc.2012.03.016).

"As clinicians, we have been taught for many years to give patients orders and expect things to happen," said Dr. Alfred A. Bove, professor emeritus, Temple University, Philadelphia, and vice chair of the patient-centered care committee, in a statement. "But when it comes to the day-to-day management of chronic conditions like heart disease, we have to empower patients to be actively involved in their own care. We won’t be effective unless we move toward a patient-centered approach. This initiative is intended to help us get there."

The statement is not designed to tell physicians how to manage their practices, said Dr. Walsh. It’s a call to payers and policy makers to help give physicians the tools they need to move to patient-centered care, she said. "The onus is not on the doctors here," said Dr. Walsh.

However, it does urge physicians to start thinking about educating patients in a variety of ways, including pamphlets, online programs, community events, and group education sessions. The statement estimates that 89 million American adults – one-third the population – are not literate enough, health-wise, to follow through on recommendations for tests and treatments and self-monitoring. Educational content should also be tailored to patients’ individual health situations and needs.

The next step should be to create easy-to-use decision aids for patients – so they are no longer passive recipients of recommendations for care – and self-management programs, including web portals, so that patients also engage in monitoring chronic conditions. Such portals are currently rare but will likely be required for physicians who want to qualify under stage 2 of the meaningful use criteria for Medicare’s electronic health record incentive program.

Dr. Walsh admitted that, even in her practice, she relies on outdated technology – giving patients a printed-out grid for monitoring their blood pressure – that is not ideal for engaging them in their own care. But for starters, she says, the ACC has a portal of sorts, the CardioSmart website, which offers patients some decision aids and information about various conditions and tests and treatments in lay-friendly language.

The ACC is also hoping to make inroads with the idea that cardiovascular specialists can lead medical homes, for certain patients. "We know that not every cardiologist will be a home for every patient," said Dr. Walsh. But for transplant patients, those with ventricular assist devices or congenital heart disease, the primary physician is a cardiologist or a surgeon, she said.

The specialist-led medical home will not operate to the exclusion of the traditional medical home; it will be one of many models, said Dr. Walsh.

The policy statement envisions a care team "to manage patients with advanced cardiac disease across the continuum of care from the stable outpatient environment to the level of intensive in-hospital care without changing care teams." Such a team would be directed by cardiologists with advanced training in cardiovascular disease management and include nurse practitioners, pharmacists, educators, and technologists with expertise in echocardiography, myocardial perfusion imaging, and other advanced imaging.

Overall, the policy statement "clearly puts a stake in the ground as far as what we as a professional society feel is important," said Dr. Walsh, who added that she expected that the statement will be used to educate physicians and payers and be taken to all of its discussions on Capitol Hill.

Dr. Walsh reported no relevant conflicts. Dr. Bove disclosed that he is a consultant for Health Station Networks. Most other authors and reviewers reported no relevant conflicts. Three who had potential conflicts were not permitted to draft text or vote on text or recommendations.

It’s time for cardiologists to pay more attention to patients’ needs and to advocate for patient-centered care with insurers and policy makers, according to a new health policy statement from the American College of Cardiology.

The statement outlines a new treatment paradigm of shared decision making with patients, and a systemic approach to care that, for the first time, urges creation of patient-centered medical homes led by cardiovascular specialists.

"In true patient-centered care, the focus is on the patient, not on the disease," Dr. Mary Norine Walsh, chair of the ACC’s patient-centered care committee, said in an interview. "Beyond knowing the technical aspects of the disease, we need to do a better job of understanding patients’ perception of their disease and their goals and life experience, so we can together chart a course for how we are going to manage the disease," said Dr. Walsh, medical director of the heart failure and cardiac transplantation programs at St. Vincent Indianapolis Hospital.

The bottom line is, physicians need to communicate better with patients, at a level that takes into account their health literacy, and patients need to be more actively engaged in their own care, according to the policy statement, which was published in the Journal of the American College of Cardiology (2012, May 14:doi:10.1016/j.jacc.2012.03.016).

"As clinicians, we have been taught for many years to give patients orders and expect things to happen," said Dr. Alfred A. Bove, professor emeritus, Temple University, Philadelphia, and vice chair of the patient-centered care committee, in a statement. "But when it comes to the day-to-day management of chronic conditions like heart disease, we have to empower patients to be actively involved in their own care. We won’t be effective unless we move toward a patient-centered approach. This initiative is intended to help us get there."

The statement is not designed to tell physicians how to manage their practices, said Dr. Walsh. It’s a call to payers and policy makers to help give physicians the tools they need to move to patient-centered care, she said. "The onus is not on the doctors here," said Dr. Walsh.

However, it does urge physicians to start thinking about educating patients in a variety of ways, including pamphlets, online programs, community events, and group education sessions. The statement estimates that 89 million American adults – one-third the population – are not literate enough, health-wise, to follow through on recommendations for tests and treatments and self-monitoring. Educational content should also be tailored to patients’ individual health situations and needs.

The next step should be to create easy-to-use decision aids for patients – so they are no longer passive recipients of recommendations for care – and self-management programs, including web portals, so that patients also engage in monitoring chronic conditions. Such portals are currently rare but will likely be required for physicians who want to qualify under stage 2 of the meaningful use criteria for Medicare’s electronic health record incentive program.

Dr. Walsh admitted that, even in her practice, she relies on outdated technology – giving patients a printed-out grid for monitoring their blood pressure – that is not ideal for engaging them in their own care. But for starters, she says, the ACC has a portal of sorts, the CardioSmart website, which offers patients some decision aids and information about various conditions and tests and treatments in lay-friendly language.

The ACC is also hoping to make inroads with the idea that cardiovascular specialists can lead medical homes, for certain patients. "We know that not every cardiologist will be a home for every patient," said Dr. Walsh. But for transplant patients, those with ventricular assist devices or congenital heart disease, the primary physician is a cardiologist or a surgeon, she said.

The specialist-led medical home will not operate to the exclusion of the traditional medical home; it will be one of many models, said Dr. Walsh.

The policy statement envisions a care team "to manage patients with advanced cardiac disease across the continuum of care from the stable outpatient environment to the level of intensive in-hospital care without changing care teams." Such a team would be directed by cardiologists with advanced training in cardiovascular disease management and include nurse practitioners, pharmacists, educators, and technologists with expertise in echocardiography, myocardial perfusion imaging, and other advanced imaging.

Overall, the policy statement "clearly puts a stake in the ground as far as what we as a professional society feel is important," said Dr. Walsh, who added that she expected that the statement will be used to educate physicians and payers and be taken to all of its discussions on Capitol Hill.

Dr. Walsh reported no relevant conflicts. Dr. Bove disclosed that he is a consultant for Health Station Networks. Most other authors and reviewers reported no relevant conflicts. Three who had potential conflicts were not permitted to draft text or vote on text or recommendations.

It’s time for cardiologists to pay more attention to patients’ needs and to advocate for patient-centered care with insurers and policy makers, according to a new health policy statement from the American College of Cardiology.

The statement outlines a new treatment paradigm of shared decision making with patients, and a systemic approach to care that, for the first time, urges creation of patient-centered medical homes led by cardiovascular specialists.

"In true patient-centered care, the focus is on the patient, not on the disease," Dr. Mary Norine Walsh, chair of the ACC’s patient-centered care committee, said in an interview. "Beyond knowing the technical aspects of the disease, we need to do a better job of understanding patients’ perception of their disease and their goals and life experience, so we can together chart a course for how we are going to manage the disease," said Dr. Walsh, medical director of the heart failure and cardiac transplantation programs at St. Vincent Indianapolis Hospital.

The bottom line is, physicians need to communicate better with patients, at a level that takes into account their health literacy, and patients need to be more actively engaged in their own care, according to the policy statement, which was published in the Journal of the American College of Cardiology (2012, May 14:doi:10.1016/j.jacc.2012.03.016).

"As clinicians, we have been taught for many years to give patients orders and expect things to happen," said Dr. Alfred A. Bove, professor emeritus, Temple University, Philadelphia, and vice chair of the patient-centered care committee, in a statement. "But when it comes to the day-to-day management of chronic conditions like heart disease, we have to empower patients to be actively involved in their own care. We won’t be effective unless we move toward a patient-centered approach. This initiative is intended to help us get there."

The statement is not designed to tell physicians how to manage their practices, said Dr. Walsh. It’s a call to payers and policy makers to help give physicians the tools they need to move to patient-centered care, she said. "The onus is not on the doctors here," said Dr. Walsh.

However, it does urge physicians to start thinking about educating patients in a variety of ways, including pamphlets, online programs, community events, and group education sessions. The statement estimates that 89 million American adults – one-third the population – are not literate enough, health-wise, to follow through on recommendations for tests and treatments and self-monitoring. Educational content should also be tailored to patients’ individual health situations and needs.

The next step should be to create easy-to-use decision aids for patients – so they are no longer passive recipients of recommendations for care – and self-management programs, including web portals, so that patients also engage in monitoring chronic conditions. Such portals are currently rare but will likely be required for physicians who want to qualify under stage 2 of the meaningful use criteria for Medicare’s electronic health record incentive program.

Dr. Walsh admitted that, even in her practice, she relies on outdated technology – giving patients a printed-out grid for monitoring their blood pressure – that is not ideal for engaging them in their own care. But for starters, she says, the ACC has a portal of sorts, the CardioSmart website, which offers patients some decision aids and information about various conditions and tests and treatments in lay-friendly language.

The ACC is also hoping to make inroads with the idea that cardiovascular specialists can lead medical homes, for certain patients. "We know that not every cardiologist will be a home for every patient," said Dr. Walsh. But for transplant patients, those with ventricular assist devices or congenital heart disease, the primary physician is a cardiologist or a surgeon, she said.

The specialist-led medical home will not operate to the exclusion of the traditional medical home; it will be one of many models, said Dr. Walsh.

The policy statement envisions a care team "to manage patients with advanced cardiac disease across the continuum of care from the stable outpatient environment to the level of intensive in-hospital care without changing care teams." Such a team would be directed by cardiologists with advanced training in cardiovascular disease management and include nurse practitioners, pharmacists, educators, and technologists with expertise in echocardiography, myocardial perfusion imaging, and other advanced imaging.

Overall, the policy statement "clearly puts a stake in the ground as far as what we as a professional society feel is important," said Dr. Walsh, who added that she expected that the statement will be used to educate physicians and payers and be taken to all of its discussions on Capitol Hill.

Dr. Walsh reported no relevant conflicts. Dr. Bove disclosed that he is a consultant for Health Station Networks. Most other authors and reviewers reported no relevant conflicts. Three who had potential conflicts were not permitted to draft text or vote on text or recommendations.

Counsel patients up to age 24 years on the merits of avoiding sun exposure to reduce the risk of skin cancers, the U.S. Preventive Services Task Force recommended May 8. The task force stopped short making the same recommendation for patients older than 24 years, saying that the evidence is not sufficient "to assess the balance of benefits and harms."

The panel noted in its recommendations the prevalence of skin cancer – affecting more than 2 million Americans yearly – and the rising incidence of can melanoma, with 70,000 cases in 2011 and about 8,800 deaths. The USPSTF said there was "convincing" evidence that ultraviolet radiation exposure during childhood and youth is linked to "a moderately increased risk for skin cancer later in life," but that for adults the evidence is only adequate, and, it is associated with just a small increase in risk.

There are potential downsides to counseling – for instance, it might lead kids to be less active – but no studies showed such a decrease, according to the task force’s recommendations. The document also noted that studies need to be done on whether sun exposure avoidance leads to lower vitamin D levels in adults.

The American Academy of Dermatology Association praised the recommendation for children and adolescents. "However, we firmly believe that behavior counseling is essential for all populations, including the adult population," said AADA President Daniel M. Siegel, in a statement. "Given this, we will continue our efforts to educate the public on skin cancer prevention, and encourage our members to conduct additional research in this important area," he said.

Counsel patients up to age 24 years on the merits of avoiding sun exposure to reduce the risk of skin cancers, the U.S. Preventive Services Task Force recommended May 8. The task force stopped short making the same recommendation for patients older than 24 years, saying that the evidence is not sufficient "to assess the balance of benefits and harms."

The panel noted in its recommendations the prevalence of skin cancer – affecting more than 2 million Americans yearly – and the rising incidence of can melanoma, with 70,000 cases in 2011 and about 8,800 deaths. The USPSTF said there was "convincing" evidence that ultraviolet radiation exposure during childhood and youth is linked to "a moderately increased risk for skin cancer later in life," but that for adults the evidence is only adequate, and, it is associated with just a small increase in risk.

There are potential downsides to counseling – for instance, it might lead kids to be less active – but no studies showed such a decrease, according to the task force’s recommendations. The document also noted that studies need to be done on whether sun exposure avoidance leads to lower vitamin D levels in adults.

The American Academy of Dermatology Association praised the recommendation for children and adolescents. "However, we firmly believe that behavior counseling is essential for all populations, including the adult population," said AADA President Daniel M. Siegel, in a statement. "Given this, we will continue our efforts to educate the public on skin cancer prevention, and encourage our members to conduct additional research in this important area," he said.

Counsel patients up to age 24 years on the merits of avoiding sun exposure to reduce the risk of skin cancers, the U.S. Preventive Services Task Force recommended May 8. The task force stopped short making the same recommendation for patients older than 24 years, saying that the evidence is not sufficient "to assess the balance of benefits and harms."

The panel noted in its recommendations the prevalence of skin cancer – affecting more than 2 million Americans yearly – and the rising incidence of can melanoma, with 70,000 cases in 2011 and about 8,800 deaths. The USPSTF said there was "convincing" evidence that ultraviolet radiation exposure during childhood and youth is linked to "a moderately increased risk for skin cancer later in life," but that for adults the evidence is only adequate, and, it is associated with just a small increase in risk.

There are potential downsides to counseling – for instance, it might lead kids to be less active – but no studies showed such a decrease, according to the task force’s recommendations. The document also noted that studies need to be done on whether sun exposure avoidance leads to lower vitamin D levels in adults.

The American Academy of Dermatology Association praised the recommendation for children and adolescents. "However, we firmly believe that behavior counseling is essential for all populations, including the adult population," said AADA President Daniel M. Siegel, in a statement. "Given this, we will continue our efforts to educate the public on skin cancer prevention, and encourage our members to conduct additional research in this important area," he said.

The Institute of Medicine is urging all Americans to come together to systematically attack the "obesity epidemic." In a report released May 8, a blue-ribbon panel convened by the IOM made five basic recommendations to fast-forward progress on curbing the nation’s growing girth.

Panel vice chair William Purcell called the recommendations "straightforward, direct goals" to not only combat obesity, but to hopefully end the problem. The panel recommended:

• integrating physical activity every day in every way for everybody.

• making healthy foods available everywhere.

• marketing what matters for a healthy life.

• activating employers and health care professionals.

• strengthening schools as "the heart of life."

The recommendations are part of the committee’s report, "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation."

The 16-member committee, made up of nutrition, obesity, and marketing experts; epidemiologists; and behaviorists, among others, said that all of the recommendations – and strategies to put them into place – hinge upon each other for success.

"We need to do it all, we need to do it now, and it involves all of us," said Mr. Purcell, an attorney and former Nashville mayor, at a plenary session on the report at the meeting.

"Obesity is both an individual and societal concern, and it will take action from all of us – individuals, communities, and the nation as a whole – to achieve a healthier society," said IOM president Harvey V. Fineberg, in a statement.

In putting together its report, the IOM committee reviewed 10 years worth of data and some 800 of previous recommendations. The scope of the problem has become very evident, panel members said.

About one-third of American adults are obese, and 17% of children are obese. Among certain racial and ethnic groups, especially blacks and Latinos, the number is even higher, according to the report. The committee estimated the annual cost of obesity-related illness at $190.2 billion, or nearly 21% of annual health spending.

Panel chair Dan Glickman said that rising costs were as likely as any other factor to push policy makers, health professionals and community leaders into action.

"We are increasing our debt by about $1 trillion a year and the biggest part of that is health care costs. We can’t sustain that," said Mr. Glickman, former Secretary of Agriculture and currently executive director of congressional programs at the Aspen Institute.

Mr. Glickman also said that business has become more engaged in trying to tackle obesity, which was not the case 10-15 years ago.

"We’ve known the problems are severe, but society has to reach a point where it’s ready to tackle them and I think we’re much closer to that than we have been," he said.

The panel’s outlined a series of strategies to address obesity in a variety of environments.

For instance, the panel suggested how schools could find ways to encourage more physical activity and serve healthier meals to students. And, schools should provide food literacy or nutrition education classes, they recommended.

Further, governments should seek ways to reduce consumption of sugar-sweetened beverages especially by children, and possibly even should prohibit serving them to kids. The panel also called for development of standards on how food and drink are marketed to children.

Health care providers should adopt standards of practice for prevention, screening, diagnosis, and treatment of obesity, and should be advocates for greater access to physical activity in their communities, according to the report. Employers should also be advocates for better lifestyles, the panel said.

Special attention was given to how all of these strategies could be applied to low-income Americans and minorities.

For instance, the lowest-cost foods are often the least healthy and most calorie dense; people in low-income communities often rely on those foods because they are inexpensive, according to panel member Shiriki K. Kumanyika, Ph.D., of the University of Pennsylvania, Philadelphia.

The panel also noted that the mix of retail outlets in low-income and certain racial communities drives people toward less healthy eating.

Marketing efforts surrounding some less-healthful food choices seek to make those foods more appealing to minorities; ads for high-calorie foods are much more prevalent in minority communities than in white communities, Dr. Kumanyika added, who added that this is especially true of marketing to black and Latino children.

"We have to be thinking about transforming the environments to get rid of the inequities," she said.

The IOM report is the first to pull together recommendations that target everything from how communities are laid out and built, to how food and beverages are marketed to how schools and work places can encourage healthier living, Jamie F. Chriqui, Ph.D., of the University of Illinois, Chicago.

She said "It’s going to take a collective effort," and that "it’s not just about food, it’s not just about physical activity, it’s about the entire environment and what we can do."

The panel advocated a number of strategies to get to the goals outlined in the recommendations. Some examples include:

• Institute physical activity requirements for child care and early-childhood education programs.

• Find ways to provide tax credits or financing arrangements to encourage retailers and distributors of healthy food to go into so-called food deserts, those areas that are underserved.

• Require all restaurants to list calorie counts on menus and food boards.

• Require that all students from kindergarten through 12th grade have 60 minutes of physical activity a day at school.

The IOM panel’s report is only part of a joint effort to raise the nation’s awareness of the obesity problem and to seek potential solutions. The effort was funded by the Robert Wood Johnson Foundation, Kaiser Permanente, and the Michael and Susan Dell Foundation.

Cable channel HBO approached the IOM about making a documentary series about obesity. The two-part film, called "The Weight of the Nation," was produced in conjunction with the IOM, the Centers for Disease Control and Prevention, and the National Institutes of Health and will be shown on May 14 and 15.

A companion book (New York: St. Martin’s Press, 2012) was cowritten by IOM executive officer Judith Salerno; John Hoffman, the documentary’s executive producer; and Alexandra Moss, the documentary’s coproducer.

The Institute of Medicine is urging all Americans to come together to systematically attack the "obesity epidemic." In a report released May 8, a blue-ribbon panel convened by the IOM made five basic recommendations to fast-forward progress on curbing the nation’s growing girth.

Panel vice chair William Purcell called the recommendations "straightforward, direct goals" to not only combat obesity, but to hopefully end the problem. The panel recommended:

• integrating physical activity every day in every way for everybody.

• making healthy foods available everywhere.

• marketing what matters for a healthy life.

• activating employers and health care professionals.

• strengthening schools as "the heart of life."

The recommendations are part of the committee’s report, "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation."

The 16-member committee, made up of nutrition, obesity, and marketing experts; epidemiologists; and behaviorists, among others, said that all of the recommendations – and strategies to put them into place – hinge upon each other for success.

"We need to do it all, we need to do it now, and it involves all of us," said Mr. Purcell, an attorney and former Nashville mayor, at a plenary session on the report at the meeting.

"Obesity is both an individual and societal concern, and it will take action from all of us – individuals, communities, and the nation as a whole – to achieve a healthier society," said IOM president Harvey V. Fineberg, in a statement.

In putting together its report, the IOM committee reviewed 10 years worth of data and some 800 of previous recommendations. The scope of the problem has become very evident, panel members said.

About one-third of American adults are obese, and 17% of children are obese. Among certain racial and ethnic groups, especially blacks and Latinos, the number is even higher, according to the report. The committee estimated the annual cost of obesity-related illness at $190.2 billion, or nearly 21% of annual health spending.

Panel chair Dan Glickman said that rising costs were as likely as any other factor to push policy makers, health professionals and community leaders into action.

"We are increasing our debt by about $1 trillion a year and the biggest part of that is health care costs. We can’t sustain that," said Mr. Glickman, former Secretary of Agriculture and currently executive director of congressional programs at the Aspen Institute.

Mr. Glickman also said that business has become more engaged in trying to tackle obesity, which was not the case 10-15 years ago.

"We’ve known the problems are severe, but society has to reach a point where it’s ready to tackle them and I think we’re much closer to that than we have been," he said.

The panel’s outlined a series of strategies to address obesity in a variety of environments.

For instance, the panel suggested how schools could find ways to encourage more physical activity and serve healthier meals to students. And, schools should provide food literacy or nutrition education classes, they recommended.

Further, governments should seek ways to reduce consumption of sugar-sweetened beverages especially by children, and possibly even should prohibit serving them to kids. The panel also called for development of standards on how food and drink are marketed to children.

Health care providers should adopt standards of practice for prevention, screening, diagnosis, and treatment of obesity, and should be advocates for greater access to physical activity in their communities, according to the report. Employers should also be advocates for better lifestyles, the panel said.

Special attention was given to how all of these strategies could be applied to low-income Americans and minorities.

For instance, the lowest-cost foods are often the least healthy and most calorie dense; people in low-income communities often rely on those foods because they are inexpensive, according to panel member Shiriki K. Kumanyika, Ph.D., of the University of Pennsylvania, Philadelphia.

The panel also noted that the mix of retail outlets in low-income and certain racial communities drives people toward less healthy eating.

Marketing efforts surrounding some less-healthful food choices seek to make those foods more appealing to minorities; ads for high-calorie foods are much more prevalent in minority communities than in white communities, Dr. Kumanyika added, who added that this is especially true of marketing to black and Latino children.

"We have to be thinking about transforming the environments to get rid of the inequities," she said.

The IOM report is the first to pull together recommendations that target everything from how communities are laid out and built, to how food and beverages are marketed to how schools and work places can encourage healthier living, Jamie F. Chriqui, Ph.D., of the University of Illinois, Chicago.

She said "It’s going to take a collective effort," and that "it’s not just about food, it’s not just about physical activity, it’s about the entire environment and what we can do."

The panel advocated a number of strategies to get to the goals outlined in the recommendations. Some examples include:

• Institute physical activity requirements for child care and early-childhood education programs.

• Find ways to provide tax credits or financing arrangements to encourage retailers and distributors of healthy food to go into so-called food deserts, those areas that are underserved.

• Require all restaurants to list calorie counts on menus and food boards.

• Require that all students from kindergarten through 12th grade have 60 minutes of physical activity a day at school.

The IOM panel’s report is only part of a joint effort to raise the nation’s awareness of the obesity problem and to seek potential solutions. The effort was funded by the Robert Wood Johnson Foundation, Kaiser Permanente, and the Michael and Susan Dell Foundation.

Cable channel HBO approached the IOM about making a documentary series about obesity. The two-part film, called "The Weight of the Nation," was produced in conjunction with the IOM, the Centers for Disease Control and Prevention, and the National Institutes of Health and will be shown on May 14 and 15.

A companion book (New York: St. Martin’s Press, 2012) was cowritten by IOM executive officer Judith Salerno; John Hoffman, the documentary’s executive producer; and Alexandra Moss, the documentary’s coproducer.

The Institute of Medicine is urging all Americans to come together to systematically attack the "obesity epidemic." In a report released May 8, a blue-ribbon panel convened by the IOM made five basic recommendations to fast-forward progress on curbing the nation’s growing girth.

Panel vice chair William Purcell called the recommendations "straightforward, direct goals" to not only combat obesity, but to hopefully end the problem. The panel recommended:

• integrating physical activity every day in every way for everybody.

• making healthy foods available everywhere.

• marketing what matters for a healthy life.

• activating employers and health care professionals.

• strengthening schools as "the heart of life."

The recommendations are part of the committee’s report, "Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation."

The 16-member committee, made up of nutrition, obesity, and marketing experts; epidemiologists; and behaviorists, among others, said that all of the recommendations – and strategies to put them into place – hinge upon each other for success.

"We need to do it all, we need to do it now, and it involves all of us," said Mr. Purcell, an attorney and former Nashville mayor, at a plenary session on the report at the meeting.

"Obesity is both an individual and societal concern, and it will take action from all of us – individuals, communities, and the nation as a whole – to achieve a healthier society," said IOM president Harvey V. Fineberg, in a statement.

In putting together its report, the IOM committee reviewed 10 years worth of data and some 800 of previous recommendations. The scope of the problem has become very evident, panel members said.

About one-third of American adults are obese, and 17% of children are obese. Among certain racial and ethnic groups, especially blacks and Latinos, the number is even higher, according to the report. The committee estimated the annual cost of obesity-related illness at $190.2 billion, or nearly 21% of annual health spending.

Panel chair Dan Glickman said that rising costs were as likely as any other factor to push policy makers, health professionals and community leaders into action.

"We are increasing our debt by about $1 trillion a year and the biggest part of that is health care costs. We can’t sustain that," said Mr. Glickman, former Secretary of Agriculture and currently executive director of congressional programs at the Aspen Institute.

Mr. Glickman also said that business has become more engaged in trying to tackle obesity, which was not the case 10-15 years ago.

"We’ve known the problems are severe, but society has to reach a point where it’s ready to tackle them and I think we’re much closer to that than we have been," he said.

The panel’s outlined a series of strategies to address obesity in a variety of environments.

For instance, the panel suggested how schools could find ways to encourage more physical activity and serve healthier meals to students. And, schools should provide food literacy or nutrition education classes, they recommended.

Further, governments should seek ways to reduce consumption of sugar-sweetened beverages especially by children, and possibly even should prohibit serving them to kids. The panel also called for development of standards on how food and drink are marketed to children.

Health care providers should adopt standards of practice for prevention, screening, diagnosis, and treatment of obesity, and should be advocates for greater access to physical activity in their communities, according to the report. Employers should also be advocates for better lifestyles, the panel said.

Special attention was given to how all of these strategies could be applied to low-income Americans and minorities.

For instance, the lowest-cost foods are often the least healthy and most calorie dense; people in low-income communities often rely on those foods because they are inexpensive, according to panel member Shiriki K. Kumanyika, Ph.D., of the University of Pennsylvania, Philadelphia.

The panel also noted that the mix of retail outlets in low-income and certain racial communities drives people toward less healthy eating.

Marketing efforts surrounding some less-healthful food choices seek to make those foods more appealing to minorities; ads for high-calorie foods are much more prevalent in minority communities than in white communities, Dr. Kumanyika added, who added that this is especially true of marketing to black and Latino children.

"We have to be thinking about transforming the environments to get rid of the inequities," she said.

The IOM report is the first to pull together recommendations that target everything from how communities are laid out and built, to how food and beverages are marketed to how schools and work places can encourage healthier living, Jamie F. Chriqui, Ph.D., of the University of Illinois, Chicago.

She said "It’s going to take a collective effort," and that "it’s not just about food, it’s not just about physical activity, it’s about the entire environment and what we can do."

The panel advocated a number of strategies to get to the goals outlined in the recommendations. Some examples include:

• Institute physical activity requirements for child care and early-childhood education programs.

• Find ways to provide tax credits or financing arrangements to encourage retailers and distributors of healthy food to go into so-called food deserts, those areas that are underserved.

• Require all restaurants to list calorie counts on menus and food boards.

• Require that all students from kindergarten through 12th grade have 60 minutes of physical activity a day at school.

The IOM panel’s report is only part of a joint effort to raise the nation’s awareness of the obesity problem and to seek potential solutions. The effort was funded by the Robert Wood Johnson Foundation, Kaiser Permanente, and the Michael and Susan Dell Foundation.

Cable channel HBO approached the IOM about making a documentary series about obesity. The two-part film, called "The Weight of the Nation," was produced in conjunction with the IOM, the Centers for Disease Control and Prevention, and the National Institutes of Health and will be shown on May 14 and 15.

A companion book (New York: St. Martin’s Press, 2012) was cowritten by IOM executive officer Judith Salerno; John Hoffman, the documentary’s executive producer; and Alexandra Moss, the documentary’s coproducer.

When it comes to Americans’ widening waistlines, the next 2 decades may serve up a side order of good news – and a heaping helping of bad news.

The good news: The rate of increase in the number of obese Americans may level off by 2030, leading to a lower prevalence of obesity than previously estimated.

© okeyphotos/iStockphoto.com

The bad news: The number of obese Americans will still climb by a third in that period, while the nation’s tally of superobese – those who are more than 80 pounds overweight – will more than double.

The result: The cost to the nation from obesity-related morbidity and mortality will be massive, according to Eric Finkelstein, Ph.D., lead author of a study published online May 7 in the American Journal of Preventive Medicine.

By 2030, the United States will see a 33% increase in the prevalence of obesity and a 130% increase in the prevalence of severe obesity, predicted Dr. Finkelstein of the Duke Global Health Institute, Durham, N.C., and deputy director of the Health Services Research Program at Duke-NUS Graduate Medical School in Singapore, and his associates.

Previous studies had suggested that 51% of the U.S. population would be considered obese by that decade. But the model created by Dr. Finkelstein and his colleagues at Duke and the Centers for Disease Control and Prevention puts the U.S. obesity rate at 42% by 2030.

A total of 11% of the nation will be considered severely obese, compared with 5% now, Dr. Finkelstein predicted at a press briefing.

Those numbers aren’t carved in stone, however.

Dr. Finkelstein called his paper’s numbers "reasonable estimates as to what the future will hold," but he added that "predicting obesity is tricky."

To create their predictive model, the researchers used data from the Behavioral Risk Factor Surveillance System (BRFSS) covering the years 1990-2008.

They added variables that might affect the rate of obesity, including unemployment rates; prices for alcohol, gas, and fast food; prices of groceries relative to non–grocery items; prices of healthier foods relative to less-healthy foods; access to the Internet; and the number of fast-food and full-service restaurants/10,000 people. Those data were drawn from the U.S. Bureau of Labor Statistics, the American Chamber of Commerce Research Association, and the Census of Retail Trade.

The analysis showed that no single variable was the cause of obesity, said Dr. Finkelstein. In fact, the study’s variables probably only explain about 5% of obesity he added. Other studies have suggested that as much as 70% of obesity is genetically determined.

The investigators noted several limitations to their predictive model, including the fact that it assumes the variables used will remain constant. In addition, the BRFSS relies on self-reported height and weight. The researchers attempted to counter that by adjusting for potential underreporting.

Getting at obesity’s causes now could help lower obesity rates later, the researchers said.

Childhood obesity may be a major risk factor for obesity later in life, noted Dr. Finkelstein and coauthor Dr. William Dietz. A child’s school environment has been shown to play a predominant role in pediatric obesity, added Dr. Finkelstein.

"Keeping obesity rates level could yield a savings of nearly $550 billion in medical expenditures over the next 2 decades," Dr. Finkelstein said in a statement.

Bending the obesity curve slightly downward would deliver more benefits.

"Even a 1% decrease from the predicted trend would lead to 2.6 million fewer obese adults in 2020 and 2.9 million fewer obese adults in 2030," the study’s authors explained.

The study’s authors reported no conflicts of interest.

When it comes to Americans’ widening waistlines, the next 2 decades may serve up a side order of good news – and a heaping helping of bad news.

The good news: The rate of increase in the number of obese Americans may level off by 2030, leading to a lower prevalence of obesity than previously estimated.

© okeyphotos/iStockphoto.com

The bad news: The number of obese Americans will still climb by a third in that period, while the nation’s tally of superobese – those who are more than 80 pounds overweight – will more than double.

The result: The cost to the nation from obesity-related morbidity and mortality will be massive, according to Eric Finkelstein, Ph.D., lead author of a study published online May 7 in the American Journal of Preventive Medicine.

By 2030, the United States will see a 33% increase in the prevalence of obesity and a 130% increase in the prevalence of severe obesity, predicted Dr. Finkelstein of the Duke Global Health Institute, Durham, N.C., and deputy director of the Health Services Research Program at Duke-NUS Graduate Medical School in Singapore, and his associates.

Previous studies had suggested that 51% of the U.S. population would be considered obese by that decade. But the model created by Dr. Finkelstein and his colleagues at Duke and the Centers for Disease Control and Prevention puts the U.S. obesity rate at 42% by 2030.

A total of 11% of the nation will be considered severely obese, compared with 5% now, Dr. Finkelstein predicted at a press briefing.

Those numbers aren’t carved in stone, however.

Dr. Finkelstein called his paper’s numbers "reasonable estimates as to what the future will hold," but he added that "predicting obesity is tricky."

To create their predictive model, the researchers used data from the Behavioral Risk Factor Surveillance System (BRFSS) covering the years 1990-2008.

They added variables that might affect the rate of obesity, including unemployment rates; prices for alcohol, gas, and fast food; prices of groceries relative to non–grocery items; prices of healthier foods relative to less-healthy foods; access to the Internet; and the number of fast-food and full-service restaurants/10,000 people. Those data were drawn from the U.S. Bureau of Labor Statistics, the American Chamber of Commerce Research Association, and the Census of Retail Trade.

The analysis showed that no single variable was the cause of obesity, said Dr. Finkelstein. In fact, the study’s variables probably only explain about 5% of obesity he added. Other studies have suggested that as much as 70% of obesity is genetically determined.

The investigators noted several limitations to their predictive model, including the fact that it assumes the variables used will remain constant. In addition, the BRFSS relies on self-reported height and weight. The researchers attempted to counter that by adjusting for potential underreporting.

Getting at obesity’s causes now could help lower obesity rates later, the researchers said.

Childhood obesity may be a major risk factor for obesity later in life, noted Dr. Finkelstein and coauthor Dr. William Dietz. A child’s school environment has been shown to play a predominant role in pediatric obesity, added Dr. Finkelstein.

"Keeping obesity rates level could yield a savings of nearly $550 billion in medical expenditures over the next 2 decades," Dr. Finkelstein said in a statement.

Bending the obesity curve slightly downward would deliver more benefits.

"Even a 1% decrease from the predicted trend would lead to 2.6 million fewer obese adults in 2020 and 2.9 million fewer obese adults in 2030," the study’s authors explained.

The study’s authors reported no conflicts of interest.

When it comes to Americans’ widening waistlines, the next 2 decades may serve up a side order of good news – and a heaping helping of bad news.

The good news: The rate of increase in the number of obese Americans may level off by 2030, leading to a lower prevalence of obesity than previously estimated.

© okeyphotos/iStockphoto.com

The bad news: The number of obese Americans will still climb by a third in that period, while the nation’s tally of superobese – those who are more than 80 pounds overweight – will more than double.

The result: The cost to the nation from obesity-related morbidity and mortality will be massive, according to Eric Finkelstein, Ph.D., lead author of a study published online May 7 in the American Journal of Preventive Medicine.

By 2030, the United States will see a 33% increase in the prevalence of obesity and a 130% increase in the prevalence of severe obesity, predicted Dr. Finkelstein of the Duke Global Health Institute, Durham, N.C., and deputy director of the Health Services Research Program at Duke-NUS Graduate Medical School in Singapore, and his associates.

Previous studies had suggested that 51% of the U.S. population would be considered obese by that decade. But the model created by Dr. Finkelstein and his colleagues at Duke and the Centers for Disease Control and Prevention puts the U.S. obesity rate at 42% by 2030.

A total of 11% of the nation will be considered severely obese, compared with 5% now, Dr. Finkelstein predicted at a press briefing.

Those numbers aren’t carved in stone, however.

Dr. Finkelstein called his paper’s numbers "reasonable estimates as to what the future will hold," but he added that "predicting obesity is tricky."

To create their predictive model, the researchers used data from the Behavioral Risk Factor Surveillance System (BRFSS) covering the years 1990-2008.

They added variables that might affect the rate of obesity, including unemployment rates; prices for alcohol, gas, and fast food; prices of groceries relative to non–grocery items; prices of healthier foods relative to less-healthy foods; access to the Internet; and the number of fast-food and full-service restaurants/10,000 people. Those data were drawn from the U.S. Bureau of Labor Statistics, the American Chamber of Commerce Research Association, and the Census of Retail Trade.

The analysis showed that no single variable was the cause of obesity, said Dr. Finkelstein. In fact, the study’s variables probably only explain about 5% of obesity he added. Other studies have suggested that as much as 70% of obesity is genetically determined.

The investigators noted several limitations to their predictive model, including the fact that it assumes the variables used will remain constant. In addition, the BRFSS relies on self-reported height and weight. The researchers attempted to counter that by adjusting for potential underreporting.

Getting at obesity’s causes now could help lower obesity rates later, the researchers said.

Childhood obesity may be a major risk factor for obesity later in life, noted Dr. Finkelstein and coauthor Dr. William Dietz. A child’s school environment has been shown to play a predominant role in pediatric obesity, added Dr. Finkelstein.

"Keeping obesity rates level could yield a savings of nearly $550 billion in medical expenditures over the next 2 decades," Dr. Finkelstein said in a statement.

Bending the obesity curve slightly downward would deliver more benefits.

"Even a 1% decrease from the predicted trend would lead to 2.6 million fewer obese adults in 2020 and 2.9 million fewer obese adults in 2030," the study’s authors explained.

The study’s authors reported no conflicts of interest.

NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.

In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.

The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.

Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.

Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.

The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.

The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.

Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.

During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.

The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.

In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.

Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.

The new intensive obesity therapy coverage is a "terrific benefit," said Dr. Newman. If a patient has a body mass index of more than 30, the physician can see the patient weekly for the first month, then biweekly for months 2-6, and monthly after that, out to a year. "This is a real advance," she said.

Finally, there is the health risk assessment, which is used to collect self-reported information about the beneficiary. The process takes no more than 20 minutes. It overlaps with some of the assessments conducted during the wellness visit, but is still required.

Dr. Newman said she uses an assessment tool that was developed by the ACP. Patients receive the tool at the front desk when they come in for a visit.

The important thing to understand about this assessment is "you don’t have to fix the problems today," said Dr. Newman. You can bring patients] back to work on components or hand off the patients to a nurse or a social worker, she said.

Also, the assessment does not have to be done completely and perfectly in 2012. The CMS has said it will allow for some variation in content for the time being and physicians will still be reimbursed for conducting the assessment.

NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.

In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.

The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.

Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.

Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.

The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.

The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.

Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.

During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.

The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.

In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.

Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.

The new intensive obesity therapy coverage is a "terrific benefit," said Dr. Newman. If a patient has a body mass index of more than 30, the physician can see the patient weekly for the first month, then biweekly for months 2-6, and monthly after that, out to a year. "This is a real advance," she said.

Finally, there is the health risk assessment, which is used to collect self-reported information about the beneficiary. The process takes no more than 20 minutes. It overlaps with some of the assessments conducted during the wellness visit, but is still required.

Dr. Newman said she uses an assessment tool that was developed by the ACP. Patients receive the tool at the front desk when they come in for a visit.

The important thing to understand about this assessment is "you don’t have to fix the problems today," said Dr. Newman. You can bring patients] back to work on components or hand off the patients to a nurse or a social worker, she said.

Also, the assessment does not have to be done completely and perfectly in 2012. The CMS has said it will allow for some variation in content for the time being and physicians will still be reimbursed for conducting the assessment.

NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.

In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.

The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.

Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.

Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.

The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.

The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.

Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.

During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.

The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.

In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.

Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.

The new intensive obesity therapy coverage is a "terrific benefit," said Dr. Newman. If a patient has a body mass index of more than 30, the physician can see the patient weekly for the first month, then biweekly for months 2-6, and monthly after that, out to a year. "This is a real advance," she said.

Finally, there is the health risk assessment, which is used to collect self-reported information about the beneficiary. The process takes no more than 20 minutes. It overlaps with some of the assessments conducted during the wellness visit, but is still required.

Dr. Newman said she uses an assessment tool that was developed by the ACP. Patients receive the tool at the front desk when they come in for a visit.

The important thing to understand about this assessment is "you don’t have to fix the problems today," said Dr. Newman. You can bring patients] back to work on components or hand off the patients to a nurse or a social worker, she said.

Also, the assessment does not have to be done completely and perfectly in 2012. The CMS has said it will allow for some variation in content for the time being and physicians will still be reimbursed for conducting the assessment.

NEW ORLEANS – The American College of Physicians has issued a policy paper containing at least a dozen recommendations to help reform the Medicare program, including support for having wealthier beneficiaries pay higher premiums and for giving the federal government the ability to negotiate drug prices.

The time to act is now, as the Medicare Trust Fund is due to run out of money in 2024, said ACP President Dr. Virginia Hood at the organization’s annual meeting. But the ACP will not advocate for any reform that would threaten beneficiaries’ access to, or quality of, care, she said.

Alicia Ault/IMNG Medical Media

"Difficult choices must be made to ensure the program’s solvency, but not at the expense of patients’ health," said Dr. Hood at a press briefing.

Robert Doherty, the ACP’s senior vice president of governmental affairs and public policy, said that Medicare had become a political football. "Republicans and Democrats alike are engaging in a war of words about Medicare, trying to scare voters into believing that the other party will destroy the program," he said at the briefing.

But neither party is facing up to the facts, said Mr. Doherty. Given rising health costs, an aging population, and increased cost-shifting to beneficiaries, the program "can’t continue as it is," he said. "Change is coming, change is necessary," Mr. Doherty said.

He and Dr. Hood said that the ACP’s recommendations for reform could help find cost savings, improve value, and protect access to care.

The ACP recommended finding ways to accelerate adoption of the patient-centered medical home concept. But it expressed concern about proposals to transform Medicare from a defined benefit to a defined contribution program. Also known as "premium support," this concept has been advanced by Rep. Paul Ryan (R-Wisc.) and has the backing of many of his GOP colleagues in the House of Representatives.

But, said Dr. Hood, "too little is known today about the impact of a Medicare premium support program on patient access to care." She added, "It’s concerning that with such little information that risky decisions would be made to transition away from the current guaranteed benefit structure."

Instead, the ACP proposes testing such a system. The College also said that the Medicare eligibility age should not be raised unless affordable, comprehensive insurance is made available to those who would now have to wait.

"Advancing the Medicare eligibility age could result in tens of millions of seniors having no access to affordable coverage from age 65 to 67, adding to the ranks of the uninsured," Mr. Doherty said.

The organization recommended that Congress instead give Medicare the authority to redesign benefits, coverage, and cost-sharing so that high-value services are rewarded and lower-value services – which might be not only inappropriate but also harmful – be given less coverage or lower reimbursement.

The ACP waded into somewhat controversial waters by urging Medicare to cover advance planning for patients with terminal illnesses. Payment for the voluntary discussions was included in the Affordable Care Act, but after Republicans said that such counseling might lead to rationing of care – or "death panels" – the Obama administration retracted a rule defining the benefit.

"Voluntary advance care planning should be covered and reimbursed by Medicare to encourage patient-physician engagement and ensure that patients are informed of their palliative and hospice care options," Mr. Doherty said.

Finally, the ACP urged an overhaul of the authority of the Independent Payment Advisory Board. Congress should have the right to approve or disapprove of the IPAB’s recommendations "by a simple majority," according to the policy paper.

Overall, "I do believe that the politicians have to show some leadership," said Mr. Doherty. Both parties need to talk responsibly "about the challenges to sustaining Medicare," and not just talk of "ending Medicare as we know it," he added. Because, he said, "Medicare as we know it is not sustainable. It’s going to have to change."

NEW ORLEANS – The American College of Physicians has issued a policy paper containing at least a dozen recommendations to help reform the Medicare program, including support for having wealthier beneficiaries pay higher premiums and for giving the federal government the ability to negotiate drug prices.

The time to act is now, as the Medicare Trust Fund is due to run out of money in 2024, said ACP President Dr. Virginia Hood at the organization’s annual meeting. But the ACP will not advocate for any reform that would threaten beneficiaries’ access to, or quality of, care, she said.

Alicia Ault/IMNG Medical Media

"Difficult choices must be made to ensure the program’s solvency, but not at the expense of patients’ health," said Dr. Hood at a press briefing.

Robert Doherty, the ACP’s senior vice president of governmental affairs and public policy, said that Medicare had become a political football. "Republicans and Democrats alike are engaging in a war of words about Medicare, trying to scare voters into believing that the other party will destroy the program," he said at the briefing.

But neither party is facing up to the facts, said Mr. Doherty. Given rising health costs, an aging population, and increased cost-shifting to beneficiaries, the program "can’t continue as it is," he said. "Change is coming, change is necessary," Mr. Doherty said.

He and Dr. Hood said that the ACP’s recommendations for reform could help find cost savings, improve value, and protect access to care.

The ACP recommended finding ways to accelerate adoption of the patient-centered medical home concept. But it expressed concern about proposals to transform Medicare from a defined benefit to a defined contribution program. Also known as "premium support," this concept has been advanced by Rep. Paul Ryan (R-Wisc.) and has the backing of many of his GOP colleagues in the House of Representatives.

But, said Dr. Hood, "too little is known today about the impact of a Medicare premium support program on patient access to care." She added, "It’s concerning that with such little information that risky decisions would be made to transition away from the current guaranteed benefit structure."

Instead, the ACP proposes testing such a system. The College also said that the Medicare eligibility age should not be raised unless affordable, comprehensive insurance is made available to those who would now have to wait.

"Advancing the Medicare eligibility age could result in tens of millions of seniors having no access to affordable coverage from age 65 to 67, adding to the ranks of the uninsured," Mr. Doherty said.

The organization recommended that Congress instead give Medicare the authority to redesign benefits, coverage, and cost-sharing so that high-value services are rewarded and lower-value services – which might be not only inappropriate but also harmful – be given less coverage or lower reimbursement.

The ACP waded into somewhat controversial waters by urging Medicare to cover advance planning for patients with terminal illnesses. Payment for the voluntary discussions was included in the Affordable Care Act, but after Republicans said that such counseling might lead to rationing of care – or "death panels" – the Obama administration retracted a rule defining the benefit.

"Voluntary advance care planning should be covered and reimbursed by Medicare to encourage patient-physician engagement and ensure that patients are informed of their palliative and hospice care options," Mr. Doherty said.

Finally, the ACP urged an overhaul of the authority of the Independent Payment Advisory Board. Congress should have the right to approve or disapprove of the IPAB’s recommendations "by a simple majority," according to the policy paper.

Overall, "I do believe that the politicians have to show some leadership," said Mr. Doherty. Both parties need to talk responsibly "about the challenges to sustaining Medicare," and not just talk of "ending Medicare as we know it," he added. Because, he said, "Medicare as we know it is not sustainable. It’s going to have to change."

NEW ORLEANS – The American College of Physicians has issued a policy paper containing at least a dozen recommendations to help reform the Medicare program, including support for having wealthier beneficiaries pay higher premiums and for giving the federal government the ability to negotiate drug prices.

The time to act is now, as the Medicare Trust Fund is due to run out of money in 2024, said ACP President Dr. Virginia Hood at the organization’s annual meeting. But the ACP will not advocate for any reform that would threaten beneficiaries’ access to, or quality of, care, she said.

Alicia Ault/IMNG Medical Media

"Difficult choices must be made to ensure the program’s solvency, but not at the expense of patients’ health," said Dr. Hood at a press briefing.

Robert Doherty, the ACP’s senior vice president of governmental affairs and public policy, said that Medicare had become a political football. "Republicans and Democrats alike are engaging in a war of words about Medicare, trying to scare voters into believing that the other party will destroy the program," he said at the briefing.

But neither party is facing up to the facts, said Mr. Doherty. Given rising health costs, an aging population, and increased cost-shifting to beneficiaries, the program "can’t continue as it is," he said. "Change is coming, change is necessary," Mr. Doherty said.

He and Dr. Hood said that the ACP’s recommendations for reform could help find cost savings, improve value, and protect access to care.

The ACP recommended finding ways to accelerate adoption of the patient-centered medical home concept. But it expressed concern about proposals to transform Medicare from a defined benefit to a defined contribution program. Also known as "premium support," this concept has been advanced by Rep. Paul Ryan (R-Wisc.) and has the backing of many of his GOP colleagues in the House of Representatives.

But, said Dr. Hood, "too little is known today about the impact of a Medicare premium support program on patient access to care." She added, "It’s concerning that with such little information that risky decisions would be made to transition away from the current guaranteed benefit structure."

Instead, the ACP proposes testing such a system. The College also said that the Medicare eligibility age should not be raised unless affordable, comprehensive insurance is made available to those who would now have to wait.

"Advancing the Medicare eligibility age could result in tens of millions of seniors having no access to affordable coverage from age 65 to 67, adding to the ranks of the uninsured," Mr. Doherty said.

The organization recommended that Congress instead give Medicare the authority to redesign benefits, coverage, and cost-sharing so that high-value services are rewarded and lower-value services – which might be not only inappropriate but also harmful – be given less coverage or lower reimbursement.

The ACP waded into somewhat controversial waters by urging Medicare to cover advance planning for patients with terminal illnesses. Payment for the voluntary discussions was included in the Affordable Care Act, but after Republicans said that such counseling might lead to rationing of care – or "death panels" – the Obama administration retracted a rule defining the benefit.

"Voluntary advance care planning should be covered and reimbursed by Medicare to encourage patient-physician engagement and ensure that patients are informed of their palliative and hospice care options," Mr. Doherty said.

Finally, the ACP urged an overhaul of the authority of the Independent Payment Advisory Board. Congress should have the right to approve or disapprove of the IPAB’s recommendations "by a simple majority," according to the policy paper.

Overall, "I do believe that the politicians have to show some leadership," said Mr. Doherty. Both parties need to talk responsibly "about the challenges to sustaining Medicare," and not just talk of "ending Medicare as we know it," he added. Because, he said, "Medicare as we know it is not sustainable. It’s going to have to change."