Alicia Ault

In a poll of senior citizens released April 23, a majority reported that their physicians were not offering recommended evidence-based services such as asking about recent falls or seeking to verify medications being taken.

The poll of 1,028 Americans aged 65 years and older, conducted by Lake Research Partners for the John A. Hartford Foundation, took place in late February and early March and has a margin of error of plus or minus 3.1 percentage points. Among other questions, the respondents were asked if their physicians had offered seven basic services that are typical of good geriatric care, Chris Langston, Ph.D., a program director at the foundation, said in a press briefing.

"Older people are not getting the care they really need that would help them live longer, more independently, and with a higher quality of life," Dr. Chris Langston said.

The vast majority of those surveyed – 93% – said that they saw their primary care physician regularly. Among the respondents, 82% had one to nine physician visits annually, with half reporting three to nine visits per year. Ninety-six percent said they were completely or somewhat satisfied with their care.

And yet, only 7% of respondents said they’d received all seven services generally considered to be good care. Just over half had received none or only one.

In addition to assessing the risk for falling and reviewing medications, seniors were asked whether their physicians told them how to avoid falling, screened them for depression, provided referrals to community-based health resources, discussed their ability to perform routine daily activities such as shopping, and determined whether they needed help with personal tasks such as showering.

The results of the poll are "extremely interesting and confirmatory of other work looking at doctors’ actual practice," said Dr. Rosanne Leipzig, a professor of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York.

Of particular concern, she said, was the finding that a third of those surveyed said that a physician had not sat down with them to review all their medications and supplements. A huge number of adverse events result from medication errors and misadventures, especially among older patients. These "data are very compelling in identifying a problem that is real," she said in the briefing.

About a third of patients said their physicians had asked them in the last year whether they’d had a fall, or if they were having any depression or other mood issue. A fifth or less said they had been asked if they had problems with activities of daily living, or that their physicians had referred them to nonmedical help in the community. Only 19% said their doctors had discussed fall prevention with them in the past year.

"Older people are not getting the care they really need that would help them live longer, more independently, and with a higher quality of life," Dr. Langston said.

When the data were broken out by various age cohorts, the results were not much different, even for older, and, theoretically, more frail people over age 80, said Tresa Undem of Lake Research Partners, a research firm. For instance, 75% of those over 80 said fall prevention had not been discussed in the last year.

Many seniors were not aware that they were eligible for an annual Medicare wellness visit, in which the physician discusses various aspects of care and offers many of the seven services. It is entirely free for the beneficiary and pays four to five times the regular Medicare physician office rate. Fifty-four percent of seniors said they had not heard of it and 72% said they had not received such a visit in the previous year.

Seniors might be confused about the benefit, however, as Medicare shows higher uptake rates than reflected in the poll, said Ms. Undem.

The poll also asked the seniors if they thought they would receive better care if physicians and nurses had more training in geriatrics. Two-thirds said yes. Most also supported a requirement for geriatrics training in nursing and medical school.

Dr. Leipzig noted that it’s difficult to convince physicians to go into geriatrics. Only about 300 physicians train in the field each year. She said that other physicians should receive specialty instruction in geriatrics to help alleviate the shortage.

But given the time intensity of caring for older Americans – and the low level of reimbursement – it will be an uphill battle, she said. The typical $45 office visit fee "doesn’t even come close to allowing someone to make a living," she said.

The Hartford Foundation is a private, nonprofit philanthropy focused on health care needs of older Americans.

In a poll of senior citizens released April 23, a majority reported that their physicians were not offering recommended evidence-based services such as asking about recent falls or seeking to verify medications being taken.

The poll of 1,028 Americans aged 65 years and older, conducted by Lake Research Partners for the John A. Hartford Foundation, took place in late February and early March and has a margin of error of plus or minus 3.1 percentage points. Among other questions, the respondents were asked if their physicians had offered seven basic services that are typical of good geriatric care, Chris Langston, Ph.D., a program director at the foundation, said in a press briefing.

"Older people are not getting the care they really need that would help them live longer, more independently, and with a higher quality of life," Dr. Chris Langston said.

The vast majority of those surveyed – 93% – said that they saw their primary care physician regularly. Among the respondents, 82% had one to nine physician visits annually, with half reporting three to nine visits per year. Ninety-six percent said they were completely or somewhat satisfied with their care.

And yet, only 7% of respondents said they’d received all seven services generally considered to be good care. Just over half had received none or only one.

In addition to assessing the risk for falling and reviewing medications, seniors were asked whether their physicians told them how to avoid falling, screened them for depression, provided referrals to community-based health resources, discussed their ability to perform routine daily activities such as shopping, and determined whether they needed help with personal tasks such as showering.

The results of the poll are "extremely interesting and confirmatory of other work looking at doctors’ actual practice," said Dr. Rosanne Leipzig, a professor of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York.

Of particular concern, she said, was the finding that a third of those surveyed said that a physician had not sat down with them to review all their medications and supplements. A huge number of adverse events result from medication errors and misadventures, especially among older patients. These "data are very compelling in identifying a problem that is real," she said in the briefing.

About a third of patients said their physicians had asked them in the last year whether they’d had a fall, or if they were having any depression or other mood issue. A fifth or less said they had been asked if they had problems with activities of daily living, or that their physicians had referred them to nonmedical help in the community. Only 19% said their doctors had discussed fall prevention with them in the past year.

"Older people are not getting the care they really need that would help them live longer, more independently, and with a higher quality of life," Dr. Langston said.

When the data were broken out by various age cohorts, the results were not much different, even for older, and, theoretically, more frail people over age 80, said Tresa Undem of Lake Research Partners, a research firm. For instance, 75% of those over 80 said fall prevention had not been discussed in the last year.

Many seniors were not aware that they were eligible for an annual Medicare wellness visit, in which the physician discusses various aspects of care and offers many of the seven services. It is entirely free for the beneficiary and pays four to five times the regular Medicare physician office rate. Fifty-four percent of seniors said they had not heard of it and 72% said they had not received such a visit in the previous year.

Seniors might be confused about the benefit, however, as Medicare shows higher uptake rates than reflected in the poll, said Ms. Undem.

The poll also asked the seniors if they thought they would receive better care if physicians and nurses had more training in geriatrics. Two-thirds said yes. Most also supported a requirement for geriatrics training in nursing and medical school.

Dr. Leipzig noted that it’s difficult to convince physicians to go into geriatrics. Only about 300 physicians train in the field each year. She said that other physicians should receive specialty instruction in geriatrics to help alleviate the shortage.

But given the time intensity of caring for older Americans – and the low level of reimbursement – it will be an uphill battle, she said. The typical $45 office visit fee "doesn’t even come close to allowing someone to make a living," she said.

The Hartford Foundation is a private, nonprofit philanthropy focused on health care needs of older Americans.

In a poll of senior citizens released April 23, a majority reported that their physicians were not offering recommended evidence-based services such as asking about recent falls or seeking to verify medications being taken.

The poll of 1,028 Americans aged 65 years and older, conducted by Lake Research Partners for the John A. Hartford Foundation, took place in late February and early March and has a margin of error of plus or minus 3.1 percentage points. Among other questions, the respondents were asked if their physicians had offered seven basic services that are typical of good geriatric care, Chris Langston, Ph.D., a program director at the foundation, said in a press briefing.

"Older people are not getting the care they really need that would help them live longer, more independently, and with a higher quality of life," Dr. Chris Langston said.

The vast majority of those surveyed – 93% – said that they saw their primary care physician regularly. Among the respondents, 82% had one to nine physician visits annually, with half reporting three to nine visits per year. Ninety-six percent said they were completely or somewhat satisfied with their care.

And yet, only 7% of respondents said they’d received all seven services generally considered to be good care. Just over half had received none or only one.

In addition to assessing the risk for falling and reviewing medications, seniors were asked whether their physicians told them how to avoid falling, screened them for depression, provided referrals to community-based health resources, discussed their ability to perform routine daily activities such as shopping, and determined whether they needed help with personal tasks such as showering.

The results of the poll are "extremely interesting and confirmatory of other work looking at doctors’ actual practice," said Dr. Rosanne Leipzig, a professor of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York.

Of particular concern, she said, was the finding that a third of those surveyed said that a physician had not sat down with them to review all their medications and supplements. A huge number of adverse events result from medication errors and misadventures, especially among older patients. These "data are very compelling in identifying a problem that is real," she said in the briefing.

About a third of patients said their physicians had asked them in the last year whether they’d had a fall, or if they were having any depression or other mood issue. A fifth or less said they had been asked if they had problems with activities of daily living, or that their physicians had referred them to nonmedical help in the community. Only 19% said their doctors had discussed fall prevention with them in the past year.

"Older people are not getting the care they really need that would help them live longer, more independently, and with a higher quality of life," Dr. Langston said.

When the data were broken out by various age cohorts, the results were not much different, even for older, and, theoretically, more frail people over age 80, said Tresa Undem of Lake Research Partners, a research firm. For instance, 75% of those over 80 said fall prevention had not been discussed in the last year.

Many seniors were not aware that they were eligible for an annual Medicare wellness visit, in which the physician discusses various aspects of care and offers many of the seven services. It is entirely free for the beneficiary and pays four to five times the regular Medicare physician office rate. Fifty-four percent of seniors said they had not heard of it and 72% said they had not received such a visit in the previous year.

Seniors might be confused about the benefit, however, as Medicare shows higher uptake rates than reflected in the poll, said Ms. Undem.

The poll also asked the seniors if they thought they would receive better care if physicians and nurses had more training in geriatrics. Two-thirds said yes. Most also supported a requirement for geriatrics training in nursing and medical school.

Dr. Leipzig noted that it’s difficult to convince physicians to go into geriatrics. Only about 300 physicians train in the field each year. She said that other physicians should receive specialty instruction in geriatrics to help alleviate the shortage.

But given the time intensity of caring for older Americans – and the low level of reimbursement – it will be an uphill battle, she said. The typical $45 office visit fee "doesn’t even come close to allowing someone to make a living," she said.

The Hartford Foundation is a private, nonprofit philanthropy focused on health care needs of older Americans.

NEW ORLEANS – The American College of Physicians has joined with Consumer Reports to create a series of guidelines designed to help consumers understand the risks and benefits – and costs – of diagnostic tests and therapies.

The collaboration is an extension of the ACP’s High Value, Cost-Conscious Care Initiative, Dr. Steven Weinberger, executive vice president and CEO of the ACP, said at a press briefing announcing the collaboration.

"Patients are clearly one of the audiences for our High Value, Cost-Conscious Care campaign and it is therefore important to have the appropriate vehicle to get information to them, and Consumer Reports is an absolutely wonderful opportunity for us," said Dr. Weinberger.

According to Consumer Reports vice president and editorial director Kevin McKean, the publication is one of the ten biggest magazines in America, with 4 million paying customers every month, and is the largest paid-content website in the world with 3.5 million online subscribers.

Everything Consumer Reports disseminates to the public will be based on the ACP’s evidence-based clinical practice guidelines. Those guidelines go through rigorous and multiple layers of review, and are published in the Annals of Internal Medicine.

The first two reports for the public will be "Imaging tests for lower-back pain," and "Choosing a type 2 diabetes drug." The back pain report is based on the ACP guidelines published April 17, 2012, in the Annals of Internal Medicine (2011;154:181-9).

As noted in the ACP guidelines, the two-page paper that is scheduled to appear in Consumer Reports recommends against immediately seeking imaging procedures for most acute-onset back pain. The report outlines some cases in which imaging might be warranted, and suggests approaches for treating back pain in the first few weeks after onset.

The two-page diabetes report for consumers makes the argument that metformin is often the best and most cost-effective drug. It also makes suggestions for managing diabetes through lifestyle changes. That report is based on a clinical practice guideline published Feb. 7, 2012, in the Annals of Internal Medicine (2012;156:218-31).

Both articles include an explanatory box stating that the information provided is to be used in discussion with a health care provider, and that it is not a substitute for professional medical advice.

The partnership with the ACP is "absolutely crucial" to Consumer Reports’ mission to be more focused on health care, Mr. McKean said. The ACP is an impressive partner because of its experience, its focus on evidence-based medicine, and "its willingness to confront the cost issue."

Dr. John Santa, director of the Consumer Reports Health Ratings Center, acknowledged that recommendations to use fewer services may not be immediately embraced by the public. "Consumer perceptions are very strong that more health care is better, [and] that more-expensive health care is better," he said at the briefing.

The guidelines will be easy to understand, and will be produced in Spanish and in low literacy versions, said Dr. Santa. Supporting videos will be posted on the Consumer Reports website. Additionally, all of the information will be available in PDF format, even to nonsubscribers of Consumer Reports. Some of the information may also appear as articles in the print magazine

Consumer Reports also is partnering with a network of organizations, including the AARP, the National Business Group on Health, and the Service Employees International Union, according to Dr. Santa. "Each of those [organizations] has committed over the next 2 or 3 years to distribute to their audience topics they feel are of interest," reaching perhaps another 1 million consumers.

Dr. Weinberger said it was premature to discuss what topics might be covered in future collaborations, or when those consumer guidelines would appear. But ACP’s clinical guidelines committee will select the topics, which could include imaging for headache and the appropriateness of cancer screening.

Dr. Santa said that Consumer Reports was already working on a version of the ACP’s colorectal screening guidelines published March 6, 2012, as a guidance statement (Ann. Intern. Med. 2012;156:378-86).

NEW ORLEANS – The American College of Physicians has joined with Consumer Reports to create a series of guidelines designed to help consumers understand the risks and benefits – and costs – of diagnostic tests and therapies.

The collaboration is an extension of the ACP’s High Value, Cost-Conscious Care Initiative, Dr. Steven Weinberger, executive vice president and CEO of the ACP, said at a press briefing announcing the collaboration.

"Patients are clearly one of the audiences for our High Value, Cost-Conscious Care campaign and it is therefore important to have the appropriate vehicle to get information to them, and Consumer Reports is an absolutely wonderful opportunity for us," said Dr. Weinberger.

According to Consumer Reports vice president and editorial director Kevin McKean, the publication is one of the ten biggest magazines in America, with 4 million paying customers every month, and is the largest paid-content website in the world with 3.5 million online subscribers.

Everything Consumer Reports disseminates to the public will be based on the ACP’s evidence-based clinical practice guidelines. Those guidelines go through rigorous and multiple layers of review, and are published in the Annals of Internal Medicine.

The first two reports for the public will be "Imaging tests for lower-back pain," and "Choosing a type 2 diabetes drug." The back pain report is based on the ACP guidelines published April 17, 2012, in the Annals of Internal Medicine (2011;154:181-9).

As noted in the ACP guidelines, the two-page paper that is scheduled to appear in Consumer Reports recommends against immediately seeking imaging procedures for most acute-onset back pain. The report outlines some cases in which imaging might be warranted, and suggests approaches for treating back pain in the first few weeks after onset.

The two-page diabetes report for consumers makes the argument that metformin is often the best and most cost-effective drug. It also makes suggestions for managing diabetes through lifestyle changes. That report is based on a clinical practice guideline published Feb. 7, 2012, in the Annals of Internal Medicine (2012;156:218-31).

Both articles include an explanatory box stating that the information provided is to be used in discussion with a health care provider, and that it is not a substitute for professional medical advice.

The partnership with the ACP is "absolutely crucial" to Consumer Reports’ mission to be more focused on health care, Mr. McKean said. The ACP is an impressive partner because of its experience, its focus on evidence-based medicine, and "its willingness to confront the cost issue."

Dr. John Santa, director of the Consumer Reports Health Ratings Center, acknowledged that recommendations to use fewer services may not be immediately embraced by the public. "Consumer perceptions are very strong that more health care is better, [and] that more-expensive health care is better," he said at the briefing.

The guidelines will be easy to understand, and will be produced in Spanish and in low literacy versions, said Dr. Santa. Supporting videos will be posted on the Consumer Reports website. Additionally, all of the information will be available in PDF format, even to nonsubscribers of Consumer Reports. Some of the information may also appear as articles in the print magazine

Consumer Reports also is partnering with a network of organizations, including the AARP, the National Business Group on Health, and the Service Employees International Union, according to Dr. Santa. "Each of those [organizations] has committed over the next 2 or 3 years to distribute to their audience topics they feel are of interest," reaching perhaps another 1 million consumers.

Dr. Weinberger said it was premature to discuss what topics might be covered in future collaborations, or when those consumer guidelines would appear. But ACP’s clinical guidelines committee will select the topics, which could include imaging for headache and the appropriateness of cancer screening.

Dr. Santa said that Consumer Reports was already working on a version of the ACP’s colorectal screening guidelines published March 6, 2012, as a guidance statement (Ann. Intern. Med. 2012;156:378-86).

NEW ORLEANS – The American College of Physicians has joined with Consumer Reports to create a series of guidelines designed to help consumers understand the risks and benefits – and costs – of diagnostic tests and therapies.

The collaboration is an extension of the ACP’s High Value, Cost-Conscious Care Initiative, Dr. Steven Weinberger, executive vice president and CEO of the ACP, said at a press briefing announcing the collaboration.

"Patients are clearly one of the audiences for our High Value, Cost-Conscious Care campaign and it is therefore important to have the appropriate vehicle to get information to them, and Consumer Reports is an absolutely wonderful opportunity for us," said Dr. Weinberger.

According to Consumer Reports vice president and editorial director Kevin McKean, the publication is one of the ten biggest magazines in America, with 4 million paying customers every month, and is the largest paid-content website in the world with 3.5 million online subscribers.

Everything Consumer Reports disseminates to the public will be based on the ACP’s evidence-based clinical practice guidelines. Those guidelines go through rigorous and multiple layers of review, and are published in the Annals of Internal Medicine.

The first two reports for the public will be "Imaging tests for lower-back pain," and "Choosing a type 2 diabetes drug." The back pain report is based on the ACP guidelines published April 17, 2012, in the Annals of Internal Medicine (2011;154:181-9).

As noted in the ACP guidelines, the two-page paper that is scheduled to appear in Consumer Reports recommends against immediately seeking imaging procedures for most acute-onset back pain. The report outlines some cases in which imaging might be warranted, and suggests approaches for treating back pain in the first few weeks after onset.

The two-page diabetes report for consumers makes the argument that metformin is often the best and most cost-effective drug. It also makes suggestions for managing diabetes through lifestyle changes. That report is based on a clinical practice guideline published Feb. 7, 2012, in the Annals of Internal Medicine (2012;156:218-31).

Both articles include an explanatory box stating that the information provided is to be used in discussion with a health care provider, and that it is not a substitute for professional medical advice.

The partnership with the ACP is "absolutely crucial" to Consumer Reports’ mission to be more focused on health care, Mr. McKean said. The ACP is an impressive partner because of its experience, its focus on evidence-based medicine, and "its willingness to confront the cost issue."

Dr. John Santa, director of the Consumer Reports Health Ratings Center, acknowledged that recommendations to use fewer services may not be immediately embraced by the public. "Consumer perceptions are very strong that more health care is better, [and] that more-expensive health care is better," he said at the briefing.

The guidelines will be easy to understand, and will be produced in Spanish and in low literacy versions, said Dr. Santa. Supporting videos will be posted on the Consumer Reports website. Additionally, all of the information will be available in PDF format, even to nonsubscribers of Consumer Reports. Some of the information may also appear as articles in the print magazine

Consumer Reports also is partnering with a network of organizations, including the AARP, the National Business Group on Health, and the Service Employees International Union, according to Dr. Santa. "Each of those [organizations] has committed over the next 2 or 3 years to distribute to their audience topics they feel are of interest," reaching perhaps another 1 million consumers.

Dr. Weinberger said it was premature to discuss what topics might be covered in future collaborations, or when those consumer guidelines would appear. But ACP’s clinical guidelines committee will select the topics, which could include imaging for headache and the appropriateness of cancer screening.

Dr. Santa said that Consumer Reports was already working on a version of the ACP’s colorectal screening guidelines published March 6, 2012, as a guidance statement (Ann. Intern. Med. 2012;156:378-86).

The risk of cardiotoxicity is five times higher in breast cancer patients given trastuzumab than in those receiving a standard chemotherapy regimen alone, according to a new systematic review from the Cochrane Collaboration.

The review found that regimens containing trastuzumab (Herceptin) significantly increased congestive heart failure and left ventricular ejection fraction (LVEF) decline, with relative risks of 5.11 and 1.83, respectively, in women with HER2-positive early and locally advanced breast cancer (Cochrane Database Syst. Rev. 2012;4 [doi: 10.1002/14651858.CD006243.pub2]).

However, trastuzumab regimens also significantly increased overall and disease-free survival, with hazard ratios of 0.66 and 0.60, respectively, noted Dr. Lorenzo Moja of the University of Milan and his coauthors. All these results were highly significant, with P values ranging from less than .0008 for risk of LVEF decline to less than .00001 for the others.

In a plain-language summary comparing trastuzumab-containing regimens with standard therapy alone in 1,000 women, the investigators wrote that 33 more women would have their lives prolonged with trastuzumab (933 women vs. 900 women with standard therapy alone). However, about 26 in 1,000 women taking trastuzumab would have serious heart toxicity, which is 21 more than the group treated with standard therapy alone.

Trastuzumab’s cardiotoxic effects have been well known, but the magnitude of the effect reported in the systematic review may be larger than what people have thought, commented Dr. Daniel J. Lenihan, director of clinical research in the cardiovascular medicine division at Vanderbilt University, Nashville, Tenn., in an interview.

And that risk may be even greater in the world outside of clinical studies, said Dr. Melinda Telli of Stanford (Calif.) University. The patients in the studies included in the systematic review were younger, and none had baseline cardiac disease, observed Dr. Telli, also in an interview.

Another issue: In practice, oncologists are offering trastuzumab to women at lower risk for cancer recurrence than those in the trials. Thus, she said, "it’s more likely the risks are underestimated in this Cochrane review."

Although the data in the systematic review were previously published, having them encapsulated – along with a number of scenarios outlining potential risks and benefits in women with different cancer recurrence and cardiac risk factors – is a significant addition to the literature, said Dr. Telli.

Cochrane reviews are known for being thorough and balanced. This review began by looking at about 3,900 studies; after applying exclusion criteria, the list was winnowed down to 35 publications that covered 8 randomized controlled clinical trials enrolling 11,991 women. A little more than 7,000 women were assigned to a trastuzumab-containing arm, and 4,971 women to a regimen without trastuzumab. The median age in the trials was 49 years. Pre- and postmenopausal women were included, but those with metastatic disease or preexisting heart conditions were excluded.

The review concluded that high-risk women with few cardiac risk factors would benefit from trastuzumab, while those at lower risk "must be carefully evaluated," adding, "The oncologist should share the decision with the patient concerning whether and how to start the treatment."

Dr. Lenihan said he was concerned that the potential cardiotoxicity might cause oncologists to steer away from trastuzumab. He is a proponent of a multidisciplinary team that involves a cardiologist at the outset of therapy.

If cardiac effects develop, "the key is not to ignore it, but to pay attention," said Dr. Lenihan, who is also president of the International CardiOncology Society USA/Canada.

Early identification enables rapid treatment, which can stabilize or correct the heart issues, he said. That allows patients to return to their cancer therapy.

Dr. Lenihan and his colleagues at Vanderbilt University are currently conducting a study testing various cardiac biomarkers to detect toxicity during chemotherapy.

It is still unknown, however, whether the cardiotoxicity that develops during therapy is ultimately reversible, or becomes a lifelong issue. While the ejection fraction may recover after withdrawal of trastuzumab, at least one study – the Herceptin Adjuvant (HERA) trial – has shown that some women had long-term loss of heart muscle cells, said Dr. Telli.

"So we know that the heart is taking a hit," she said, adding that the trastuzumab damage is not "some sort of reversible thing."

The key, she said, is for oncologists to weigh the risks and benefits individually in each patient.

A targeted therapy, trastuzumab is approved for treatment of HER2-positive breast cancer and of metastatic HER2-positive adenocarcinoma of the stomach or gastroesophageal junction. About 20% of tumors in women with early breast cancer are HER2-positive.

Dr. Telli reported no conflicts of interest. Dr. Lenihan reported receiving consulting fees from Roche and AstraZeneca and research support from Acorda.

The risk of cardiotoxicity is five times higher in breast cancer patients given trastuzumab than in those receiving a standard chemotherapy regimen alone, according to a new systematic review from the Cochrane Collaboration.

The review found that regimens containing trastuzumab (Herceptin) significantly increased congestive heart failure and left ventricular ejection fraction (LVEF) decline, with relative risks of 5.11 and 1.83, respectively, in women with HER2-positive early and locally advanced breast cancer (Cochrane Database Syst. Rev. 2012;4 [doi: 10.1002/14651858.CD006243.pub2]).

However, trastuzumab regimens also significantly increased overall and disease-free survival, with hazard ratios of 0.66 and 0.60, respectively, noted Dr. Lorenzo Moja of the University of Milan and his coauthors. All these results were highly significant, with P values ranging from less than .0008 for risk of LVEF decline to less than .00001 for the others.

In a plain-language summary comparing trastuzumab-containing regimens with standard therapy alone in 1,000 women, the investigators wrote that 33 more women would have their lives prolonged with trastuzumab (933 women vs. 900 women with standard therapy alone). However, about 26 in 1,000 women taking trastuzumab would have serious heart toxicity, which is 21 more than the group treated with standard therapy alone.

Trastuzumab’s cardiotoxic effects have been well known, but the magnitude of the effect reported in the systematic review may be larger than what people have thought, commented Dr. Daniel J. Lenihan, director of clinical research in the cardiovascular medicine division at Vanderbilt University, Nashville, Tenn., in an interview.

And that risk may be even greater in the world outside of clinical studies, said Dr. Melinda Telli of Stanford (Calif.) University. The patients in the studies included in the systematic review were younger, and none had baseline cardiac disease, observed Dr. Telli, also in an interview.

Another issue: In practice, oncologists are offering trastuzumab to women at lower risk for cancer recurrence than those in the trials. Thus, she said, "it’s more likely the risks are underestimated in this Cochrane review."

Although the data in the systematic review were previously published, having them encapsulated – along with a number of scenarios outlining potential risks and benefits in women with different cancer recurrence and cardiac risk factors – is a significant addition to the literature, said Dr. Telli.

Cochrane reviews are known for being thorough and balanced. This review began by looking at about 3,900 studies; after applying exclusion criteria, the list was winnowed down to 35 publications that covered 8 randomized controlled clinical trials enrolling 11,991 women. A little more than 7,000 women were assigned to a trastuzumab-containing arm, and 4,971 women to a regimen without trastuzumab. The median age in the trials was 49 years. Pre- and postmenopausal women were included, but those with metastatic disease or preexisting heart conditions were excluded.

The review concluded that high-risk women with few cardiac risk factors would benefit from trastuzumab, while those at lower risk "must be carefully evaluated," adding, "The oncologist should share the decision with the patient concerning whether and how to start the treatment."

Dr. Lenihan said he was concerned that the potential cardiotoxicity might cause oncologists to steer away from trastuzumab. He is a proponent of a multidisciplinary team that involves a cardiologist at the outset of therapy.

If cardiac effects develop, "the key is not to ignore it, but to pay attention," said Dr. Lenihan, who is also president of the International CardiOncology Society USA/Canada.

Early identification enables rapid treatment, which can stabilize or correct the heart issues, he said. That allows patients to return to their cancer therapy.

Dr. Lenihan and his colleagues at Vanderbilt University are currently conducting a study testing various cardiac biomarkers to detect toxicity during chemotherapy.

It is still unknown, however, whether the cardiotoxicity that develops during therapy is ultimately reversible, or becomes a lifelong issue. While the ejection fraction may recover after withdrawal of trastuzumab, at least one study – the Herceptin Adjuvant (HERA) trial – has shown that some women had long-term loss of heart muscle cells, said Dr. Telli.

"So we know that the heart is taking a hit," she said, adding that the trastuzumab damage is not "some sort of reversible thing."

The key, she said, is for oncologists to weigh the risks and benefits individually in each patient.

A targeted therapy, trastuzumab is approved for treatment of HER2-positive breast cancer and of metastatic HER2-positive adenocarcinoma of the stomach or gastroesophageal junction. About 20% of tumors in women with early breast cancer are HER2-positive.

Dr. Telli reported no conflicts of interest. Dr. Lenihan reported receiving consulting fees from Roche and AstraZeneca and research support from Acorda.

The risk of cardiotoxicity is five times higher in breast cancer patients given trastuzumab than in those receiving a standard chemotherapy regimen alone, according to a new systematic review from the Cochrane Collaboration.

The review found that regimens containing trastuzumab (Herceptin) significantly increased congestive heart failure and left ventricular ejection fraction (LVEF) decline, with relative risks of 5.11 and 1.83, respectively, in women with HER2-positive early and locally advanced breast cancer (Cochrane Database Syst. Rev. 2012;4 [doi: 10.1002/14651858.CD006243.pub2]).

However, trastuzumab regimens also significantly increased overall and disease-free survival, with hazard ratios of 0.66 and 0.60, respectively, noted Dr. Lorenzo Moja of the University of Milan and his coauthors. All these results were highly significant, with P values ranging from less than .0008 for risk of LVEF decline to less than .00001 for the others.

In a plain-language summary comparing trastuzumab-containing regimens with standard therapy alone in 1,000 women, the investigators wrote that 33 more women would have their lives prolonged with trastuzumab (933 women vs. 900 women with standard therapy alone). However, about 26 in 1,000 women taking trastuzumab would have serious heart toxicity, which is 21 more than the group treated with standard therapy alone.

Trastuzumab’s cardiotoxic effects have been well known, but the magnitude of the effect reported in the systematic review may be larger than what people have thought, commented Dr. Daniel J. Lenihan, director of clinical research in the cardiovascular medicine division at Vanderbilt University, Nashville, Tenn., in an interview.

And that risk may be even greater in the world outside of clinical studies, said Dr. Melinda Telli of Stanford (Calif.) University. The patients in the studies included in the systematic review were younger, and none had baseline cardiac disease, observed Dr. Telli, also in an interview.

Another issue: In practice, oncologists are offering trastuzumab to women at lower risk for cancer recurrence than those in the trials. Thus, she said, "it’s more likely the risks are underestimated in this Cochrane review."

Although the data in the systematic review were previously published, having them encapsulated – along with a number of scenarios outlining potential risks and benefits in women with different cancer recurrence and cardiac risk factors – is a significant addition to the literature, said Dr. Telli.

Cochrane reviews are known for being thorough and balanced. This review began by looking at about 3,900 studies; after applying exclusion criteria, the list was winnowed down to 35 publications that covered 8 randomized controlled clinical trials enrolling 11,991 women. A little more than 7,000 women were assigned to a trastuzumab-containing arm, and 4,971 women to a regimen without trastuzumab. The median age in the trials was 49 years. Pre- and postmenopausal women were included, but those with metastatic disease or preexisting heart conditions were excluded.

The review concluded that high-risk women with few cardiac risk factors would benefit from trastuzumab, while those at lower risk "must be carefully evaluated," adding, "The oncologist should share the decision with the patient concerning whether and how to start the treatment."

Dr. Lenihan said he was concerned that the potential cardiotoxicity might cause oncologists to steer away from trastuzumab. He is a proponent of a multidisciplinary team that involves a cardiologist at the outset of therapy.

If cardiac effects develop, "the key is not to ignore it, but to pay attention," said Dr. Lenihan, who is also president of the International CardiOncology Society USA/Canada.

Early identification enables rapid treatment, which can stabilize or correct the heart issues, he said. That allows patients to return to their cancer therapy.

Dr. Lenihan and his colleagues at Vanderbilt University are currently conducting a study testing various cardiac biomarkers to detect toxicity during chemotherapy.

It is still unknown, however, whether the cardiotoxicity that develops during therapy is ultimately reversible, or becomes a lifelong issue. While the ejection fraction may recover after withdrawal of trastuzumab, at least one study – the Herceptin Adjuvant (HERA) trial – has shown that some women had long-term loss of heart muscle cells, said Dr. Telli.

"So we know that the heart is taking a hit," she said, adding that the trastuzumab damage is not "some sort of reversible thing."

The key, she said, is for oncologists to weigh the risks and benefits individually in each patient.

A targeted therapy, trastuzumab is approved for treatment of HER2-positive breast cancer and of metastatic HER2-positive adenocarcinoma of the stomach or gastroesophageal junction. About 20% of tumors in women with early breast cancer are HER2-positive.

Dr. Telli reported no conflicts of interest. Dr. Lenihan reported receiving consulting fees from Roche and AstraZeneca and research support from Acorda.

A new study finds that chemotherapy for privately insured patients is less expensive in a physician’s office than in an outpatient department at a hospital.

The same analysis, however, found that radiation therapy was more expensive in physician offices when it lasted 3 months or more. Radiation of 1 or 2 months’ duration was less costly when it was delivered in offices.

"Our study documents that chemotherapy treatment in an oncologist’s office costs less than in a hospital regardless of the length of treatment," said Eric Hammelman, a study author, in a statement. "At a time when the health care community is focused on managing costs, these findings show the importance of where care is delivered, and raise important questions about how best to manage cancer treatment," said Mr. Hammelman, who is also a vice president at Avalere Health.

The Community Oncology Alliance (COA), in partnership with the National Association of Managed Care Physicians (NAMCP) Medical Directors Institute, commissioned Avalere to do the study. Avalere analyzed data from three commercial managed care plans and a large self-funded employer. In total, the study analyzed 26,168 episodes of care for 22,204 patients.

Overall, chemotherapy that was delivered in an outpatient hospital setting cost 24% more, on average, than did chemotherapy given in a physician’s office. This was true regardless of the duration of therapy, according to the study, which controlled for age, sex, and prior history of cancer. The study did not control for other factors that might have influenced cost, such as mortality, morbidity, or type of chemotherapeutic used.

The total cost included the amount paid by the insurer and the patient’s copay or coinsurance. On an unadjusted basis, the average cost per episode for office-based therapy was $19,640, compared with $26,300 for hospital-based therapy, a difference of 34%. After applying the risk adjustment model, the difference was less, but the hospital-based therapy still cost 24% more ($35,000 compared with $28,200 for office-based care).

Older patients were more likely to be managed in an office, compared with younger patients. The majority of episodes analyzed (about 80%) were in physician offices. Overall, 11 cancers accounted for more than 90% of the episodes. In decreasing order, they were lung, prostate, genitourinary system, breast, Hodgkin’s/lymphoma, colon, digestive system, leukemia, ovarian, multiple myeloma, and rectal cancers.

Costs varied widely for those cancers, as did the differences between office and hospital treatment. The biggest gap was for genitourinary cancers; the adjusted per-episode cost was $19,592 in the hospital, compared with $8,960 in the office, a 118% difference.

Avalere offered some theories on why hospital costs were so much higher overall for chemotherapy. It found that 14 of every 100 hospital-based episodes had a hospitalization during the episode, compared with 11 of every 100 office-based episodes. There was also variation in hospital and physician office billing practices, said the authors.

For radiation therapy, about half of episodes were delivered in hospital outpatient settings. Older patients were more likely to receive office-based radiation. Again, 11 cancers accounted for the majority of treatment episodes. Breast, prostate, and lung cancers accounted for 57% of the episodes.

Overall, the unadjusted cost was $16,300 for office-based therapy, compared with $16,000 for hospital-based treatment. Treatment duration of less than 1 or 2 months was 7%-17% more expensive in the hospital, but longer episodes were 4% less expensive when they were hospital managed.

After adjustment, office-based therapy overall was $25,100, compared with $23,800 for hospital-based radiation. Again, shorter episodes were more expensive when hospital managed, but longer episodes were less expensive with hospital-based rather than office-based care.

A new study finds that chemotherapy for privately insured patients is less expensive in a physician’s office than in an outpatient department at a hospital.

The same analysis, however, found that radiation therapy was more expensive in physician offices when it lasted 3 months or more. Radiation of 1 or 2 months’ duration was less costly when it was delivered in offices.

"Our study documents that chemotherapy treatment in an oncologist’s office costs less than in a hospital regardless of the length of treatment," said Eric Hammelman, a study author, in a statement. "At a time when the health care community is focused on managing costs, these findings show the importance of where care is delivered, and raise important questions about how best to manage cancer treatment," said Mr. Hammelman, who is also a vice president at Avalere Health.

The Community Oncology Alliance (COA), in partnership with the National Association of Managed Care Physicians (NAMCP) Medical Directors Institute, commissioned Avalere to do the study. Avalere analyzed data from three commercial managed care plans and a large self-funded employer. In total, the study analyzed 26,168 episodes of care for 22,204 patients.

Overall, chemotherapy that was delivered in an outpatient hospital setting cost 24% more, on average, than did chemotherapy given in a physician’s office. This was true regardless of the duration of therapy, according to the study, which controlled for age, sex, and prior history of cancer. The study did not control for other factors that might have influenced cost, such as mortality, morbidity, or type of chemotherapeutic used.

The total cost included the amount paid by the insurer and the patient’s copay or coinsurance. On an unadjusted basis, the average cost per episode for office-based therapy was $19,640, compared with $26,300 for hospital-based therapy, a difference of 34%. After applying the risk adjustment model, the difference was less, but the hospital-based therapy still cost 24% more ($35,000 compared with $28,200 for office-based care).

Older patients were more likely to be managed in an office, compared with younger patients. The majority of episodes analyzed (about 80%) were in physician offices. Overall, 11 cancers accounted for more than 90% of the episodes. In decreasing order, they were lung, prostate, genitourinary system, breast, Hodgkin’s/lymphoma, colon, digestive system, leukemia, ovarian, multiple myeloma, and rectal cancers.

Costs varied widely for those cancers, as did the differences between office and hospital treatment. The biggest gap was for genitourinary cancers; the adjusted per-episode cost was $19,592 in the hospital, compared with $8,960 in the office, a 118% difference.

Avalere offered some theories on why hospital costs were so much higher overall for chemotherapy. It found that 14 of every 100 hospital-based episodes had a hospitalization during the episode, compared with 11 of every 100 office-based episodes. There was also variation in hospital and physician office billing practices, said the authors.

For radiation therapy, about half of episodes were delivered in hospital outpatient settings. Older patients were more likely to receive office-based radiation. Again, 11 cancers accounted for the majority of treatment episodes. Breast, prostate, and lung cancers accounted for 57% of the episodes.

Overall, the unadjusted cost was $16,300 for office-based therapy, compared with $16,000 for hospital-based treatment. Treatment duration of less than 1 or 2 months was 7%-17% more expensive in the hospital, but longer episodes were 4% less expensive when they were hospital managed.

After adjustment, office-based therapy overall was $25,100, compared with $23,800 for hospital-based radiation. Again, shorter episodes were more expensive when hospital managed, but longer episodes were less expensive with hospital-based rather than office-based care.

A new study finds that chemotherapy for privately insured patients is less expensive in a physician’s office than in an outpatient department at a hospital.

The same analysis, however, found that radiation therapy was more expensive in physician offices when it lasted 3 months or more. Radiation of 1 or 2 months’ duration was less costly when it was delivered in offices.

"Our study documents that chemotherapy treatment in an oncologist’s office costs less than in a hospital regardless of the length of treatment," said Eric Hammelman, a study author, in a statement. "At a time when the health care community is focused on managing costs, these findings show the importance of where care is delivered, and raise important questions about how best to manage cancer treatment," said Mr. Hammelman, who is also a vice president at Avalere Health.

The Community Oncology Alliance (COA), in partnership with the National Association of Managed Care Physicians (NAMCP) Medical Directors Institute, commissioned Avalere to do the study. Avalere analyzed data from three commercial managed care plans and a large self-funded employer. In total, the study analyzed 26,168 episodes of care for 22,204 patients.

Overall, chemotherapy that was delivered in an outpatient hospital setting cost 24% more, on average, than did chemotherapy given in a physician’s office. This was true regardless of the duration of therapy, according to the study, which controlled for age, sex, and prior history of cancer. The study did not control for other factors that might have influenced cost, such as mortality, morbidity, or type of chemotherapeutic used.

The total cost included the amount paid by the insurer and the patient’s copay or coinsurance. On an unadjusted basis, the average cost per episode for office-based therapy was $19,640, compared with $26,300 for hospital-based therapy, a difference of 34%. After applying the risk adjustment model, the difference was less, but the hospital-based therapy still cost 24% more ($35,000 compared with $28,200 for office-based care).

Older patients were more likely to be managed in an office, compared with younger patients. The majority of episodes analyzed (about 80%) were in physician offices. Overall, 11 cancers accounted for more than 90% of the episodes. In decreasing order, they were lung, prostate, genitourinary system, breast, Hodgkin’s/lymphoma, colon, digestive system, leukemia, ovarian, multiple myeloma, and rectal cancers.

Costs varied widely for those cancers, as did the differences between office and hospital treatment. The biggest gap was for genitourinary cancers; the adjusted per-episode cost was $19,592 in the hospital, compared with $8,960 in the office, a 118% difference.

Avalere offered some theories on why hospital costs were so much higher overall for chemotherapy. It found that 14 of every 100 hospital-based episodes had a hospitalization during the episode, compared with 11 of every 100 office-based episodes. There was also variation in hospital and physician office billing practices, said the authors.

For radiation therapy, about half of episodes were delivered in hospital outpatient settings. Older patients were more likely to receive office-based radiation. Again, 11 cancers accounted for the majority of treatment episodes. Breast, prostate, and lung cancers accounted for 57% of the episodes.

Overall, the unadjusted cost was $16,300 for office-based therapy, compared with $16,000 for hospital-based treatment. Treatment duration of less than 1 or 2 months was 7%-17% more expensive in the hospital, but longer episodes were 4% less expensive when they were hospital managed.

After adjustment, office-based therapy overall was $25,100, compared with $23,800 for hospital-based radiation. Again, shorter episodes were more expensive when hospital managed, but longer episodes were less expensive with hospital-based rather than office-based care.

Although a growing number of physicians are earning federal payments for reporting quality measures or writing electronic prescriptions, nearly three-quarters of eligible physicians still aren’t taking part in the incentive programs, according to the Centers for Medicare and Medicaid Services.

In 2010, about 269,000 eligible health care professionals participated in the Physician Quality Reporting System (PQRS, formerly known as the Physician Quality Reporting Incentive program), up from 210,000 in 2009 and 153,000 in 2008. That means that 26% of the 1 million eligible professionals participated in 2010, according to CMS payment and reporting data for that year, as well as data from the Electronic Prescribing Incentive Program.

Physicians’ use of registries to report data also increased. In 2010, there were 89 CMS-qualified registries submitting data from 56,000 eligible professionals. Ninety percent of those using a registry received an incentive payment.

The agency paid out $391.6 million in incentives in 2010 for the PQRS. Eligible professionals were able to earn 2% of the CMS’s estimate for allowed charged under Medicare Part B during the reporting period.

Close to 131,000 of the 696,000 eligible professionals participated in the eRx incentive program in 2010, receiving about $271 million. In 2009, only 89,000 participated. As with PQRS, the incentive was equal to 2% of the estimate of allowed charges for service during the reporting period.

Under the PQRS program, the most frequently reported measures included performance of an electrocardiogram in the emergency department; adoption or use of electronic health records; and giving timely and appropriate antibiotics before surgery.

There were big boosts in performance for a number of measures. About 93% of physicians screened diabetics for eye-related complications and then reported it to the patients’ endocrinologist, up from 70% in 2007. Almost 100% of patients with chronic obstructive pulmonary disease were given prescriptions for bronchodilators, up from 78% in 2007.

Although the measures are supposed to make it possible for a broad range of specialties to participate, a large number of measures apply to emergency medicine and family practice. Not surprisingly, emergency physicians had the highest rate of participation, with 65%, or 32,030 of the 49,278 who were eligible, reporting on at least one measure. Almost half of anesthesiologists participated; while 16% of family physicians who were eligible participated (14,778 of 91,533). Internal medicine physicians were close behind, with just over 15% (14,427 of 92,424) participating.

Family medicine and internal medicine specialists were among the largest numbers who participated in a registry to submit data, followed by cardiologists.

Cardiologists had the highest rates and highest numbers of participants in e-prescribing. A total of 35%, or 7,994 of the 22,606 eligible cardiologists, successfully reported on at least 25 unique prescribing events. A total of 26% of family practice physicians and 24% of internists participated, making them the top specialty participants by numbers. But ophthalmology, rheumatology, and urology had higher rates of participation for their specialties.

Beginning in 2015, CMS will cut physician pay by 1.5% for those who do not satisfactorily report data under the PQRS. From 2016 on, payments will be cut by 2%.

The "downward adjustment" is already in effect this year for the e-prescribing program. Professionals who did not meet criteria will have a 1% pay cut in 2012 and a 1.5% cut in 2013. Some, however, will be exempt from the pay cut. More information on becoming exempt is available here.

Although a growing number of physicians are earning federal payments for reporting quality measures or writing electronic prescriptions, nearly three-quarters of eligible physicians still aren’t taking part in the incentive programs, according to the Centers for Medicare and Medicaid Services.

In 2010, about 269,000 eligible health care professionals participated in the Physician Quality Reporting System (PQRS, formerly known as the Physician Quality Reporting Incentive program), up from 210,000 in 2009 and 153,000 in 2008. That means that 26% of the 1 million eligible professionals participated in 2010, according to CMS payment and reporting data for that year, as well as data from the Electronic Prescribing Incentive Program.

Physicians’ use of registries to report data also increased. In 2010, there were 89 CMS-qualified registries submitting data from 56,000 eligible professionals. Ninety percent of those using a registry received an incentive payment.

The agency paid out $391.6 million in incentives in 2010 for the PQRS. Eligible professionals were able to earn 2% of the CMS’s estimate for allowed charged under Medicare Part B during the reporting period.

Close to 131,000 of the 696,000 eligible professionals participated in the eRx incentive program in 2010, receiving about $271 million. In 2009, only 89,000 participated. As with PQRS, the incentive was equal to 2% of the estimate of allowed charges for service during the reporting period.

Under the PQRS program, the most frequently reported measures included performance of an electrocardiogram in the emergency department; adoption or use of electronic health records; and giving timely and appropriate antibiotics before surgery.

There were big boosts in performance for a number of measures. About 93% of physicians screened diabetics for eye-related complications and then reported it to the patients’ endocrinologist, up from 70% in 2007. Almost 100% of patients with chronic obstructive pulmonary disease were given prescriptions for bronchodilators, up from 78% in 2007.

Although the measures are supposed to make it possible for a broad range of specialties to participate, a large number of measures apply to emergency medicine and family practice. Not surprisingly, emergency physicians had the highest rate of participation, with 65%, or 32,030 of the 49,278 who were eligible, reporting on at least one measure. Almost half of anesthesiologists participated; while 16% of family physicians who were eligible participated (14,778 of 91,533). Internal medicine physicians were close behind, with just over 15% (14,427 of 92,424) participating.

Family medicine and internal medicine specialists were among the largest numbers who participated in a registry to submit data, followed by cardiologists.

Cardiologists had the highest rates and highest numbers of participants in e-prescribing. A total of 35%, or 7,994 of the 22,606 eligible cardiologists, successfully reported on at least 25 unique prescribing events. A total of 26% of family practice physicians and 24% of internists participated, making them the top specialty participants by numbers. But ophthalmology, rheumatology, and urology had higher rates of participation for their specialties.

Beginning in 2015, CMS will cut physician pay by 1.5% for those who do not satisfactorily report data under the PQRS. From 2016 on, payments will be cut by 2%.

The "downward adjustment" is already in effect this year for the e-prescribing program. Professionals who did not meet criteria will have a 1% pay cut in 2012 and a 1.5% cut in 2013. Some, however, will be exempt from the pay cut. More information on becoming exempt is available here.

Although a growing number of physicians are earning federal payments for reporting quality measures or writing electronic prescriptions, nearly three-quarters of eligible physicians still aren’t taking part in the incentive programs, according to the Centers for Medicare and Medicaid Services.

In 2010, about 269,000 eligible health care professionals participated in the Physician Quality Reporting System (PQRS, formerly known as the Physician Quality Reporting Incentive program), up from 210,000 in 2009 and 153,000 in 2008. That means that 26% of the 1 million eligible professionals participated in 2010, according to CMS payment and reporting data for that year, as well as data from the Electronic Prescribing Incentive Program.

Physicians’ use of registries to report data also increased. In 2010, there were 89 CMS-qualified registries submitting data from 56,000 eligible professionals. Ninety percent of those using a registry received an incentive payment.

The agency paid out $391.6 million in incentives in 2010 for the PQRS. Eligible professionals were able to earn 2% of the CMS’s estimate for allowed charged under Medicare Part B during the reporting period.

Close to 131,000 of the 696,000 eligible professionals participated in the eRx incentive program in 2010, receiving about $271 million. In 2009, only 89,000 participated. As with PQRS, the incentive was equal to 2% of the estimate of allowed charges for service during the reporting period.

Under the PQRS program, the most frequently reported measures included performance of an electrocardiogram in the emergency department; adoption or use of electronic health records; and giving timely and appropriate antibiotics before surgery.

There were big boosts in performance for a number of measures. About 93% of physicians screened diabetics for eye-related complications and then reported it to the patients’ endocrinologist, up from 70% in 2007. Almost 100% of patients with chronic obstructive pulmonary disease were given prescriptions for bronchodilators, up from 78% in 2007.

Although the measures are supposed to make it possible for a broad range of specialties to participate, a large number of measures apply to emergency medicine and family practice. Not surprisingly, emergency physicians had the highest rate of participation, with 65%, or 32,030 of the 49,278 who were eligible, reporting on at least one measure. Almost half of anesthesiologists participated; while 16% of family physicians who were eligible participated (14,778 of 91,533). Internal medicine physicians were close behind, with just over 15% (14,427 of 92,424) participating.

Family medicine and internal medicine specialists were among the largest numbers who participated in a registry to submit data, followed by cardiologists.

Cardiologists had the highest rates and highest numbers of participants in e-prescribing. A total of 35%, or 7,994 of the 22,606 eligible cardiologists, successfully reported on at least 25 unique prescribing events. A total of 26% of family practice physicians and 24% of internists participated, making them the top specialty participants by numbers. But ophthalmology, rheumatology, and urology had higher rates of participation for their specialties.

Beginning in 2015, CMS will cut physician pay by 1.5% for those who do not satisfactorily report data under the PQRS. From 2016 on, payments will be cut by 2%.

The "downward adjustment" is already in effect this year for the e-prescribing program. Professionals who did not meet criteria will have a 1% pay cut in 2012 and a 1.5% cut in 2013. Some, however, will be exempt from the pay cut. More information on becoming exempt is available here.

WASHINGTON – The Affordable Care Act’s future was thrown further into doubt on March 28 as the Supreme Court concluded its 3 days of oral arguments.

In the morning, a potential majority of the justices seemed to be leaning toward the idea that if they found the so-called individual mandate to be unconstitutional, they might strike down the entire law.

Photos Alicia Ault/IMNG Medical Media

Later in the day, the court heard arguments on whether the law’s Medicaid expansion was unduly coercive to the states. It was not as clear from that discussion whether the court would overturn the expansion or keep it.

In the morning, U.S. Deputy Solicitor General Edwin S. Kneedler argued on behalf of the federal government that even if the court ruled that the individual mandate is unconstitutional, the rest of the ACA should remain law. "This is a huge act with many provisions that are completely unrelated to market reforms and operate in different ways," he said.

He called striking the entire law "extraordinary," and said that millions of people who already have gained health coverage would be "thrown off the insurance rolls."

Instead, the court could parse the law to determine where it best meets congressional intent, Mr. Kneedler argued.

Most of the justices said that that was not realistic.

Striking some parts but not others might "impose a risk on insurance companies that Congress never intended," Justice Anthony Kennedy said. "That, it seems to me, can be argued at least to be a more extreme exercise of judicial power than to strike the whole."

Justices Antonin Scalia and Samuel Alito expressed concerns about overstepping the court’s bounds. In parsing the law, "there is no way that this court’s decision is not going to distort the congressional process," Justice Scalia said.

The challengers – 26 states and the National Federation of Independent Business – argued that if the mandate were ruled unconstitutional, it would gut the law, and thus, the rest would have to be invalidated.

Justice Ruth Bader Ginsburg questioned that assertion. "Why should we say it’s a choice between a wrecking operation – which is what you are requesting – or a salvage job?" she asked. "The more conservative approach would be salvage rather than throwing out everything."

Some of the justices said that not all of the law’s provisions seemed to be related or carefully and thoughtfully included by Congress, as Paul Clement, attorney for the ACA’s challengers, argued.

"A lot of this is reauthorization of appropriations that have been reauthorized for the previous 5 or 10 years, and it was just more convenient for Congress to throw it in the middle of the 2,700 pages than to do it separately," Chief Justice John Roberts said.

In the afternoon, Mr. Clement also represented the 26 states who challenged the ACA’s requirement that states expand Medicaid to residents with incomes equal to or below 133% of the federal poverty line. Under the law, states would have the option to choose what kind of coverage they offered; the federal government would cover 100% of the cost of coverage for the first 2 years, and then 90%-93% of the cost indefinitely.

The challengers said that even though much of the cost would be covered by the federal government, the law provided no way to opt out of the program. As such, the expansion was coercive, Mr. Clement said.

"Why is a big gift from the federal government a matter of coercion?" asked Justice Elena Kagan. "It’s just a boatload of federal money for [the states] to take and spend on poor people’s health care."

Mr. Clement argued that under the law, if the state did not accept the funds for expansion, the U.S. Health and Human Services department could decide to withhold all of the federal Medicaid funds designated for the state.

"Isn’t that true of every Medicaid increase?" Justice Ginsburg asked. Every time Congress has added new Medicaid benefits, "the condition is, if you want the Medicaid program, this is the program; take it or leave it."

Solicitor General Donald B. Verrilli Jr. said that the government has never actually used that authority – that usually, a compromise is reached between the states and the federal government.

But several justices noted that just the threat could amount to coercion.

"When you say you’re coerced, it means you’ve been given an offer you can’t refuse," said Justice Scalia. "You can’t refuse your money or your life."

Justice Roberts also expressed doubt that HHS would not use its authority to withhold its share of a state’s Medicaid funding. "We have to analyze the case on the assumption that that power will be exercised."

At the end of the day, Mr. Verrilli made a somewhat emotional appeal to the justices to keep the ACA intact. Americans who receive health care under the Medicaid expansion will be "unshackled from the disabilities" of their diseases and "have the opportunity to enjoy the blessings of liberty," he said.

The health reform law "was a judgment of policy, that democratically accountable branches of this government made by their best lights," Mr. Verrilli said. "I would encourage this court to respect that judgment and ask that the Affordable Care Act, in its entirety, be upheld."

WASHINGTON – The Affordable Care Act’s future was thrown further into doubt on March 28 as the Supreme Court concluded its 3 days of oral arguments.

In the morning, a potential majority of the justices seemed to be leaning toward the idea that if they found the so-called individual mandate to be unconstitutional, they might strike down the entire law.

Photos Alicia Ault/IMNG Medical Media

Later in the day, the court heard arguments on whether the law’s Medicaid expansion was unduly coercive to the states. It was not as clear from that discussion whether the court would overturn the expansion or keep it.

In the morning, U.S. Deputy Solicitor General Edwin S. Kneedler argued on behalf of the federal government that even if the court ruled that the individual mandate is unconstitutional, the rest of the ACA should remain law. "This is a huge act with many provisions that are completely unrelated to market reforms and operate in different ways," he said.

He called striking the entire law "extraordinary," and said that millions of people who already have gained health coverage would be "thrown off the insurance rolls."

Instead, the court could parse the law to determine where it best meets congressional intent, Mr. Kneedler argued.

Most of the justices said that that was not realistic.

Striking some parts but not others might "impose a risk on insurance companies that Congress never intended," Justice Anthony Kennedy said. "That, it seems to me, can be argued at least to be a more extreme exercise of judicial power than to strike the whole."

Justices Antonin Scalia and Samuel Alito expressed concerns about overstepping the court’s bounds. In parsing the law, "there is no way that this court’s decision is not going to distort the congressional process," Justice Scalia said.

The challengers – 26 states and the National Federation of Independent Business – argued that if the mandate were ruled unconstitutional, it would gut the law, and thus, the rest would have to be invalidated.

Justice Ruth Bader Ginsburg questioned that assertion. "Why should we say it’s a choice between a wrecking operation – which is what you are requesting – or a salvage job?" she asked. "The more conservative approach would be salvage rather than throwing out everything."

Some of the justices said that not all of the law’s provisions seemed to be related or carefully and thoughtfully included by Congress, as Paul Clement, attorney for the ACA’s challengers, argued.

"A lot of this is reauthorization of appropriations that have been reauthorized for the previous 5 or 10 years, and it was just more convenient for Congress to throw it in the middle of the 2,700 pages than to do it separately," Chief Justice John Roberts said.

In the afternoon, Mr. Clement also represented the 26 states who challenged the ACA’s requirement that states expand Medicaid to residents with incomes equal to or below 133% of the federal poverty line. Under the law, states would have the option to choose what kind of coverage they offered; the federal government would cover 100% of the cost of coverage for the first 2 years, and then 90%-93% of the cost indefinitely.

The challengers said that even though much of the cost would be covered by the federal government, the law provided no way to opt out of the program. As such, the expansion was coercive, Mr. Clement said.

"Why is a big gift from the federal government a matter of coercion?" asked Justice Elena Kagan. "It’s just a boatload of federal money for [the states] to take and spend on poor people’s health care."

Mr. Clement argued that under the law, if the state did not accept the funds for expansion, the U.S. Health and Human Services department could decide to withhold all of the federal Medicaid funds designated for the state.

"Isn’t that true of every Medicaid increase?" Justice Ginsburg asked. Every time Congress has added new Medicaid benefits, "the condition is, if you want the Medicaid program, this is the program; take it or leave it."

Solicitor General Donald B. Verrilli Jr. said that the government has never actually used that authority – that usually, a compromise is reached between the states and the federal government.

But several justices noted that just the threat could amount to coercion.

"When you say you’re coerced, it means you’ve been given an offer you can’t refuse," said Justice Scalia. "You can’t refuse your money or your life."

Justice Roberts also expressed doubt that HHS would not use its authority to withhold its share of a state’s Medicaid funding. "We have to analyze the case on the assumption that that power will be exercised."

At the end of the day, Mr. Verrilli made a somewhat emotional appeal to the justices to keep the ACA intact. Americans who receive health care under the Medicaid expansion will be "unshackled from the disabilities" of their diseases and "have the opportunity to enjoy the blessings of liberty," he said.

The health reform law "was a judgment of policy, that democratically accountable branches of this government made by their best lights," Mr. Verrilli said. "I would encourage this court to respect that judgment and ask that the Affordable Care Act, in its entirety, be upheld."

WASHINGTON – The Affordable Care Act’s future was thrown further into doubt on March 28 as the Supreme Court concluded its 3 days of oral arguments.

In the morning, a potential majority of the justices seemed to be leaning toward the idea that if they found the so-called individual mandate to be unconstitutional, they might strike down the entire law.

Photos Alicia Ault/IMNG Medical Media

Later in the day, the court heard arguments on whether the law’s Medicaid expansion was unduly coercive to the states. It was not as clear from that discussion whether the court would overturn the expansion or keep it.

In the morning, U.S. Deputy Solicitor General Edwin S. Kneedler argued on behalf of the federal government that even if the court ruled that the individual mandate is unconstitutional, the rest of the ACA should remain law. "This is a huge act with many provisions that are completely unrelated to market reforms and operate in different ways," he said.

He called striking the entire law "extraordinary," and said that millions of people who already have gained health coverage would be "thrown off the insurance rolls."

Instead, the court could parse the law to determine where it best meets congressional intent, Mr. Kneedler argued.

Most of the justices said that that was not realistic.

Striking some parts but not others might "impose a risk on insurance companies that Congress never intended," Justice Anthony Kennedy said. "That, it seems to me, can be argued at least to be a more extreme exercise of judicial power than to strike the whole."

Justices Antonin Scalia and Samuel Alito expressed concerns about overstepping the court’s bounds. In parsing the law, "there is no way that this court’s decision is not going to distort the congressional process," Justice Scalia said.

The challengers – 26 states and the National Federation of Independent Business – argued that if the mandate were ruled unconstitutional, it would gut the law, and thus, the rest would have to be invalidated.

Justice Ruth Bader Ginsburg questioned that assertion. "Why should we say it’s a choice between a wrecking operation – which is what you are requesting – or a salvage job?" she asked. "The more conservative approach would be salvage rather than throwing out everything."

Some of the justices said that not all of the law’s provisions seemed to be related or carefully and thoughtfully included by Congress, as Paul Clement, attorney for the ACA’s challengers, argued.

"A lot of this is reauthorization of appropriations that have been reauthorized for the previous 5 or 10 years, and it was just more convenient for Congress to throw it in the middle of the 2,700 pages than to do it separately," Chief Justice John Roberts said.

In the afternoon, Mr. Clement also represented the 26 states who challenged the ACA’s requirement that states expand Medicaid to residents with incomes equal to or below 133% of the federal poverty line. Under the law, states would have the option to choose what kind of coverage they offered; the federal government would cover 100% of the cost of coverage for the first 2 years, and then 90%-93% of the cost indefinitely.

The challengers said that even though much of the cost would be covered by the federal government, the law provided no way to opt out of the program. As such, the expansion was coercive, Mr. Clement said.

"Why is a big gift from the federal government a matter of coercion?" asked Justice Elena Kagan. "It’s just a boatload of federal money for [the states] to take and spend on poor people’s health care."

Mr. Clement argued that under the law, if the state did not accept the funds for expansion, the U.S. Health and Human Services department could decide to withhold all of the federal Medicaid funds designated for the state.

"Isn’t that true of every Medicaid increase?" Justice Ginsburg asked. Every time Congress has added new Medicaid benefits, "the condition is, if you want the Medicaid program, this is the program; take it or leave it."

Solicitor General Donald B. Verrilli Jr. said that the government has never actually used that authority – that usually, a compromise is reached between the states and the federal government.

But several justices noted that just the threat could amount to coercion.

"When you say you’re coerced, it means you’ve been given an offer you can’t refuse," said Justice Scalia. "You can’t refuse your money or your life."

Justice Roberts also expressed doubt that HHS would not use its authority to withhold its share of a state’s Medicaid funding. "We have to analyze the case on the assumption that that power will be exercised."

At the end of the day, Mr. Verrilli made a somewhat emotional appeal to the justices to keep the ACA intact. Americans who receive health care under the Medicaid expansion will be "unshackled from the disabilities" of their diseases and "have the opportunity to enjoy the blessings of liberty," he said.

The health reform law "was a judgment of policy, that democratically accountable branches of this government made by their best lights," Mr. Verrilli said. "I would encourage this court to respect that judgment and ask that the Affordable Care Act, in its entirety, be upheld."

WASHINGTON – In the second day of oral arguments, a majority of Supreme Court justices expressed skepticism that one of the central tenets of the Affordable Care Act – the requirement that Americans have minimum health insurance coverage – is constitutional.

But at least two justices – Chief Justice John Roberts and Justice Anthony Kennedy – also were dubious about the challengers’ assertion that requiring Americans to buy insurance was an unprecedented act that exceeded Congress’ powers under the U.S. Constitution’s commerce clause.

Alicia Ault/IMNG Medical Media 

The apparent rift leaves an open question as to whether the justices will uphold or strike down the so-called individual mandate when they render their decision in late June.

The federal government contends that it can require most Americans to buy health insurance – or pay a penalty if they don’t – because those who go without insurance shift the cost of their care onto those who have coverage. The idea is that their "inactivity" affects a substantial portion of U.S. commerce, and thus can be regulated under the commerce clause, U.S. Solicitor General Donald B. Verrilli Jr. argued.

Many of the justices, though, hammered away at Mr. Verrilli, asking him to explain how the Affordable Care Act (ACA) could be considered constitutional.

And, they said, allowing the ACA to stand could result in the expansion of federal powers. If the federal government can compel Americans to buy insurance with the idea that they might need it someday, it could also compel Americans to purchase cell phones so they could make 9-1-1 calls to access government-provided fire and ambulance services, Justice Roberts said.

If the individual mandate – or the whole health reform law – is struck down, it could mean millions of Americans would continue to be uninsured and would directly affect physicians’ practices, said Dr. Jack Lewin, CEO of the American College of Cardiology, in an interview.

"It’s largely a negative thing for doctors and for the country if the law is struck down," Dr. Lewin said. The ACA "expands access to 35 million people who right now have the emergency room as their medical home."

If the law is upheld, Dr. Lewin said, "the nation still has a need for additional policy and legislative action to more emphatically and clearly address delivery system reforms," as well as "payment reforms that will actually reduce the rate of cost increase."

Neal K. Katyal, a Georgetown University law professor who observed the arguments said that it was too soon to speculate on the outcome.

"I would caution anyone from reading anything into the [justices’] questioning," he said in an interview.

Justice Roberts noted that the federal government is "supposed to be a government of limited powers. If the government can do this, what else can it not do?"*

Justice Antonin Scalia called "extraordinary" Mr. Verrilli’s assertion that requiring insurance or payment of a penalty was within congressional taxing powers. Justice Scalia said that following the government’s logic, Congress could require people to exercise, or "make people buy broccoli."

Paul Clement, an attorney for the challengers (26 states and the National Federation of Independent Business), said that the government shouldn’t be allowed to force people to purchase something they don’t want.

Mr. Clement illustrated his point with the federal effort to support the U.S. auto industry during the 2009 recession.

"When we had problems in the automobile industry" instead of saying "everybody over $100,000 has to buy a new car" the federal government came up with an incentive program – Cash for Clunkers, he pointed out.

Justice Roberts, though, noted that the government is arguing that all Americans already participate in the health care market, which "makes it very different than the market for cars or the other hypotheticals."

Justice Kennedy said that if the court upholds the government’s contention that the insurance market is unique, "in the next case, [the government] will say the next market is unique." He acknowledged, though, that in some ways health care is different. "The young person who is uninsured is uniquely proximate to affecting the rates of insurance and the costs of providing medical care in a way that is not true in other industries," said Justice Kennedy. "That’s my concern in the case."

*Correction 3/27/12: Justice Roberts' quote was attributed incorrectly in a previous rendition.

WASHINGTON – In the second day of oral arguments, a majority of Supreme Court justices expressed skepticism that one of the central tenets of the Affordable Care Act – the requirement that Americans have minimum health insurance coverage – is constitutional.

But at least two justices – Chief Justice John Roberts and Justice Anthony Kennedy – also were dubious about the challengers’ assertion that requiring Americans to buy insurance was an unprecedented act that exceeded Congress’ powers under the U.S. Constitution’s commerce clause.

Alicia Ault/IMNG Medical Media 

The apparent rift leaves an open question as to whether the justices will uphold or strike down the so-called individual mandate when they render their decision in late June.

The federal government contends that it can require most Americans to buy health insurance – or pay a penalty if they don’t – because those who go without insurance shift the cost of their care onto those who have coverage. The idea is that their "inactivity" affects a substantial portion of U.S. commerce, and thus can be regulated under the commerce clause, U.S. Solicitor General Donald B. Verrilli Jr. argued.

Many of the justices, though, hammered away at Mr. Verrilli, asking him to explain how the Affordable Care Act (ACA) could be considered constitutional.

And, they said, allowing the ACA to stand could result in the expansion of federal powers. If the federal government can compel Americans to buy insurance with the idea that they might need it someday, it could also compel Americans to purchase cell phones so they could make 9-1-1 calls to access government-provided fire and ambulance services, Justice Roberts said.

If the individual mandate – or the whole health reform law – is struck down, it could mean millions of Americans would continue to be uninsured and would directly affect physicians’ practices, said Dr. Jack Lewin, CEO of the American College of Cardiology, in an interview.

"It’s largely a negative thing for doctors and for the country if the law is struck down," Dr. Lewin said. The ACA "expands access to 35 million people who right now have the emergency room as their medical home."

If the law is upheld, Dr. Lewin said, "the nation still has a need for additional policy and legislative action to more emphatically and clearly address delivery system reforms," as well as "payment reforms that will actually reduce the rate of cost increase."

Neal K. Katyal, a Georgetown University law professor who observed the arguments said that it was too soon to speculate on the outcome.

"I would caution anyone from reading anything into the [justices’] questioning," he said in an interview.

Justice Roberts noted that the federal government is "supposed to be a government of limited powers. If the government can do this, what else can it not do?"*

Justice Antonin Scalia called "extraordinary" Mr. Verrilli’s assertion that requiring insurance or payment of a penalty was within congressional taxing powers. Justice Scalia said that following the government’s logic, Congress could require people to exercise, or "make people buy broccoli."

Paul Clement, an attorney for the challengers (26 states and the National Federation of Independent Business), said that the government shouldn’t be allowed to force people to purchase something they don’t want.

Mr. Clement illustrated his point with the federal effort to support the U.S. auto industry during the 2009 recession.

"When we had problems in the automobile industry" instead of saying "everybody over $100,000 has to buy a new car" the federal government came up with an incentive program – Cash for Clunkers, he pointed out.

Justice Roberts, though, noted that the government is arguing that all Americans already participate in the health care market, which "makes it very different than the market for cars or the other hypotheticals."

Justice Kennedy said that if the court upholds the government’s contention that the insurance market is unique, "in the next case, [the government] will say the next market is unique." He acknowledged, though, that in some ways health care is different. "The young person who is uninsured is uniquely proximate to affecting the rates of insurance and the costs of providing medical care in a way that is not true in other industries," said Justice Kennedy. "That’s my concern in the case."

*Correction 3/27/12: Justice Roberts' quote was attributed incorrectly in a previous rendition.

WASHINGTON – In the second day of oral arguments, a majority of Supreme Court justices expressed skepticism that one of the central tenets of the Affordable Care Act – the requirement that Americans have minimum health insurance coverage – is constitutional.

But at least two justices – Chief Justice John Roberts and Justice Anthony Kennedy – also were dubious about the challengers’ assertion that requiring Americans to buy insurance was an unprecedented act that exceeded Congress’ powers under the U.S. Constitution’s commerce clause.

Alicia Ault/IMNG Medical Media 

The apparent rift leaves an open question as to whether the justices will uphold or strike down the so-called individual mandate when they render their decision in late June.

The federal government contends that it can require most Americans to buy health insurance – or pay a penalty if they don’t – because those who go without insurance shift the cost of their care onto those who have coverage. The idea is that their "inactivity" affects a substantial portion of U.S. commerce, and thus can be regulated under the commerce clause, U.S. Solicitor General Donald B. Verrilli Jr. argued.

Many of the justices, though, hammered away at Mr. Verrilli, asking him to explain how the Affordable Care Act (ACA) could be considered constitutional.

And, they said, allowing the ACA to stand could result in the expansion of federal powers. If the federal government can compel Americans to buy insurance with the idea that they might need it someday, it could also compel Americans to purchase cell phones so they could make 9-1-1 calls to access government-provided fire and ambulance services, Justice Roberts said.

If the individual mandate – or the whole health reform law – is struck down, it could mean millions of Americans would continue to be uninsured and would directly affect physicians’ practices, said Dr. Jack Lewin, CEO of the American College of Cardiology, in an interview.

"It’s largely a negative thing for doctors and for the country if the law is struck down," Dr. Lewin said. The ACA "expands access to 35 million people who right now have the emergency room as their medical home."

If the law is upheld, Dr. Lewin said, "the nation still has a need for additional policy and legislative action to more emphatically and clearly address delivery system reforms," as well as "payment reforms that will actually reduce the rate of cost increase."

Neal K. Katyal, a Georgetown University law professor who observed the arguments said that it was too soon to speculate on the outcome.

"I would caution anyone from reading anything into the [justices’] questioning," he said in an interview.

Justice Roberts noted that the federal government is "supposed to be a government of limited powers. If the government can do this, what else can it not do?"*

Justice Antonin Scalia called "extraordinary" Mr. Verrilli’s assertion that requiring insurance or payment of a penalty was within congressional taxing powers. Justice Scalia said that following the government’s logic, Congress could require people to exercise, or "make people buy broccoli."

Paul Clement, an attorney for the challengers (26 states and the National Federation of Independent Business), said that the government shouldn’t be allowed to force people to purchase something they don’t want.

Mr. Clement illustrated his point with the federal effort to support the U.S. auto industry during the 2009 recession.

"When we had problems in the automobile industry" instead of saying "everybody over $100,000 has to buy a new car" the federal government came up with an incentive program – Cash for Clunkers, he pointed out.

Justice Roberts, though, noted that the government is arguing that all Americans already participate in the health care market, which "makes it very different than the market for cars or the other hypotheticals."

Justice Kennedy said that if the court upholds the government’s contention that the insurance market is unique, "in the next case, [the government] will say the next market is unique." He acknowledged, though, that in some ways health care is different. "The young person who is uninsured is uniquely proximate to affecting the rates of insurance and the costs of providing medical care in a way that is not true in other industries," said Justice Kennedy. "That’s my concern in the case."

*Correction 3/27/12: Justice Roberts' quote was attributed incorrectly in a previous rendition.

WASHINGTON – As the Affordable Care Act finally got its day in the Supreme Court, justices seemed eager to set aside preliminary issues and move on to the important question of whether the law’s individual mandate is constitutional.

Outside the court, Families USA executive director Ron Pollack said that arguments March 26 – which bogged down in discussions of whether Americans would be paying a "tax" or a "penalty" if they failed to secure insurance coverage – were the "hors d’oeuvres," before the "main meal," on Tuesday.

Alicia Ault/IMNG Medical Media

Mr. Pollack said that after seeing the arguments, "clearly, the justices want to get on and render a decision."

Supporters and opponents of the Affordable Care Act rallied outside the court building. A group of physicians representing the grassroots organization Doctors for America (DFA) said they were there to show their support.

Dr. Vivek Murthy, president of DFA, said in an interview that the Affordable Care Act (ACA) provides a window of opportunity to address the problems with the health care system. If all or part of the law is struck down, DFA will continue a planned effort to educate 1,000,000 Americans on the law.

The individual mandate is particularly important because it could help reduce health care costs by ensuring more Americans are insured, according to Dr. Murthy, a hospitalist at Brigham and Women’s Hospital in Boston.

The justices asked several questions about the mandate during Monday’s arguments. Some asked who would be hurt and how if the mandate stayed in place.

Justice Sonia Sotomayor asked U.S. Solicitor General Donald B. Verrilli Jr. what the consequences would be for those who did not pay the penalty, noting that the challengers to the law said that there could be "other collateral consequences."

Mr. Verrilli said that there would be no other consequences and, in addition, that there are several exemptions from the penalty, including for low-income individuals and families.

The challengers – 26 states and the National Federation of Independent Business – represented by attorney Gregory G. Katsas, argued that the mandate would hurt even those not directly subject to the provision.

"We have individuals who are planning for compliance in order to avoid a penalty, which is what their affidavits say. And we have the states, who will be subject no doubt to all sorts of adverse ramifications if they refuse to enroll in Medicaid the people who are forced into Medicaid by virtue of the mandate," said Mr. Katsas, with a Washington law firm.

The justices will consider on Wednesday whether the ACA is unduly coercive by requiring states to expand their Medicaid programs.

Louisiana is one of the 26 states that has alleged it will be harmed by the individual mandate. If the law is upheld, "it will be devastating" to the state, Attorney General Buddy Caldwell said in an interview. Residents already get access to free health care through a statewide charity system, he said, adding that many small businesses as well as low-income residents will suffer if they have to buy insurance coverage.

That’s why the states sued, Mr. Katsas said.

"The purpose of this lawsuit is to challenge a requirement – a federal requirement to buy health insurance. That requirement itself is not a tax," he said. Mr. Katsas said that 19th-century precedents should not prevent the justices from hearing this case and that the penalty could be treated as a separate matter from the mandate.

WASHINGTON – As the Affordable Care Act finally got its day in the Supreme Court, justices seemed eager to set aside preliminary issues and move on to the important question of whether the law’s individual mandate is constitutional.

Outside the court, Families USA executive director Ron Pollack said that arguments March 26 – which bogged down in discussions of whether Americans would be paying a "tax" or a "penalty" if they failed to secure insurance coverage – were the "hors d’oeuvres," before the "main meal," on Tuesday.

Alicia Ault/IMNG Medical Media

Mr. Pollack said that after seeing the arguments, "clearly, the justices want to get on and render a decision."

Supporters and opponents of the Affordable Care Act rallied outside the court building. A group of physicians representing the grassroots organization Doctors for America (DFA) said they were there to show their support.

Dr. Vivek Murthy, president of DFA, said in an interview that the Affordable Care Act (ACA) provides a window of opportunity to address the problems with the health care system. If all or part of the law is struck down, DFA will continue a planned effort to educate 1,000,000 Americans on the law.

The individual mandate is particularly important because it could help reduce health care costs by ensuring more Americans are insured, according to Dr. Murthy, a hospitalist at Brigham and Women’s Hospital in Boston.

The justices asked several questions about the mandate during Monday’s arguments. Some asked who would be hurt and how if the mandate stayed in place.

Justice Sonia Sotomayor asked U.S. Solicitor General Donald B. Verrilli Jr. what the consequences would be for those who did not pay the penalty, noting that the challengers to the law said that there could be "other collateral consequences."

Mr. Verrilli said that there would be no other consequences and, in addition, that there are several exemptions from the penalty, including for low-income individuals and families.

The challengers – 26 states and the National Federation of Independent Business – represented by attorney Gregory G. Katsas, argued that the mandate would hurt even those not directly subject to the provision.

"We have individuals who are planning for compliance in order to avoid a penalty, which is what their affidavits say. And we have the states, who will be subject no doubt to all sorts of adverse ramifications if they refuse to enroll in Medicaid the people who are forced into Medicaid by virtue of the mandate," said Mr. Katsas, with a Washington law firm.

The justices will consider on Wednesday whether the ACA is unduly coercive by requiring states to expand their Medicaid programs.

Louisiana is one of the 26 states that has alleged it will be harmed by the individual mandate. If the law is upheld, "it will be devastating" to the state, Attorney General Buddy Caldwell said in an interview. Residents already get access to free health care through a statewide charity system, he said, adding that many small businesses as well as low-income residents will suffer if they have to buy insurance coverage.

That’s why the states sued, Mr. Katsas said.

"The purpose of this lawsuit is to challenge a requirement – a federal requirement to buy health insurance. That requirement itself is not a tax," he said. Mr. Katsas said that 19th-century precedents should not prevent the justices from hearing this case and that the penalty could be treated as a separate matter from the mandate.

WASHINGTON – As the Affordable Care Act finally got its day in the Supreme Court, justices seemed eager to set aside preliminary issues and move on to the important question of whether the law’s individual mandate is constitutional.

Outside the court, Families USA executive director Ron Pollack said that arguments March 26 – which bogged down in discussions of whether Americans would be paying a "tax" or a "penalty" if they failed to secure insurance coverage – were the "hors d’oeuvres," before the "main meal," on Tuesday.

Alicia Ault/IMNG Medical Media

Mr. Pollack said that after seeing the arguments, "clearly, the justices want to get on and render a decision."

Supporters and opponents of the Affordable Care Act rallied outside the court building. A group of physicians representing the grassroots organization Doctors for America (DFA) said they were there to show their support.

Dr. Vivek Murthy, president of DFA, said in an interview that the Affordable Care Act (ACA) provides a window of opportunity to address the problems with the health care system. If all or part of the law is struck down, DFA will continue a planned effort to educate 1,000,000 Americans on the law.

The individual mandate is particularly important because it could help reduce health care costs by ensuring more Americans are insured, according to Dr. Murthy, a hospitalist at Brigham and Women’s Hospital in Boston.

The justices asked several questions about the mandate during Monday’s arguments. Some asked who would be hurt and how if the mandate stayed in place.

Justice Sonia Sotomayor asked U.S. Solicitor General Donald B. Verrilli Jr. what the consequences would be for those who did not pay the penalty, noting that the challengers to the law said that there could be "other collateral consequences."

Mr. Verrilli said that there would be no other consequences and, in addition, that there are several exemptions from the penalty, including for low-income individuals and families.

The challengers – 26 states and the National Federation of Independent Business – represented by attorney Gregory G. Katsas, argued that the mandate would hurt even those not directly subject to the provision.

"We have individuals who are planning for compliance in order to avoid a penalty, which is what their affidavits say. And we have the states, who will be subject no doubt to all sorts of adverse ramifications if they refuse to enroll in Medicaid the people who are forced into Medicaid by virtue of the mandate," said Mr. Katsas, with a Washington law firm.

The justices will consider on Wednesday whether the ACA is unduly coercive by requiring states to expand their Medicaid programs.

Louisiana is one of the 26 states that has alleged it will be harmed by the individual mandate. If the law is upheld, "it will be devastating" to the state, Attorney General Buddy Caldwell said in an interview. Residents already get access to free health care through a statewide charity system, he said, adding that many small businesses as well as low-income residents will suffer if they have to buy insurance coverage.

That’s why the states sued, Mr. Katsas said.

"The purpose of this lawsuit is to challenge a requirement – a federal requirement to buy health insurance. That requirement itself is not a tax," he said. Mr. Katsas said that 19th-century precedents should not prevent the justices from hearing this case and that the penalty could be treated as a separate matter from the mandate.

WASHINGTON – The historically low growth in health spending in 2009 continued through 2010, driven largely by the recession, Centers for Medicare and Medicaid officials haveannounced.

U.S. health spending grew 3.9% in 2010, to a total of $2.6 trillion or $8,402 per person. That was a 0.1% rise from 2009, which was already at an all-time low growth rate.

As the nation’s economy slumped throughout 2009 and 2010, consumers cut back on elective surgical procedures, emergency room visits, physician office visits, and prescription drug use, according to the officials.

"Even though the recession officially ended in 2009, its impact on the health sector appears to have continued into 2010," said Anne Martin, an economist with the CMS.

Employers shifted the costs of insurance and care to employees, which drove up out-of-pocket spending in 2010. But consumers overall spent only 1.8% more out-of-pocket in 2010 than they had in 2009, which was a slow rate of growth when compared with historical patterns, Ms. Martin said.

Consumers reacted to cost-shifting by choosing health insurance plans with lower premiums and higher deductibles, and by reducing, where they could, use of personal health care services. Medical prices and the U.S. population remained relatively stable before, during, and after the recession, and yet, personal health spending fell, indicating a willful pullback.

"The slower growth in personal health care spending was mainly driven by the slowdown in the use and intensity of health care goods and services," Ms. Martin said.

The agency documented a shrinkage in the use of hospital care and physician services as compared with historical levels.

Hospital spending grew only 5% to $814 billion in 2010, compared to 6% in 2009. There was a decline in median inpatient admissions, and slower growth in emergency department visits, outpatient visits, and outpatient surgeries.

Overall spending on physicians and clinical services – totaling $515 billion in 2010 – accounted for 20% of total health spending. As consumers went to the doctor less frequently, fewer prescriptions were written. And, many of those dispensed were for less expensive generic drugs. These and other factors led to the slowest rate of growth in prescription drug spending ever recorded – a 1% increase from 2009 to $259 billion. The data were published in the journal Health Affairs (Health Aff. 2012 [doi: 10.1377/hlthaff.2011.1135]).

Growth in spending on physician and clinical services also was historically low, growing 2.5% in 2010 as compared with 3.3% in 2009, said Ms. Martin.

Meanwhile, as employers and private insurers reduced the amount they spent on health care, the federal government’s share of health spending rose – to 29% or a total of $742 billion in 2010.

The rise in federal spending also was attributed to federal subsidies to state Medicaid programs. Medicaid was about 15% of the nation’s health bill in 2010, at $401 billion.

In 2009, the federal government spent 22% more than in 2008; in 2010, spending rose by almost 9%. That compares to a 10% decrease in spending by states and localities in 2008, and a 4% increase in 2010.

Medicare saw an increase in enrollment, both in Medicare Advantage managed care program and traditional fee-for-service Medicare. The increase in traditional enrollment reversed a several-year pattern of decline. Overall, Medicare spending increased 5% in 2010 to $524 billion, but per-enrollee spending did not rise as quickly as it had in 2009.

This is because there was a big reduction in payments for certain types of home health services, but also because of low use of physician services. Small increases in physician fees in 2009 and 2010 also kept a lid on Medicare spending. Those increases were instituted by Congress in response to cuts that would otherwise have been required by Medicare’s Sustainable Growth Rate formula.

The Affordable Care Act had a negligible impact on overall spending, perhaps accounting for less than 0.1% of the slowdown, according to the CMS economists. This small impact is because few of its provisions were in effect in 2010, and some, such as coverage for patients with preexisting conditions, did not enroll as many people as had been expected.

WASHINGTON – The historically low growth in health spending in 2009 continued through 2010, driven largely by the recession, Centers for Medicare and Medicaid officials haveannounced.

U.S. health spending grew 3.9% in 2010, to a total of $2.6 trillion or $8,402 per person. That was a 0.1% rise from 2009, which was already at an all-time low growth rate.

As the nation’s economy slumped throughout 2009 and 2010, consumers cut back on elective surgical procedures, emergency room visits, physician office visits, and prescription drug use, according to the officials.

"Even though the recession officially ended in 2009, its impact on the health sector appears to have continued into 2010," said Anne Martin, an economist with the CMS.

Employers shifted the costs of insurance and care to employees, which drove up out-of-pocket spending in 2010. But consumers overall spent only 1.8% more out-of-pocket in 2010 than they had in 2009, which was a slow rate of growth when compared with historical patterns, Ms. Martin said.

Consumers reacted to cost-shifting by choosing health insurance plans with lower premiums and higher deductibles, and by reducing, where they could, use of personal health care services. Medical prices and the U.S. population remained relatively stable before, during, and after the recession, and yet, personal health spending fell, indicating a willful pullback.

"The slower growth in personal health care spending was mainly driven by the slowdown in the use and intensity of health care goods and services," Ms. Martin said.

The agency documented a shrinkage in the use of hospital care and physician services as compared with historical levels.

Hospital spending grew only 5% to $814 billion in 2010, compared to 6% in 2009. There was a decline in median inpatient admissions, and slower growth in emergency department visits, outpatient visits, and outpatient surgeries.

Overall spending on physicians and clinical services – totaling $515 billion in 2010 – accounted for 20% of total health spending. As consumers went to the doctor less frequently, fewer prescriptions were written. And, many of those dispensed were for less expensive generic drugs. These and other factors led to the slowest rate of growth in prescription drug spending ever recorded – a 1% increase from 2009 to $259 billion. The data were published in the journal Health Affairs (Health Aff. 2012 [doi: 10.1377/hlthaff.2011.1135]).

Growth in spending on physician and clinical services also was historically low, growing 2.5% in 2010 as compared with 3.3% in 2009, said Ms. Martin.

Meanwhile, as employers and private insurers reduced the amount they spent on health care, the federal government’s share of health spending rose – to 29% or a total of $742 billion in 2010.

The rise in federal spending also was attributed to federal subsidies to state Medicaid programs. Medicaid was about 15% of the nation’s health bill in 2010, at $401 billion.

In 2009, the federal government spent 22% more than in 2008; in 2010, spending rose by almost 9%. That compares to a 10% decrease in spending by states and localities in 2008, and a 4% increase in 2010.

Medicare saw an increase in enrollment, both in Medicare Advantage managed care program and traditional fee-for-service Medicare. The increase in traditional enrollment reversed a several-year pattern of decline. Overall, Medicare spending increased 5% in 2010 to $524 billion, but per-enrollee spending did not rise as quickly as it had in 2009.

This is because there was a big reduction in payments for certain types of home health services, but also because of low use of physician services. Small increases in physician fees in 2009 and 2010 also kept a lid on Medicare spending. Those increases were instituted by Congress in response to cuts that would otherwise have been required by Medicare’s Sustainable Growth Rate formula.

The Affordable Care Act had a negligible impact on overall spending, perhaps accounting for less than 0.1% of the slowdown, according to the CMS economists. This small impact is because few of its provisions were in effect in 2010, and some, such as coverage for patients with preexisting conditions, did not enroll as many people as had been expected.

WASHINGTON – The historically low growth in health spending in 2009 continued through 2010, driven largely by the recession, Centers for Medicare and Medicaid officials haveannounced.

U.S. health spending grew 3.9% in 2010, to a total of $2.6 trillion or $8,402 per person. That was a 0.1% rise from 2009, which was already at an all-time low growth rate.

As the nation’s economy slumped throughout 2009 and 2010, consumers cut back on elective surgical procedures, emergency room visits, physician office visits, and prescription drug use, according to the officials.

"Even though the recession officially ended in 2009, its impact on the health sector appears to have continued into 2010," said Anne Martin, an economist with the CMS.

Employers shifted the costs of insurance and care to employees, which drove up out-of-pocket spending in 2010. But consumers overall spent only 1.8% more out-of-pocket in 2010 than they had in 2009, which was a slow rate of growth when compared with historical patterns, Ms. Martin said.

Consumers reacted to cost-shifting by choosing health insurance plans with lower premiums and higher deductibles, and by reducing, where they could, use of personal health care services. Medical prices and the U.S. population remained relatively stable before, during, and after the recession, and yet, personal health spending fell, indicating a willful pullback.

"The slower growth in personal health care spending was mainly driven by the slowdown in the use and intensity of health care goods and services," Ms. Martin said.

The agency documented a shrinkage in the use of hospital care and physician services as compared with historical levels.

Hospital spending grew only 5% to $814 billion in 2010, compared to 6% in 2009. There was a decline in median inpatient admissions, and slower growth in emergency department visits, outpatient visits, and outpatient surgeries.

Overall spending on physicians and clinical services – totaling $515 billion in 2010 – accounted for 20% of total health spending. As consumers went to the doctor less frequently, fewer prescriptions were written. And, many of those dispensed were for less expensive generic drugs. These and other factors led to the slowest rate of growth in prescription drug spending ever recorded – a 1% increase from 2009 to $259 billion. The data were published in the journal Health Affairs (Health Aff. 2012 [doi: 10.1377/hlthaff.2011.1135]).

Growth in spending on physician and clinical services also was historically low, growing 2.5% in 2010 as compared with 3.3% in 2009, said Ms. Martin.

Meanwhile, as employers and private insurers reduced the amount they spent on health care, the federal government’s share of health spending rose – to 29% or a total of $742 billion in 2010.

The rise in federal spending also was attributed to federal subsidies to state Medicaid programs. Medicaid was about 15% of the nation’s health bill in 2010, at $401 billion.

In 2009, the federal government spent 22% more than in 2008; in 2010, spending rose by almost 9%. That compares to a 10% decrease in spending by states and localities in 2008, and a 4% increase in 2010.

Medicare saw an increase in enrollment, both in Medicare Advantage managed care program and traditional fee-for-service Medicare. The increase in traditional enrollment reversed a several-year pattern of decline. Overall, Medicare spending increased 5% in 2010 to $524 billion, but per-enrollee spending did not rise as quickly as it had in 2009.

This is because there was a big reduction in payments for certain types of home health services, but also because of low use of physician services. Small increases in physician fees in 2009 and 2010 also kept a lid on Medicare spending. Those increases were instituted by Congress in response to cuts that would otherwise have been required by Medicare’s Sustainable Growth Rate formula.

The Affordable Care Act had a negligible impact on overall spending, perhaps accounting for less than 0.1% of the slowdown, according to the CMS economists. This small impact is because few of its provisions were in effect in 2010, and some, such as coverage for patients with preexisting conditions, did not enroll as many people as had been expected.

Yep, that’s a shameless bid to appear higher on Google search results, but it’s also a pretty good metaphor for what’s happening in Washington in advance of the Supreme Court oral arguments on the Affordable Care Act–due to be heard March 26, 27 and 28.  Although speculation about how the Justices may rule has been going on for months, the gambling has reached a fever pitch.

Next week is to Court Watchers as the Final Four is to legions of NCAA Division 1 basketball fans: The brackets have been completed; it’s just a question now of who will come out on top.

Alicia Ault/IMNG Medical Media

Conventional wisdom has the Supreme Court splitting along perceived “party lines” in a 5-4 vote either in favor of upholding the law, or against it.

But with the Justices taking on three separate, major issues within the law, Washington wonks, soothsayers, and legal eagles have gone into a frenzy of handicapping. Not a day goes by without a backgrounder or briefing that professes to have the best read on the tea leaves.

The Court, as is its wont, has shied from the limelight. Until today, it had not even determined how it would accommodate the legions of journalists (myself included) who will descend upon the courtroom to cover the historic arguments. Details are still being worked out, but one thing was not going to change: the Court has steadfastly refused to allow audio or video broadcasts of the proceedings. (Which means there cannot be any contests requiring a shot every time the challengers’ attorney, Paul Clement, utters “individual mandate.”) The Court is even banning–heaven forbid–cellphones. That means no pithy Tweets on Justice Clarence Thomas’ enduring silence.

This morning–at a briefing sponsored by Politico–came new predictions from an estimable panel of D.C. insiders: former U.S. Solicitor General Walter Dellinger, Neal Katyal, Al Gore’s co-counsel at the Court in Bush v. Gore,  Tom Goldstein, a former Court clerk and publisher of Scotusblog, Kevin Walsh, a former clerk to Justice Antonin Scalia, and Nina Totenberg, the veteran Court correspondent for NPR.

Alicia Ault/IMNG Medical Media

The Justices to watch, said Ms. Totenberg: Anthony Kennedy and Chief Justice John Roberts. They are both widely considered swing votes. Some have also have put Justice Scalia in that camp, “which I personally think is a crock,” Ms. Totenberg said. Mr. Katyal said that Samuel Alito could also be “in play.”

Will politics come into play? Justices “have a grasp of politics that defies imagination in terms of its inaccuracy,” said Ms. Totenberg, who, like the others discounted the idea that the Justices would be influenced–or motivated–to vote in one direction or another based on the prevailing political winds.

The panel was unanimous–except for Ms. Totenberg, who recused herself from making a wager–in its opinion that the Court would uphold the law, most likely in its entirety.

Mr.  Goldstein said he could not effectively imagine a victory by the law’s challengers. If the Justices threw out the Act, it “would lead to probably an array of attacks on different parts of the federal regulatory state because for the first time you would have had five justices that take very seriously limits on congressional power,” he said.

By the end of next week, the Court will likely hold one closed-door conference and a series of votes, said Mr. Walsh.

He and the other panelists went out on a limb, saying that the 5-4 prediction may no longer hold.  Mr. Goldstein said it could even be a 6-3 or 7-2 ruling upholding the law.

So who will write the opinion, expected to be issued in June? Mr. Dellinger predicted that it would be Justice Roberts. Mr. Goldstein, however, said this might be the rare case where the Court issues a per curiam opinion–that is, written in the name of the Court, rather than by any of the Justices. Interestingly, Bush v. Gore was a per curiam decision.

What is your opinion?

Yep, that’s a shameless bid to appear higher on Google search results, but it’s also a pretty good metaphor for what’s happening in Washington in advance of the Supreme Court oral arguments on the Affordable Care Act–due to be heard March 26, 27 and 28.  Although speculation about how the Justices may rule has been going on for months, the gambling has reached a fever pitch.

Next week is to Court Watchers as the Final Four is to legions of NCAA Division 1 basketball fans: The brackets have been completed; it’s just a question now of who will come out on top.

Alicia Ault/IMNG Medical Media

Conventional wisdom has the Supreme Court splitting along perceived “party lines” in a 5-4 vote either in favor of upholding the law, or against it.

But with the Justices taking on three separate, major issues within the law, Washington wonks, soothsayers, and legal eagles have gone into a frenzy of handicapping. Not a day goes by without a backgrounder or briefing that professes to have the best read on the tea leaves.

The Court, as is its wont, has shied from the limelight. Until today, it had not even determined how it would accommodate the legions of journalists (myself included) who will descend upon the courtroom to cover the historic arguments. Details are still being worked out, but one thing was not going to change: the Court has steadfastly refused to allow audio or video broadcasts of the proceedings. (Which means there cannot be any contests requiring a shot every time the challengers’ attorney, Paul Clement, utters “individual mandate.”) The Court is even banning–heaven forbid–cellphones. That means no pithy Tweets on Justice Clarence Thomas’ enduring silence.

This morning–at a briefing sponsored by Politico–came new predictions from an estimable panel of D.C. insiders: former U.S. Solicitor General Walter Dellinger, Neal Katyal, Al Gore’s co-counsel at the Court in Bush v. Gore,  Tom Goldstein, a former Court clerk and publisher of Scotusblog, Kevin Walsh, a former clerk to Justice Antonin Scalia, and Nina Totenberg, the veteran Court correspondent for NPR.

Alicia Ault/IMNG Medical Media

The Justices to watch, said Ms. Totenberg: Anthony Kennedy and Chief Justice John Roberts. They are both widely considered swing votes. Some have also have put Justice Scalia in that camp, “which I personally think is a crock,” Ms. Totenberg said. Mr. Katyal said that Samuel Alito could also be “in play.”

Will politics come into play? Justices “have a grasp of politics that defies imagination in terms of its inaccuracy,” said Ms. Totenberg, who, like the others discounted the idea that the Justices would be influenced–or motivated–to vote in one direction or another based on the prevailing political winds.

The panel was unanimous–except for Ms. Totenberg, who recused herself from making a wager–in its opinion that the Court would uphold the law, most likely in its entirety.

Mr.  Goldstein said he could not effectively imagine a victory by the law’s challengers. If the Justices threw out the Act, it “would lead to probably an array of attacks on different parts of the federal regulatory state because for the first time you would have had five justices that take very seriously limits on congressional power,” he said.

By the end of next week, the Court will likely hold one closed-door conference and a series of votes, said Mr. Walsh.

He and the other panelists went out on a limb, saying that the 5-4 prediction may no longer hold.  Mr. Goldstein said it could even be a 6-3 or 7-2 ruling upholding the law.

So who will write the opinion, expected to be issued in June? Mr. Dellinger predicted that it would be Justice Roberts. Mr. Goldstein, however, said this might be the rare case where the Court issues a per curiam opinion–that is, written in the name of the Court, rather than by any of the Justices. Interestingly, Bush v. Gore was a per curiam decision.

What is your opinion?

Yep, that’s a shameless bid to appear higher on Google search results, but it’s also a pretty good metaphor for what’s happening in Washington in advance of the Supreme Court oral arguments on the Affordable Care Act–due to be heard March 26, 27 and 28.  Although speculation about how the Justices may rule has been going on for months, the gambling has reached a fever pitch.

Next week is to Court Watchers as the Final Four is to legions of NCAA Division 1 basketball fans: The brackets have been completed; it’s just a question now of who will come out on top.

Alicia Ault/IMNG Medical Media

Conventional wisdom has the Supreme Court splitting along perceived “party lines” in a 5-4 vote either in favor of upholding the law, or against it.

But with the Justices taking on three separate, major issues within the law, Washington wonks, soothsayers, and legal eagles have gone into a frenzy of handicapping. Not a day goes by without a backgrounder or briefing that professes to have the best read on the tea leaves.

The Court, as is its wont, has shied from the limelight. Until today, it had not even determined how it would accommodate the legions of journalists (myself included) who will descend upon the courtroom to cover the historic arguments. Details are still being worked out, but one thing was not going to change: the Court has steadfastly refused to allow audio or video broadcasts of the proceedings. (Which means there cannot be any contests requiring a shot every time the challengers’ attorney, Paul Clement, utters “individual mandate.”) The Court is even banning–heaven forbid–cellphones. That means no pithy Tweets on Justice Clarence Thomas’ enduring silence.

This morning–at a briefing sponsored by Politico–came new predictions from an estimable panel of D.C. insiders: former U.S. Solicitor General Walter Dellinger, Neal Katyal, Al Gore’s co-counsel at the Court in Bush v. Gore,  Tom Goldstein, a former Court clerk and publisher of Scotusblog, Kevin Walsh, a former clerk to Justice Antonin Scalia, and Nina Totenberg, the veteran Court correspondent for NPR.

Alicia Ault/IMNG Medical Media

The Justices to watch, said Ms. Totenberg: Anthony Kennedy and Chief Justice John Roberts. They are both widely considered swing votes. Some have also have put Justice Scalia in that camp, “which I personally think is a crock,” Ms. Totenberg said. Mr. Katyal said that Samuel Alito could also be “in play.”

Will politics come into play? Justices “have a grasp of politics that defies imagination in terms of its inaccuracy,” said Ms. Totenberg, who, like the others discounted the idea that the Justices would be influenced–or motivated–to vote in one direction or another based on the prevailing political winds.

The panel was unanimous–except for Ms. Totenberg, who recused herself from making a wager–in its opinion that the Court would uphold the law, most likely in its entirety.

Mr.  Goldstein said he could not effectively imagine a victory by the law’s challengers. If the Justices threw out the Act, it “would lead to probably an array of attacks on different parts of the federal regulatory state because for the first time you would have had five justices that take very seriously limits on congressional power,” he said.

By the end of next week, the Court will likely hold one closed-door conference and a series of votes, said Mr. Walsh.

He and the other panelists went out on a limb, saying that the 5-4 prediction may no longer hold.  Mr. Goldstein said it could even be a 6-3 or 7-2 ruling upholding the law.

So who will write the opinion, expected to be issued in June? Mr. Dellinger predicted that it would be Justice Roberts. Mr. Goldstein, however, said this might be the rare case where the Court issues a per curiam opinion–that is, written in the name of the Court, rather than by any of the Justices. Interestingly, Bush v. Gore was a per curiam decision.

What is your opinion?