Alicia Ault

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

Courtesy of Dr. Ari Laliotis

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation’s almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago’s National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

Many physicians have hesitated to fully embrace the concierge model because it may mean alienating patients.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he also on call.

A few years ago, he decided he wanted off what he calls the “treadmill” and wanted to be “proactive instead of reactive.”

After hearing CCP’s pitch, Dr. Levinson says he was sold, largely because the company’s model would give him an opportunity to keep his existing patients. He and his partner have about 3,500 to 4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice’s patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later. The practice has held one additional meeting since then but has otherwise not sought actively to recruit more patients, he said.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, Dr. Levinson said.

Dr. Levinson said that his office has a separate staff member who’s devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He’s also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he’s capping the number of patients he’ll enroll at 150.

Aside from the revenue boost that’s come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner, he said. The traditional practice patients reap the benefits of his lowered stress levels. Not only is he less rushed, but, he added, “Overall, I’m happier. I enjoy my job more because I’m not beating myself up to make a living.”

Dr. Robert Altbaum, an internist in Westport, Conn., said that he’s also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. They’ve been a part of the community for 60 years. Dr. Altbaum said that he wanted to keep his place in the community and his obligation to his patients.

Ironically, a few years later, some of the practice’s patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, 4 of the 7 partners decided to give it a try a year ago.

Dr. Altbaum said he’s limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day –which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it’s made him more available to his other patients because, in a sense, he’s now seeing 100 fewer patients.

His practice also has a concierge-specific staff person. But when she’s not busy, she helps the rest of the office staff, Dr. Altbaum said.

All his patients are “uniformly happy,” he said, adding that he’s more relaxed.

And, he said, he’s more secure that he can “continue medicine the way I want to practice.”

Disclosures: Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

Courtesy of Dr. Ari Laliotis

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation’s almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago’s National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

Many physicians have hesitated to fully embrace the concierge model because it may mean alienating patients.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he also on call.

A few years ago, he decided he wanted off what he calls the “treadmill” and wanted to be “proactive instead of reactive.”

After hearing CCP’s pitch, Dr. Levinson says he was sold, largely because the company’s model would give him an opportunity to keep his existing patients. He and his partner have about 3,500 to 4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice’s patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later. The practice has held one additional meeting since then but has otherwise not sought actively to recruit more patients, he said.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, Dr. Levinson said.

Dr. Levinson said that his office has a separate staff member who’s devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He’s also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he’s capping the number of patients he’ll enroll at 150.

Aside from the revenue boost that’s come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner, he said. The traditional practice patients reap the benefits of his lowered stress levels. Not only is he less rushed, but, he added, “Overall, I’m happier. I enjoy my job more because I’m not beating myself up to make a living.”

Dr. Robert Altbaum, an internist in Westport, Conn., said that he’s also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. They’ve been a part of the community for 60 years. Dr. Altbaum said that he wanted to keep his place in the community and his obligation to his patients.

Ironically, a few years later, some of the practice’s patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, 4 of the 7 partners decided to give it a try a year ago.

Dr. Altbaum said he’s limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day –which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it’s made him more available to his other patients because, in a sense, he’s now seeing 100 fewer patients.

His practice also has a concierge-specific staff person. But when she’s not busy, she helps the rest of the office staff, Dr. Altbaum said.

All his patients are “uniformly happy,” he said, adding that he’s more relaxed.

And, he said, he’s more secure that he can “continue medicine the way I want to practice.”

Disclosures: Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

Courtesy of Dr. Ari Laliotis

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation’s almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago’s National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

Many physicians have hesitated to fully embrace the concierge model because it may mean alienating patients.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he also on call.

A few years ago, he decided he wanted off what he calls the “treadmill” and wanted to be “proactive instead of reactive.”

After hearing CCP’s pitch, Dr. Levinson says he was sold, largely because the company’s model would give him an opportunity to keep his existing patients. He and his partner have about 3,500 to 4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice’s patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later. The practice has held one additional meeting since then but has otherwise not sought actively to recruit more patients, he said.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, Dr. Levinson said.

Dr. Levinson said that his office has a separate staff member who’s devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He’s also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he’s capping the number of patients he’ll enroll at 150.

Aside from the revenue boost that’s come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner, he said. The traditional practice patients reap the benefits of his lowered stress levels. Not only is he less rushed, but, he added, “Overall, I’m happier. I enjoy my job more because I’m not beating myself up to make a living.”

Dr. Robert Altbaum, an internist in Westport, Conn., said that he’s also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. They’ve been a part of the community for 60 years. Dr. Altbaum said that he wanted to keep his place in the community and his obligation to his patients.

Ironically, a few years later, some of the practice’s patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, 4 of the 7 partners decided to give it a try a year ago.

Dr. Altbaum said he’s limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day –which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it’s made him more available to his other patients because, in a sense, he’s now seeing 100 fewer patients.

His practice also has a concierge-specific staff person. But when she’s not busy, she helps the rest of the office staff, Dr. Altbaum said.

All his patients are “uniformly happy,” he said, adding that he’s more relaxed.

And, he said, he’s more secure that he can “continue medicine the way I want to practice.”

Disclosures: Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

Courtesy of Dr. Ari Laliotis

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation’s almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago’s National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

Many physicians have hesitated to fully embrace the concierge model because it may mean alienating patients.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he also on call.

A few years ago, he decided he wanted off what he calls the “treadmill” and wanted to be “proactive instead of reactive.”

After hearing CCP’s pitch, Dr. Levinson says he was sold, largely because the company’s model would give him an opportunity to keep his existing patients. He and his partner have about 3,500 to 4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice’s patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later. The practice has held one additional meeting since then but has otherwise not sought actively to recruit more patients, he said.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, Dr. Levinson said.

Dr. Levinson said that his office has a separate staff member who’s devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He’s also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he’s capping the number of patients he’ll enroll at 150.

Aside from the revenue boost that’s come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner, he said. The traditional practice patients reap the benefits of his lowered stress levels. Not only is he less rushed, but, he added, “Overall, I’m happier. I enjoy my job more because I’m not beating myself up to make a living.”

Dr. Robert Altbaum, an internist in Westport, Conn., said that he’s also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. They’ve been a part of the community for 60 years. Dr. Altbaum said that he wanted to keep his place in the community and his obligation to his patients.

Ironically, a few years later, some of the practice’s patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, 4 of the 7 partners decided to give it a try a year ago.

Dr. Altbaum said he’s limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day –which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it’s made him more available to his other patients because, in a sense, he’s now seeing 100 fewer patients.

His practice also has a concierge-specific staff person. But when she’s not busy, she helps the rest of the office staff, Dr. Altbaum said.

All his patients are “uniformly happy,” he said, adding that he’s more relaxed.

And, he said, he’s more secure that he can “continue medicine the way I want to practice.”

Disclosures: Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

Courtesy of Dr. Ari Laliotis

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation’s almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago’s National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

Many physicians have hesitated to fully embrace the concierge model because it may mean alienating patients.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he also on call.

A few years ago, he decided he wanted off what he calls the “treadmill” and wanted to be “proactive instead of reactive.”

After hearing CCP’s pitch, Dr. Levinson says he was sold, largely because the company’s model would give him an opportunity to keep his existing patients. He and his partner have about 3,500 to 4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice’s patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later. The practice has held one additional meeting since then but has otherwise not sought actively to recruit more patients, he said.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, Dr. Levinson said.

Dr. Levinson said that his office has a separate staff member who’s devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He’s also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he’s capping the number of patients he’ll enroll at 150.

Aside from the revenue boost that’s come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner, he said. The traditional practice patients reap the benefits of his lowered stress levels. Not only is he less rushed, but, he added, “Overall, I’m happier. I enjoy my job more because I’m not beating myself up to make a living.”

Dr. Robert Altbaum, an internist in Westport, Conn., said that he’s also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. They’ve been a part of the community for 60 years. Dr. Altbaum said that he wanted to keep his place in the community and his obligation to his patients.

Ironically, a few years later, some of the practice’s patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, 4 of the 7 partners decided to give it a try a year ago.

Dr. Altbaum said he’s limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day –which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it’s made him more available to his other patients because, in a sense, he’s now seeing 100 fewer patients.

His practice also has a concierge-specific staff person. But when she’s not busy, she helps the rest of the office staff, Dr. Altbaum said.

All his patients are “uniformly happy,” he said, adding that he’s more relaxed.

And, he said, he’s more secure that he can “continue medicine the way I want to practice.”

Disclosures: Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

Some physicians looking for the steady income and slower pace of concierge medicine who have not wanted to give up their traditional practice have found a new solution: a hybrid practice that lets them devote a small percentage to the retainer side while keeping their roster of traditional patients.

Courtesy of Dr. Ari Laliotis

So far, the full concierge model has not proven to be very popular. Only a tiny fraction of the nation’s almost 1 million physicians have chosen the concierge route, according to a recent study for the Medicare Payment Advisory Commission (MedPAC).

Researchers at the University of Chicago’s National Opinion Research Center and Georgetown University determined that about 750 physicians have gone to such retainer-only practices in which patients pay a monthly fee in exchange for longer appointments, same-day appointments, annual physicals, and the ability to reach the physician directly by e-mail or cell phone.

Many physicians have hesitated to fully embrace the concierge model because it may mean alienating patients.

The hybrid model is being promoted as an alternative by Concierge Choice Physicians, a Rockville Centre, N.Y.–based private company. CCP says more than 300,000 traditional and concierge patients are being managed by physicians who have contracts with the company.

Dr. Gary Levinson, an internist in private practice in San Diego, is one of the physicians who has chosen to try a hybrid approach with CCP. Dr. Levinson said that he was looking for a way to spend more time with patients; besides a busy office practice, he also on call.

A few years ago, he decided he wanted off what he calls the “treadmill” and wanted to be “proactive instead of reactive.”

After hearing CCP’s pitch, Dr. Levinson says he was sold, largely because the company’s model would give him an opportunity to keep his existing patients. He and his partner have about 3,500 to 4,000 patients. Of those, less than 100 are in the concierge practice. These patients pay $1,800 a year for an annual physical (the practice bears the costs of all diagnostics), faster and longer appointments, and direct access to the physicians.

Initially, CCP mailed letters to the practice’s patients to let them know there was a new concierge option and invited them to meet with Dr. Levinson and his partner over two evening sessions. At those sessions, the physicians described why they went into medicine, and what they saw as the merits of the concierge practice, Dr. Levinson said. Some patients signed up on the spot, while others joined later. The practice has held one additional meeting since then but has otherwise not sought actively to recruit more patients, he said.

So what kinds of patients signed up? Some have serious chronic illnesses, but others are just more proactive about their health, Dr. Levinson said.

Dr. Levinson said that his office has a separate staff member who’s devoted to concierge patients. An hour each morning is blocked for the concierge patients; if the slot is unused, Dr. Levinson takes advantage of the time to catch up on paperwork or uses it to accommodate a non–concierge patient.

He’s also found that the concierge patients do not abuse the 24/7 personal access. So, while it could be a burden, it has ended up being completely manageable, he said.

Even so, to keep an appropriate balance between the concierge side and traditional practice, he’s capping the number of patients he’ll enroll at 150.

Aside from the revenue boost that’s come with the hybrid model, everyone – from his staff, to his patients, to himself – is happier, Dr. Levinson noted. He gets to know the concierge patients better, which makes him a sharper practitioner, he said. The traditional practice patients reap the benefits of his lowered stress levels. Not only is he less rushed, but, he added, “Overall, I’m happier. I enjoy my job more because I’m not beating myself up to make a living.”

Dr. Robert Altbaum, an internist in Westport, Conn., said that he’s also been a lot happier since adopting the CCP hybrid approach. He first began looking at a concierge model about 8 years ago when Medicare physician fee cuts appeared to be something that could happen.

But he and his six partners decided to table the idea because they worried that they would lose too many patients. They’ve been a part of the community for 60 years. Dr. Altbaum said that he wanted to keep his place in the community and his obligation to his patients.

Ironically, a few years later, some of the practice’s patients started migrating to a concierge model.

The partners started searching again for a way to fend off Medicare cuts and better serve patients. After reading about the hybrid approach, 4 of the 7 partners decided to give it a try a year ago.

Dr. Altbaum said he’s limited his concierge patients to 5% of his practice, or 100 patients. He comes in a half hour earlier and leaves a half hour later – concierge patients get the first and last slots of the day –which has added 5 hours to his week.

He has given up what used to be a day off, but, it has added 20% to his bottom line for about 10% of his time. And, he said it’s made him more available to his other patients because, in a sense, he’s now seeing 100 fewer patients.

His practice also has a concierge-specific staff person. But when she’s not busy, she helps the rest of the office staff, Dr. Altbaum said.

All his patients are “uniformly happy,” he said, adding that he’s more relaxed.

And, he said, he’s more secure that he can “continue medicine the way I want to practice.”

Disclosures: Dr. Altbaum and Dr. Levinson both reported no conflicts of interest.

A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.

The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill’s introduction in the state Senate (S. 4498 and A. 7617) to its signing.

Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It’s a nice thought, but I don’t know how they’re going to put it into effect.”

Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient’s legal rights to comprehensive pain and symptom management at the end of life.”

The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.

There is no reimbursement offered for the required services.

Because it is an amendment to the state’s public health law, violations of the new law could result in penalties or fines. It’s not clear how it will be enforced or what might trigger the penalties; the health department has until the law’s effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.

That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.

The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients’ wishes aren’t being respected, to the detriment of both patients and the practice of medicine.

The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.

Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.

She said she wasn’t sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.

The law will be positive, however, she said. Palliative care won’t just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.

But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It’s a very hard discussion to have; it’s not something doctors are trained to do.”

A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.

Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society’s senior vice president for legislative and regulatory affairs.

Mandating that information be given on palliative care “may undermine the patient’s belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.

The medical society also said that physicians are not licensed to provide legal advice in areas such as pain or symptom management, and that they may not know what they are supposed to be communicating to patients under certain provisions, while still being subject to penalties.

Although the medical society might object to requiring any such talk, both Dr. Flansbaum and Dr. Edwards said that, realistically, the law should be requiring palliative care to be offered sooner in the disease process and to a broader group of patients, such as those who have chronic life-limiting conditions such as heart failure.

“By the time you’re invoking palliative care in terminal patients, you’re behind the curve,” said Dr. Flansbaum.

A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.

The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill’s introduction in the state Senate (S. 4498 and A. 7617) to its signing.

Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It’s a nice thought, but I don’t know how they’re going to put it into effect.”

Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient’s legal rights to comprehensive pain and symptom management at the end of life.”

The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.

There is no reimbursement offered for the required services.

Because it is an amendment to the state’s public health law, violations of the new law could result in penalties or fines. It’s not clear how it will be enforced or what might trigger the penalties; the health department has until the law’s effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.

That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.

The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients’ wishes aren’t being respected, to the detriment of both patients and the practice of medicine.

The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.

Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.

She said she wasn’t sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.

The law will be positive, however, she said. Palliative care won’t just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.

But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It’s a very hard discussion to have; it’s not something doctors are trained to do.”

A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.

Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society’s senior vice president for legislative and regulatory affairs.

Mandating that information be given on palliative care “may undermine the patient’s belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.

The medical society also said that physicians are not licensed to provide legal advice in areas such as pain or symptom management, and that they may not know what they are supposed to be communicating to patients under certain provisions, while still being subject to penalties.

Although the medical society might object to requiring any such talk, both Dr. Flansbaum and Dr. Edwards said that, realistically, the law should be requiring palliative care to be offered sooner in the disease process and to a broader group of patients, such as those who have chronic life-limiting conditions such as heart failure.

“By the time you’re invoking palliative care in terminal patients, you’re behind the curve,” said Dr. Flansbaum.

A new law requiring New York physicians to discuss palliative care and end-of-life options with terminally ill patients is well intentioned, but may not do much to change clinical practice or institutional culture, according to some observers in the state.

The New York Palliative Care Information Act was signed into law by Gov. David Paterson (D) in August. Perhaps as a sign that palliative care is being embraced more readily and becoming better understood, it took just 14 months from the bill’s introduction in the state Senate (S. 4498 and A. 7617) to its signing.

Even so, “whether or not it will change behavior is a bit of a black box,” said Dr. Bradley Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York. “It’s a nice thought, but I don’t know how they’re going to put it into effect.”

Under the law, physicians and nurse practitioners are required to provide a patient who has less than 6 months to live with information and counseling on palliative care and end-of-life options, including, “the range of options appropriate to the patient, the prognosis, risks and benefits of the various options, and the patient’s legal rights to comprehensive pain and symptom management at the end of life.”

The physician or nurse practitioner can refer the patient to another provider who is willing to meet the legal statute or who is “professionally qualified” to offer the services.

There is no reimbursement offered for the required services.

Because it is an amendment to the state’s public health law, violations of the new law could result in penalties or fines. It’s not clear how it will be enforced or what might trigger the penalties; the health department has until the law’s effective date (February 2011) to devise regulations, said David Leven, executive director of Compassion and Choices of New York.

That advocacy group helped devise the proposal and then shepherded it though the legislature, said Mr. Leven. California has a similar statute, but is not as strong because it does not put the onus on physicians, he said.

The organization sought the legislation because even with increased training on end-of-life issues, too few physicians are having conversations with their dying patients, Mr. Leven said. That means patients’ wishes aren’t being respected, to the detriment of both patients and the practice of medicine.

The organization also hoped that the law would be a catalyst to improving end-of-life education in medical school and at the professional level, he said.

Dr. Wendy Edwards, director of the palliative medicine program at Lenox Hill, said that education would be a key component, but there appeared to be no such formal requirements in the law. About 15 years ago, she was part of a group that attempted to get a bill passed to mandate the teaching of palliative care in medical schools, but it did not get anywhere.

She said she wasn’t sure that the new law was the way to increase attention to palliative care, but that it had likely come about as a result of frustration and impatience on the part of palliative specialists.

The law will be positive, however, she said. Palliative care won’t just be the standard of care, but will be the law, which gives some backing to hospitals that seek to implement and strengthen their quality of care, and end-of-life care in particular.

But it still will not make it easier for physicians who do not have experience in palliative care, Dr. Edwards said. “It’s a very hard discussion to have; it’s not something doctors are trained to do.”

A recent study in non–small cell lung cancer patients found that those who were given palliative care at the time of diagnosis had a better quality of life than did those in standard care (N. Engl. J. Med. 2010;363:733-42). This study may do more to advance the field than does the New York law, Dr. Edwards noted.

Although the Hospice and Palliative Care Association of New York State supported the law, the Medical Society of the State of New York did not. The medical society, which represents 25,000 physicians, opposed the law because of concerns that it would interfere with the way each and every doctor navigates through end-of-life situations with each individual patient, said Elizabeth C. Dears, the society’s senior vice president for legislative and regulatory affairs.

Mandating that information be given on palliative care “may undermine the patient’s belief and conviction in prevailing against their disease and undercut the confidence in their treating physician,” said Ms. Dears.

The medical society also said that physicians are not licensed to provide legal advice in areas such as pain or symptom management, and that they may not know what they are supposed to be communicating to patients under certain provisions, while still being subject to penalties.

Although the medical society might object to requiring any such talk, both Dr. Flansbaum and Dr. Edwards said that, realistically, the law should be requiring palliative care to be offered sooner in the disease process and to a broader group of patients, such as those who have chronic life-limiting conditions such as heart failure.

“By the time you’re invoking palliative care in terminal patients, you’re behind the curve,” said Dr. Flansbaum.

WASHINGTON – More than a quarter (28%) of all acute care visits in the United States are made to the emergency department, while 20% of acute care visits are made to subspecialist offices, according to a study released Sept. 7.

Slightly less than half (42%) take place in primary care offices, said lead study author Dr. Stephen R. Pitts, who spoke at a briefing sponsored by the journal Health Affairs.

Photo credit: Alicia Ault/Skin & Allergy News Digital Network

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta. However, the ED is frequently the only option for care, he said, noting that, "too often, patients can't get the care they need, when they need it."

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, Dr. Pitts and his colleagues found.

Uninsured patients received more than half their acute care in EDs, according to the study, which appears in the journal's September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Conversely, patients who presented to their primary care physician’s office for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Seventy-five percent of patients with acute respiratory problems received care in a primary care practice or hospital outpatient department, the authors found.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Previous studies have shown that emergency care accounts for only 3% of all health spending, Dr. Arthur L. Kellermann, a study coauthor, said at the briefing.

"The fact that 3% of our dollars and 4% of our doctors are delivering that percentage of care is not such a bad deal," said Dr. Kellermann, an emergency physician and the Paul O'Neill Alcoa Chair in Policy Analysis at the Rand Corp. But, he said, it might not be the best possible care for patients or the optimum use of dollars for the health system.

In a separate study, Dr. Ateev Mehrotra and his colleagues reported that 14%-27% of ED visits could have been handled at either a retail clinic or an urgent care center. Switching to these alternate sites could save the system $4.4 billion a year, said Dr. Mehrotra of the University of Pittsburgh and a policy analyst at Rand.

The authors determined that most visits for nine common conditions treated at EDs could be switched easily to those alternate sites. Those conditions include upper-respiratory infections; musculoskeletal conditions such as strains, fractures, and back pain; dermatologic conditions; abdominal pain, headache, and other symptoms without a specific diagnosis; urinary tract infections, some chronic illnesses, and psychiatric conditions; lower-respiratory conditions; such minor problems as insect bites and conjunctivitis; and preventive care.

Dr. Mehrotra and his coauthors disclosed that they received funding from the California HealthCare Foundation for their study.

One of Dr. Pitts' coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts

WASHINGTON – More than a quarter (28%) of all acute care visits in the United States are made to the emergency department, while 20% of acute care visits are made to subspecialist offices, according to a study released Sept. 7.

Slightly less than half (42%) take place in primary care offices, said lead study author Dr. Stephen R. Pitts, who spoke at a briefing sponsored by the journal Health Affairs.

Photo credit: Alicia Ault/Skin & Allergy News Digital Network

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta. However, the ED is frequently the only option for care, he said, noting that, "too often, patients can't get the care they need, when they need it."

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, Dr. Pitts and his colleagues found.

Uninsured patients received more than half their acute care in EDs, according to the study, which appears in the journal's September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Conversely, patients who presented to their primary care physician’s office for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Seventy-five percent of patients with acute respiratory problems received care in a primary care practice or hospital outpatient department, the authors found.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Previous studies have shown that emergency care accounts for only 3% of all health spending, Dr. Arthur L. Kellermann, a study coauthor, said at the briefing.

"The fact that 3% of our dollars and 4% of our doctors are delivering that percentage of care is not such a bad deal," said Dr. Kellermann, an emergency physician and the Paul O'Neill Alcoa Chair in Policy Analysis at the Rand Corp. But, he said, it might not be the best possible care for patients or the optimum use of dollars for the health system.

In a separate study, Dr. Ateev Mehrotra and his colleagues reported that 14%-27% of ED visits could have been handled at either a retail clinic or an urgent care center. Switching to these alternate sites could save the system $4.4 billion a year, said Dr. Mehrotra of the University of Pittsburgh and a policy analyst at Rand.

The authors determined that most visits for nine common conditions treated at EDs could be switched easily to those alternate sites. Those conditions include upper-respiratory infections; musculoskeletal conditions such as strains, fractures, and back pain; dermatologic conditions; abdominal pain, headache, and other symptoms without a specific diagnosis; urinary tract infections, some chronic illnesses, and psychiatric conditions; lower-respiratory conditions; such minor problems as insect bites and conjunctivitis; and preventive care.

Dr. Mehrotra and his coauthors disclosed that they received funding from the California HealthCare Foundation for their study.

One of Dr. Pitts' coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts

WASHINGTON – More than a quarter (28%) of all acute care visits in the United States are made to the emergency department, while 20% of acute care visits are made to subspecialist offices, according to a study released Sept. 7.

Slightly less than half (42%) take place in primary care offices, said lead study author Dr. Stephen R. Pitts, who spoke at a briefing sponsored by the journal Health Affairs.

Photo credit: Alicia Ault/Skin & Allergy News Digital Network

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta. However, the ED is frequently the only option for care, he said, noting that, "too often, patients can't get the care they need, when they need it."

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, Dr. Pitts and his colleagues found.

Uninsured patients received more than half their acute care in EDs, according to the study, which appears in the journal's September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Conversely, patients who presented to their primary care physician’s office for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Seventy-five percent of patients with acute respiratory problems received care in a primary care practice or hospital outpatient department, the authors found.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Previous studies have shown that emergency care accounts for only 3% of all health spending, Dr. Arthur L. Kellermann, a study coauthor, said at the briefing.

"The fact that 3% of our dollars and 4% of our doctors are delivering that percentage of care is not such a bad deal," said Dr. Kellermann, an emergency physician and the Paul O'Neill Alcoa Chair in Policy Analysis at the Rand Corp. But, he said, it might not be the best possible care for patients or the optimum use of dollars for the health system.

In a separate study, Dr. Ateev Mehrotra and his colleagues reported that 14%-27% of ED visits could have been handled at either a retail clinic or an urgent care center. Switching to these alternate sites could save the system $4.4 billion a year, said Dr. Mehrotra of the University of Pittsburgh and a policy analyst at Rand.

The authors determined that most visits for nine common conditions treated at EDs could be switched easily to those alternate sites. Those conditions include upper-respiratory infections; musculoskeletal conditions such as strains, fractures, and back pain; dermatologic conditions; abdominal pain, headache, and other symptoms without a specific diagnosis; urinary tract infections, some chronic illnesses, and psychiatric conditions; lower-respiratory conditions; such minor problems as insect bites and conjunctivitis; and preventive care.

Dr. Mehrotra and his coauthors disclosed that they received funding from the California HealthCare Foundation for their study.

One of Dr. Pitts' coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts

WASHINGTON – More than a quarter (28%) of all acute care visits in the United States are made to the emergency department, while slightly less than half (42%) take place in primary care physicians’ offices, according to a study released Sept. 7.

Another 20% of acute care visits are made to subspecialist offices, lead study author Dr. Stephen R. Pitts, who spoke at a briefing sponsored by the journal Health Affairs.

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta. However, the ED is frequently the only option for care, he said, noting that, “too often, patients can’t get the care they need, when they need it, from their family doctor.”

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, Dr. Pitts and his colleagues found.

Uninsured patients received more than half their acute care in EDs, according to the study, which appears in the journal’s September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Conversely, patients who presented to their primary care physician’s office for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Seventy-five percent of patients with acute respiratory problems received care in a primary care practice or hospital outpatient department, the authors found.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Previous studies have shown that emergency care accounts for only 3% of all health spending, Dr. Arthur L. Kellermann, a study coauthor, said at the briefing.

“The fact that 3% of our dollars and 4% of our doctors are delivering that percentage of care is not such a bad deal,” said Dr. Kellermann, an emergency physician and the Paul O’Neill Alcoa Chair in Policy Analysis at the Rand Corp. But, he said, it might not be the best possible care for patients or the optimum use of dollars for the health system.

In a separate study, Dr. Ateev Mehrotra and his colleagues reported that 14%-27% of ED visits could have been handled at either a retail clinic or an urgent care center. Switching to these alternate sites could save the system $4.4 billion a year, said Dr. Mehrotra of the University of Pittsburgh and a policy analyst at Rand.

The authors determined that most visits for nine common conditions treated at EDs could be switched easily to those alternate sites. Those conditions include upper-respiratory infections; musculoskeletal conditions such as strains, fractures, and back pain; dermatologic conditions; abdominal pain, headache, and other symptoms without a specific diagnosis; urinary tract infections, some chronic illnesses, and psychiatric conditions; lower-respiratory conditions; such minor problems as insect bites and conjunctivitis; and preventive care.

Dr. Mehrotra and his coauthors disclosed that they received funding from the California HealthCare Foundation for their study.

One of Dr. Pitts’ coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts.

Dr. Stephen R. Pitts speaks at a briefing. He is an associate professor in the department of emergency medicine, Emory University School of Medicine.

WASHINGTON – More than a quarter (28%) of all acute care visits in the United States are made to the emergency department, while slightly less than half (42%) take place in primary care physicians’ offices, according to a study released Sept. 7.

Another 20% of acute care visits are made to subspecialist offices, lead study author Dr. Stephen R. Pitts, who spoke at a briefing sponsored by the journal Health Affairs.

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta. However, the ED is frequently the only option for care, he said, noting that, “too often, patients can’t get the care they need, when they need it, from their family doctor.”

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, Dr. Pitts and his colleagues found.

Uninsured patients received more than half their acute care in EDs, according to the study, which appears in the journal’s September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Conversely, patients who presented to their primary care physician’s office for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Seventy-five percent of patients with acute respiratory problems received care in a primary care practice or hospital outpatient department, the authors found.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Previous studies have shown that emergency care accounts for only 3% of all health spending, Dr. Arthur L. Kellermann, a study coauthor, said at the briefing.

“The fact that 3% of our dollars and 4% of our doctors are delivering that percentage of care is not such a bad deal,” said Dr. Kellermann, an emergency physician and the Paul O’Neill Alcoa Chair in Policy Analysis at the Rand Corp. But, he said, it might not be the best possible care for patients or the optimum use of dollars for the health system.

In a separate study, Dr. Ateev Mehrotra and his colleagues reported that 14%-27% of ED visits could have been handled at either a retail clinic or an urgent care center. Switching to these alternate sites could save the system $4.4 billion a year, said Dr. Mehrotra of the University of Pittsburgh and a policy analyst at Rand.

The authors determined that most visits for nine common conditions treated at EDs could be switched easily to those alternate sites. Those conditions include upper-respiratory infections; musculoskeletal conditions such as strains, fractures, and back pain; dermatologic conditions; abdominal pain, headache, and other symptoms without a specific diagnosis; urinary tract infections, some chronic illnesses, and psychiatric conditions; lower-respiratory conditions; such minor problems as insect bites and conjunctivitis; and preventive care.

Dr. Mehrotra and his coauthors disclosed that they received funding from the California HealthCare Foundation for their study.

One of Dr. Pitts’ coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts.

Dr. Stephen R. Pitts speaks at a briefing. He is an associate professor in the department of emergency medicine, Emory University School of Medicine.

WASHINGTON – More than a quarter (28%) of all acute care visits in the United States are made to the emergency department, while slightly less than half (42%) take place in primary care physicians’ offices, according to a study released Sept. 7.

Another 20% of acute care visits are made to subspecialist offices, lead study author Dr. Stephen R. Pitts, who spoke at a briefing sponsored by the journal Health Affairs.

It appears that the more severe a complaint, the more likely a patient will seek care in the ED, said Dr. Pitts of the department of medicine at Emory University, Atlanta. However, the ED is frequently the only option for care, he said, noting that, “too often, patients can’t get the care they need, when they need it, from their family doctor.”

Two-thirds of acute care ED occurred on weekends or on weekdays after office hours, Dr. Pitts and his colleagues found.

Uninsured patients received more than half their acute care in EDs, according to the study, which appears in the journal’s September issue.

The authors based their study on data from the three federal surveys of ambulatory medical care in the outpatient, ED, and physician office setting.

Presenting complaints including stomach and abdominal pain, chest pain, and fever dominated the list of what brought patients to the ED. Conversely, patients who presented to their primary care physician’s office for acute care most frequently complained of cough, throat symptoms, rash, and earache.

Seventy-five percent of patients with acute respiratory problems received care in a primary care practice or hospital outpatient department, the authors found.

Overall, emergency physicians took care of 11% of all ambulatory care visits, yet make up only 4% of the physician workforce, the authors said.

Previous studies have shown that emergency care accounts for only 3% of all health spending, Dr. Arthur L. Kellermann, a study coauthor, said at the briefing.

“The fact that 3% of our dollars and 4% of our doctors are delivering that percentage of care is not such a bad deal,” said Dr. Kellermann, an emergency physician and the Paul O’Neill Alcoa Chair in Policy Analysis at the Rand Corp. But, he said, it might not be the best possible care for patients or the optimum use of dollars for the health system.

In a separate study, Dr. Ateev Mehrotra and his colleagues reported that 14%-27% of ED visits could have been handled at either a retail clinic or an urgent care center. Switching to these alternate sites could save the system $4.4 billion a year, said Dr. Mehrotra of the University of Pittsburgh and a policy analyst at Rand.

The authors determined that most visits for nine common conditions treated at EDs could be switched easily to those alternate sites. Those conditions include upper-respiratory infections; musculoskeletal conditions such as strains, fractures, and back pain; dermatologic conditions; abdominal pain, headache, and other symptoms without a specific diagnosis; urinary tract infections, some chronic illnesses, and psychiatric conditions; lower-respiratory conditions; such minor problems as insect bites and conjunctivitis; and preventive care.

Dr. Mehrotra and his coauthors disclosed that they received funding from the California HealthCare Foundation for their study.

One of Dr. Pitts’ coauthors disclosed that she received a training grant from the Centers for Disease Control and Prevention; others reported no conflicts.

Dr. Stephen R. Pitts speaks at a briefing. He is an associate professor in the department of emergency medicine, Emory University School of Medicine.

Allergan agreed on Sept. 1 to plead guilty to charges that it had illegally promoted Botox Therapeutic for uses not approved by the Food and Drug Administration.

The U.S. Department of Justice announced the plea and said that the company would pay a total of $600 million – $375 million in criminal fines and $225 million in a civil settlement with the federal government and all of the states.

The plea came as the result of three lawsuits filed by five “whistle-blowers,” including Dr. Amy Lang, a pain management physician in Lawrenceville, Ga. The whistle-blowers will receive $37.8 million from the federal settlement.

In a statement, the Department of Justice said Allergan had made it a “top corporate priority” to maximize Botox off-label sales. The company was cited for promoting the therapy for headache, pain, spasticity, and juvenile cerebral palsy.

Allergan also held workshops to teach physicians and their staffs how to bill for off-label uses, wined and dined physicians in an effort to encourage off-label use, and “created a purportedly independent online neurotoxin education organization to stimulate increased use of Botox for off-label indications,” according to the statement.

Allergan “demanded tremendous growth in these off-label sales year after year, even when there was little clinical evidence that these uses were effective,” said Sally Q. Yates, U.S. Attorney for the Northern District of Georgia, in a statement. The Georgia district is prosecuting the criminal case.

As a result of the investigation and settlement, Allergan has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services. Under the terms of the 5-year agreement, its board will be charged with reviewing the company’s compliance each year.

The company will also have to post information on its Web site disclosing payments to physicians and send a letter to physicians notifying them about the settlement.

Last fall, Allergan sued the FDA, claiming that restrictions on discussions of off-label use violated the company’s first amendment right to freedom of speech, and its ability to “proactively share truthful and relevant information with the medical community,” according to a company statement.

Allergan agreed on Sept. 1 to plead guilty to charges that it had illegally promoted Botox Therapeutic for uses not approved by the Food and Drug Administration.

The U.S. Department of Justice announced the plea and said that the company would pay a total of $600 million – $375 million in criminal fines and $225 million in a civil settlement with the federal government and all of the states.

The plea came as the result of three lawsuits filed by five “whistle-blowers,” including Dr. Amy Lang, a pain management physician in Lawrenceville, Ga. The whistle-blowers will receive $37.8 million from the federal settlement.

In a statement, the Department of Justice said Allergan had made it a “top corporate priority” to maximize Botox off-label sales. The company was cited for promoting the therapy for headache, pain, spasticity, and juvenile cerebral palsy.

Allergan also held workshops to teach physicians and their staffs how to bill for off-label uses, wined and dined physicians in an effort to encourage off-label use, and “created a purportedly independent online neurotoxin education organization to stimulate increased use of Botox for off-label indications,” according to the statement.

Allergan “demanded tremendous growth in these off-label sales year after year, even when there was little clinical evidence that these uses were effective,” said Sally Q. Yates, U.S. Attorney for the Northern District of Georgia, in a statement. The Georgia district is prosecuting the criminal case.

As a result of the investigation and settlement, Allergan has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services. Under the terms of the 5-year agreement, its board will be charged with reviewing the company’s compliance each year.

The company will also have to post information on its Web site disclosing payments to physicians and send a letter to physicians notifying them about the settlement.

Last fall, Allergan sued the FDA, claiming that restrictions on discussions of off-label use violated the company’s first amendment right to freedom of speech, and its ability to “proactively share truthful and relevant information with the medical community,” according to a company statement.

Allergan agreed on Sept. 1 to plead guilty to charges that it had illegally promoted Botox Therapeutic for uses not approved by the Food and Drug Administration.

The U.S. Department of Justice announced the plea and said that the company would pay a total of $600 million – $375 million in criminal fines and $225 million in a civil settlement with the federal government and all of the states.

The plea came as the result of three lawsuits filed by five “whistle-blowers,” including Dr. Amy Lang, a pain management physician in Lawrenceville, Ga. The whistle-blowers will receive $37.8 million from the federal settlement.

In a statement, the Department of Justice said Allergan had made it a “top corporate priority” to maximize Botox off-label sales. The company was cited for promoting the therapy for headache, pain, spasticity, and juvenile cerebral palsy.

Allergan also held workshops to teach physicians and their staffs how to bill for off-label uses, wined and dined physicians in an effort to encourage off-label use, and “created a purportedly independent online neurotoxin education organization to stimulate increased use of Botox for off-label indications,” according to the statement.

Allergan “demanded tremendous growth in these off-label sales year after year, even when there was little clinical evidence that these uses were effective,” said Sally Q. Yates, U.S. Attorney for the Northern District of Georgia, in a statement. The Georgia district is prosecuting the criminal case.

As a result of the investigation and settlement, Allergan has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services. Under the terms of the 5-year agreement, its board will be charged with reviewing the company’s compliance each year.

The company will also have to post information on its Web site disclosing payments to physicians and send a letter to physicians notifying them about the settlement.

Last fall, Allergan sued the FDA, claiming that restrictions on discussions of off-label use violated the company’s first amendment right to freedom of speech, and its ability to “proactively share truthful and relevant information with the medical community,” according to a company statement.

Allergan agreed on Sept. 1 to plead guilty to charges that it had illegally promoted Botox Therapeutic for uses not approved by the Food and Drug Administration.

The U.S. Department of Justice announced the plea and said that the company would pay a total of $600 million – $375 million in criminal fines and $225 million in a civil settlement with the federal government and all of the states.

The plea came as the result of three lawsuits filed by five “whistle-blowers,” including Dr. Amy Lang, a pain management physician in Lawrenceville, Ga. The whistle-blowers will receive $37.8 million from the federal settlement.

In a statement, the Department of Justice said Allergan had made it a “top corporate priority” to maximize Botox off-label sales. The company was cited for promoting the therapy for headache, pain, spasticity, and juvenile cerebral palsy.

Allergan also held workshops to teach physicians and their staffs how to bill for off-label uses, wined and dined physicians in an effort to encourage off-label use, and “created a purportedly independent online neurotoxin education organization to stimulate increased use of Botox for off-label indications,” according to the statement.

Allergan “demanded tremendous growth in these off-label sales year after year, even when there was little clinical evidence that these uses were effective,” said Sally Q. Yates, U.S. Attorney for the Northern District of Georgia, in a statement. The Georgia district is prosecuting the criminal case.

As a result of the investigation and settlement, Allergan has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services. Under the terms of the 5-year agreement, its board will be charged with reviewing the company’s compliance each year.

The company will also have to post information on its Web site disclosing payments to physicians and send a letter to physicians notifying them about the settlement.

Last fall, Allergan sued the FDA, claiming that restrictions on discussions of off-label use violated the company’s first amendment right to freedom of speech, and its ability to “proactively share truthful and relevant information with the medical community,” according to a company statement.

Allergan agreed on Sept. 1 to plead guilty to charges that it had illegally promoted Botox Therapeutic for uses not approved by the Food and Drug Administration.

The U.S. Department of Justice announced the plea and said that the company would pay a total of $600 million – $375 million in criminal fines and $225 million in a civil settlement with the federal government and all of the states.

The plea came as the result of three lawsuits filed by five “whistle-blowers,” including Dr. Amy Lang, a pain management physician in Lawrenceville, Ga. The whistle-blowers will receive $37.8 million from the federal settlement.

In a statement, the Department of Justice said Allergan had made it a “top corporate priority” to maximize Botox off-label sales. The company was cited for promoting the therapy for headache, pain, spasticity, and juvenile cerebral palsy.

Allergan also held workshops to teach physicians and their staffs how to bill for off-label uses, wined and dined physicians in an effort to encourage off-label use, and “created a purportedly independent online neurotoxin education organization to stimulate increased use of Botox for off-label indications,” according to the statement.

Allergan “demanded tremendous growth in these off-label sales year after year, even when there was little clinical evidence that these uses were effective,” said Sally Q. Yates, U.S. Attorney for the Northern District of Georgia, in a statement. The Georgia district is prosecuting the criminal case.

As a result of the investigation and settlement, Allergan has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services. Under the terms of the 5-year agreement, its board will be charged with reviewing the company’s compliance each year.

The company will also have to post information on its Web site disclosing payments to physicians and send a letter to physicians notifying them about the settlement.

Last fall, Allergan sued the FDA, claiming that restrictions on discussions of off-label use violated the company’s first amendment right to freedom of speech, and its ability to “proactively share truthful and relevant information with the medical community,” according to a company statement.

Allergan agreed on Sept. 1 to plead guilty to charges that it had illegally promoted Botox Therapeutic for uses not approved by the Food and Drug Administration.

The U.S. Department of Justice announced the plea and said that the company would pay a total of $600 million – $375 million in criminal fines and $225 million in a civil settlement with the federal government and all of the states.

The plea came as the result of three lawsuits filed by five “whistle-blowers,” including Dr. Amy Lang, a pain management physician in Lawrenceville, Ga. The whistle-blowers will receive $37.8 million from the federal settlement.

In a statement, the Department of Justice said Allergan had made it a “top corporate priority” to maximize Botox off-label sales. The company was cited for promoting the therapy for headache, pain, spasticity, and juvenile cerebral palsy.

Allergan also held workshops to teach physicians and their staffs how to bill for off-label uses, wined and dined physicians in an effort to encourage off-label use, and “created a purportedly independent online neurotoxin education organization to stimulate increased use of Botox for off-label indications,” according to the statement.

Allergan “demanded tremendous growth in these off-label sales year after year, even when there was little clinical evidence that these uses were effective,” said Sally Q. Yates, U.S. Attorney for the Northern District of Georgia, in a statement. The Georgia district is prosecuting the criminal case.

As a result of the investigation and settlement, Allergan has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services. Under the terms of the 5-year agreement, its board will be charged with reviewing the company’s compliance each year.

The company will also have to post information on its Web site disclosing payments to physicians and send a letter to physicians notifying them about the settlement.

Last fall, Allergan sued the FDA, claiming that restrictions on discussions of off-label use violated the company’s first amendment right to freedom of speech, and its ability to “proactively share truthful and relevant information with the medical community,” according to a company statement.

The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty.

The 16-member ACGME task force that wrote the standards will review public comments and make any modifications considered necessary before July 2011, when the new standards will go into effect.

The original ACGME standards, established in 2003, have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.

According to the latest report, written by Dr. Thomas J. Nasca, Dr. Susan H. Day, and Dr. E. Stephen Amis Jr. on behalf of the ACGME task force, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:

▸ The limits on duty hours may have created a shift mentality among residents, which tends to conflict with the duty to serve patients.

▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.

▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.

In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.

The ACGME convened the task force to consider the IOM recommendations. One of the biggest challenges, according to the authors, was to reconcile the IOM's suggestion for an across-the-board restriction on duty hours with the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]).

For surgery, in particular, it would be difficult—and contrary to learning—to have a resident leave in the midst of a procedure because his or her duty hours had been reached.

The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors, as has been suggested by many critics of the duty hour standards.

According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm for the first year of residency, whereby residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision.

All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs—an area of concern for patient safety.

The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty.”

The IOM had also criticized the ACGME for not properly enforcing the duty hours. The task force said that enforcement is an “inherent” challenge, partly because there are some 9,000 accredited programs. However, the ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems.

Wake Up Doctor, a coalition of public interest and patient safety groups that has been pushing the ACGME to further restrict resident hours, said that the new standards don't go far enough. The group gave the ACGME an “F” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents.

The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty.

The 16-member ACGME task force that wrote the standards will review public comments and make any modifications considered necessary before July 2011, when the new standards will go into effect.

The original ACGME standards, established in 2003, have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.

According to the latest report, written by Dr. Thomas J. Nasca, Dr. Susan H. Day, and Dr. E. Stephen Amis Jr. on behalf of the ACGME task force, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:

▸ The limits on duty hours may have created a shift mentality among residents, which tends to conflict with the duty to serve patients.

▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.

▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.

In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.

The ACGME convened the task force to consider the IOM recommendations. One of the biggest challenges, according to the authors, was to reconcile the IOM's suggestion for an across-the-board restriction on duty hours with the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]).

For surgery, in particular, it would be difficult—and contrary to learning—to have a resident leave in the midst of a procedure because his or her duty hours had been reached.

The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors, as has been suggested by many critics of the duty hour standards.

According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm for the first year of residency, whereby residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision.

All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs—an area of concern for patient safety.

The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty.”

The IOM had also criticized the ACGME for not properly enforcing the duty hours. The task force said that enforcement is an “inherent” challenge, partly because there are some 9,000 accredited programs. However, the ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems.

Wake Up Doctor, a coalition of public interest and patient safety groups that has been pushing the ACGME to further restrict resident hours, said that the new standards don't go far enough. The group gave the ACGME an “F” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents.

The Accreditation Council for Graduate Medical Education has revisited its standards for resident duty hours and determined that some modifications should be made, mostly for first-year residents. All other residents should still be subject to an 80-hour work week and up to 24 hours of continuous duty.

The 16-member ACGME task force that wrote the standards will review public comments and make any modifications considered necessary before July 2011, when the new standards will go into effect.

The original ACGME standards, established in 2003, have been the subject of much consternation in the medical community, with opinions differing over whether they have been too restrictive or too loose to properly protect patients and ensure a good quality of life for residents.

According to the latest report, written by Dr. Thomas J. Nasca, Dr. Susan H. Day, and Dr. E. Stephen Amis Jr. on behalf of the ACGME task force, the 2003 standards had the following three “problematic” elements, as identified by the educational community and the public:

▸ The limits on duty hours may have created a shift mentality among residents, which tends to conflict with the duty to serve patients.

▸ Many academic programs began focusing on meeting the duty hour restrictions, perhaps at the expense of education.

▸ The 80-hour work week, with up to 24 hours of continuous duty, was seen by many as compromising patient safety.

In 2008, the Institute of Medicine took a hard look at the ACGME standards and, among other things, recommended that no residents should exceed 16 hours of continuous duty.

The ACGME convened the task force to consider the IOM recommendations. One of the biggest challenges, according to the authors, was to reconcile the IOM's suggestion for an across-the-board restriction on duty hours with the continuing plea from academic programs that duty hours needed to be tailored to each specialty (N. Engl. J. Med. 2010 [doi:10.1056/NEJMsb1005800]).

For surgery, in particular, it would be difficult—and contrary to learning—to have a resident leave in the midst of a procedure because his or her duty hours had been reached.

The ACGME panel also had to weigh whether there was sufficient evidence to show that working more than 16 hours or up to 30 hours continuously led to more medical errors, as has been suggested by many critics of the duty hour standards.

According to the ACGME panel, the data thus far indicate only that first-year residents are more prone to mistakes as a result of sleep deprivation. Therefore, the task force urged a new paradigm for the first year of residency, whereby residents cannot be on duty for longer than 16 hours continuously and should have 10 hours off and 8 hours free of duty between their scheduled duty periods. First-year residents are not allowed to moonlight, and they must have direct, in-house, attending-level supervision.

All residents are allowed to work up to an additional 4 hours to facilitate patient handoffs—an area of concern for patient safety.

The panel decided not to tailor duty hours to specialties “because studies have not shown that the safety effect of current standards varies with specialty.”

The IOM had also criticized the ACGME for not properly enforcing the duty hours. The task force said that enforcement is an “inherent” challenge, partly because there are some 9,000 accredited programs. However, the ACGME is now undertaking annual site visits and analyzing whether institutions can comply. Eventually, the organization will give each institution a report on its compliance status and recommendations for resolving problems.

Wake Up Doctor, a coalition of public interest and patient safety groups that has been pushing the ACGME to further restrict resident hours, said that the new standards don't go far enough. The group gave the ACGME an “F” for failing to comply with the IOM recommendation that continuous duty be restricted to 16 hours for all residents.

Imaging Project to Close Bids

The Centers for Medicare and Medicaid Services is about to close off bids from physician groups wishing to participate in a Medicare demonstration project to test whether real-time decision-support systems ensure appropriate use of imaging, improve quality of care, and reduce radiation exposure. Participating practices will be paid for reporting data. The project will cover SPECT-MPI, MRI, and CT of the lumbar spine; MRI and CT of the brain; CT of the sinus, abdomen, and pelvis; and MRI of the knee and shoulder. All these exams are covered by specialty society guidelines that can be part of the systems, and they account for high use and costs among Medicare enrollees. Applications must be submitted by Sept. 21.

Bill Targets Radiation Dose

Sen. Mike Enzi (R-Wyo.) and Sen. Tom Harkin (D-Iowa) have introduced a proposal to create education and credentialing standards for people who deliver radiation therapy and imaging procedures to Medicare patients. The CARE (Consistency, Accuracy, Responsibility, and Excellence) in Medical Imaging and Radiation Therapy Act, S. 3737, would, however, grandfather in technicians and others who do not meet the bill's standards. “This bill will reduce the risk of medical errors associated with misdiagnosis or inappropriate exposure to medical radiation, and save millions of health care dollars by decreasing the number of examinations that must be repeated due to poor quality,” said Sen. Harkin in a statement. The CARE act was first introduced in September 2009 in the House, as H.R. 3652, by Rep. John Barrow (D-Ga.).

CABG Mortality Down

The Agency for Healthcare Research and Quality says that there was a huge decline in mortality among patients undergoing coronary artery bypass graft surgery from 2000 to 2006. In 2000, the death rate was 42 per 1,000 admissions; 6 years later, it had declined to 24 per 1,000. Women still had higher mortality (36 per 1,000) than men (21 per 1,000), and, despite a 92% decline in the death rate, rural hospitals still posted a 38 per 1,000 mortality figure in 2006. There were few differences in death rates among whites, African Americans, and Hispanics. Perhaps surprisingly, uninsured patients had the lowest death rate by insurance status, 23 per 1,000. Medicaid patients had the highest, at 29 per 1,000. The data are contained in the 2009 National Healthcare Quality and Disparities Report, published by the agency.

Low Income Trumps Race in Risk

An epidemiological study by researchers at the University of California, Los Angeles has shown that socioeconomic status is a bigger risk factor in cardiovascular disease than is race or ethnicity. The researchers looked at data on 12,154 people from the National Health and Nutrition Examination Survey (2001-2006), focusing on 10-year risk for coronary heart disease as predicted by National Cholesterol Education Program Adult Treatment Panel III guidelines. People with a lower socioeconomic status turned out to have a higher risk of cardiovascular disease, regardless of race or ethnicity. Most of the increase comes from greater rates of smoking and less physical activity in low-income/low-education groups. The National Institutes of Health–funded study appeared in the August issue of the Annals of Epidemiology.

Hypothermia Therapy Going Mobile

New York City's paramedics are now using hypothermia therapy on eligible cardiac arrest patients outside hospitals. In cooperation with Greater New York Hospital Association, Emergency Medical Service personnel have begun administering cold intravenous liquids to people in cardiac arrest who have not responded to CPR or a defibrillator. The treatment was already being used in city hospitals, where it has saved “hundreds of lives during the past 18 months,” according to a statement from the City Health and Hospitals Corporation. Since the in-hospital project began in January 2009, there has been a 20% increase in survival of arrest patients admitted after being stabilized in emergency departments, the statement said.

Imaging Project to Close Bids

The Centers for Medicare and Medicaid Services is about to close off bids from physician groups wishing to participate in a Medicare demonstration project to test whether real-time decision-support systems ensure appropriate use of imaging, improve quality of care, and reduce radiation exposure. Participating practices will be paid for reporting data. The project will cover SPECT-MPI, MRI, and CT of the lumbar spine; MRI and CT of the brain; CT of the sinus, abdomen, and pelvis; and MRI of the knee and shoulder. All these exams are covered by specialty society guidelines that can be part of the systems, and they account for high use and costs among Medicare enrollees. Applications must be submitted by Sept. 21.

Bill Targets Radiation Dose

Sen. Mike Enzi (R-Wyo.) and Sen. Tom Harkin (D-Iowa) have introduced a proposal to create education and credentialing standards for people who deliver radiation therapy and imaging procedures to Medicare patients. The CARE (Consistency, Accuracy, Responsibility, and Excellence) in Medical Imaging and Radiation Therapy Act, S. 3737, would, however, grandfather in technicians and others who do not meet the bill's standards. “This bill will reduce the risk of medical errors associated with misdiagnosis or inappropriate exposure to medical radiation, and save millions of health care dollars by decreasing the number of examinations that must be repeated due to poor quality,” said Sen. Harkin in a statement. The CARE act was first introduced in September 2009 in the House, as H.R. 3652, by Rep. John Barrow (D-Ga.).

CABG Mortality Down

The Agency for Healthcare Research and Quality says that there was a huge decline in mortality among patients undergoing coronary artery bypass graft surgery from 2000 to 2006. In 2000, the death rate was 42 per 1,000 admissions; 6 years later, it had declined to 24 per 1,000. Women still had higher mortality (36 per 1,000) than men (21 per 1,000), and, despite a 92% decline in the death rate, rural hospitals still posted a 38 per 1,000 mortality figure in 2006. There were few differences in death rates among whites, African Americans, and Hispanics. Perhaps surprisingly, uninsured patients had the lowest death rate by insurance status, 23 per 1,000. Medicaid patients had the highest, at 29 per 1,000. The data are contained in the 2009 National Healthcare Quality and Disparities Report, published by the agency.

Low Income Trumps Race in Risk

An epidemiological study by researchers at the University of California, Los Angeles has shown that socioeconomic status is a bigger risk factor in cardiovascular disease than is race or ethnicity. The researchers looked at data on 12,154 people from the National Health and Nutrition Examination Survey (2001-2006), focusing on 10-year risk for coronary heart disease as predicted by National Cholesterol Education Program Adult Treatment Panel III guidelines. People with a lower socioeconomic status turned out to have a higher risk of cardiovascular disease, regardless of race or ethnicity. Most of the increase comes from greater rates of smoking and less physical activity in low-income/low-education groups. The National Institutes of Health–funded study appeared in the August issue of the Annals of Epidemiology.

Hypothermia Therapy Going Mobile

New York City's paramedics are now using hypothermia therapy on eligible cardiac arrest patients outside hospitals. In cooperation with Greater New York Hospital Association, Emergency Medical Service personnel have begun administering cold intravenous liquids to people in cardiac arrest who have not responded to CPR or a defibrillator. The treatment was already being used in city hospitals, where it has saved “hundreds of lives during the past 18 months,” according to a statement from the City Health and Hospitals Corporation. Since the in-hospital project began in January 2009, there has been a 20% increase in survival of arrest patients admitted after being stabilized in emergency departments, the statement said.

Imaging Project to Close Bids

The Centers for Medicare and Medicaid Services is about to close off bids from physician groups wishing to participate in a Medicare demonstration project to test whether real-time decision-support systems ensure appropriate use of imaging, improve quality of care, and reduce radiation exposure. Participating practices will be paid for reporting data. The project will cover SPECT-MPI, MRI, and CT of the lumbar spine; MRI and CT of the brain; CT of the sinus, abdomen, and pelvis; and MRI of the knee and shoulder. All these exams are covered by specialty society guidelines that can be part of the systems, and they account for high use and costs among Medicare enrollees. Applications must be submitted by Sept. 21.

Bill Targets Radiation Dose

Sen. Mike Enzi (R-Wyo.) and Sen. Tom Harkin (D-Iowa) have introduced a proposal to create education and credentialing standards for people who deliver radiation therapy and imaging procedures to Medicare patients. The CARE (Consistency, Accuracy, Responsibility, and Excellence) in Medical Imaging and Radiation Therapy Act, S. 3737, would, however, grandfather in technicians and others who do not meet the bill's standards. “This bill will reduce the risk of medical errors associated with misdiagnosis or inappropriate exposure to medical radiation, and save millions of health care dollars by decreasing the number of examinations that must be repeated due to poor quality,” said Sen. Harkin in a statement. The CARE act was first introduced in September 2009 in the House, as H.R. 3652, by Rep. John Barrow (D-Ga.).

CABG Mortality Down

The Agency for Healthcare Research and Quality says that there was a huge decline in mortality among patients undergoing coronary artery bypass graft surgery from 2000 to 2006. In 2000, the death rate was 42 per 1,000 admissions; 6 years later, it had declined to 24 per 1,000. Women still had higher mortality (36 per 1,000) than men (21 per 1,000), and, despite a 92% decline in the death rate, rural hospitals still posted a 38 per 1,000 mortality figure in 2006. There were few differences in death rates among whites, African Americans, and Hispanics. Perhaps surprisingly, uninsured patients had the lowest death rate by insurance status, 23 per 1,000. Medicaid patients had the highest, at 29 per 1,000. The data are contained in the 2009 National Healthcare Quality and Disparities Report, published by the agency.

Low Income Trumps Race in Risk

An epidemiological study by researchers at the University of California, Los Angeles has shown that socioeconomic status is a bigger risk factor in cardiovascular disease than is race or ethnicity. The researchers looked at data on 12,154 people from the National Health and Nutrition Examination Survey (2001-2006), focusing on 10-year risk for coronary heart disease as predicted by National Cholesterol Education Program Adult Treatment Panel III guidelines. People with a lower socioeconomic status turned out to have a higher risk of cardiovascular disease, regardless of race or ethnicity. Most of the increase comes from greater rates of smoking and less physical activity in low-income/low-education groups. The National Institutes of Health–funded study appeared in the August issue of the Annals of Epidemiology.

Hypothermia Therapy Going Mobile

New York City's paramedics are now using hypothermia therapy on eligible cardiac arrest patients outside hospitals. In cooperation with Greater New York Hospital Association, Emergency Medical Service personnel have begun administering cold intravenous liquids to people in cardiac arrest who have not responded to CPR or a defibrillator. The treatment was already being used in city hospitals, where it has saved “hundreds of lives during the past 18 months,” according to a statement from the City Health and Hospitals Corporation. Since the in-hospital project began in January 2009, there has been a 20% increase in survival of arrest patients admitted after being stabilized in emergency departments, the statement said.