Jane Anderson

The Centers for Medicare and Medicaid Services will cut reimbursement for physicians who provide their diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said American Academy of Family Physicians (AAFP) coding specialist Cynthia Hughes, who noted that the academy had lobbied hard for several years for the increase in reimbursement.

“It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to the SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in either a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point-of-care, Ms. Hughes said, adding that reimbursement for testing using the in-office analyzers—which cost about $2,700—is not affected.

The Centers for Medicare and Medicaid Services will cut reimbursement for physicians who provide their diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said American Academy of Family Physicians (AAFP) coding specialist Cynthia Hughes, who noted that the academy had lobbied hard for several years for the increase in reimbursement.

“It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to the SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in either a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point-of-care, Ms. Hughes said, adding that reimbursement for testing using the in-office analyzers—which cost about $2,700—is not affected.

The Centers for Medicare and Medicaid Services will cut reimbursement for physicians who provide their diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said American Academy of Family Physicians (AAFP) coding specialist Cynthia Hughes, who noted that the academy had lobbied hard for several years for the increase in reimbursement.

“It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to the SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in either a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point-of-care, Ms. Hughes said, adding that reimbursement for testing using the in-office analyzers—which cost about $2,700—is not affected.

FDA Would Expand Promotion

The Food and Drug Administration last month proposed draft guidance that would allow drug and medical device makers to distribute medical or scientific journal articles and reference publications that involve unapproved uses of FDA-approved drugs and medical devices. Drug and device makers had been allowed to disseminate such materials under guidelines set by the FDA, but that authority expired in September 2006.

The FDA's new “Good Reprint Practices” draft guidance states that the article or reference should be published by an organization that has an editorial board and fully discloses conflicts of interest. In addition, articles should be peer reviewed, and manufacturers should not distribute special supplements or publications funded by product manufacturers, or articles not supported by credible medical evidence.

Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, blasted the FDA for its proposal, which he said in a statement “is great news for the drug industry but terrible for the public health. It caters to the industry's desire to market [its] products without adequate testing or review. The FDA should suspend its proposal to weaken the law until Congress can ensure that the new policies will protect the American people.”

Products Threaten Tobacco Progress

An “insidious” new generation of tobacco products is threatening efforts to reduce tobacco use in the United States, warned a new report from a coalition of public health organizations. The report, funded by the Robert Wood Johnson Foundation and produced by a coalition that includes the American Cancer Society, the American Heart Association, the American Lung Association, and the Campaign for Tobacco-Free Kids, describes how tobacco manufacturers are finding new ways to gain new users, especially children, and to discourage quitting. For example, cigarettes, smokeless tobacco, and cigars have been introduced in an array of candy, fruit, and alcohol flavors, and new smokeless products have been marketed as ways to help smokers sustain their addiction in the growing number of places where they cannot smoke, the report said. New products and marketing have been aimed at women, girls, and other populations. For example, R.J. Reynolds' Camel cigarettes now are available in pink, according to the report, and smokeless tobacco now comes in teabaglike pouches and even in dissolvable, candylike tablets. “Until Congress grants the FDA authority over tobacco products, America's kids and consumers will remain guinea pigs in the tobacco industry's never-ending experiments to sell more of its deadly and addictive products,” William Corr, executive director of the Campaign for Tobacco-Free Kids, said in a statement.

ADA: Amalgam Fillings Safe

Dental amalgam tooth fillings do not adversely affect children's brain development and neurologic status, researchers reported in the February issue of The Journal of the American Dental Association. The authors of the report studied the possible neurologic effects of dental amalgam, which contains elemental mercury combined with other metals such as copper, silver, tin, and zinc. Beginning in 1997, the team followed 507 Portuguese children aged 8–12 years who received either amalgam or resin-based composite fillings, conducting clinical neurologic exams to assess two types of neurologic signs: hard (indicating damage to specific neural structures), and soft (subtle signs of central nervous system dysfunction that likely point to immature sensory-motor skills rather than to any structural damage in the brain). The researchers also evaluated the children for presence of tremor. After 7 years, the two groups of children did not differ in any of the measures. “Even at the levels of amalgam exposure in this study (a mean of 7.7–10.7 amalgam surfaces per subject), [we] conclude that exposure to mercury from dental amalgam does not adversely affect neurological status,” the authors wrote.

Early Intervention in Autism Tested

Researchers at the University of Washington, Seattle, are investigating the benefits of early parental intervention with young siblings of children who have autism spectrum disorders, in effect testing whether extra interaction between these babies and young toddlers and their parents can prevent or reduce the delays in social interaction associated with such disorders.

The study will test such techniques as coos, lilting speech, eye contact and other interactions delivered by parents. The $11.3 million research project is expected to include 200 6-month-old babies from the Seattle area who have older siblings already diagnosed with autism or another autism spectrum disorder. Parents will receive developmental evaluations along with advice regarding appropriate services, and those families assigned to the intervention group will receive parent training, and, if appropriate, more intensive intervention for their infants.

FDA Would Expand Promotion

The Food and Drug Administration last month proposed draft guidance that would allow drug and medical device makers to distribute medical or scientific journal articles and reference publications that involve unapproved uses of FDA-approved drugs and medical devices. Drug and device makers had been allowed to disseminate such materials under guidelines set by the FDA, but that authority expired in September 2006.

The FDA's new “Good Reprint Practices” draft guidance states that the article or reference should be published by an organization that has an editorial board and fully discloses conflicts of interest. In addition, articles should be peer reviewed, and manufacturers should not distribute special supplements or publications funded by product manufacturers, or articles not supported by credible medical evidence.

Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, blasted the FDA for its proposal, which he said in a statement “is great news for the drug industry but terrible for the public health. It caters to the industry's desire to market [its] products without adequate testing or review. The FDA should suspend its proposal to weaken the law until Congress can ensure that the new policies will protect the American people.”

Products Threaten Tobacco Progress

An “insidious” new generation of tobacco products is threatening efforts to reduce tobacco use in the United States, warned a new report from a coalition of public health organizations. The report, funded by the Robert Wood Johnson Foundation and produced by a coalition that includes the American Cancer Society, the American Heart Association, the American Lung Association, and the Campaign for Tobacco-Free Kids, describes how tobacco manufacturers are finding new ways to gain new users, especially children, and to discourage quitting. For example, cigarettes, smokeless tobacco, and cigars have been introduced in an array of candy, fruit, and alcohol flavors, and new smokeless products have been marketed as ways to help smokers sustain their addiction in the growing number of places where they cannot smoke, the report said. New products and marketing have been aimed at women, girls, and other populations. For example, R.J. Reynolds' Camel cigarettes now are available in pink, according to the report, and smokeless tobacco now comes in teabaglike pouches and even in dissolvable, candylike tablets. “Until Congress grants the FDA authority over tobacco products, America's kids and consumers will remain guinea pigs in the tobacco industry's never-ending experiments to sell more of its deadly and addictive products,” William Corr, executive director of the Campaign for Tobacco-Free Kids, said in a statement.

ADA: Amalgam Fillings Safe

Dental amalgam tooth fillings do not adversely affect children's brain development and neurologic status, researchers reported in the February issue of The Journal of the American Dental Association. The authors of the report studied the possible neurologic effects of dental amalgam, which contains elemental mercury combined with other metals such as copper, silver, tin, and zinc. Beginning in 1997, the team followed 507 Portuguese children aged 8–12 years who received either amalgam or resin-based composite fillings, conducting clinical neurologic exams to assess two types of neurologic signs: hard (indicating damage to specific neural structures), and soft (subtle signs of central nervous system dysfunction that likely point to immature sensory-motor skills rather than to any structural damage in the brain). The researchers also evaluated the children for presence of tremor. After 7 years, the two groups of children did not differ in any of the measures. “Even at the levels of amalgam exposure in this study (a mean of 7.7–10.7 amalgam surfaces per subject), [we] conclude that exposure to mercury from dental amalgam does not adversely affect neurological status,” the authors wrote.

Early Intervention in Autism Tested

Researchers at the University of Washington, Seattle, are investigating the benefits of early parental intervention with young siblings of children who have autism spectrum disorders, in effect testing whether extra interaction between these babies and young toddlers and their parents can prevent or reduce the delays in social interaction associated with such disorders.

The study will test such techniques as coos, lilting speech, eye contact and other interactions delivered by parents. The $11.3 million research project is expected to include 200 6-month-old babies from the Seattle area who have older siblings already diagnosed with autism or another autism spectrum disorder. Parents will receive developmental evaluations along with advice regarding appropriate services, and those families assigned to the intervention group will receive parent training, and, if appropriate, more intensive intervention for their infants.

FDA Would Expand Promotion

The Food and Drug Administration last month proposed draft guidance that would allow drug and medical device makers to distribute medical or scientific journal articles and reference publications that involve unapproved uses of FDA-approved drugs and medical devices. Drug and device makers had been allowed to disseminate such materials under guidelines set by the FDA, but that authority expired in September 2006.

The FDA's new “Good Reprint Practices” draft guidance states that the article or reference should be published by an organization that has an editorial board and fully discloses conflicts of interest. In addition, articles should be peer reviewed, and manufacturers should not distribute special supplements or publications funded by product manufacturers, or articles not supported by credible medical evidence.

Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, blasted the FDA for its proposal, which he said in a statement “is great news for the drug industry but terrible for the public health. It caters to the industry's desire to market [its] products without adequate testing or review. The FDA should suspend its proposal to weaken the law until Congress can ensure that the new policies will protect the American people.”

Products Threaten Tobacco Progress

An “insidious” new generation of tobacco products is threatening efforts to reduce tobacco use in the United States, warned a new report from a coalition of public health organizations. The report, funded by the Robert Wood Johnson Foundation and produced by a coalition that includes the American Cancer Society, the American Heart Association, the American Lung Association, and the Campaign for Tobacco-Free Kids, describes how tobacco manufacturers are finding new ways to gain new users, especially children, and to discourage quitting. For example, cigarettes, smokeless tobacco, and cigars have been introduced in an array of candy, fruit, and alcohol flavors, and new smokeless products have been marketed as ways to help smokers sustain their addiction in the growing number of places where they cannot smoke, the report said. New products and marketing have been aimed at women, girls, and other populations. For example, R.J. Reynolds' Camel cigarettes now are available in pink, according to the report, and smokeless tobacco now comes in teabaglike pouches and even in dissolvable, candylike tablets. “Until Congress grants the FDA authority over tobacco products, America's kids and consumers will remain guinea pigs in the tobacco industry's never-ending experiments to sell more of its deadly and addictive products,” William Corr, executive director of the Campaign for Tobacco-Free Kids, said in a statement.

ADA: Amalgam Fillings Safe

Dental amalgam tooth fillings do not adversely affect children's brain development and neurologic status, researchers reported in the February issue of The Journal of the American Dental Association. The authors of the report studied the possible neurologic effects of dental amalgam, which contains elemental mercury combined with other metals such as copper, silver, tin, and zinc. Beginning in 1997, the team followed 507 Portuguese children aged 8–12 years who received either amalgam or resin-based composite fillings, conducting clinical neurologic exams to assess two types of neurologic signs: hard (indicating damage to specific neural structures), and soft (subtle signs of central nervous system dysfunction that likely point to immature sensory-motor skills rather than to any structural damage in the brain). The researchers also evaluated the children for presence of tremor. After 7 years, the two groups of children did not differ in any of the measures. “Even at the levels of amalgam exposure in this study (a mean of 7.7–10.7 amalgam surfaces per subject), [we] conclude that exposure to mercury from dental amalgam does not adversely affect neurological status,” the authors wrote.

Early Intervention in Autism Tested

Researchers at the University of Washington, Seattle, are investigating the benefits of early parental intervention with young siblings of children who have autism spectrum disorders, in effect testing whether extra interaction between these babies and young toddlers and their parents can prevent or reduce the delays in social interaction associated with such disorders.

The study will test such techniques as coos, lilting speech, eye contact and other interactions delivered by parents. The $11.3 million research project is expected to include 200 6-month-old babies from the Seattle area who have older siblings already diagnosed with autism or another autism spectrum disorder. Parents will receive developmental evaluations along with advice regarding appropriate services, and those families assigned to the intervention group will receive parent training, and, if appropriate, more intensive intervention for their infants.

The Centers for Medicare & Medicaid Services will cut reimbursement for physicians who provide diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said AAFP coding specialist Cynthia Hughes, who noted that AAFP had lobbied hard for several years for the increase in reimbursement.

“It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in either a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point-of-care, Ms. Hughes said, adding that reimbursement for testing using the in-office analyzers—which cost about $2,700—is not affected.

The Centers for Medicare & Medicaid Services will cut reimbursement for physicians who provide diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said AAFP coding specialist Cynthia Hughes, who noted that AAFP had lobbied hard for several years for the increase in reimbursement.

“It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in either a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point-of-care, Ms. Hughes said, adding that reimbursement for testing using the in-office analyzers—which cost about $2,700—is not affected.

The Centers for Medicare & Medicaid Services will cut reimbursement for physicians who provide diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said AAFP coding specialist Cynthia Hughes, who noted that AAFP had lobbied hard for several years for the increase in reimbursement.

“It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in either a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point-of-care, Ms. Hughes said, adding that reimbursement for testing using the in-office analyzers—which cost about $2,700—is not affected.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to a study by researchers at the Centers for Disease Control and Prevention and RTI International. The researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking, observing a decline in prevalence from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs, they wrote. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher cost health problems, it said. This could create high premiums and instability in the insurance pools that enroll those individuals. In addition, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, the report noted.

Recertification Could Improve Care

The quality of care provided to patients with hypertension seems to erode as the time since the physician's last board certification increases, a study published online in Circulation found. Researchers analyzed treatment of more than 8,000 patients with hypertension and comorbid diabetes who were treated by 301 internists, and looked specifically at patient visits with documented blood pressure equal or greater to 130/85 mm Hg. They analyzed the association between the number of years since the physician's last board certification and the probability of pharmacologic antihypertensive treatment intensification at a given visit and found that frequency of treatment intensification decreased from about 27% for physicians who were board certified the previous year to about 7% for those who were board certified 31 years before the visit. For physicians recertified more than 10 years previously, the treatment intensification rate was about 22%, compared with 17% for those recertified in the last decade.

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit is $117 billion lower over the next 10 years than it estimated last summer. The difference results from the slowing of drug cost trends, lower estimates of plan spending, and higher rebates from drug manufacturers, CMS said. Compared with original projections, the net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Patient Safety Goals Updated

The Joint Commission has released a preliminary version of its 2009 National Patient Safety Goals for hospitals and critical care facilities, and is seeking to add several new requirements to its list of priorities. According to the draft, the commission would like to add a requirement highlighting the need to eliminate transfusion errors related to patient misidentification. It would also add a requirement that acute care facilities implement best practices to prevent the spread of multiple drug-resistant organisms. Last, the draft specifies new requirements for using best practices to prevent catheter-associated bloodstream infections and surgical site infections and refines points to work toward the commission's goal of reconciling patient medications across the care continuum.

Top 10 Cost Half a Trillion

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion, and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

CMS May Cover Artificial Heart

CMS has proposed covering artificial heart devices in Medicare beneficiaries enrolled in Food and Drug Administration-approved studies, reversing a 20-year-old policy. The use of artificial heart technology has not been available to Medicare beneficiaries because of a 1986 noncoverage policy. But since then, two artificial heart makers have run clinical trials studying the safety and health outcomes of using their devices, CMS said. The agency said it now believes there is sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries “in the carefully controlled clinical environment of an FDA-approved study.” A final coverage determination is expected in May.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to a study by researchers at the Centers for Disease Control and Prevention and RTI International. The researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking, observing a decline in prevalence from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs, they wrote. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher cost health problems, it said. This could create high premiums and instability in the insurance pools that enroll those individuals. In addition, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, the report noted.

Recertification Could Improve Care

The quality of care provided to patients with hypertension seems to erode as the time since the physician's last board certification increases, a study published online in Circulation found. Researchers analyzed treatment of more than 8,000 patients with hypertension and comorbid diabetes who were treated by 301 internists, and looked specifically at patient visits with documented blood pressure equal or greater to 130/85 mm Hg. They analyzed the association between the number of years since the physician's last board certification and the probability of pharmacologic antihypertensive treatment intensification at a given visit and found that frequency of treatment intensification decreased from about 27% for physicians who were board certified the previous year to about 7% for those who were board certified 31 years before the visit. For physicians recertified more than 10 years previously, the treatment intensification rate was about 22%, compared with 17% for those recertified in the last decade.

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit is $117 billion lower over the next 10 years than it estimated last summer. The difference results from the slowing of drug cost trends, lower estimates of plan spending, and higher rebates from drug manufacturers, CMS said. Compared with original projections, the net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Patient Safety Goals Updated

The Joint Commission has released a preliminary version of its 2009 National Patient Safety Goals for hospitals and critical care facilities, and is seeking to add several new requirements to its list of priorities. According to the draft, the commission would like to add a requirement highlighting the need to eliminate transfusion errors related to patient misidentification. It would also add a requirement that acute care facilities implement best practices to prevent the spread of multiple drug-resistant organisms. Last, the draft specifies new requirements for using best practices to prevent catheter-associated bloodstream infections and surgical site infections and refines points to work toward the commission's goal of reconciling patient medications across the care continuum.

Top 10 Cost Half a Trillion

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion, and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

CMS May Cover Artificial Heart

CMS has proposed covering artificial heart devices in Medicare beneficiaries enrolled in Food and Drug Administration-approved studies, reversing a 20-year-old policy. The use of artificial heart technology has not been available to Medicare beneficiaries because of a 1986 noncoverage policy. But since then, two artificial heart makers have run clinical trials studying the safety and health outcomes of using their devices, CMS said. The agency said it now believes there is sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries “in the carefully controlled clinical environment of an FDA-approved study.” A final coverage determination is expected in May.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to a study by researchers at the Centers for Disease Control and Prevention and RTI International. The researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking, observing a decline in prevalence from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs, they wrote. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher cost health problems, it said. This could create high premiums and instability in the insurance pools that enroll those individuals. In addition, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, the report noted.

Recertification Could Improve Care

The quality of care provided to patients with hypertension seems to erode as the time since the physician's last board certification increases, a study published online in Circulation found. Researchers analyzed treatment of more than 8,000 patients with hypertension and comorbid diabetes who were treated by 301 internists, and looked specifically at patient visits with documented blood pressure equal or greater to 130/85 mm Hg. They analyzed the association between the number of years since the physician's last board certification and the probability of pharmacologic antihypertensive treatment intensification at a given visit and found that frequency of treatment intensification decreased from about 27% for physicians who were board certified the previous year to about 7% for those who were board certified 31 years before the visit. For physicians recertified more than 10 years previously, the treatment intensification rate was about 22%, compared with 17% for those recertified in the last decade.

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit is $117 billion lower over the next 10 years than it estimated last summer. The difference results from the slowing of drug cost trends, lower estimates of plan spending, and higher rebates from drug manufacturers, CMS said. Compared with original projections, the net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Patient Safety Goals Updated

The Joint Commission has released a preliminary version of its 2009 National Patient Safety Goals for hospitals and critical care facilities, and is seeking to add several new requirements to its list of priorities. According to the draft, the commission would like to add a requirement highlighting the need to eliminate transfusion errors related to patient misidentification. It would also add a requirement that acute care facilities implement best practices to prevent the spread of multiple drug-resistant organisms. Last, the draft specifies new requirements for using best practices to prevent catheter-associated bloodstream infections and surgical site infections and refines points to work toward the commission's goal of reconciling patient medications across the care continuum.

Top 10 Cost Half a Trillion

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion, and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

CMS May Cover Artificial Heart

CMS has proposed covering artificial heart devices in Medicare beneficiaries enrolled in Food and Drug Administration-approved studies, reversing a 20-year-old policy. The use of artificial heart technology has not been available to Medicare beneficiaries because of a 1986 noncoverage policy. But since then, two artificial heart makers have run clinical trials studying the safety and health outcomes of using their devices, CMS said. The agency said it now believes there is sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries “in the carefully controlled clinical environment of an FDA-approved study.” A final coverage determination is expected in May.

MassHealth, Massachusetts' Medicaid program, has begun requiring primary care doctors and nurses to use a standardized behavioral health screening tool at every well-child visit for children under the age of 21.

The new requirement, which took effect Dec. 31, resulted from a 2007 U.S. District Court decision in Rosie D. v. Romney. In its decision, the court ruled that Medicaid-eligible children with “serious emotional disturbances” were not receiving appropriate mental health screenings, service coordination, and home-based treatment services, and ordered MassHealth to implement a plan to improve care.

As such, MassHealth is setting up several initiatives to improve mental health services for Medicaid beneficiaries under age 21 years, said MassHealth spokeswoman Jennifer Kritz in an interview.

For the new standardized behavioral health screens by primary care physicians and nurses, Medicaid will ask providers to choose from eight standardized tools for the screening, depending on the patient's age, and will pay for the screening as well as the standard office visit reimbursement.

The goal is to help detect issues with behavioral health, social-emotional well-being, or mental health in the state's 460,000 children and young adults covered by Medicaid, Ms. Kritz said. If a potential problem is detected, the primary care provider will refer the patient to a mental health provider, according to the state. A parent or guardian can decline screening for a child if they wish.

Other measures prompted by the Rosie D. case will take effect over the next 2 years, Ms. Kritz said. Starting in late 2008, children who see a behavioral health provider will be assessed by that provider using the Child and Adolescent Needs and Strengths tool.

And, MassHealth expects to cover several new behavioral health services for beneficiaries under age 21 years, although the agency hasn't yet received federal approval for those new services, she added.

Massachusetts faces challenges in providing mental health services to those additional children and young adults who are expected to be identified as part of the stepped-up screening, according to the Massachusetts Medicaid Policy Institute.

“Massachusetts faces a shortage of qualified 'child-trained' providers … as well as an inadequate number of bilingual and multicultural providers,” the institute said in a brief last year. “Existing providers also are not spread out evenly across the state, making access a problem in many areas. One of the state's biggest challenges will be to engage more qualified providers and train them in the new delivery structure, which is vastly different from the existing model of care that most clinicians are used to.”

However, Ms. Kritz said MassHealth has a “robust” behavioral health system and is working with primary care physicians to streamline the referral process. It also is partnering with schools and professional organizations to recruit more people to the behavioral health field.

MassHealth, Massachusetts' Medicaid program, has begun requiring primary care doctors and nurses to use a standardized behavioral health screening tool at every well-child visit for children under the age of 21.

The new requirement, which took effect Dec. 31, resulted from a 2007 U.S. District Court decision in Rosie D. v. Romney. In its decision, the court ruled that Medicaid-eligible children with “serious emotional disturbances” were not receiving appropriate mental health screenings, service coordination, and home-based treatment services, and ordered MassHealth to implement a plan to improve care.

As such, MassHealth is setting up several initiatives to improve mental health services for Medicaid beneficiaries under age 21 years, said MassHealth spokeswoman Jennifer Kritz in an interview.

For the new standardized behavioral health screens by primary care physicians and nurses, Medicaid will ask providers to choose from eight standardized tools for the screening, depending on the patient's age, and will pay for the screening as well as the standard office visit reimbursement.

The goal is to help detect issues with behavioral health, social-emotional well-being, or mental health in the state's 460,000 children and young adults covered by Medicaid, Ms. Kritz said. If a potential problem is detected, the primary care provider will refer the patient to a mental health provider, according to the state. A parent or guardian can decline screening for a child if they wish.

Other measures prompted by the Rosie D. case will take effect over the next 2 years, Ms. Kritz said. Starting in late 2008, children who see a behavioral health provider will be assessed by that provider using the Child and Adolescent Needs and Strengths tool.

And, MassHealth expects to cover several new behavioral health services for beneficiaries under age 21 years, although the agency hasn't yet received federal approval for those new services, she added.

Massachusetts faces challenges in providing mental health services to those additional children and young adults who are expected to be identified as part of the stepped-up screening, according to the Massachusetts Medicaid Policy Institute.

“Massachusetts faces a shortage of qualified 'child-trained' providers … as well as an inadequate number of bilingual and multicultural providers,” the institute said in a brief last year. “Existing providers also are not spread out evenly across the state, making access a problem in many areas. One of the state's biggest challenges will be to engage more qualified providers and train them in the new delivery structure, which is vastly different from the existing model of care that most clinicians are used to.”

However, Ms. Kritz said MassHealth has a “robust” behavioral health system and is working with primary care physicians to streamline the referral process. It also is partnering with schools and professional organizations to recruit more people to the behavioral health field.

MassHealth, Massachusetts' Medicaid program, has begun requiring primary care doctors and nurses to use a standardized behavioral health screening tool at every well-child visit for children under the age of 21.

The new requirement, which took effect Dec. 31, resulted from a 2007 U.S. District Court decision in Rosie D. v. Romney. In its decision, the court ruled that Medicaid-eligible children with “serious emotional disturbances” were not receiving appropriate mental health screenings, service coordination, and home-based treatment services, and ordered MassHealth to implement a plan to improve care.

As such, MassHealth is setting up several initiatives to improve mental health services for Medicaid beneficiaries under age 21 years, said MassHealth spokeswoman Jennifer Kritz in an interview.

For the new standardized behavioral health screens by primary care physicians and nurses, Medicaid will ask providers to choose from eight standardized tools for the screening, depending on the patient's age, and will pay for the screening as well as the standard office visit reimbursement.

The goal is to help detect issues with behavioral health, social-emotional well-being, or mental health in the state's 460,000 children and young adults covered by Medicaid, Ms. Kritz said. If a potential problem is detected, the primary care provider will refer the patient to a mental health provider, according to the state. A parent or guardian can decline screening for a child if they wish.

Other measures prompted by the Rosie D. case will take effect over the next 2 years, Ms. Kritz said. Starting in late 2008, children who see a behavioral health provider will be assessed by that provider using the Child and Adolescent Needs and Strengths tool.

And, MassHealth expects to cover several new behavioral health services for beneficiaries under age 21 years, although the agency hasn't yet received federal approval for those new services, she added.

Massachusetts faces challenges in providing mental health services to those additional children and young adults who are expected to be identified as part of the stepped-up screening, according to the Massachusetts Medicaid Policy Institute.

“Massachusetts faces a shortage of qualified 'child-trained' providers … as well as an inadequate number of bilingual and multicultural providers,” the institute said in a brief last year. “Existing providers also are not spread out evenly across the state, making access a problem in many areas. One of the state's biggest challenges will be to engage more qualified providers and train them in the new delivery structure, which is vastly different from the existing model of care that most clinicians are used to.”

However, Ms. Kritz said MassHealth has a “robust” behavioral health system and is working with primary care physicians to streamline the referral process. It also is partnering with schools and professional organizations to recruit more people to the behavioral health field.

Aetna Inc. said in January that it is working with the American Medical Association and state medical societies to resolve issues involving nonparticipating physicians after the AMA complained that the insurer was paying those physicians just 125% of Medicare rates and then telling patients they didn't need to pay the rest.

In a letter sent to Aetna, Dr. Michael Maves, AMA's chief executive officer and senior vice president, noted that Aetna's policy–implemented last June–fails to take into account different practice costs that are reflected by physicians' billed charges.

“It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board,” Dr. Maves wrote in his letter to Dr. Troyen Brennan, Aetna's chief medical officer.

Dr. Maves also said in the letter that physicians nationwide are reporting receiving Aetna Explanation of Benefits (EOB) forms stating that the patient has no obligation to pay the nonparticipating physician the difference between the physician's charge and the amount Aetna has paid.

This practice, Dr. Maves said, potentially violates the 2003 settlement agreement with Aetna in Multidistrict Litigation 1334, the large class action lawsuit in which physicians sued large managed care companies, including Aetna, over business practices.

However, Dr. Brennan said in an interview that the settlement in that case “clearly differentiates between HMO-based plans and traditional plans.” It requires Aetna to tell members in traditional plans that they can be balance-billed by nonparticipating physicians, but it treats HMO plans differently, he said.

HMO members receive an EOB stating that Aetna does not contract with a nonparticipating provider, and that the provider might not accept Aetna's payment as payment in full for services, Dr. Brennan said.

“In the notice, we inform the member that we 'seek to ensure that they do not pay this provider any amount above any applicable copayment, coinsurance, or deductible at the in-network (referred) benefit level,' and if they receive a bill for the difference, they should send the bill to us,” Dr. Brennan said.

Aetna believes it has complied with the 2003 settlement agreement “in all respects,” but is in discussions with the AMA and state medical societies about the issues involved, Dr. Brennan said. However, “no substantive discussions have occurred as of yet with the AMA,” said AMA spokesman Robert Mills.

Meanwhile, nonparticipating physicians are being placed in an awkward situation, said Dr. Alan Schorr, a Langhorne, Pa.-based endocrinologist who does not participate with Aetna. Some of his patients have received the Aetna EOBs.

“This puts the patient and physician into adversarial roles,” said Dr. Schorr, who added that, although Aetna might believe that 125% of Medicare represents fair reimbursement, “the patient has to have some sense of responsibility.”

But the EOBs from Aetna state that the patient has no responsibility to pay the difference between 125% of Medicare rates and the actual charges, Dr. Schorr said in an interview, and patients therefore don't want to pay the difference. “We've had comments made to our office manager along the lines of 'Just write off the difference–you make enough anyway,'” he said.

Aetna “is trying to force physicians back into the [network] fold,” Dr. Schorr said, adding that he had complained to the AMA and to the Pennsylvania Medical Society about Aetna's practice. “What we're looking at, in my opinion, is restraint of trade. They're trying to ratchet down physicians' fees,” he said.

Aetna Inc. said in January that it is working with the American Medical Association and state medical societies to resolve issues involving nonparticipating physicians after the AMA complained that the insurer was paying those physicians just 125% of Medicare rates and then telling patients they didn't need to pay the rest.

In a letter sent to Aetna, Dr. Michael Maves, AMA's chief executive officer and senior vice president, noted that Aetna's policy–implemented last June–fails to take into account different practice costs that are reflected by physicians' billed charges.

“It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board,” Dr. Maves wrote in his letter to Dr. Troyen Brennan, Aetna's chief medical officer.

Dr. Maves also said in the letter that physicians nationwide are reporting receiving Aetna Explanation of Benefits (EOB) forms stating that the patient has no obligation to pay the nonparticipating physician the difference between the physician's charge and the amount Aetna has paid.

This practice, Dr. Maves said, potentially violates the 2003 settlement agreement with Aetna in Multidistrict Litigation 1334, the large class action lawsuit in which physicians sued large managed care companies, including Aetna, over business practices.

However, Dr. Brennan said in an interview that the settlement in that case “clearly differentiates between HMO-based plans and traditional plans.” It requires Aetna to tell members in traditional plans that they can be balance-billed by nonparticipating physicians, but it treats HMO plans differently, he said.

HMO members receive an EOB stating that Aetna does not contract with a nonparticipating provider, and that the provider might not accept Aetna's payment as payment in full for services, Dr. Brennan said.

“In the notice, we inform the member that we 'seek to ensure that they do not pay this provider any amount above any applicable copayment, coinsurance, or deductible at the in-network (referred) benefit level,' and if they receive a bill for the difference, they should send the bill to us,” Dr. Brennan said.

Aetna believes it has complied with the 2003 settlement agreement “in all respects,” but is in discussions with the AMA and state medical societies about the issues involved, Dr. Brennan said. However, “no substantive discussions have occurred as of yet with the AMA,” said AMA spokesman Robert Mills.

Meanwhile, nonparticipating physicians are being placed in an awkward situation, said Dr. Alan Schorr, a Langhorne, Pa.-based endocrinologist who does not participate with Aetna. Some of his patients have received the Aetna EOBs.

“This puts the patient and physician into adversarial roles,” said Dr. Schorr, who added that, although Aetna might believe that 125% of Medicare represents fair reimbursement, “the patient has to have some sense of responsibility.”

But the EOBs from Aetna state that the patient has no responsibility to pay the difference between 125% of Medicare rates and the actual charges, Dr. Schorr said in an interview, and patients therefore don't want to pay the difference. “We've had comments made to our office manager along the lines of 'Just write off the difference–you make enough anyway,'” he said.

Aetna “is trying to force physicians back into the [network] fold,” Dr. Schorr said, adding that he had complained to the AMA and to the Pennsylvania Medical Society about Aetna's practice. “What we're looking at, in my opinion, is restraint of trade. They're trying to ratchet down physicians' fees,” he said.

Aetna Inc. said in January that it is working with the American Medical Association and state medical societies to resolve issues involving nonparticipating physicians after the AMA complained that the insurer was paying those physicians just 125% of Medicare rates and then telling patients they didn't need to pay the rest.

In a letter sent to Aetna, Dr. Michael Maves, AMA's chief executive officer and senior vice president, noted that Aetna's policy–implemented last June–fails to take into account different practice costs that are reflected by physicians' billed charges.

“It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board,” Dr. Maves wrote in his letter to Dr. Troyen Brennan, Aetna's chief medical officer.

Dr. Maves also said in the letter that physicians nationwide are reporting receiving Aetna Explanation of Benefits (EOB) forms stating that the patient has no obligation to pay the nonparticipating physician the difference between the physician's charge and the amount Aetna has paid.

This practice, Dr. Maves said, potentially violates the 2003 settlement agreement with Aetna in Multidistrict Litigation 1334, the large class action lawsuit in which physicians sued large managed care companies, including Aetna, over business practices.

However, Dr. Brennan said in an interview that the settlement in that case “clearly differentiates between HMO-based plans and traditional plans.” It requires Aetna to tell members in traditional plans that they can be balance-billed by nonparticipating physicians, but it treats HMO plans differently, he said.

HMO members receive an EOB stating that Aetna does not contract with a nonparticipating provider, and that the provider might not accept Aetna's payment as payment in full for services, Dr. Brennan said.

“In the notice, we inform the member that we 'seek to ensure that they do not pay this provider any amount above any applicable copayment, coinsurance, or deductible at the in-network (referred) benefit level,' and if they receive a bill for the difference, they should send the bill to us,” Dr. Brennan said.

Aetna believes it has complied with the 2003 settlement agreement “in all respects,” but is in discussions with the AMA and state medical societies about the issues involved, Dr. Brennan said. However, “no substantive discussions have occurred as of yet with the AMA,” said AMA spokesman Robert Mills.

Meanwhile, nonparticipating physicians are being placed in an awkward situation, said Dr. Alan Schorr, a Langhorne, Pa.-based endocrinologist who does not participate with Aetna. Some of his patients have received the Aetna EOBs.

“This puts the patient and physician into adversarial roles,” said Dr. Schorr, who added that, although Aetna might believe that 125% of Medicare represents fair reimbursement, “the patient has to have some sense of responsibility.”

But the EOBs from Aetna state that the patient has no responsibility to pay the difference between 125% of Medicare rates and the actual charges, Dr. Schorr said in an interview, and patients therefore don't want to pay the difference. “We've had comments made to our office manager along the lines of 'Just write off the difference–you make enough anyway,'” he said.

Aetna “is trying to force physicians back into the [network] fold,” Dr. Schorr said, adding that he had complained to the AMA and to the Pennsylvania Medical Society about Aetna's practice. “What we're looking at, in my opinion, is restraint of trade. They're trying to ratchet down physicians' fees,” he said.

Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples, according to a study by physicians from Cambridge Health Alliance and Harvard Medical School.

The investigators found that, in 2003, 12% of Americans received at least one free drug sample (Am. J. Public Health 2008;98:284–9).

More people who were continuously insured received a free sample than people who were uninsured for all or part of the year, and the poorest third were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or more.

“We know that many doctors try to get free samples to needy patients,” said study senior author Dr. David Himmelstein in a statement.

“We found that such efforts do not counter society-wide factors that determine access to care and selectively direct free samples to the affluent. Our findings strongly suggest that free drug samples serve as a marketing tool, not as a safety net,” he said.

But Ken Johnson, senior vice president at the Pharmaceutical Research and Manufacturers of America, said in a statement that free samples help millions of Americans, regardless of income, and “offer an option for those who have difficulty affording their medicines.

Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples, according to a study by physicians from Cambridge Health Alliance and Harvard Medical School.

The investigators found that, in 2003, 12% of Americans received at least one free drug sample (Am. J. Public Health 2008;98:284–9).

More people who were continuously insured received a free sample than people who were uninsured for all or part of the year, and the poorest third were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or more.

“We know that many doctors try to get free samples to needy patients,” said study senior author Dr. David Himmelstein in a statement.

“We found that such efforts do not counter society-wide factors that determine access to care and selectively direct free samples to the affluent. Our findings strongly suggest that free drug samples serve as a marketing tool, not as a safety net,” he said.

But Ken Johnson, senior vice president at the Pharmaceutical Research and Manufacturers of America, said in a statement that free samples help millions of Americans, regardless of income, and “offer an option for those who have difficulty affording their medicines.

Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples, according to a study by physicians from Cambridge Health Alliance and Harvard Medical School.

The investigators found that, in 2003, 12% of Americans received at least one free drug sample (Am. J. Public Health 2008;98:284–9).

More people who were continuously insured received a free sample than people who were uninsured for all or part of the year, and the poorest third were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or more.

“We know that many doctors try to get free samples to needy patients,” said study senior author Dr. David Himmelstein in a statement.

“We found that such efforts do not counter society-wide factors that determine access to care and selectively direct free samples to the affluent. Our findings strongly suggest that free drug samples serve as a marketing tool, not as a safety net,” he said.

But Ken Johnson, senior vice president at the Pharmaceutical Research and Manufacturers of America, said in a statement that free samples help millions of Americans, regardless of income, and “offer an option for those who have difficulty affording their medicines.

The Centers for Medicare and Medicaid Services will cut reimbursement for physicians who provide their diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said AAFP coding specialist Cynthia Hughes, who noted that AAFP had lobbied hard for several years for the increase in reimbursement. “It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to the SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point of care, Ms. Hughes said.

The Centers for Medicare and Medicaid Services will cut reimbursement for physicians who provide their diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said AAFP coding specialist Cynthia Hughes, who noted that AAFP had lobbied hard for several years for the increase in reimbursement. “It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to the SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point of care, Ms. Hughes said.

The Centers for Medicare and Medicaid Services will cut reimbursement for physicians who provide their diabetic patients with point-of-care hemoglobin A_1c testing using a “glycosylated Hb home device” from about $21 a test to about $13.50 a test on April 1, a coding expert from the American Academy of Family Physicians said.

The reimbursement cut was mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted at the end of last year. That provision reverses a decision by CMS in late 2006 to increase reimbursement for the HbA_1c test, said AAFP coding specialist Cynthia Hughes, who noted that AAFP had lobbied hard for several years for the increase in reimbursement. “It was slipped into SCHIP,” Ms. Hughes said. “It would take another act of Congress to reverse it.”

The language added to the SCHIP legislation states that point-of-care HbA_1c testing using the kit and billed under CPT code 83037 should be paid at the same rate as HbA_1c testing done with an in-office analyzer in a physician's office or laboratory setting and billed with CPT code 83036.

Ms. Hughes said that the average cost to physicians' offices for each test kit is about $13, but that costs also include shipping and handling of the kits themselves, staff time to administer the test, supplies, and additional overhead expenses. AAFP has suggested to CMS that an appropriate payment—one that takes into account all the costs of purchasing and administering the test—would be more than $34.

Providing the test at the point of care is more convenient for the patient and augments care because the test results are available in just a few minutes, in time for the physician to counsel the patient about those results, Ms. Hughes said.

The decreased reimbursement for the test kits could lead to fewer patients receiving the HbA_1c test at the point of care, Ms. Hughes said.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to researchers at the Centers for Disease Control and Prevention and RTI International. The researchers observed a decline in the prevalence of adult smoking, from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a new report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher cost health problems, the report said, noting that this could create high premiums and instability in the insurance pools that enroll those individuals. Also, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, according to the report, “Do Individual Mandates Matter?”

Recertification Could Improve Care

The quality of care provided to patients with hypertension appears to erode as the time since the physician's last board certification increases, a study published online in Circulation found. The researchers analyzed treatment of more than 8,000 patients with hypertension and comorbid diabetes who were treated by 301 internists, looking at patient visits with documented blood pressure of at least 130/85 mm Hg. The frequency of pharmacologic antihypertensive treatment intensification decreased from about 27% for physicians who were board certified the previous year to about 7% for those who were board certified 31 years before the visit. For physicians recertified more than 10 years ago, the treatment intensification rate was about 22%, compared with 17% for those recertified in the last decade.

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit is $117 billion lower over the next 10 years than it estimated last summer. The difference results from the slowing of drug cost trends, lower estimates of plan spending, and higher rebates from drug manufacturers, CMS said. Compared with original projections, the net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Patient Safety Goals Updated

The Joint Commission has released a preliminary version of its 2009 National Patient Safety Goals for hospitals and critical care facilities, and is seeking to add several new requirements to its list of priorities. According to the draft, the commission would like to add a requirement specifically highlighting the need to eliminate transfusion errors related to patient misidentification. In addition, the commission would add a requirement that acute care facilities implement best practices to prevent the spread of multiple drug-resistant organisms. Last, the draft specifies new requirements for using best practices to prevent catheter-associated bloodstream infections and surgical site infections, and also refines points to work toward the commission's goal of reconciling patient medications across the care continuum.

Top 10 Cost Half a Trillion

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion, and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

CMS May Cover Artificial Heart

CMS has proposed covering artificial heart devices in Medicare beneficiaries who are enrolled in Food and Drug Administration-approved studies, reversing a 20-year-old policy. The use of artificial heart technology has not been available to Medicare beneficiaries because of a 1986 noncoverage policy. But since that policy was implemented, two artificial heart manufacturers have run clinical trials studying the safety and health outcomes of using their devices, CMS said. The agency said that it now believes there is sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries “in the carefully controlled clinical environment of an FDA-approved study.” A final coverage determination is expected in May.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to researchers at the Centers for Disease Control and Prevention and RTI International. The researchers observed a decline in the prevalence of adult smoking, from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a new report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher cost health problems, the report said, noting that this could create high premiums and instability in the insurance pools that enroll those individuals. Also, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, according to the report, “Do Individual Mandates Matter?”

Recertification Could Improve Care

The quality of care provided to patients with hypertension appears to erode as the time since the physician's last board certification increases, a study published online in Circulation found. The researchers analyzed treatment of more than 8,000 patients with hypertension and comorbid diabetes who were treated by 301 internists, looking at patient visits with documented blood pressure of at least 130/85 mm Hg. The frequency of pharmacologic antihypertensive treatment intensification decreased from about 27% for physicians who were board certified the previous year to about 7% for those who were board certified 31 years before the visit. For physicians recertified more than 10 years ago, the treatment intensification rate was about 22%, compared with 17% for those recertified in the last decade.

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit is $117 billion lower over the next 10 years than it estimated last summer. The difference results from the slowing of drug cost trends, lower estimates of plan spending, and higher rebates from drug manufacturers, CMS said. Compared with original projections, the net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Patient Safety Goals Updated

The Joint Commission has released a preliminary version of its 2009 National Patient Safety Goals for hospitals and critical care facilities, and is seeking to add several new requirements to its list of priorities. According to the draft, the commission would like to add a requirement specifically highlighting the need to eliminate transfusion errors related to patient misidentification. In addition, the commission would add a requirement that acute care facilities implement best practices to prevent the spread of multiple drug-resistant organisms. Last, the draft specifies new requirements for using best practices to prevent catheter-associated bloodstream infections and surgical site infections, and also refines points to work toward the commission's goal of reconciling patient medications across the care continuum.

Top 10 Cost Half a Trillion

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion, and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

CMS May Cover Artificial Heart

CMS has proposed covering artificial heart devices in Medicare beneficiaries who are enrolled in Food and Drug Administration-approved studies, reversing a 20-year-old policy. The use of artificial heart technology has not been available to Medicare beneficiaries because of a 1986 noncoverage policy. But since that policy was implemented, two artificial heart manufacturers have run clinical trials studying the safety and health outcomes of using their devices, CMS said. The agency said that it now believes there is sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries “in the carefully controlled clinical environment of an FDA-approved study.” A final coverage determination is expected in May.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to researchers at the Centers for Disease Control and Prevention and RTI International. The researchers observed a decline in the prevalence of adult smoking, from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a new report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher cost health problems, the report said, noting that this could create high premiums and instability in the insurance pools that enroll those individuals. Also, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, according to the report, “Do Individual Mandates Matter?”

Recertification Could Improve Care

The quality of care provided to patients with hypertension appears to erode as the time since the physician's last board certification increases, a study published online in Circulation found. The researchers analyzed treatment of more than 8,000 patients with hypertension and comorbid diabetes who were treated by 301 internists, looking at patient visits with documented blood pressure of at least 130/85 mm Hg. The frequency of pharmacologic antihypertensive treatment intensification decreased from about 27% for physicians who were board certified the previous year to about 7% for those who were board certified 31 years before the visit. For physicians recertified more than 10 years ago, the treatment intensification rate was about 22%, compared with 17% for those recertified in the last decade.

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit is $117 billion lower over the next 10 years than it estimated last summer. The difference results from the slowing of drug cost trends, lower estimates of plan spending, and higher rebates from drug manufacturers, CMS said. Compared with original projections, the net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Patient Safety Goals Updated

The Joint Commission has released a preliminary version of its 2009 National Patient Safety Goals for hospitals and critical care facilities, and is seeking to add several new requirements to its list of priorities. According to the draft, the commission would like to add a requirement specifically highlighting the need to eliminate transfusion errors related to patient misidentification. In addition, the commission would add a requirement that acute care facilities implement best practices to prevent the spread of multiple drug-resistant organisms. Last, the draft specifies new requirements for using best practices to prevent catheter-associated bloodstream infections and surgical site infections, and also refines points to work toward the commission's goal of reconciling patient medications across the care continuum.

Top 10 Cost Half a Trillion

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion, and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

CMS May Cover Artificial Heart

CMS has proposed covering artificial heart devices in Medicare beneficiaries who are enrolled in Food and Drug Administration-approved studies, reversing a 20-year-old policy. The use of artificial heart technology has not been available to Medicare beneficiaries because of a 1986 noncoverage policy. But since that policy was implemented, two artificial heart manufacturers have run clinical trials studying the safety and health outcomes of using their devices, CMS said. The agency said that it now believes there is sufficient scientific evidence on the use of artificial hearts to allow coverage of these devices for beneficiaries “in the carefully controlled clinical environment of an FDA-approved study.” A final coverage determination is expected in May.

Aetna Inc. has announced that it is working with the American Medical Association and state medical societies to resolve issues involving nonparticipating physicians after the AMA complained that the insurer was paying those physicians just 125% of Medicare rates and then telling patients they didn't need to pay the rest.

In a letter to Aetna, Dr. Michael Maves, AMA's chief executive officer and senior vice president, noted that Aetna's policy—which was implemented last June—fails to take into account different practice costs that are reflected by physicians' billed charges.

“It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board,” Dr. Maves wrote in his letter to Dr. Troyen Brennan, Aetna's chief medical officer.

Dr. Maves also said in the letter that physicians nationwide have been reporting that they received Aetna Explanation of Benefits (EOB) forms stating that the patient has no obligation to pay the nonparticipating physician the difference between the physician's charge and the amount that Aetna has paid.

This practice, Dr. Maves said, potentially violates the 2003 settlement agreement with Aetna in Multidistrict Litigation 1334, the large class action lawsuit in which physicians sued large managed care companies, including Aetna, over business practices.

However, Dr. Brennan said in an interview that the settlement in that case “clearly differentiates between HMO-based plans and traditional plans.” The settlement requires Aetna to tell members in traditional plans that they can be balance-billed by nonparticipating physicians, but it treats HMO plans differently, he said.

HMO members receive an EOB stating that Aetna does not contract with a nonparticipating provider, and that the provider might not accept Aetna's payment as payment in full for services, Dr. Brennan said.

“In the notice, we inform the member that we 'seek to ensure that they do not pay this provider any amount above any applicable copayment, coinsurance, or deductible at the in-network (referred) benefit level,' and if they receive a bill for the difference, they should send the bill to us,” he said.

Aetna believes that it has complied with the 2003 settlement agreement “in all respects,” Dr. Brennan said, adding that the company is in discussions with the AMA and state medical societies regarding the issues involved. However, “no substantive discussions have occurred as of yet with the AMA,” said AMA spokesman Robert Mills.

Meanwhile, nonparticipating physicians are being placed in an awkward situation, said Dr. Alan Schorr, a Langhorne, Pa.-based endocrinologist who does not participate with Aetna. Some of his patients have received the Aetna EOBs.

“This puts the patient and physician into adversarial roles,” said Dr. Schorr, who added that, although Aetna might believe that 125% of Medicare represents fair reimbursement, “the patient has to have some sense of responsibility.”

But the EOBs from Aetna state that the patient has no responsibility to pay the difference between 125% of Medicare rates and the actual charges, Dr. Schorr said in an interview, and patients therefore don't want to pay the difference.

“We've had comments made to our office manager along the lines of 'Just write off the difference—you make enough anyway,'” he said.

Aetna “is trying to force physicians back into the [network] fold,” Dr. Schorr said, adding that he had complained to the AMA and to the Pennsylvania Medical Society about Aetna's practice.

“What we're looking at, in my opinion, is restraint of trade. They're trying to ratchet down physicians' fees,” Dr. Schorr said.

Aetna Inc. has announced that it is working with the American Medical Association and state medical societies to resolve issues involving nonparticipating physicians after the AMA complained that the insurer was paying those physicians just 125% of Medicare rates and then telling patients they didn't need to pay the rest.

In a letter to Aetna, Dr. Michael Maves, AMA's chief executive officer and senior vice president, noted that Aetna's policy—which was implemented last June—fails to take into account different practice costs that are reflected by physicians' billed charges.

“It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board,” Dr. Maves wrote in his letter to Dr. Troyen Brennan, Aetna's chief medical officer.

Dr. Maves also said in the letter that physicians nationwide have been reporting that they received Aetna Explanation of Benefits (EOB) forms stating that the patient has no obligation to pay the nonparticipating physician the difference between the physician's charge and the amount that Aetna has paid.

This practice, Dr. Maves said, potentially violates the 2003 settlement agreement with Aetna in Multidistrict Litigation 1334, the large class action lawsuit in which physicians sued large managed care companies, including Aetna, over business practices.

However, Dr. Brennan said in an interview that the settlement in that case “clearly differentiates between HMO-based plans and traditional plans.” The settlement requires Aetna to tell members in traditional plans that they can be balance-billed by nonparticipating physicians, but it treats HMO plans differently, he said.

HMO members receive an EOB stating that Aetna does not contract with a nonparticipating provider, and that the provider might not accept Aetna's payment as payment in full for services, Dr. Brennan said.

“In the notice, we inform the member that we 'seek to ensure that they do not pay this provider any amount above any applicable copayment, coinsurance, or deductible at the in-network (referred) benefit level,' and if they receive a bill for the difference, they should send the bill to us,” he said.

Aetna believes that it has complied with the 2003 settlement agreement “in all respects,” Dr. Brennan said, adding that the company is in discussions with the AMA and state medical societies regarding the issues involved. However, “no substantive discussions have occurred as of yet with the AMA,” said AMA spokesman Robert Mills.

Meanwhile, nonparticipating physicians are being placed in an awkward situation, said Dr. Alan Schorr, a Langhorne, Pa.-based endocrinologist who does not participate with Aetna. Some of his patients have received the Aetna EOBs.

“This puts the patient and physician into adversarial roles,” said Dr. Schorr, who added that, although Aetna might believe that 125% of Medicare represents fair reimbursement, “the patient has to have some sense of responsibility.”

But the EOBs from Aetna state that the patient has no responsibility to pay the difference between 125% of Medicare rates and the actual charges, Dr. Schorr said in an interview, and patients therefore don't want to pay the difference.

“We've had comments made to our office manager along the lines of 'Just write off the difference—you make enough anyway,'” he said.

Aetna “is trying to force physicians back into the [network] fold,” Dr. Schorr said, adding that he had complained to the AMA and to the Pennsylvania Medical Society about Aetna's practice.

“What we're looking at, in my opinion, is restraint of trade. They're trying to ratchet down physicians' fees,” Dr. Schorr said.

Aetna Inc. has announced that it is working with the American Medical Association and state medical societies to resolve issues involving nonparticipating physicians after the AMA complained that the insurer was paying those physicians just 125% of Medicare rates and then telling patients they didn't need to pay the rest.

In a letter to Aetna, Dr. Michael Maves, AMA's chief executive officer and senior vice president, noted that Aetna's policy—which was implemented last June—fails to take into account different practice costs that are reflected by physicians' billed charges.

“It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board,” Dr. Maves wrote in his letter to Dr. Troyen Brennan, Aetna's chief medical officer.

Dr. Maves also said in the letter that physicians nationwide have been reporting that they received Aetna Explanation of Benefits (EOB) forms stating that the patient has no obligation to pay the nonparticipating physician the difference between the physician's charge and the amount that Aetna has paid.

This practice, Dr. Maves said, potentially violates the 2003 settlement agreement with Aetna in Multidistrict Litigation 1334, the large class action lawsuit in which physicians sued large managed care companies, including Aetna, over business practices.

However, Dr. Brennan said in an interview that the settlement in that case “clearly differentiates between HMO-based plans and traditional plans.” The settlement requires Aetna to tell members in traditional plans that they can be balance-billed by nonparticipating physicians, but it treats HMO plans differently, he said.

HMO members receive an EOB stating that Aetna does not contract with a nonparticipating provider, and that the provider might not accept Aetna's payment as payment in full for services, Dr. Brennan said.

“In the notice, we inform the member that we 'seek to ensure that they do not pay this provider any amount above any applicable copayment, coinsurance, or deductible at the in-network (referred) benefit level,' and if they receive a bill for the difference, they should send the bill to us,” he said.

Aetna believes that it has complied with the 2003 settlement agreement “in all respects,” Dr. Brennan said, adding that the company is in discussions with the AMA and state medical societies regarding the issues involved. However, “no substantive discussions have occurred as of yet with the AMA,” said AMA spokesman Robert Mills.

Meanwhile, nonparticipating physicians are being placed in an awkward situation, said Dr. Alan Schorr, a Langhorne, Pa.-based endocrinologist who does not participate with Aetna. Some of his patients have received the Aetna EOBs.

“This puts the patient and physician into adversarial roles,” said Dr. Schorr, who added that, although Aetna might believe that 125% of Medicare represents fair reimbursement, “the patient has to have some sense of responsibility.”

But the EOBs from Aetna state that the patient has no responsibility to pay the difference between 125% of Medicare rates and the actual charges, Dr. Schorr said in an interview, and patients therefore don't want to pay the difference.

“We've had comments made to our office manager along the lines of 'Just write off the difference—you make enough anyway,'” he said.

Aetna “is trying to force physicians back into the [network] fold,” Dr. Schorr said, adding that he had complained to the AMA and to the Pennsylvania Medical Society about Aetna's practice.

“What we're looking at, in my opinion, is restraint of trade. They're trying to ratchet down physicians' fees,” Dr. Schorr said.