Joyce Frieden

Kahn to Retire From ADA

The American Diabetes Association has announced that Richard A. Kahn, Ph.D., its chief scientific and medical officer, will retire in June. Dr. Kahn has been with the ADA since 1985; he spearheaded the association's publication of clinical practice guidelines. He also provided leadership for the association's consensus-development conferences. “No one who has worked directly with Dr. Kahn can doubt his passion for the science and medicine of diabetes or his dedication to working toward a cure,” said Larry Hausner, the ADA's CEO. Dr. Kahn will consult on various ADA projects through 2009.

Diabetics' Costs Are Higher

A 50-year-old person newly diagnosed with diabetes spends an average of $4,174 more on medical care per year than a person the same age without diabetes, according to a study by RTI International, a Research Triangle Park, N.C., research firm. The diabetes patients' costs increase by $158 every year after diagnosis, on top of health care cost increases normally associated with aging. Most of the extra burden comes from diabetes-related complications, such as heart and kidney disease, the researchers found in their study, which they published in the December issue of Diabetes Care. “The good news is that many of these costs could be contained through proper diabetes management and lifestyle changes,” said economist and lead researcher Justin Trogdon, Ph.D. “Numerous studies show that losing weight and increasing physical activity, along with maintaining proper blood glucose levels, can substantially delay or reduce the risk for diabetes-related complications. What our study does is to point out that there is also a cumulative, financial impact to the progression of this disease.” The study was funded by the Centers for Disease Control and Prevention.

RAC Program Heavily Criticized

Medicare's effort to recover overpayments made to physicians and hospitals and to make good on underpayments—dubbed the Recovery Audit Contractor (RAC) program—was lambasted by members of the Practicing Physicians Advisory Council (PPAC). The program is currently on hold while the Government Accountability Office studies whether the Centers for Medicare and Medicaid Services has implemented it properly (see story, p. 21). During a demonstration project, however, RAC auditors found $1 billion in improper payments among $317 billion worth of claims, a CMS official reported to PPAC. As of July 2008, about 7% of those determinations were overturned on appeal. Once the program is restarted—which is expected by February—there will be limits on the number of years of claims an auditor can examine and how many records can be requested from practices of various sizes. Even with those plans, PPAC panelists recommended further limits and suggested that the CMS require auditors to reimburse providers for fulfilling records requests. Also, more information should be available on the appeals process, said PPAC members.

Medical Emissions Curbed

The Environmental Protection Agency has proposed tougher air pollution standards for medical waste incinerators, which environmental groups said have been among the country's worst emitters of mercury and dioxins. The new rule, which is subject to public comment until late January, resulted from an 11-year legal challenge to existing standards by the environmental groups Earthjustice, the Sierra Club, and the Natural Resources Defense Council. Earthjustice attorney Jim Pew said in a statement that incineration of medical waste has shifted from individual hospitals to commercial incinerators. Pollution reductions at these larger facilities will be significant under the new rules, which is especially good for nearby communities, Mr. Pew said.

CMS Launches Enrollment Site

A new Internet-based system will allow physicians and nonphysician practitioners to apply for Medicare enrollment, check on their applications, make changes, and view their information on file. The Provider Enrollment, Chain, and Ownership System (PECOS) is now available to physicians in 15 states and the District of Columbia. The Centers for Medicare and Medicaid Services said it would expand availability to all states over the next 2 months. The PECOS can process a practitioner's enrollment application as much as 50% faster than can be done on paper, CMS said. In addition, practitioners are required to report certain changes in their enrollment information, and PECOS will allow them to make these changes much faster, CMS said.

Kahn to Retire From ADA

The American Diabetes Association has announced that Richard A. Kahn, Ph.D., its chief scientific and medical officer, will retire in June. Dr. Kahn has been with the ADA since 1985; he spearheaded the association's publication of clinical practice guidelines. He also provided leadership for the association's consensus-development conferences. “No one who has worked directly with Dr. Kahn can doubt his passion for the science and medicine of diabetes or his dedication to working toward a cure,” said Larry Hausner, the ADA's CEO. Dr. Kahn will consult on various ADA projects through 2009.

Diabetics' Costs Are Higher

A 50-year-old person newly diagnosed with diabetes spends an average of $4,174 more on medical care per year than a person the same age without diabetes, according to a study by RTI International, a Research Triangle Park, N.C., research firm. The diabetes patients' costs increase by $158 every year after diagnosis, on top of health care cost increases normally associated with aging. Most of the extra burden comes from diabetes-related complications, such as heart and kidney disease, the researchers found in their study, which they published in the December issue of Diabetes Care. “The good news is that many of these costs could be contained through proper diabetes management and lifestyle changes,” said economist and lead researcher Justin Trogdon, Ph.D. “Numerous studies show that losing weight and increasing physical activity, along with maintaining proper blood glucose levels, can substantially delay or reduce the risk for diabetes-related complications. What our study does is to point out that there is also a cumulative, financial impact to the progression of this disease.” The study was funded by the Centers for Disease Control and Prevention.

RAC Program Heavily Criticized

Medicare's effort to recover overpayments made to physicians and hospitals and to make good on underpayments—dubbed the Recovery Audit Contractor (RAC) program—was lambasted by members of the Practicing Physicians Advisory Council (PPAC). The program is currently on hold while the Government Accountability Office studies whether the Centers for Medicare and Medicaid Services has implemented it properly (see story, p. 21). During a demonstration project, however, RAC auditors found $1 billion in improper payments among $317 billion worth of claims, a CMS official reported to PPAC. As of July 2008, about 7% of those determinations were overturned on appeal. Once the program is restarted—which is expected by February—there will be limits on the number of years of claims an auditor can examine and how many records can be requested from practices of various sizes. Even with those plans, PPAC panelists recommended further limits and suggested that the CMS require auditors to reimburse providers for fulfilling records requests. Also, more information should be available on the appeals process, said PPAC members.

Medical Emissions Curbed

The Environmental Protection Agency has proposed tougher air pollution standards for medical waste incinerators, which environmental groups said have been among the country's worst emitters of mercury and dioxins. The new rule, which is subject to public comment until late January, resulted from an 11-year legal challenge to existing standards by the environmental groups Earthjustice, the Sierra Club, and the Natural Resources Defense Council. Earthjustice attorney Jim Pew said in a statement that incineration of medical waste has shifted from individual hospitals to commercial incinerators. Pollution reductions at these larger facilities will be significant under the new rules, which is especially good for nearby communities, Mr. Pew said.

CMS Launches Enrollment Site

A new Internet-based system will allow physicians and nonphysician practitioners to apply for Medicare enrollment, check on their applications, make changes, and view their information on file. The Provider Enrollment, Chain, and Ownership System (PECOS) is now available to physicians in 15 states and the District of Columbia. The Centers for Medicare and Medicaid Services said it would expand availability to all states over the next 2 months. The PECOS can process a practitioner's enrollment application as much as 50% faster than can be done on paper, CMS said. In addition, practitioners are required to report certain changes in their enrollment information, and PECOS will allow them to make these changes much faster, CMS said.

Kahn to Retire From ADA

The American Diabetes Association has announced that Richard A. Kahn, Ph.D., its chief scientific and medical officer, will retire in June. Dr. Kahn has been with the ADA since 1985; he spearheaded the association's publication of clinical practice guidelines. He also provided leadership for the association's consensus-development conferences. “No one who has worked directly with Dr. Kahn can doubt his passion for the science and medicine of diabetes or his dedication to working toward a cure,” said Larry Hausner, the ADA's CEO. Dr. Kahn will consult on various ADA projects through 2009.

Diabetics' Costs Are Higher

A 50-year-old person newly diagnosed with diabetes spends an average of $4,174 more on medical care per year than a person the same age without diabetes, according to a study by RTI International, a Research Triangle Park, N.C., research firm. The diabetes patients' costs increase by $158 every year after diagnosis, on top of health care cost increases normally associated with aging. Most of the extra burden comes from diabetes-related complications, such as heart and kidney disease, the researchers found in their study, which they published in the December issue of Diabetes Care. “The good news is that many of these costs could be contained through proper diabetes management and lifestyle changes,” said economist and lead researcher Justin Trogdon, Ph.D. “Numerous studies show that losing weight and increasing physical activity, along with maintaining proper blood glucose levels, can substantially delay or reduce the risk for diabetes-related complications. What our study does is to point out that there is also a cumulative, financial impact to the progression of this disease.” The study was funded by the Centers for Disease Control and Prevention.

RAC Program Heavily Criticized

Medicare's effort to recover overpayments made to physicians and hospitals and to make good on underpayments—dubbed the Recovery Audit Contractor (RAC) program—was lambasted by members of the Practicing Physicians Advisory Council (PPAC). The program is currently on hold while the Government Accountability Office studies whether the Centers for Medicare and Medicaid Services has implemented it properly (see story, p. 21). During a demonstration project, however, RAC auditors found $1 billion in improper payments among $317 billion worth of claims, a CMS official reported to PPAC. As of July 2008, about 7% of those determinations were overturned on appeal. Once the program is restarted—which is expected by February—there will be limits on the number of years of claims an auditor can examine and how many records can be requested from practices of various sizes. Even with those plans, PPAC panelists recommended further limits and suggested that the CMS require auditors to reimburse providers for fulfilling records requests. Also, more information should be available on the appeals process, said PPAC members.

Medical Emissions Curbed

The Environmental Protection Agency has proposed tougher air pollution standards for medical waste incinerators, which environmental groups said have been among the country's worst emitters of mercury and dioxins. The new rule, which is subject to public comment until late January, resulted from an 11-year legal challenge to existing standards by the environmental groups Earthjustice, the Sierra Club, and the Natural Resources Defense Council. Earthjustice attorney Jim Pew said in a statement that incineration of medical waste has shifted from individual hospitals to commercial incinerators. Pollution reductions at these larger facilities will be significant under the new rules, which is especially good for nearby communities, Mr. Pew said.

CMS Launches Enrollment Site

A new Internet-based system will allow physicians and nonphysician practitioners to apply for Medicare enrollment, check on their applications, make changes, and view their information on file. The Provider Enrollment, Chain, and Ownership System (PECOS) is now available to physicians in 15 states and the District of Columbia. The Centers for Medicare and Medicaid Services said it would expand availability to all states over the next 2 months. The PECOS can process a practitioner's enrollment application as much as 50% faster than can be done on paper, CMS said. In addition, practitioners are required to report certain changes in their enrollment information, and PECOS will allow them to make these changes much faster, CMS said.

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency then has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said that the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for even those diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, in New York.

Dr. Mechanick noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency then has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said that the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for even those diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, in New York.

Dr. Mechanick noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency then has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said that the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for even those diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, in New York.

Dr. Mechanick noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

PHILADELPHIA – The Food and Drug Administration needs to change the way it regulates promotion of off-label drug use, according to the chair of the department of health policy and public health at the University of the Sciences in Philadelphia.

The FDA has issued draft guidance regarding off-label promotion. The draft guidance states that although any materials promoting off-label use must be peer reviewed, approval by the agency is not required, and the pharmaceutical company does not need to prove its intent to submit a new drug application for the off-label use, Robert I. Field, J.D., Ph.D., said at a meeting of the American Society of Law, Medicine, and Ethics. “This is considered to be a significant loosening of the requirements, certainly of the FDA's enforcement attitude.”

However, the company must clearly disclose that the suggested use is off-label, and any published negative findings regarding the off-label use must be included in the materials. “The problem is, negative findings don't get published very often,” he added.

But medicine only advances when information is shared, “and there are good reasons to allow off-label uses and therefore to allow physicians to know about those off-label uses,” he said. However, “lack of oversight will lead to overzealous, aggressive promotion of uses that have limited, if any, scientific substantiation. The big question [is whether the] average physician, who's working 80 hours a week [is] really going to be able to evaluate this information, even if it has a disclosure written at the top?”

PHILADELPHIA – The Food and Drug Administration needs to change the way it regulates promotion of off-label drug use, according to the chair of the department of health policy and public health at the University of the Sciences in Philadelphia.

The FDA has issued draft guidance regarding off-label promotion. The draft guidance states that although any materials promoting off-label use must be peer reviewed, approval by the agency is not required, and the pharmaceutical company does not need to prove its intent to submit a new drug application for the off-label use, Robert I. Field, J.D., Ph.D., said at a meeting of the American Society of Law, Medicine, and Ethics. “This is considered to be a significant loosening of the requirements, certainly of the FDA's enforcement attitude.”

However, the company must clearly disclose that the suggested use is off-label, and any published negative findings regarding the off-label use must be included in the materials. “The problem is, negative findings don't get published very often,” he added.

But medicine only advances when information is shared, “and there are good reasons to allow off-label uses and therefore to allow physicians to know about those off-label uses,” he said. However, “lack of oversight will lead to overzealous, aggressive promotion of uses that have limited, if any, scientific substantiation. The big question [is whether the] average physician, who's working 80 hours a week [is] really going to be able to evaluate this information, even if it has a disclosure written at the top?”

PHILADELPHIA – The Food and Drug Administration needs to change the way it regulates promotion of off-label drug use, according to the chair of the department of health policy and public health at the University of the Sciences in Philadelphia.

The FDA has issued draft guidance regarding off-label promotion. The draft guidance states that although any materials promoting off-label use must be peer reviewed, approval by the agency is not required, and the pharmaceutical company does not need to prove its intent to submit a new drug application for the off-label use, Robert I. Field, J.D., Ph.D., said at a meeting of the American Society of Law, Medicine, and Ethics. “This is considered to be a significant loosening of the requirements, certainly of the FDA's enforcement attitude.”

However, the company must clearly disclose that the suggested use is off-label, and any published negative findings regarding the off-label use must be included in the materials. “The problem is, negative findings don't get published very often,” he added.

But medicine only advances when information is shared, “and there are good reasons to allow off-label uses and therefore to allow physicians to know about those off-label uses,” he said. However, “lack of oversight will lead to overzealous, aggressive promotion of uses that have limited, if any, scientific substantiation. The big question [is whether the] average physician, who's working 80 hours a week [is] really going to be able to evaluate this information, even if it has a disclosure written at the top?”

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, New York.

He noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

Dr. Philip Schauer, past president of the American Society for Metabolic and Bariatric Surgery, said he was not disappointed with the proposed decision memo. To the contrary, “we in the surgical community were somewhat surprised this came up at all because our organization was not necessarily pushing CMS to address the issue,” said Dr. Schauer, who is director of the Bariatric and Metabolic Institute at the Cleveland Clinic.

“However, there is increasing evidence on bariatric surgery for patients with diabetes and BMI 30–34. When more of this evidence emerges, I think CMS will look at the issue again.”

Dr. Schauer said he was pleased that the agency reaffirmed its support for surgery for diabetes patients with the standard BMI threshold of 35 kg/m

Dr. Schauer was one of four organizers of the Diabetes Surgery Summit held in Rome in 2007 with the goal of developing consensus guidelines for gastrointestinal surgery to treat type 2 diabetes. The guidelines have been completed and were accepted for publication in the Lancet; they will probably appear early in 2009, he said. The guidelines affirm that uncontrolled type 2 diabetes patients with BMIs greater than 35 should be strongly considered for surgical intervention; they also state that for similar patients whose BMIs are less than 35 but greater than 30, surgery may be a reasonable option.

The American Diabetes Association is in agreement with the CMS proposal, a spokeswoman said. She noted that the association has stated that “people with type 2 diabetes and a BMI of 35 or above may be candidates for bariatric surgery.”

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, New York.

He noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

Dr. Philip Schauer, past president of the American Society for Metabolic and Bariatric Surgery, said he was not disappointed with the proposed decision memo. To the contrary, “we in the surgical community were somewhat surprised this came up at all because our organization was not necessarily pushing CMS to address the issue,” said Dr. Schauer, who is director of the Bariatric and Metabolic Institute at the Cleveland Clinic.

“However, there is increasing evidence on bariatric surgery for patients with diabetes and BMI 30–34. When more of this evidence emerges, I think CMS will look at the issue again.”

Dr. Schauer said he was pleased that the agency reaffirmed its support for surgery for diabetes patients with the standard BMI threshold of 35 kg/m

Dr. Schauer was one of four organizers of the Diabetes Surgery Summit held in Rome in 2007 with the goal of developing consensus guidelines for gastrointestinal surgery to treat type 2 diabetes. The guidelines have been completed and were accepted for publication in the Lancet; they will probably appear early in 2009, he said. The guidelines affirm that uncontrolled type 2 diabetes patients with BMIs greater than 35 should be strongly considered for surgical intervention; they also state that for similar patients whose BMIs are less than 35 but greater than 30, surgery may be a reasonable option.

The American Diabetes Association is in agreement with the CMS proposal, a spokeswoman said. She noted that the association has stated that “people with type 2 diabetes and a BMI of 35 or above may be candidates for bariatric surgery.”

Medicare will not cover bariatric surgery for beneficiaries who have type 2 diabetes but do not have a body mass index greater than 35 kg/m

“While recent medical reports claimed that bariatric surgery may be helpful for these patients, [the Centers for Medicare and Medicaid Services] did not find convincing medical evidence that bariatric surgery improved health outcomes for non-morbidly obese individuals,” according to a CMS statement.

Dr. Barry Straube, the agency's director of its Office of Clinical Standards and Quality, said, “Limiting coverage of bariatric surgery in type 2 diabetic patients whose BMI is less than 35 is part of Medicare's ongoing commitment to ensure access to the most effective treatment alternatives with good evidence of benefit, while limiting coverage where the current evidence suggests the risks outweigh the benefits.” The proposal also clarifies that type 2 diabetes is one of the comorbidities that would be acceptable criteria for surgery.

In 2006, the CMS issued a national coverage decision for bariatric surgery in morbid obesity. That decision said that Medicare would cover only three procedures—open and laparoscopic Roux-en-Y gastric bypass surgery, open and laparoscopic biliopancreatic diversion with duodenal switch, and laparoscopic adjustable gastric banding—for beneficiaries who have a BMI greater than 35, have at least one comorbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.

At that time, the agency then asked for comments on whether Medicare should cover various gastric and intestinal bypass procedures to improve diabetes status among obese, overweight, and nonoverweight diabetes patients.

The proposed decision memo is an outcome of that query; the CMS accepted comments on the memo until mid-December. The agency has up to 30 days to issue a final decision memo. (The proposed memo is available online at www.cms.hhs.gov/mcd/index_list.asp?list_type=nca

Dr. Jeffrey Mechanick, who cochaired a bariatric surgery guidelines committee for the American Association of Clinical Endocrinologists, said the CMS was responding to a trend in the medical literature and meeting presentations suggesting that bariatric surgery might be helpful for diabetes patients who are not overweight.

“A lot of surgeons began noticing that after bariatric surgery, patients with diabetes had amelioration of their hyperglycemia,” he said. “At first glance, it seems pretty easy—you lose weight and so your diabetes should be getting better. But they found that a lot of the improvement was independent of weight loss; there was something else.”

The theories included two hypotheses: proximal changes, such as factors in the proximal small bowel, and distal changes, such as glucagonlike protein-1 and other factors made by the small bowel in the distal ileum, said Dr. Mechanick, who is also director of metabolic support in the division of endocrinology, diabetes, and bone disease at the Mount Sinai School of Medicine, New York.

He noted that although the CMS currently is not covering the surgery for patients with a BMI under 35, that could change if long-term follow-up data on the procedure became available.

Dr. Philip Schauer, past president of the American Society for Metabolic and Bariatric Surgery, said he was not disappointed with the proposed decision memo. To the contrary, “we in the surgical community were somewhat surprised this came up at all because our organization was not necessarily pushing CMS to address the issue,” said Dr. Schauer, who is director of the Bariatric and Metabolic Institute at the Cleveland Clinic.

“However, there is increasing evidence on bariatric surgery for patients with diabetes and BMI 30–34. When more of this evidence emerges, I think CMS will look at the issue again.”

Dr. Schauer said he was pleased that the agency reaffirmed its support for surgery for diabetes patients with the standard BMI threshold of 35 kg/m

Dr. Schauer was one of four organizers of the Diabetes Surgery Summit held in Rome in 2007 with the goal of developing consensus guidelines for gastrointestinal surgery to treat type 2 diabetes. The guidelines have been completed and were accepted for publication in the Lancet; they will probably appear early in 2009, he said. The guidelines affirm that uncontrolled type 2 diabetes patients with BMIs greater than 35 should be strongly considered for surgical intervention; they also state that for similar patients whose BMIs are less than 35 but greater than 30, surgery may be a reasonable option.

The American Diabetes Association is in agreement with the CMS proposal, a spokeswoman said. She noted that the association has stated that “people with type 2 diabetes and a BMI of 35 or above may be candidates for bariatric surgery.”

Kaufman Begins NDEP Post

Dr. Francine R. Kaufman recently began a 3-year term as chair of the National Diabetes Education Program. Jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, the program provides free diabetes information to health care providers and patients. “It is with immense pleasure that I welcome Dr. Kaufman, a proven leader in the diabetes community, who will focus on disseminating materials and continuing and building on partnerships to improve diabetes prevention and care,” said Dr. Griffin P. Rodgers, director of the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Kaufman, who has served on NDEP advisory committees since 2000, is director of the comprehensive childhood diabetes center and head of the center for endocrinology, diabetes, and metabolism at Children's Hospital Los Angeles.

Poor Marks for 2007 PQRI

Most physicians who participated in Medicare's 2007 Physician Quality Reporting Initiative found the program at least moderately difficult, according to a survey conducted by the American Medical Association. Only 22% of respondents to the online survey were able to successfully download their feedback report. Of those who downloaded the report, less than half found it helpful. In an open-ended question about their experience with the program, nearly all the responses were negatives, according to the AMA. The results are based on responses from 408 physicians. The AMA plans to work with Congress and the administration to alter the program to provide physicians with interim feedback reports. A recent survey from the Medical Group Management Association reported similar problems in accessing feedback reports.

Many Have Drug 'Gap' Coverage

A total of 13% of Medicare beneficiaries enrolled in Part D prescription drug plans and 63% of those in Medicare Advantage plans with prescription benefits had some form of coverage in the “doughnut hole,” or coverage gap, according to a Centers for Medicare and Medicaid Services study on Part D drug claims. The study, which included data on Medicare drug claims for the 25 million Part D beneficiaries, also indicated that the vast majority of enrollees used the drug benefit: In the program's first year, 90% of enrollees filled at least one prescription. In addition, the use of generic drugs has been high in Part D, rising from 60% in 2006 to nearly 68% in the first quarter of this year.

Behavioral Paths Aid Weight Loss

Obese school-aged children and teenagers can lose weight or prevent further weight gain if they participate in medium- to high-intensity behavioral management programs, according to a study by the Agency for Healthcare Research and Quality. Effective programs taught techniques to improve dietary and physical activity habits, with some using strategies such as goal setting, problem solving, and relapse prevention. These programs met for a total of more than 25 hours, usually once or twice a week, for 6-12 months. Researchers found that after completing weight management programs, obese children would weigh 3-23 pounds less, on average, than would those who were not involved in the programs. The weight difference was greatest among heavier children as well as those enrolled in more intensive programs, and weight improvements were maintained for up to 1 year after the program ended, the AHRQ study found.

More Join Consumer-Directed Plans

The number of people enrolling in consumer-directed health plans rose 25% from last year, according to a survey of nearly 2,800 private insurance enrollees by the Blue Cross and Blue Shield Association. The survey also found that consumers in CDHPs are more cost conscious than are non-CDHP consumers; they are 30% more likely to track their health expenses than are those in more traditional health insurance plans, and 27% more likely to ask their doctors about the cost of treatment. “[CDHP] consumers are demonstrating more active engagement in their own health care than are non-CDHP consumers, as evidenced by an increased use of health and wellness programs and better tracking, estimating, and budgeting” for health care costs, said Maureen Sullivan, senior vice president for strategic services at BCBSA. The 39 independent Blue Cross and Blue Shield companies serve a total of 4.4 million CDHP enrollees—a 50% increase from last year.

Pharmaceutical Sales Outlook

The U.S. pharmaceutical market is expected to grow 1%-2% in 2009, resulting in sales of about $292-$302 billion, according to analysis from the health care market research firm IMS Health. This latest projection is down from the 2%-3% increase projected by IMS earlier this year, and reflects the expected impact of patent expirations, fewer launches of new products, and the slowing U.S. economy. Worldwide pharmaceutical sales are expected to grow 4.5%-5.5% in 2009, similar to growth this year. “The market will continue to contend with a number of forces—among them the shift in growth from developed countries to emerging ones, specialist-driven products playing a larger role, blockbuster drugs losing patent protection, and the rising influence of regulators and payers on health care decisions,” Murray Aitken, senior vice president of Healthcare Insight at IMS, said in a statement.

Kaufman Begins NDEP Post

Dr. Francine R. Kaufman recently began a 3-year term as chair of the National Diabetes Education Program. Jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, the program provides free diabetes information to health care providers and patients. “It is with immense pleasure that I welcome Dr. Kaufman, a proven leader in the diabetes community, who will focus on disseminating materials and continuing and building on partnerships to improve diabetes prevention and care,” said Dr. Griffin P. Rodgers, director of the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Kaufman, who has served on NDEP advisory committees since 2000, is director of the comprehensive childhood diabetes center and head of the center for endocrinology, diabetes, and metabolism at Children's Hospital Los Angeles.

Poor Marks for 2007 PQRI

Most physicians who participated in Medicare's 2007 Physician Quality Reporting Initiative found the program at least moderately difficult, according to a survey conducted by the American Medical Association. Only 22% of respondents to the online survey were able to successfully download their feedback report. Of those who downloaded the report, less than half found it helpful. In an open-ended question about their experience with the program, nearly all the responses were negatives, according to the AMA. The results are based on responses from 408 physicians. The AMA plans to work with Congress and the administration to alter the program to provide physicians with interim feedback reports. A recent survey from the Medical Group Management Association reported similar problems in accessing feedback reports.

Many Have Drug 'Gap' Coverage

A total of 13% of Medicare beneficiaries enrolled in Part D prescription drug plans and 63% of those in Medicare Advantage plans with prescription benefits had some form of coverage in the “doughnut hole,” or coverage gap, according to a Centers for Medicare and Medicaid Services study on Part D drug claims. The study, which included data on Medicare drug claims for the 25 million Part D beneficiaries, also indicated that the vast majority of enrollees used the drug benefit: In the program's first year, 90% of enrollees filled at least one prescription. In addition, the use of generic drugs has been high in Part D, rising from 60% in 2006 to nearly 68% in the first quarter of this year.

Behavioral Paths Aid Weight Loss

Obese school-aged children and teenagers can lose weight or prevent further weight gain if they participate in medium- to high-intensity behavioral management programs, according to a study by the Agency for Healthcare Research and Quality. Effective programs taught techniques to improve dietary and physical activity habits, with some using strategies such as goal setting, problem solving, and relapse prevention. These programs met for a total of more than 25 hours, usually once or twice a week, for 6-12 months. Researchers found that after completing weight management programs, obese children would weigh 3-23 pounds less, on average, than would those who were not involved in the programs. The weight difference was greatest among heavier children as well as those enrolled in more intensive programs, and weight improvements were maintained for up to 1 year after the program ended, the AHRQ study found.

More Join Consumer-Directed Plans

The number of people enrolling in consumer-directed health plans rose 25% from last year, according to a survey of nearly 2,800 private insurance enrollees by the Blue Cross and Blue Shield Association. The survey also found that consumers in CDHPs are more cost conscious than are non-CDHP consumers; they are 30% more likely to track their health expenses than are those in more traditional health insurance plans, and 27% more likely to ask their doctors about the cost of treatment. “[CDHP] consumers are demonstrating more active engagement in their own health care than are non-CDHP consumers, as evidenced by an increased use of health and wellness programs and better tracking, estimating, and budgeting” for health care costs, said Maureen Sullivan, senior vice president for strategic services at BCBSA. The 39 independent Blue Cross and Blue Shield companies serve a total of 4.4 million CDHP enrollees—a 50% increase from last year.

Pharmaceutical Sales Outlook

The U.S. pharmaceutical market is expected to grow 1%-2% in 2009, resulting in sales of about $292-$302 billion, according to analysis from the health care market research firm IMS Health. This latest projection is down from the 2%-3% increase projected by IMS earlier this year, and reflects the expected impact of patent expirations, fewer launches of new products, and the slowing U.S. economy. Worldwide pharmaceutical sales are expected to grow 4.5%-5.5% in 2009, similar to growth this year. “The market will continue to contend with a number of forces—among them the shift in growth from developed countries to emerging ones, specialist-driven products playing a larger role, blockbuster drugs losing patent protection, and the rising influence of regulators and payers on health care decisions,” Murray Aitken, senior vice president of Healthcare Insight at IMS, said in a statement.

Kaufman Begins NDEP Post

Dr. Francine R. Kaufman recently began a 3-year term as chair of the National Diabetes Education Program. Jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, the program provides free diabetes information to health care providers and patients. “It is with immense pleasure that I welcome Dr. Kaufman, a proven leader in the diabetes community, who will focus on disseminating materials and continuing and building on partnerships to improve diabetes prevention and care,” said Dr. Griffin P. Rodgers, director of the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Kaufman, who has served on NDEP advisory committees since 2000, is director of the comprehensive childhood diabetes center and head of the center for endocrinology, diabetes, and metabolism at Children's Hospital Los Angeles.

Poor Marks for 2007 PQRI

Most physicians who participated in Medicare's 2007 Physician Quality Reporting Initiative found the program at least moderately difficult, according to a survey conducted by the American Medical Association. Only 22% of respondents to the online survey were able to successfully download their feedback report. Of those who downloaded the report, less than half found it helpful. In an open-ended question about their experience with the program, nearly all the responses were negatives, according to the AMA. The results are based on responses from 408 physicians. The AMA plans to work with Congress and the administration to alter the program to provide physicians with interim feedback reports. A recent survey from the Medical Group Management Association reported similar problems in accessing feedback reports.

Many Have Drug 'Gap' Coverage

A total of 13% of Medicare beneficiaries enrolled in Part D prescription drug plans and 63% of those in Medicare Advantage plans with prescription benefits had some form of coverage in the “doughnut hole,” or coverage gap, according to a Centers for Medicare and Medicaid Services study on Part D drug claims. The study, which included data on Medicare drug claims for the 25 million Part D beneficiaries, also indicated that the vast majority of enrollees used the drug benefit: In the program's first year, 90% of enrollees filled at least one prescription. In addition, the use of generic drugs has been high in Part D, rising from 60% in 2006 to nearly 68% in the first quarter of this year.

Behavioral Paths Aid Weight Loss

Obese school-aged children and teenagers can lose weight or prevent further weight gain if they participate in medium- to high-intensity behavioral management programs, according to a study by the Agency for Healthcare Research and Quality. Effective programs taught techniques to improve dietary and physical activity habits, with some using strategies such as goal setting, problem solving, and relapse prevention. These programs met for a total of more than 25 hours, usually once or twice a week, for 6-12 months. Researchers found that after completing weight management programs, obese children would weigh 3-23 pounds less, on average, than would those who were not involved in the programs. The weight difference was greatest among heavier children as well as those enrolled in more intensive programs, and weight improvements were maintained for up to 1 year after the program ended, the AHRQ study found.

More Join Consumer-Directed Plans

The number of people enrolling in consumer-directed health plans rose 25% from last year, according to a survey of nearly 2,800 private insurance enrollees by the Blue Cross and Blue Shield Association. The survey also found that consumers in CDHPs are more cost conscious than are non-CDHP consumers; they are 30% more likely to track their health expenses than are those in more traditional health insurance plans, and 27% more likely to ask their doctors about the cost of treatment. “[CDHP] consumers are demonstrating more active engagement in their own health care than are non-CDHP consumers, as evidenced by an increased use of health and wellness programs and better tracking, estimating, and budgeting” for health care costs, said Maureen Sullivan, senior vice president for strategic services at BCBSA. The 39 independent Blue Cross and Blue Shield companies serve a total of 4.4 million CDHP enrollees—a 50% increase from last year.

Pharmaceutical Sales Outlook

The U.S. pharmaceutical market is expected to grow 1%-2% in 2009, resulting in sales of about $292-$302 billion, according to analysis from the health care market research firm IMS Health. This latest projection is down from the 2%-3% increase projected by IMS earlier this year, and reflects the expected impact of patent expirations, fewer launches of new products, and the slowing U.S. economy. Worldwide pharmaceutical sales are expected to grow 4.5%-5.5% in 2009, similar to growth this year. “The market will continue to contend with a number of forces—among them the shift in growth from developed countries to emerging ones, specialist-driven products playing a larger role, blockbuster drugs losing patent protection, and the rising influence of regulators and payers on health care decisions,” Murray Aitken, senior vice president of Healthcare Insight at IMS, said in a statement.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to a leading health care consultant.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” asked Robert Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm headquartered in Alexandria, Va. He spoke at a conference on the impact of the November elections. The conference was sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health, Boston. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform, but when and in exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group Families USA.

Although there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

“It's going to be kind of an organic process,” he said. “I'm sure there will be fits and starts.”

In the weeks leading up to the election, aides to Senate Democrats have been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. And now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau chief for the International Medical News Group, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to a leading health care consultant.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” asked Robert Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm headquartered in Alexandria, Va. He spoke at a conference on the impact of the November elections. The conference was sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health, Boston. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform, but when and in exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group Families USA.

Although there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

“It's going to be kind of an organic process,” he said. “I'm sure there will be fits and starts.”

In the weeks leading up to the election, aides to Senate Democrats have been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. And now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau chief for the International Medical News Group, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to a leading health care consultant.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” asked Robert Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm headquartered in Alexandria, Va. He spoke at a conference on the impact of the November elections. The conference was sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health, Boston. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform, but when and in exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group Families USA.

Although there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

“It's going to be kind of an organic process,” he said. “I'm sure there will be fits and starts.”

In the weeks leading up to the election, aides to Senate Democrats have been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. And now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau chief for the International Medical News Group, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszew-ski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about their overall goals, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “[Some] want to use health reform to improve health outcomes; [others want] to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group wants to protect people from high [out-of-pocket] costs. It's important that we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” said Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA. There are many health reform proposals circulating, but the best chance for success is a single-bill strategy, he said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said. “It's going to be kind of an organic process. I'm sure there will be fits and starts.”

In the weeks before the election, aides to Senate Democrats tried to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. Now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” he said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszew-ski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about their overall goals, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “[Some] want to use health reform to improve health outcomes; [others want] to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group wants to protect people from high [out-of-pocket] costs. It's important that we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” said Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA. There are many health reform proposals circulating, but the best chance for success is a single-bill strategy, he said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said. “It's going to be kind of an organic process. I'm sure there will be fits and starts.”

In the weeks before the election, aides to Senate Democrats tried to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. Now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” he said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON — Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszew-ski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about their overall goals, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “[Some] want to use health reform to improve health outcomes; [others want] to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group wants to protect people from high [out-of-pocket] costs. It's important that we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” said Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA. There are many health reform proposals circulating, but the best chance for success is a single-bill strategy, he said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said. “It's going to be kind of an organic process. I'm sure there will be fits and starts.”

In the weeks before the election, aides to Senate Democrats tried to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. Now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” he said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON – Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm.

“The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid,” he said.

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington.

“There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” Ms. Ferguson said.

“So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP).

In addition, the new administration might focus on setting up a cost-containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance–possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, who serves as staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

(At press time, former Sen. Tom Daschle of South Dakota has emerged in press reports as the president-elect's likely nominee as the next secretary of the Department of Health and Human Services. Such a selection would suggest that Mr. Obama is serious about making health care reform a top priority.)

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

Legislation has not yet been drafted, but whatever comes out of the Congress will need to address both the cost and quality of health care in addition to expansion of coverage to the uninsured, according to Mr. Myers.

“It's going to be kind of an organic process,” he said. “I'm sure there will be fits and starts.”

In the weeks leading up to the election, aides to Senate Democrats had been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum.

And now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA.

“There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON – Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm.

“The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid,” he said.

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington.

“There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” Ms. Ferguson said.

“So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP).

In addition, the new administration might focus on setting up a cost-containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance–possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, who serves as staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

(At press time, former Sen. Tom Daschle of South Dakota has emerged in press reports as the president-elect's likely nominee as the next secretary of the Department of Health and Human Services. Such a selection would suggest that Mr. Obama is serious about making health care reform a top priority.)

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

Legislation has not yet been drafted, but whatever comes out of the Congress will need to address both the cost and quality of health care in addition to expansion of coverage to the uninsured, according to Mr. Myers.

“It's going to be kind of an organic process,” he said. “I'm sure there will be fits and starts.”

In the weeks leading up to the election, aides to Senate Democrats had been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum.

And now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA.

“There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON – Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Unfortunately, many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm.

“The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid,” he said.

Although everyone agrees that the Medicare payment system needs to be reformed and that Medicare costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

“Do you have to do something big?” asked Robert Blendon, Ph.D., professor of health policy and political analysis at the Harvard University School of Public Health. “I believe not, but it has to be something that looks like a big down payment.”

And policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington.

“There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” Ms. Ferguson said.

“So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP).

In addition, the new administration might focus on setting up a cost-containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance–possibly by giving them subsidies to help pay for it.

“These items are all no-brainers,” according to Mr. Laszewski.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, who serves as staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

(At press time, former Sen. Tom Daschle of South Dakota has emerged in press reports as the president-elect's likely nominee as the next secretary of the Department of Health and Human Services. Such a selection would suggest that Mr. Obama is serious about making health care reform a top priority.)

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

Legislation has not yet been drafted, but whatever comes out of the Congress will need to address both the cost and quality of health care in addition to expansion of coverage to the uninsured, according to Mr. Myers.

“It's going to be kind of an organic process,” he said. “I'm sure there will be fits and starts.”

In the weeks leading up to the election, aides to Senate Democrats had been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum.

And now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA.

“There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON—Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

Policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost-containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

In the weeks leading up to the election, aides to Senate Democrats have been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. Now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON—Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

Policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost-containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

In the weeks leading up to the election, aides to Senate Democrats have been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. Now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.

Mary Ellen Schneider, New York Bureau, contributed to this report.

WASHINGTON—Can President-elect Barack Obama really shepherd through major health reform? Not until the Medicare physician payment system gets fixed, according to Robert Laszewski.

“How do you plan a health care budget in Medicare and the private sector for years on out if you haven't agreed on how you're going to pay the doctors?” Mr. Laszewski said at a conference on the impact of the November elections sponsored by Congressional Quarterly and the Public Affairs Council.

Many obstacles lie ahead before the payment system can be fixed, said Mr. Laszewski, president of Health Policy and Strategy Associates, a health care consulting firm. “The primary care physicians are clearly underpaid, and a lot of people think that the specialists are overpaid.”

Although everyone agrees that the Medicare payment system needs to be reformed and costs need to be trimmed, “the problem is, who's going to give up the money?” he continued. “The definition of physician payment reform is to pay the primary care physicians more and pay the rest of us more, and that's not going to fly.”

Congress can't keep making temporary fixes, Mr. Laszewski said, because a fix that lasts for, say, 3 years will be followed by a 36% fee cut because of the way the Sustainable Growth Rate (SGR) payment formula works.

In the meantime, analysts and legislative aides are considering whether smaller health reforms might be possible.

Policy makers have to be clear about what their overall goals are, said Christine Ferguson, J.D., of the department of health policy at George Washington University, Washington. “There is a group of people who want to use health reform to improve health outcomes; another group that wants to control costs [in terms of] the percentage of gross domestic product that goes to health care; and a third group that wants to protect people from high [out-of-pocket] costs,” she said. “So it's very important we're very clear about which of those goals we're trying to achieve.”

Rather than passing a major health reform bill right away, the panelists suggested that President-elect Obama could urge Congress to pass a package of smaller reforms, which could include less-controversial items as expanding the State Children's Health Insurance Program (SCHIP), setting up a cost-containment board to come up with ideas for reducing health spending, and helping individuals and small businesses buy health insurance—possibly by giving them subsidies to help pay for it.

But some Senate Democrats are looking to take a more aggressive approach. Sen. Edward M. Kennedy (D-Mass.), who chairs the Senate Health, Education, Labor and Pensions Committee, wants to craft comprehensive health reform legislation that follows the framework of the Obama plan, said Michael Myers, staff director for the committee.

“With the Obama victory, the question is no longer whether we'll pursue comprehensive health reform but when and exactly what form,” Mr. Myers said during a postelection briefing sponsored by the advocacy group, Families USA.

While there are many health reform proposals circulating on Capitol Hill, the best chance for success is a single-bill strategy, Mr. Myers said, and Sen. Kennedy is urging fellow Democrats to unite behind the proposal from President-elect Obama.

No legislation has been drafted yet, but whatever comes out of the Congress will need to address both the cost and quality of health care and expanding coverage to the uninsured, Mr. Myers said.

In the weeks leading up to the election, aides to Senate Democrats have been trying to lay the groundwork for this legislation by meeting with stakeholders from across the spectrum. Now that the election is over, Mr. Myers said there will be more discussions with Republicans in Congress.

The interest in achieving comprehensive health reform and the cooperation among stakeholders is higher now than at any point in the last 25 years, said Ron Pollack, executive director of Families USA. “There's a very significant likelihood that meaningful health reform will be a top and early priority for action in the 111th Congress,” Mr. Pollack said.