Joyce Frieden

ARLINGTON, VA. — International medical graduates have become an integral part of providing medical care in federally designated physician shortage areas, according to results from a recent study.

“Compared to U.S.-trained physicians, IMGs provide more primary care and more [overall] medical care to populations living in primary care shortage areas” as well as to minorities, immigrants, patients in poor areas, and Medicaid recipients, said Esther Hing of the National Center for Health Statistics, in Hyattsville, Md.

Ms. Hing and her colleague Susan Lin, Dr. P.H., studied 2005–2006 data from the National Ambulatory Medical Care Survey. The survey was nationally representative, and the data used by the researchers included information from 2,390 physicians in office-based practices. Surveyors performed a face-to-face interview and abstracted medical records for about 30 office visits. Ms. Hing presented the survey results at the 2008 Physician Workforce Research Conference.

The survey showed that IMGs make up 25% of office-based physicians. They also tend to be a little older that U.S.-trained doctors, with an average age of 52 years, compared with 50 years for physicians trained in the United States. The racial and ethnic differences were more pronounced: 71% of U.S. medical graduates were non-Hispanic white, compared with 26% of IMGs. Asian/Pacific Islanders made up 32% of IMGs, compared with 5% of U.S. medical graduates. More of the IMGs than U.S. medical graduates were working as primary care physicians—57% vs. 46%—a statistically significant difference, Ms. Hing noted.

IMGs also practiced more often in counties that included primary care shortage areas than did U.S.-trained physicians—87% vs. 79%. And IMGs more often saw patients during evening and weekend hours than their U.S.-trained counterparts. IMGs also were more likely to accept new patients and to accept Medicaid—nearly one-third of IMGs surveyed derived 20% or more of their incomes from Medicaid, compared with less than one-fourth of U.S.-trained physicians.

“This study illustrates how the U.S. health care system continues to rely on IMGs to address shortages in primary care,” Ms. Hing said at the conference, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. “The U.S. health care system faces challenges if the future supply … of IMGs is constrained by recent changes in visa policy that reduce the number of incoming [graduates]. This is an important consideration for policy makers.”

ARLINGTON, VA. — International medical graduates have become an integral part of providing medical care in federally designated physician shortage areas, according to results from a recent study.

“Compared to U.S.-trained physicians, IMGs provide more primary care and more [overall] medical care to populations living in primary care shortage areas” as well as to minorities, immigrants, patients in poor areas, and Medicaid recipients, said Esther Hing of the National Center for Health Statistics, in Hyattsville, Md.

Ms. Hing and her colleague Susan Lin, Dr. P.H., studied 2005–2006 data from the National Ambulatory Medical Care Survey. The survey was nationally representative, and the data used by the researchers included information from 2,390 physicians in office-based practices. Surveyors performed a face-to-face interview and abstracted medical records for about 30 office visits. Ms. Hing presented the survey results at the 2008 Physician Workforce Research Conference.

The survey showed that IMGs make up 25% of office-based physicians. They also tend to be a little older that U.S.-trained doctors, with an average age of 52 years, compared with 50 years for physicians trained in the United States. The racial and ethnic differences were more pronounced: 71% of U.S. medical graduates were non-Hispanic white, compared with 26% of IMGs. Asian/Pacific Islanders made up 32% of IMGs, compared with 5% of U.S. medical graduates. More of the IMGs than U.S. medical graduates were working as primary care physicians—57% vs. 46%—a statistically significant difference, Ms. Hing noted.

IMGs also practiced more often in counties that included primary care shortage areas than did U.S.-trained physicians—87% vs. 79%. And IMGs more often saw patients during evening and weekend hours than their U.S.-trained counterparts. IMGs also were more likely to accept new patients and to accept Medicaid—nearly one-third of IMGs surveyed derived 20% or more of their incomes from Medicaid, compared with less than one-fourth of U.S.-trained physicians.

“This study illustrates how the U.S. health care system continues to rely on IMGs to address shortages in primary care,” Ms. Hing said at the conference, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. “The U.S. health care system faces challenges if the future supply … of IMGs is constrained by recent changes in visa policy that reduce the number of incoming [graduates]. This is an important consideration for policy makers.”

ARLINGTON, VA. — International medical graduates have become an integral part of providing medical care in federally designated physician shortage areas, according to results from a recent study.

“Compared to U.S.-trained physicians, IMGs provide more primary care and more [overall] medical care to populations living in primary care shortage areas” as well as to minorities, immigrants, patients in poor areas, and Medicaid recipients, said Esther Hing of the National Center for Health Statistics, in Hyattsville, Md.

Ms. Hing and her colleague Susan Lin, Dr. P.H., studied 2005–2006 data from the National Ambulatory Medical Care Survey. The survey was nationally representative, and the data used by the researchers included information from 2,390 physicians in office-based practices. Surveyors performed a face-to-face interview and abstracted medical records for about 30 office visits. Ms. Hing presented the survey results at the 2008 Physician Workforce Research Conference.

The survey showed that IMGs make up 25% of office-based physicians. They also tend to be a little older that U.S.-trained doctors, with an average age of 52 years, compared with 50 years for physicians trained in the United States. The racial and ethnic differences were more pronounced: 71% of U.S. medical graduates were non-Hispanic white, compared with 26% of IMGs. Asian/Pacific Islanders made up 32% of IMGs, compared with 5% of U.S. medical graduates. More of the IMGs than U.S. medical graduates were working as primary care physicians—57% vs. 46%—a statistically significant difference, Ms. Hing noted.

IMGs also practiced more often in counties that included primary care shortage areas than did U.S.-trained physicians—87% vs. 79%. And IMGs more often saw patients during evening and weekend hours than their U.S.-trained counterparts. IMGs also were more likely to accept new patients and to accept Medicaid—nearly one-third of IMGs surveyed derived 20% or more of their incomes from Medicaid, compared with less than one-fourth of U.S.-trained physicians.

“This study illustrates how the U.S. health care system continues to rely on IMGs to address shortages in primary care,” Ms. Hing said at the conference, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. “The U.S. health care system faces challenges if the future supply … of IMGs is constrained by recent changes in visa policy that reduce the number of incoming [graduates]. This is an important consideration for policy makers.”

LAKE BUENA VISTA, FLA. — Endocrinologists who want to put Medicare patients with diabetes on continuous glucose monitors may soon have a more updated CPT code to use, according to Dr. Eric Orzeck.

The current reimbursement code for continuous glucose monitoring (95250) covers “ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.” A companion code (95251) covers physician interpretation of the monitor's printout.

But Dr. Orzeck, who presents proposed coding changes to the CPT Editorial Panel on behalf of the American Association of Clinical Endocrinologists (AACE), said the panel proposed that the code should accommodate the continuous glucose monitoring system staying in place for a minimum of 72 hours, rather than the current “up to 72 hours.” Dr. Orzeck said he was optimistic about the panel's revision being published. “I have a feeling it's going to be accepted because it's just an editorial revision. It doesn't have to go to another step,” he said at the AACE annual meeting.

Another piece of good news was that “there was no change in the laboratory platform,” so endocrinologists can continue to use their in-house labs for testing and can bill Medicare, said Dr. Orzeck, an endocrinologist at Baylor College of Medicine, Houston. “This was definitely resisted by the [commercial] lab people.” Of course, in-office testing requires a CLIA (Clinical Laboratory Improvement Amendment) waiver or certification to be paid, he added. One proposed change that is currently on appeal would allow other technology—such as nerve conduction studies—in the office, he added.

Dr. Orzeck urged endocrinologists to look carefully at their billing processes. He said endocrinologists often do not code properly. “We tend to undercode. It has to do with our training and the fact that we're a much more cognitive specialty.”

Dr. Orzeck and his colleagues recently looked at the frequency of billing codes used by endocrinologists, as compared with oncologists—another specialty that's primarily cognitive.

“If you look at curves of coding, endocrinologists tend to have a spike at the '4s',” with 45%–50% of their coding being for either 99204 or 99214, for office visits for new or established patients involving problems of moderate to high severity. On the other hand, he said, oncologists have a “very nice ramp up with 3s, 4s, and 5s, with their coding being at the 55% level for 99215,” which is a higher-complexity office visit code.

Dr. Orzeck stressed that he is not urging people “to upcode just because other groups do it. I'm advocating that you look at time spent and the complexity of what you do and code appropriately. You are the final [arbiter] of your services. You know what it took to do what you did, and therefore you know best how to code. [But] don't be afraid to bill for the time that you actually expend, taking into account the complexity of the visit.”

Dr. Orzeck also stressed the importance of using modifiers. “You have to know how to use them and your biller has to know how to bill them,” he said. Otherwise, “you're going to be leaving a lot of money on the table, and you're not going to realize exactly what the potentials are. It's the means by which we tell the insurance company that a certain procedure had to be performed, but it was different from what the standard coding manuals said would be performed on a regular basis.”

He reviewed the following codes and modifiers that endocrinologists can use to help them get paid appropriately:

▸ 99354. This is a time-based, not a complexity-based, code and can be added on to a regular office visit. The code is defined as “prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service.” For instance, suppose you're discussing radioactive iodine treatment with a hyperthyroid patient. “The patient read somewhere that it causes sterility and she desires a pregnancy somewhere down the line. You're not going to convince her or even have the ability to tell her what the issues are and what your thoughts are in an 8- to 10-minute visit,” he said. “So you can then bill [at] a 4 level, for example, and then add 99354 for prolonged services above the time for the initial service.” With a visit lasting more than 30 minutes, report the evaluation and management code, then add 99354 for up to 1 hour and 14 minutes, he suggested.

▸ 90774. This code applies to one of the few procedures endocrinologists do perform: thyrotropin-releasing hormone injection for follow-up of thyroid cancer patients. The 90774 code is for an intravenous push, Dr. Orzeck said. If you buy the medication yourself, use the appropriate J code (J2725) to bill for it, he said, noting that the medication must be billed in units of 250 mcg.

▸ 90765. This code is used for an intravenous infusion, such as that used for zoledronic acid. That drug now has its own J code (J3488), said Dr. Orzeck, who is a member of AACE's socioeconomic committee. “If you do provide [Reclast], the quantity is only 1 mg for that J code,” he warned. “So if you don't bill 'times 5' for the 5 mg that you administer to the patient, you will not be paid for the whole cost; you'll only be paid at the rate of 1 mg. … This is one of the areas that we as physicians often don't get paid for doing what we do, when the money is there and we just didn't get it done.”

▸ Modifier 25. This modifier “is the one that gives us the most improvement on our billing,” he said. The CPT code book definition reads, “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” This would apply, for instance, when you admit a patient to the hospital after seeing them in the office to identify that the second service needed to be performed on the same day.

▸ Modifier 26. This is used when you are interpreting a stream of data or other information, and utilizing equipment you don't own or control. For example, said Dr. Orzeck, “If I dose a patient with radioactive iodine, and I want to get a [follow-up] scan, the patient goes to hospital and gets scanned on their equipment and comes back to office with the scan in hand. I'm going to use modifier 26 to show that I'm interpreting data that I did not obtain on my own but is not going to be interpreted by anyone else.”

▸ Modifier 51. This modifier is appended to a secondary procedure when multiple procedures are performed on the same day, Dr. Orzeck explained. “You will not get paid for a second procedure on the same day without putting a modifier in to show that you actually did do two separate procedures at the same time on the same patient, but they were distinct and not an extension of one procedure to another.”

▸ Modifier 91. Endocrinologists should use this code more often, according to Dr. Orzeck; it's for repeating the same test on the same patient at different times during the day. “The patient comes in and their blood sugar is 41, 58, or 396, and you say, 'I want to see what it is in 30 minutes' or an hour or whatever. You will not get paid for that repeat test unless you put the modifier on to explain that you're not doing it to verify that the test is appropriate or because the sample came from a different site, but [instead] you're doing it to look at actual information for dealing with patient management in the acute phase” of a problem, he said. With the modifier, “you will get paid for the subsequent tests at the same rate as the initial test,” he added.

▸ Bundled codes. Endocrinology does not have many “bundled” codes—which would encompass several time-consuming services usually performed as a package—but bundled codes have been proposed for certain services performed by endocrinologists. One example would be a code that comprises starting insulin, training the patient to use a meter, and instituting a new diet for a newly diagnosed type 1 diabetes patient, he said. “This is working its way through consideration, and there may be a bundled code that would incorporate the fact that the time involved is quite high in certain procedures.”

LAKE BUENA VISTA, FLA. — Endocrinologists who want to put Medicare patients with diabetes on continuous glucose monitors may soon have a more updated CPT code to use, according to Dr. Eric Orzeck.

The current reimbursement code for continuous glucose monitoring (95250) covers “ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.” A companion code (95251) covers physician interpretation of the monitor's printout.

But Dr. Orzeck, who presents proposed coding changes to the CPT Editorial Panel on behalf of the American Association of Clinical Endocrinologists (AACE), said the panel proposed that the code should accommodate the continuous glucose monitoring system staying in place for a minimum of 72 hours, rather than the current “up to 72 hours.” Dr. Orzeck said he was optimistic about the panel's revision being published. “I have a feeling it's going to be accepted because it's just an editorial revision. It doesn't have to go to another step,” he said at the AACE annual meeting.

Another piece of good news was that “there was no change in the laboratory platform,” so endocrinologists can continue to use their in-house labs for testing and can bill Medicare, said Dr. Orzeck, an endocrinologist at Baylor College of Medicine, Houston. “This was definitely resisted by the [commercial] lab people.” Of course, in-office testing requires a CLIA (Clinical Laboratory Improvement Amendment) waiver or certification to be paid, he added. One proposed change that is currently on appeal would allow other technology—such as nerve conduction studies—in the office, he added.

Dr. Orzeck urged endocrinologists to look carefully at their billing processes. He said endocrinologists often do not code properly. “We tend to undercode. It has to do with our training and the fact that we're a much more cognitive specialty.”

Dr. Orzeck and his colleagues recently looked at the frequency of billing codes used by endocrinologists, as compared with oncologists—another specialty that's primarily cognitive.

“If you look at curves of coding, endocrinologists tend to have a spike at the '4s',” with 45%–50% of their coding being for either 99204 or 99214, for office visits for new or established patients involving problems of moderate to high severity. On the other hand, he said, oncologists have a “very nice ramp up with 3s, 4s, and 5s, with their coding being at the 55% level for 99215,” which is a higher-complexity office visit code.

Dr. Orzeck stressed that he is not urging people “to upcode just because other groups do it. I'm advocating that you look at time spent and the complexity of what you do and code appropriately. You are the final [arbiter] of your services. You know what it took to do what you did, and therefore you know best how to code. [But] don't be afraid to bill for the time that you actually expend, taking into account the complexity of the visit.”

Dr. Orzeck also stressed the importance of using modifiers. “You have to know how to use them and your biller has to know how to bill them,” he said. Otherwise, “you're going to be leaving a lot of money on the table, and you're not going to realize exactly what the potentials are. It's the means by which we tell the insurance company that a certain procedure had to be performed, but it was different from what the standard coding manuals said would be performed on a regular basis.”

He reviewed the following codes and modifiers that endocrinologists can use to help them get paid appropriately:

▸ 99354. This is a time-based, not a complexity-based, code and can be added on to a regular office visit. The code is defined as “prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service.” For instance, suppose you're discussing radioactive iodine treatment with a hyperthyroid patient. “The patient read somewhere that it causes sterility and she desires a pregnancy somewhere down the line. You're not going to convince her or even have the ability to tell her what the issues are and what your thoughts are in an 8- to 10-minute visit,” he said. “So you can then bill [at] a 4 level, for example, and then add 99354 for prolonged services above the time for the initial service.” With a visit lasting more than 30 minutes, report the evaluation and management code, then add 99354 for up to 1 hour and 14 minutes, he suggested.

▸ 90774. This code applies to one of the few procedures endocrinologists do perform: thyrotropin-releasing hormone injection for follow-up of thyroid cancer patients. The 90774 code is for an intravenous push, Dr. Orzeck said. If you buy the medication yourself, use the appropriate J code (J2725) to bill for it, he said, noting that the medication must be billed in units of 250 mcg.

▸ 90765. This code is used for an intravenous infusion, such as that used for zoledronic acid. That drug now has its own J code (J3488), said Dr. Orzeck, who is a member of AACE's socioeconomic committee. “If you do provide [Reclast], the quantity is only 1 mg for that J code,” he warned. “So if you don't bill 'times 5' for the 5 mg that you administer to the patient, you will not be paid for the whole cost; you'll only be paid at the rate of 1 mg. … This is one of the areas that we as physicians often don't get paid for doing what we do, when the money is there and we just didn't get it done.”

▸ Modifier 25. This modifier “is the one that gives us the most improvement on our billing,” he said. The CPT code book definition reads, “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” This would apply, for instance, when you admit a patient to the hospital after seeing them in the office to identify that the second service needed to be performed on the same day.

▸ Modifier 26. This is used when you are interpreting a stream of data or other information, and utilizing equipment you don't own or control. For example, said Dr. Orzeck, “If I dose a patient with radioactive iodine, and I want to get a [follow-up] scan, the patient goes to hospital and gets scanned on their equipment and comes back to office with the scan in hand. I'm going to use modifier 26 to show that I'm interpreting data that I did not obtain on my own but is not going to be interpreted by anyone else.”

▸ Modifier 51. This modifier is appended to a secondary procedure when multiple procedures are performed on the same day, Dr. Orzeck explained. “You will not get paid for a second procedure on the same day without putting a modifier in to show that you actually did do two separate procedures at the same time on the same patient, but they were distinct and not an extension of one procedure to another.”

▸ Modifier 91. Endocrinologists should use this code more often, according to Dr. Orzeck; it's for repeating the same test on the same patient at different times during the day. “The patient comes in and their blood sugar is 41, 58, or 396, and you say, 'I want to see what it is in 30 minutes' or an hour or whatever. You will not get paid for that repeat test unless you put the modifier on to explain that you're not doing it to verify that the test is appropriate or because the sample came from a different site, but [instead] you're doing it to look at actual information for dealing with patient management in the acute phase” of a problem, he said. With the modifier, “you will get paid for the subsequent tests at the same rate as the initial test,” he added.

▸ Bundled codes. Endocrinology does not have many “bundled” codes—which would encompass several time-consuming services usually performed as a package—but bundled codes have been proposed for certain services performed by endocrinologists. One example would be a code that comprises starting insulin, training the patient to use a meter, and instituting a new diet for a newly diagnosed type 1 diabetes patient, he said. “This is working its way through consideration, and there may be a bundled code that would incorporate the fact that the time involved is quite high in certain procedures.”

LAKE BUENA VISTA, FLA. — Endocrinologists who want to put Medicare patients with diabetes on continuous glucose monitors may soon have a more updated CPT code to use, according to Dr. Eric Orzeck.

The current reimbursement code for continuous glucose monitoring (95250) covers “ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.” A companion code (95251) covers physician interpretation of the monitor's printout.

But Dr. Orzeck, who presents proposed coding changes to the CPT Editorial Panel on behalf of the American Association of Clinical Endocrinologists (AACE), said the panel proposed that the code should accommodate the continuous glucose monitoring system staying in place for a minimum of 72 hours, rather than the current “up to 72 hours.” Dr. Orzeck said he was optimistic about the panel's revision being published. “I have a feeling it's going to be accepted because it's just an editorial revision. It doesn't have to go to another step,” he said at the AACE annual meeting.

Another piece of good news was that “there was no change in the laboratory platform,” so endocrinologists can continue to use their in-house labs for testing and can bill Medicare, said Dr. Orzeck, an endocrinologist at Baylor College of Medicine, Houston. “This was definitely resisted by the [commercial] lab people.” Of course, in-office testing requires a CLIA (Clinical Laboratory Improvement Amendment) waiver or certification to be paid, he added. One proposed change that is currently on appeal would allow other technology—such as nerve conduction studies—in the office, he added.

Dr. Orzeck urged endocrinologists to look carefully at their billing processes. He said endocrinologists often do not code properly. “We tend to undercode. It has to do with our training and the fact that we're a much more cognitive specialty.”

Dr. Orzeck and his colleagues recently looked at the frequency of billing codes used by endocrinologists, as compared with oncologists—another specialty that's primarily cognitive.

“If you look at curves of coding, endocrinologists tend to have a spike at the '4s',” with 45%–50% of their coding being for either 99204 or 99214, for office visits for new or established patients involving problems of moderate to high severity. On the other hand, he said, oncologists have a “very nice ramp up with 3s, 4s, and 5s, with their coding being at the 55% level for 99215,” which is a higher-complexity office visit code.

Dr. Orzeck stressed that he is not urging people “to upcode just because other groups do it. I'm advocating that you look at time spent and the complexity of what you do and code appropriately. You are the final [arbiter] of your services. You know what it took to do what you did, and therefore you know best how to code. [But] don't be afraid to bill for the time that you actually expend, taking into account the complexity of the visit.”

Dr. Orzeck also stressed the importance of using modifiers. “You have to know how to use them and your biller has to know how to bill them,” he said. Otherwise, “you're going to be leaving a lot of money on the table, and you're not going to realize exactly what the potentials are. It's the means by which we tell the insurance company that a certain procedure had to be performed, but it was different from what the standard coding manuals said would be performed on a regular basis.”

He reviewed the following codes and modifiers that endocrinologists can use to help them get paid appropriately:

▸ 99354. This is a time-based, not a complexity-based, code and can be added on to a regular office visit. The code is defined as “prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service.” For instance, suppose you're discussing radioactive iodine treatment with a hyperthyroid patient. “The patient read somewhere that it causes sterility and she desires a pregnancy somewhere down the line. You're not going to convince her or even have the ability to tell her what the issues are and what your thoughts are in an 8- to 10-minute visit,” he said. “So you can then bill [at] a 4 level, for example, and then add 99354 for prolonged services above the time for the initial service.” With a visit lasting more than 30 minutes, report the evaluation and management code, then add 99354 for up to 1 hour and 14 minutes, he suggested.

▸ 90774. This code applies to one of the few procedures endocrinologists do perform: thyrotropin-releasing hormone injection for follow-up of thyroid cancer patients. The 90774 code is for an intravenous push, Dr. Orzeck said. If you buy the medication yourself, use the appropriate J code (J2725) to bill for it, he said, noting that the medication must be billed in units of 250 mcg.

▸ 90765. This code is used for an intravenous infusion, such as that used for zoledronic acid. That drug now has its own J code (J3488), said Dr. Orzeck, who is a member of AACE's socioeconomic committee. “If you do provide [Reclast], the quantity is only 1 mg for that J code,” he warned. “So if you don't bill 'times 5' for the 5 mg that you administer to the patient, you will not be paid for the whole cost; you'll only be paid at the rate of 1 mg. … This is one of the areas that we as physicians often don't get paid for doing what we do, when the money is there and we just didn't get it done.”

▸ Modifier 25. This modifier “is the one that gives us the most improvement on our billing,” he said. The CPT code book definition reads, “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” This would apply, for instance, when you admit a patient to the hospital after seeing them in the office to identify that the second service needed to be performed on the same day.

▸ Modifier 26. This is used when you are interpreting a stream of data or other information, and utilizing equipment you don't own or control. For example, said Dr. Orzeck, “If I dose a patient with radioactive iodine, and I want to get a [follow-up] scan, the patient goes to hospital and gets scanned on their equipment and comes back to office with the scan in hand. I'm going to use modifier 26 to show that I'm interpreting data that I did not obtain on my own but is not going to be interpreted by anyone else.”

▸ Modifier 51. This modifier is appended to a secondary procedure when multiple procedures are performed on the same day, Dr. Orzeck explained. “You will not get paid for a second procedure on the same day without putting a modifier in to show that you actually did do two separate procedures at the same time on the same patient, but they were distinct and not an extension of one procedure to another.”

▸ Modifier 91. Endocrinologists should use this code more often, according to Dr. Orzeck; it's for repeating the same test on the same patient at different times during the day. “The patient comes in and their blood sugar is 41, 58, or 396, and you say, 'I want to see what it is in 30 minutes' or an hour or whatever. You will not get paid for that repeat test unless you put the modifier on to explain that you're not doing it to verify that the test is appropriate or because the sample came from a different site, but [instead] you're doing it to look at actual information for dealing with patient management in the acute phase” of a problem, he said. With the modifier, “you will get paid for the subsequent tests at the same rate as the initial test,” he added.

▸ Bundled codes. Endocrinology does not have many “bundled” codes—which would encompass several time-consuming services usually performed as a package—but bundled codes have been proposed for certain services performed by endocrinologists. One example would be a code that comprises starting insulin, training the patient to use a meter, and instituting a new diet for a newly diagnosed type 1 diabetes patient, he said. “This is working its way through consideration, and there may be a bundled code that would incorporate the fact that the time involved is quite high in certain procedures.”

CRYSTAL CITY, VA. — Suppose the federal government has designated your part of the state as a physician shortage area, but charges haven't gone up and you still have lots of openings for new patients in your practice. Does that mean there's really not a problem getting care? Not necessarily, according to Carol J. Simon, Ph.D.

The usual symptoms of a “demand-driven” physician shortage are waits to see providers, new patients being turned away, and rising prices, Dr. Simon said at the 2008 Physician Workforce Research Conference. However, “we don't find a lot of systematic evidence of demand-driven shortage in [federally] defined primary care shortage areas. What we do find … is a lot of evidence of inadequate demand—inability to pay and inability to access the care that patients may need.”

To find out more about access problems, Dr. Simon, vice president at the Lewin Group, a health care consulting firm, and her colleagues sent surveys to 2,834 primary care physicians in five states: California, Georgia, Illinois, Pennsylvania, and Texas. About half the physicians surveyed were pediatricians; 15% were African American or Hispanic. The response rate was 69% (n = 1,967).

According to their preliminary findings, 49% of respondents overall were accepting all new patients, while 44% accepted some and 7% accepted none. But those numbers changed when looked at by the type of area surveyed. For example, in areas designated as having a primary care shortage, 71% of physicians were accepting all new patients, compared with only 34% of physicians in areas of high population growth and 52% of physicians in poor areas.

As to the growth in physician incomes, the data were not consistent with a lack of providers, Dr. Simon said at the meeting, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. Over a 3-year period, physician incomes dropped an average of 4% per year in shortage areas, compared with a 5% annual increase in high-growth areas and a decline of 1.6% per year in poor areas. Physician incomes as compared with the national average also were not consistent with shortage designations: incomes of physicians practicing in designated shortage areas were found to be at 89% of the national average, compared with 107% for physicians in high-growth areas and 78% for physicians in poor areas.

The researchers also looked at a particular example of delayed follow-up care: follow-up exceeding 4 weeks for mild persistent asthma. There was little difference between the amount of delayed follow-up that occurred in the designated shortage areas and high-growth areas, but poor areas had a slightly higher percentage (see box). “It's hard to tell whether this is evidence of capacity issues or [of] scheduling difficulties,” said Dr. Simon.

The results seem to suggest that in designated shortage areas, “the immediate need may be to bolster willingness and ability to pay for care—that is, [increasing] insurance coverage and incomes,” she said. “Increasing supply alone in the absence of a basis for paying for care could threaten the financial viability of system providers.”

In areas with high population growth, “there is indeed evidence of [lines], longer follow-up times, practices closed to new patients, and upward pressure on income and prices,” she said. “Here, increasing supply will promote access to services and mitigate cost increases. Clearly we're seeing pressure in some areas not historically defined as shortage areas.”

ELSEVIER GLOBAL MEDICAL NEWS

CRYSTAL CITY, VA. — Suppose the federal government has designated your part of the state as a physician shortage area, but charges haven't gone up and you still have lots of openings for new patients in your practice. Does that mean there's really not a problem getting care? Not necessarily, according to Carol J. Simon, Ph.D.

The usual symptoms of a “demand-driven” physician shortage are waits to see providers, new patients being turned away, and rising prices, Dr. Simon said at the 2008 Physician Workforce Research Conference. However, “we don't find a lot of systematic evidence of demand-driven shortage in [federally] defined primary care shortage areas. What we do find … is a lot of evidence of inadequate demand—inability to pay and inability to access the care that patients may need.”

To find out more about access problems, Dr. Simon, vice president at the Lewin Group, a health care consulting firm, and her colleagues sent surveys to 2,834 primary care physicians in five states: California, Georgia, Illinois, Pennsylvania, and Texas. About half the physicians surveyed were pediatricians; 15% were African American or Hispanic. The response rate was 69% (n = 1,967).

According to their preliminary findings, 49% of respondents overall were accepting all new patients, while 44% accepted some and 7% accepted none. But those numbers changed when looked at by the type of area surveyed. For example, in areas designated as having a primary care shortage, 71% of physicians were accepting all new patients, compared with only 34% of physicians in areas of high population growth and 52% of physicians in poor areas.

As to the growth in physician incomes, the data were not consistent with a lack of providers, Dr. Simon said at the meeting, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. Over a 3-year period, physician incomes dropped an average of 4% per year in shortage areas, compared with a 5% annual increase in high-growth areas and a decline of 1.6% per year in poor areas. Physician incomes as compared with the national average also were not consistent with shortage designations: incomes of physicians practicing in designated shortage areas were found to be at 89% of the national average, compared with 107% for physicians in high-growth areas and 78% for physicians in poor areas.

The researchers also looked at a particular example of delayed follow-up care: follow-up exceeding 4 weeks for mild persistent asthma. There was little difference between the amount of delayed follow-up that occurred in the designated shortage areas and high-growth areas, but poor areas had a slightly higher percentage (see box). “It's hard to tell whether this is evidence of capacity issues or [of] scheduling difficulties,” said Dr. Simon.

The results seem to suggest that in designated shortage areas, “the immediate need may be to bolster willingness and ability to pay for care—that is, [increasing] insurance coverage and incomes,” she said. “Increasing supply alone in the absence of a basis for paying for care could threaten the financial viability of system providers.”

In areas with high population growth, “there is indeed evidence of [lines], longer follow-up times, practices closed to new patients, and upward pressure on income and prices,” she said. “Here, increasing supply will promote access to services and mitigate cost increases. Clearly we're seeing pressure in some areas not historically defined as shortage areas.”

ELSEVIER GLOBAL MEDICAL NEWS

CRYSTAL CITY, VA. — Suppose the federal government has designated your part of the state as a physician shortage area, but charges haven't gone up and you still have lots of openings for new patients in your practice. Does that mean there's really not a problem getting care? Not necessarily, according to Carol J. Simon, Ph.D.

The usual symptoms of a “demand-driven” physician shortage are waits to see providers, new patients being turned away, and rising prices, Dr. Simon said at the 2008 Physician Workforce Research Conference. However, “we don't find a lot of systematic evidence of demand-driven shortage in [federally] defined primary care shortage areas. What we do find … is a lot of evidence of inadequate demand—inability to pay and inability to access the care that patients may need.”

To find out more about access problems, Dr. Simon, vice president at the Lewin Group, a health care consulting firm, and her colleagues sent surveys to 2,834 primary care physicians in five states: California, Georgia, Illinois, Pennsylvania, and Texas. About half the physicians surveyed were pediatricians; 15% were African American or Hispanic. The response rate was 69% (n = 1,967).

According to their preliminary findings, 49% of respondents overall were accepting all new patients, while 44% accepted some and 7% accepted none. But those numbers changed when looked at by the type of area surveyed. For example, in areas designated as having a primary care shortage, 71% of physicians were accepting all new patients, compared with only 34% of physicians in areas of high population growth and 52% of physicians in poor areas.

As to the growth in physician incomes, the data were not consistent with a lack of providers, Dr. Simon said at the meeting, which was sponsored by the Association of American Medical Colleges and Harvard Medical School. Over a 3-year period, physician incomes dropped an average of 4% per year in shortage areas, compared with a 5% annual increase in high-growth areas and a decline of 1.6% per year in poor areas. Physician incomes as compared with the national average also were not consistent with shortage designations: incomes of physicians practicing in designated shortage areas were found to be at 89% of the national average, compared with 107% for physicians in high-growth areas and 78% for physicians in poor areas.

The researchers also looked at a particular example of delayed follow-up care: follow-up exceeding 4 weeks for mild persistent asthma. There was little difference between the amount of delayed follow-up that occurred in the designated shortage areas and high-growth areas, but poor areas had a slightly higher percentage (see box). “It's hard to tell whether this is evidence of capacity issues or [of] scheduling difficulties,” said Dr. Simon.

The results seem to suggest that in designated shortage areas, “the immediate need may be to bolster willingness and ability to pay for care—that is, [increasing] insurance coverage and incomes,” she said. “Increasing supply alone in the absence of a basis for paying for care could threaten the financial viability of system providers.”

In areas with high population growth, “there is indeed evidence of [lines], longer follow-up times, practices closed to new patients, and upward pressure on income and prices,” she said. “Here, increasing supply will promote access to services and mitigate cost increases. Clearly we're seeing pressure in some areas not historically defined as shortage areas.”

ELSEVIER GLOBAL MEDICAL NEWS

CMS Mulls Surgery for Diabetes

The Centers for Medicare and Medicaid Services is considering whether to institute a national coverage policy for bariatric surgery to treat diabetes. “Various bariatric surgery procedures, including gastric bypass surgery, have been reported to 'cure diabetes,' possibly by increasing insulin production or altering metabolism in other ways, in patients who are overweight or even of normal body mass index,” CMS noted in announcing its analysis. “The evidence for improved health outcomes is scant, however, and leaders of the American Diabetes Association and academic institutions have urged caution in attributing a benefit to such procedures in the absence of convincing scientific data.” CMS currently covers bariatric surgery under certain circumstances; bariatric surgery for diabetes can be covered at the discretion of local Medicare carriers.

Diabetes Prevention Act Introduced

Sen. Frank Lautenberg (D-N.J.) and Sen. Johnny Isakson, (R-Ga.) have introduced the Diabetes Prevention Access and Care Act of 2008. The legislation would coordinate prevention, research, treatment, and education efforts across the National Institutes of Health and the Centers for Disease Control and Prevention. The legislation also would require the Department of Health and Human Services to develop a plan to address diabetes among minority populations and increase the number of minority physicians who focus on diabetes care and treatment. The American Diabetes Association applauded the legislation. “Diabetes has emerged as the greatest public health crisis of the 21st century, and among minority communities the footprint of this disease is even greater,” said Dr. John Anderson, chair of the association's national advocacy committee.

Osteoporosis Study Launched

Researchers recently launched a multinational osteoporosis trial of nearly 60,000 postmenopausal women that aims to provide a real-world look at how patients at risk for osteoporotic fractures are treated. The Global Longitudinal Registry of Osteoporosis in Women (GLOW) is an observational study of women over age 55 years who visited their primary care physician during the 2 years prior to their study enrollment; enrollment is not linked to an osteoporosis diagnosis. Participants were recruited through primary care physicians at 17 sites in North America, Europe, and Australia. Researchers will collect information on osteoporosis risk factors, treatments, patient and physician behavior, and fracture outcomes over a 5-year period. “We want to understand regional differences in physician and patient behavior and how [they affect] patient outcomes,” Dr. Pierre Delmas, cochair of the study's executive committee, said in a statement. The study is being conducted by researchers at the Center for Outcomes Research at the University of Massachusetts, Worcester, and is supported by an unrestricted research grant from the Alliance for Better Bone Health, funded by Sanofi-aventis U.S. and Procter & Gamble Pharmaceuticals. More information is available at

www.outcomes.org/glow

Disciplinary Actions Decline

The number and rate of serious disciplinary actions against physicians has decreased for the third consecutive year, according to Public Citizen's annual ranking of state medical boards. The advocacy group said the analysis indicates that many states are not living up to their obligations to protect patients from bad doctors. Since 2004, the number of serious disciplinary actions against doctors has decreased 17%. Taking into account the increasing number of U.S. physicians since 2004, the rate of serious actions has fallen 22% since then, when calculated per 1,000 physicians, according to Public Citizen. The annual rankings are based on data from the Federation of State Medical Boards.

CMS Mulls Surgery for Diabetes

The Centers for Medicare and Medicaid Services is considering whether to institute a national coverage policy for bariatric surgery to treat diabetes. “Various bariatric surgery procedures, including gastric bypass surgery, have been reported to 'cure diabetes,' possibly by increasing insulin production or altering metabolism in other ways, in patients who are overweight or even of normal body mass index,” CMS noted in announcing its analysis. “The evidence for improved health outcomes is scant, however, and leaders of the American Diabetes Association and academic institutions have urged caution in attributing a benefit to such procedures in the absence of convincing scientific data.” CMS currently covers bariatric surgery under certain circumstances; bariatric surgery for diabetes can be covered at the discretion of local Medicare carriers.

Diabetes Prevention Act Introduced

Sen. Frank Lautenberg (D-N.J.) and Sen. Johnny Isakson, (R-Ga.) have introduced the Diabetes Prevention Access and Care Act of 2008. The legislation would coordinate prevention, research, treatment, and education efforts across the National Institutes of Health and the Centers for Disease Control and Prevention. The legislation also would require the Department of Health and Human Services to develop a plan to address diabetes among minority populations and increase the number of minority physicians who focus on diabetes care and treatment. The American Diabetes Association applauded the legislation. “Diabetes has emerged as the greatest public health crisis of the 21st century, and among minority communities the footprint of this disease is even greater,” said Dr. John Anderson, chair of the association's national advocacy committee.

Osteoporosis Study Launched

Researchers recently launched a multinational osteoporosis trial of nearly 60,000 postmenopausal women that aims to provide a real-world look at how patients at risk for osteoporotic fractures are treated. The Global Longitudinal Registry of Osteoporosis in Women (GLOW) is an observational study of women over age 55 years who visited their primary care physician during the 2 years prior to their study enrollment; enrollment is not linked to an osteoporosis diagnosis. Participants were recruited through primary care physicians at 17 sites in North America, Europe, and Australia. Researchers will collect information on osteoporosis risk factors, treatments, patient and physician behavior, and fracture outcomes over a 5-year period. “We want to understand regional differences in physician and patient behavior and how [they affect] patient outcomes,” Dr. Pierre Delmas, cochair of the study's executive committee, said in a statement. The study is being conducted by researchers at the Center for Outcomes Research at the University of Massachusetts, Worcester, and is supported by an unrestricted research grant from the Alliance for Better Bone Health, funded by Sanofi-aventis U.S. and Procter & Gamble Pharmaceuticals. More information is available at

www.outcomes.org/glow

Disciplinary Actions Decline

The number and rate of serious disciplinary actions against physicians has decreased for the third consecutive year, according to Public Citizen's annual ranking of state medical boards. The advocacy group said the analysis indicates that many states are not living up to their obligations to protect patients from bad doctors. Since 2004, the number of serious disciplinary actions against doctors has decreased 17%. Taking into account the increasing number of U.S. physicians since 2004, the rate of serious actions has fallen 22% since then, when calculated per 1,000 physicians, according to Public Citizen. The annual rankings are based on data from the Federation of State Medical Boards.

CMS Mulls Surgery for Diabetes

The Centers for Medicare and Medicaid Services is considering whether to institute a national coverage policy for bariatric surgery to treat diabetes. “Various bariatric surgery procedures, including gastric bypass surgery, have been reported to 'cure diabetes,' possibly by increasing insulin production or altering metabolism in other ways, in patients who are overweight or even of normal body mass index,” CMS noted in announcing its analysis. “The evidence for improved health outcomes is scant, however, and leaders of the American Diabetes Association and academic institutions have urged caution in attributing a benefit to such procedures in the absence of convincing scientific data.” CMS currently covers bariatric surgery under certain circumstances; bariatric surgery for diabetes can be covered at the discretion of local Medicare carriers.

Diabetes Prevention Act Introduced

Sen. Frank Lautenberg (D-N.J.) and Sen. Johnny Isakson, (R-Ga.) have introduced the Diabetes Prevention Access and Care Act of 2008. The legislation would coordinate prevention, research, treatment, and education efforts across the National Institutes of Health and the Centers for Disease Control and Prevention. The legislation also would require the Department of Health and Human Services to develop a plan to address diabetes among minority populations and increase the number of minority physicians who focus on diabetes care and treatment. The American Diabetes Association applauded the legislation. “Diabetes has emerged as the greatest public health crisis of the 21st century, and among minority communities the footprint of this disease is even greater,” said Dr. John Anderson, chair of the association's national advocacy committee.

Osteoporosis Study Launched

Researchers recently launched a multinational osteoporosis trial of nearly 60,000 postmenopausal women that aims to provide a real-world look at how patients at risk for osteoporotic fractures are treated. The Global Longitudinal Registry of Osteoporosis in Women (GLOW) is an observational study of women over age 55 years who visited their primary care physician during the 2 years prior to their study enrollment; enrollment is not linked to an osteoporosis diagnosis. Participants were recruited through primary care physicians at 17 sites in North America, Europe, and Australia. Researchers will collect information on osteoporosis risk factors, treatments, patient and physician behavior, and fracture outcomes over a 5-year period. “We want to understand regional differences in physician and patient behavior and how [they affect] patient outcomes,” Dr. Pierre Delmas, cochair of the study's executive committee, said in a statement. The study is being conducted by researchers at the Center for Outcomes Research at the University of Massachusetts, Worcester, and is supported by an unrestricted research grant from the Alliance for Better Bone Health, funded by Sanofi-aventis U.S. and Procter & Gamble Pharmaceuticals. More information is available at

www.outcomes.org/glow

Disciplinary Actions Decline

The number and rate of serious disciplinary actions against physicians has decreased for the third consecutive year, according to Public Citizen's annual ranking of state medical boards. The advocacy group said the analysis indicates that many states are not living up to their obligations to protect patients from bad doctors. Since 2004, the number of serious disciplinary actions against doctors has decreased 17%. Taking into account the increasing number of U.S. physicians since 2004, the rate of serious actions has fallen 22% since then, when calculated per 1,000 physicians, according to Public Citizen. The annual rankings are based on data from the Federation of State Medical Boards.

WASHINGTON – Don't believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much.

That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. “We've expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured,” he said at a diabetes meeting sponsored by Avalere Health.

But significant challenges are ahead. The state government recently announced that the program will cost “significantly” more than the proposed $869 million budgeted for it in 2009. One reason for the increase is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums. The insurers had sought a 15% increase but agreed to settle for 10% after lengthy negotiations.

Richard Powers, a spokesman for the program, said in an interview that the real driving force behind the increased cost is growing enrollment. “Certainly, the rate increases will factor into the final figure–which has yet to be determined–but it is minor in comparison to the enrollment,” he said.

The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees–the other three-fourths will continue to pay no premiums–while copays will go up for half of those enrolled. (See box.)

Dr. McDonough said cost increases were not unexpected. “Yes, it's true … When you enroll a ton of people, costs do go up,” he said during his talk, which was given before the announcement but after state officials had projected an increase in the program's budget. “Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts.”

The Massachusetts plan has engendered dislike on both extremes of the health care reform debate, Dr. McDonough said. “We know we're in radically experimental terrain, and we hope we're providing some ideas and some paths for [the] system [to] advance.”

Health Care for All receives financial support from the Massachusetts state government to support its enrollment and outreach efforts.

Medicaid Expansion for Children Is a Key Feature

Under the plan, the state has expanded Medicaid eligibility for children from those families making 200% of the federal poverty level to those families making 300%, Dr. McDonough explained. The state also set up Commonwealth Care for adults making less than 300% of the poverty level who can't get insurance anywhere else. In that program, there are no premiums for those under 150% of the poverty level, and then there is a sliding-scale premium structure for those between 150% and 300% of poverty, up to $107 per month.

For people above 300% of poverty who are having difficulty finding affordable coverage, the state offers coverage plans through a variety of private insurers, Dr. McDonough continued. Some plans have higher premiums in exchange for lower cost sharing; others offer the opposite approach. In addition, employers are required to set up “cafeteria plans” that allow workers to deduct their health insurance premiums from their paychecks pretax.

As of July 1, 2007, the state also requires all residents to be insured, provided that affordable coverage is available to them. Residents who do not comply with the law must pay penalties. In 2007, the penalty for not having coverage was a standard $219.

WASHINGTON – Don't believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much.

That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. “We've expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured,” he said at a diabetes meeting sponsored by Avalere Health.

But significant challenges are ahead. The state government recently announced that the program will cost “significantly” more than the proposed $869 million budgeted for it in 2009. One reason for the increase is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums. The insurers had sought a 15% increase but agreed to settle for 10% after lengthy negotiations.

Richard Powers, a spokesman for the program, said in an interview that the real driving force behind the increased cost is growing enrollment. “Certainly, the rate increases will factor into the final figure–which has yet to be determined–but it is minor in comparison to the enrollment,” he said.

The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees–the other three-fourths will continue to pay no premiums–while copays will go up for half of those enrolled. (See box.)

Dr. McDonough said cost increases were not unexpected. “Yes, it's true … When you enroll a ton of people, costs do go up,” he said during his talk, which was given before the announcement but after state officials had projected an increase in the program's budget. “Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts.”

The Massachusetts plan has engendered dislike on both extremes of the health care reform debate, Dr. McDonough said. “We know we're in radically experimental terrain, and we hope we're providing some ideas and some paths for [the] system [to] advance.”

Health Care for All receives financial support from the Massachusetts state government to support its enrollment and outreach efforts.

Medicaid Expansion for Children Is a Key Feature

Under the plan, the state has expanded Medicaid eligibility for children from those families making 200% of the federal poverty level to those families making 300%, Dr. McDonough explained. The state also set up Commonwealth Care for adults making less than 300% of the poverty level who can't get insurance anywhere else. In that program, there are no premiums for those under 150% of the poverty level, and then there is a sliding-scale premium structure for those between 150% and 300% of poverty, up to $107 per month.

For people above 300% of poverty who are having difficulty finding affordable coverage, the state offers coverage plans through a variety of private insurers, Dr. McDonough continued. Some plans have higher premiums in exchange for lower cost sharing; others offer the opposite approach. In addition, employers are required to set up “cafeteria plans” that allow workers to deduct their health insurance premiums from their paychecks pretax.

As of July 1, 2007, the state also requires all residents to be insured, provided that affordable coverage is available to them. Residents who do not comply with the law must pay penalties. In 2007, the penalty for not having coverage was a standard $219.

WASHINGTON – Don't believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much.

That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. “We've expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured,” he said at a diabetes meeting sponsored by Avalere Health.

But significant challenges are ahead. The state government recently announced that the program will cost “significantly” more than the proposed $869 million budgeted for it in 2009. One reason for the increase is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums. The insurers had sought a 15% increase but agreed to settle for 10% after lengthy negotiations.

Richard Powers, a spokesman for the program, said in an interview that the real driving force behind the increased cost is growing enrollment. “Certainly, the rate increases will factor into the final figure–which has yet to be determined–but it is minor in comparison to the enrollment,” he said.

The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees–the other three-fourths will continue to pay no premiums–while copays will go up for half of those enrolled. (See box.)

Dr. McDonough said cost increases were not unexpected. “Yes, it's true … When you enroll a ton of people, costs do go up,” he said during his talk, which was given before the announcement but after state officials had projected an increase in the program's budget. “Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts.”

The Massachusetts plan has engendered dislike on both extremes of the health care reform debate, Dr. McDonough said. “We know we're in radically experimental terrain, and we hope we're providing some ideas and some paths for [the] system [to] advance.”

Health Care for All receives financial support from the Massachusetts state government to support its enrollment and outreach efforts.

Medicaid Expansion for Children Is a Key Feature

Under the plan, the state has expanded Medicaid eligibility for children from those families making 200% of the federal poverty level to those families making 300%, Dr. McDonough explained. The state also set up Commonwealth Care for adults making less than 300% of the poverty level who can't get insurance anywhere else. In that program, there are no premiums for those under 150% of the poverty level, and then there is a sliding-scale premium structure for those between 150% and 300% of poverty, up to $107 per month.

For people above 300% of poverty who are having difficulty finding affordable coverage, the state offers coverage plans through a variety of private insurers, Dr. McDonough continued. Some plans have higher premiums in exchange for lower cost sharing; others offer the opposite approach. In addition, employers are required to set up “cafeteria plans” that allow workers to deduct their health insurance premiums from their paychecks pretax.

As of July 1, 2007, the state also requires all residents to be insured, provided that affordable coverage is available to them. Residents who do not comply with the law must pay penalties. In 2007, the penalty for not having coverage was a standard $219.

WASHINGTON — Don't believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much.

That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. "We've expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured," he said at a diabetes meeting sponsored by Avalere Health.

But significant challenges are ahead. The state government recently announced that the program will cost "significantly" more than the proposed $869 million budgeted for it in 2009. One reason for the increase is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums.

Richard Powers, a spokesman for the program, said in an interview that the real driving force behind the increased cost is growing enrollment.

The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees—the other three-fourths will continue to pay no premiums—while copays will go up for half of those enrolled. (See box.)

Dr. McDonough said cost increases were not unexpected. "Yes, it's true … When you enroll a ton of people, costs do go up," he said. "Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts."

The plan has engendered dislike on both extremes of the health care reform debate, Dr. McDonough said. "You have health care fundamentalists on the left who worship at the shrine of the perpetual single payer, and you have fundamentalists on the right who bow down before the consumer-driven goddess of the unregulated market," he said. "They agree on absolutely nothing, except for one thing: they hate Massachusetts' ecumenical experiment. … We're just doing our best; we know we're in radically experimental terrain, and we hope we're providing some ideas and some paths for [the] system [to] advance."

Details of the Coverage Plan

Under the plan, the state has expanded Medicaid eligibility for children from those families making 200% of the federal poverty level to those families making 300%, Dr. McDonough explained. The state also set up Commonwealth Care for adults making less than 300% of the poverty level who can't get insurance anywhere else. In that program, there are no premiums for those under 150% of the poverty level, and then there is a sliding-scale premium structure for those between 150% and 300% of poverty, up to $107 per month. This program "gets at a significantly uncovered group: childless adults," he said.

For people above 300% of poverty who are having difficulty finding affordable coverage, the state offers coverage plans through a variety of private insurers, Dr. McDonough continued. Some plans have higher premiums in exchange for lower cost sharing, while others offer the opposite approach. In addition, employers are required to set up "cafeteria plans" that allow workers to deduct their health insurance premiums from their paychecks pretax.

As of July 1, 2007, the state also required all residents to be insured, provided that there is affordable coverage available to them. Residents who do not comply with the law must pay penalties. Because some people "made a calculated decision to pay the penalty" rather than pay for coverage, the Massachusetts plan is not considered a universal coverage plan, he said.

WASHINGTON — Don't believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much.

That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. "We've expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured," he said at a diabetes meeting sponsored by Avalere Health.

But significant challenges are ahead. The state government recently announced that the program will cost "significantly" more than the proposed $869 million budgeted for it in 2009. One reason for the increase is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums.

Richard Powers, a spokesman for the program, said in an interview that the real driving force behind the increased cost is growing enrollment.

The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees—the other three-fourths will continue to pay no premiums—while copays will go up for half of those enrolled. (See box.)

Dr. McDonough said cost increases were not unexpected. "Yes, it's true … When you enroll a ton of people, costs do go up," he said. "Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts."

The plan has engendered dislike on both extremes of the health care reform debate, Dr. McDonough said. "You have health care fundamentalists on the left who worship at the shrine of the perpetual single payer, and you have fundamentalists on the right who bow down before the consumer-driven goddess of the unregulated market," he said. "They agree on absolutely nothing, except for one thing: they hate Massachusetts' ecumenical experiment. … We're just doing our best; we know we're in radically experimental terrain, and we hope we're providing some ideas and some paths for [the] system [to] advance."

Details of the Coverage Plan

Under the plan, the state has expanded Medicaid eligibility for children from those families making 200% of the federal poverty level to those families making 300%, Dr. McDonough explained. The state also set up Commonwealth Care for adults making less than 300% of the poverty level who can't get insurance anywhere else. In that program, there are no premiums for those under 150% of the poverty level, and then there is a sliding-scale premium structure for those between 150% and 300% of poverty, up to $107 per month. This program "gets at a significantly uncovered group: childless adults," he said.

For people above 300% of poverty who are having difficulty finding affordable coverage, the state offers coverage plans through a variety of private insurers, Dr. McDonough continued. Some plans have higher premiums in exchange for lower cost sharing, while others offer the opposite approach. In addition, employers are required to set up "cafeteria plans" that allow workers to deduct their health insurance premiums from their paychecks pretax.

As of July 1, 2007, the state also required all residents to be insured, provided that there is affordable coverage available to them. Residents who do not comply with the law must pay penalties. Because some people "made a calculated decision to pay the penalty" rather than pay for coverage, the Massachusetts plan is not considered a universal coverage plan, he said.

WASHINGTON — Don't believe what you read in the national media: The Massachusetts health coverage plan enacted in 2006 is actually doing quite well, thank you very much.

That was the message from John McDonough, D.P.H., executive director of Health Care for All, a consumer health advocacy organization in Boston that has supported the plan. "We've expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured," he said at a diabetes meeting sponsored by Avalere Health.

But significant challenges are ahead. The state government recently announced that the program will cost "significantly" more than the proposed $869 million budgeted for it in 2009. One reason for the increase is that state regulators approved a 10% increase in payments to private insurers for each person enrolled in the program, in which the state subsidizes the insurance premiums.

Richard Powers, a spokesman for the program, said in an interview that the real driving force behind the increased cost is growing enrollment.

The payment increase will take effect July 1. In addition, the state said it would be willing to take on additional financial risk if enrollees end up using more medical care than expected. Also, premiums will be increased for about one-fourth of enrollees—the other three-fourths will continue to pay no premiums—while copays will go up for half of those enrolled. (See box.)

Dr. McDonough said cost increases were not unexpected. "Yes, it's true … When you enroll a ton of people, costs do go up," he said. "Most of [those costs] were expected and, by the way, most of those costs are being paid by the federal government, not by Massachusetts."

The plan has engendered dislike on both extremes of the health care reform debate, Dr. McDonough said. "You have health care fundamentalists on the left who worship at the shrine of the perpetual single payer, and you have fundamentalists on the right who bow down before the consumer-driven goddess of the unregulated market," he said. "They agree on absolutely nothing, except for one thing: they hate Massachusetts' ecumenical experiment. … We're just doing our best; we know we're in radically experimental terrain, and we hope we're providing some ideas and some paths for [the] system [to] advance."

Details of the Coverage Plan

Under the plan, the state has expanded Medicaid eligibility for children from those families making 200% of the federal poverty level to those families making 300%, Dr. McDonough explained. The state also set up Commonwealth Care for adults making less than 300% of the poverty level who can't get insurance anywhere else. In that program, there are no premiums for those under 150% of the poverty level, and then there is a sliding-scale premium structure for those between 150% and 300% of poverty, up to $107 per month. This program "gets at a significantly uncovered group: childless adults," he said.

For people above 300% of poverty who are having difficulty finding affordable coverage, the state offers coverage plans through a variety of private insurers, Dr. McDonough continued. Some plans have higher premiums in exchange for lower cost sharing, while others offer the opposite approach. In addition, employers are required to set up "cafeteria plans" that allow workers to deduct their health insurance premiums from their paychecks pretax.

As of July 1, 2007, the state also required all residents to be insured, provided that there is affordable coverage available to them. Residents who do not comply with the law must pay penalties. Because some people "made a calculated decision to pay the penalty" rather than pay for coverage, the Massachusetts plan is not considered a universal coverage plan, he said.

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“History shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

He added, however, that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well. We had a charismatic president [John F. Kennedy] elected in 1960 who did not have very bold social programs that he proposed, yet he triggered a very broad outpouring of sentiment that succeeded in passing major social initiatives.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, said Dr. Davis.

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response to the recession,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although the recession is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. Employers “would have more money because suddenly [they] don't have [health care] tax credits for employers, and the federal government gets back all that money that they're giving to employers right now. And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “I'm an optimist—I think it's always dark before it gets really dark, but then it gets lighter,” said Mr. Miller, who favors a free-market approach to health care. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care.”

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

'History shows us that major social initiatives do happen exactly at a time of major economic crisis.' DR. HIMMELSTEIN

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“History shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

He added, however, that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well. We had a charismatic president [John F. Kennedy] elected in 1960 who did not have very bold social programs that he proposed, yet he triggered a very broad outpouring of sentiment that succeeded in passing major social initiatives.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, said Dr. Davis.

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response to the recession,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although the recession is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. Employers “would have more money because suddenly [they] don't have [health care] tax credits for employers, and the federal government gets back all that money that they're giving to employers right now. And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “I'm an optimist—I think it's always dark before it gets really dark, but then it gets lighter,” said Mr. Miller, who favors a free-market approach to health care. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care.”

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

'History shows us that major social initiatives do happen exactly at a time of major economic crisis.' DR. HIMMELSTEIN

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“History shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

He added, however, that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well. We had a charismatic president [John F. Kennedy] elected in 1960 who did not have very bold social programs that he proposed, yet he triggered a very broad outpouring of sentiment that succeeded in passing major social initiatives.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, said Dr. Davis.

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response to the recession,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although the recession is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. Employers “would have more money because suddenly [they] don't have [health care] tax credits for employers, and the federal government gets back all that money that they're giving to employers right now. And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “I'm an optimist—I think it's always dark before it gets really dark, but then it gets lighter,” said Mr. Miller, who favors a free-market approach to health care. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care.”

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

'History shows us that major social initiatives do happen exactly at a time of major economic crisis.' DR. HIMMELSTEIN

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“I think past history shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

Dr. Himmelstein added that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, Dr. Davis said. “Those are good jobs.”

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although a recession would affect individuals more, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. Employers “would have more money because suddenly [they] don't have [health care] tax credits for employers, and the federal government gets back all that money that they're giving to employers right now. And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care,” said Mr. Miller, who favors a free-market approach to health care.

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“I think past history shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

Dr. Himmelstein added that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, Dr. Davis said. “Those are good jobs.”

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although a recession would affect individuals more, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. Employers “would have more money because suddenly [they] don't have [health care] tax credits for employers, and the federal government gets back all that money that they're giving to employers right now. And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care,” said Mr. Miller, who favors a free-market approach to health care.

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“I think past history shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

Dr. Himmelstein added that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, Dr. Davis said. “Those are good jobs.”

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although a recession would affect individuals more, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. Employers “would have more money because suddenly [they] don't have [health care] tax credits for employers, and the federal government gets back all that money that they're giving to employers right now. And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care,” said Mr. Miller, who favors a free-market approach to health care.

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

New IOF President

Dr. John A. Kanis has been elected president of the International Osteoporosis Foundation, the organization announced last month. Dr. Kanis is professor emeritus in human metabolism and director of the WHO (World Health Organization) Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England). Dr. Kanis' research interests include osteoporosis, Paget's disease of bone, hyperparathyroidism, and renal osteodystrophy. He was a founding member and trustee of the European Foundation for Osteoporosis and Bone Disease (the predecessor of IOF) as well as a founding member of the British Menopause Society. Other officers elected include Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at the Human Nutrition Research Center on Aging at Tufts University, Boston, as general secretary; and Dr. René Rizzoli, professor of medicine at the University Hospitals of Geneva, as treasurer.

NYC Calorie Displays a Step Closer

A federal appeals judge has ruled that the New York City health department's regulation requiring chain restaurants to display calorie counts on their menus is legal. Judge Richard Holwell of the U.S. District Court for the Southern District of New York threw out a claim by the New York State Restaurant Association that the regulation was preempted by a federal law, the Nutrition Labeling and Education Act of 1990. New York City officials argued that since the federal law “does not seek to impose or regulate the mandatory disclosure of nutrition information by restaurants, the new regulation is not preempted by the federal statute.” The court agreed with the city, and also found that “the required disclosure of caloric information is reasonably related to the government's interest in providing consumers with accurate nutritional information and therefore does not unduly infringe on the First Amendment rights of [restaurant association] members,” the judge wrote. The American Diabetes Association applauded the decision. “We strongly support the court's ruling in favor of upholding this important measure to protect consumers,” said Dr. John Buse, president of medicine and science at the ADA. “If individuals are expected to make informed, healthy food choices, we must give them the nutritional tools they need to do so.”

Health Sector Biggest Lobby

The health care industry was the biggest spender when it came to lobbying Congress in 2007. Pharmaceutical, medical device, physician, and hospital groups spent $227 million, a larger tally than for any other sector, according to the Center for Responsive Politics, a Washington-based watchdog group. Of individual lobbying concerns, the U.S. Chamber of Commerce was No. 1, spending $53 million on in-house and external personnel, the center reported. Close behind was General Electric ($24 million), followed by the Pharmaceutical Research and Manufacturers of America ($23 million), the American Medical Association ($22 million), and the American Hospital Association ($20 million). Broken out by industries, the pharmaceutical sector has spent more on lobbying than any other industry in the last decade, laying out an accumulated $1.3 billion since 1997, according to the center. The data are taken from official lobbying reports that are submitted to the Senate Office of Public Records. The figures do not include other spending that is still aimed at influencing policy, the center noted in its report.

Cancer Info New to Exubera Label

Pfizer has updated its U.S. label for Exubera (insulin human [rDNA origin] inhalation powder) to include information about lung cancer. The company reported last month that over the course of its clinical trials, 6 of the 4,740 Exubera-treated patients developed lung cancer, compared with 1 of 4,292 patients not treated with the drug. Pfizer also received a postmarketing report of lung cancer in one Exubera patient. The labeling update notes that all patients who developed lung cancer had a prior history of cigarette smoking, and that there were too few cases to determine whether the development of lung cancer was related to the use of Exubera. Pfizer discontinued marketing Exubera in October 2007 because of poor sales. After Pfizer announced the labeling change, Nektar Therapeutics, which had been working on an inhaled insulin product, announced that it had stopped development of its product. “The concern over this new data analysis from ongoing clinical trials has resulted in the termination of all negotiations with potential partners,” said Howard W. Robin, company president. “Fortunately, over the past year Nektar has significantly transformed its business, moving away from inhaled insulin.”

New IOF President

Dr. John A. Kanis has been elected president of the International Osteoporosis Foundation, the organization announced last month. Dr. Kanis is professor emeritus in human metabolism and director of the WHO (World Health Organization) Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England). Dr. Kanis' research interests include osteoporosis, Paget's disease of bone, hyperparathyroidism, and renal osteodystrophy. He was a founding member and trustee of the European Foundation for Osteoporosis and Bone Disease (the predecessor of IOF) as well as a founding member of the British Menopause Society. Other officers elected include Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at the Human Nutrition Research Center on Aging at Tufts University, Boston, as general secretary; and Dr. René Rizzoli, professor of medicine at the University Hospitals of Geneva, as treasurer.

NYC Calorie Displays a Step Closer

A federal appeals judge has ruled that the New York City health department's regulation requiring chain restaurants to display calorie counts on their menus is legal. Judge Richard Holwell of the U.S. District Court for the Southern District of New York threw out a claim by the New York State Restaurant Association that the regulation was preempted by a federal law, the Nutrition Labeling and Education Act of 1990. New York City officials argued that since the federal law “does not seek to impose or regulate the mandatory disclosure of nutrition information by restaurants, the new regulation is not preempted by the federal statute.” The court agreed with the city, and also found that “the required disclosure of caloric information is reasonably related to the government's interest in providing consumers with accurate nutritional information and therefore does not unduly infringe on the First Amendment rights of [restaurant association] members,” the judge wrote. The American Diabetes Association applauded the decision. “We strongly support the court's ruling in favor of upholding this important measure to protect consumers,” said Dr. John Buse, president of medicine and science at the ADA. “If individuals are expected to make informed, healthy food choices, we must give them the nutritional tools they need to do so.”

Health Sector Biggest Lobby

The health care industry was the biggest spender when it came to lobbying Congress in 2007. Pharmaceutical, medical device, physician, and hospital groups spent $227 million, a larger tally than for any other sector, according to the Center for Responsive Politics, a Washington-based watchdog group. Of individual lobbying concerns, the U.S. Chamber of Commerce was No. 1, spending $53 million on in-house and external personnel, the center reported. Close behind was General Electric ($24 million), followed by the Pharmaceutical Research and Manufacturers of America ($23 million), the American Medical Association ($22 million), and the American Hospital Association ($20 million). Broken out by industries, the pharmaceutical sector has spent more on lobbying than any other industry in the last decade, laying out an accumulated $1.3 billion since 1997, according to the center. The data are taken from official lobbying reports that are submitted to the Senate Office of Public Records. The figures do not include other spending that is still aimed at influencing policy, the center noted in its report.

Cancer Info New to Exubera Label

Pfizer has updated its U.S. label for Exubera (insulin human [rDNA origin] inhalation powder) to include information about lung cancer. The company reported last month that over the course of its clinical trials, 6 of the 4,740 Exubera-treated patients developed lung cancer, compared with 1 of 4,292 patients not treated with the drug. Pfizer also received a postmarketing report of lung cancer in one Exubera patient. The labeling update notes that all patients who developed lung cancer had a prior history of cigarette smoking, and that there were too few cases to determine whether the development of lung cancer was related to the use of Exubera. Pfizer discontinued marketing Exubera in October 2007 because of poor sales. After Pfizer announced the labeling change, Nektar Therapeutics, which had been working on an inhaled insulin product, announced that it had stopped development of its product. “The concern over this new data analysis from ongoing clinical trials has resulted in the termination of all negotiations with potential partners,” said Howard W. Robin, company president. “Fortunately, over the past year Nektar has significantly transformed its business, moving away from inhaled insulin.”

New IOF President

Dr. John A. Kanis has been elected president of the International Osteoporosis Foundation, the organization announced last month. Dr. Kanis is professor emeritus in human metabolism and director of the WHO (World Health Organization) Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England). Dr. Kanis' research interests include osteoporosis, Paget's disease of bone, hyperparathyroidism, and renal osteodystrophy. He was a founding member and trustee of the European Foundation for Osteoporosis and Bone Disease (the predecessor of IOF) as well as a founding member of the British Menopause Society. Other officers elected include Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at the Human Nutrition Research Center on Aging at Tufts University, Boston, as general secretary; and Dr. René Rizzoli, professor of medicine at the University Hospitals of Geneva, as treasurer.

NYC Calorie Displays a Step Closer

A federal appeals judge has ruled that the New York City health department's regulation requiring chain restaurants to display calorie counts on their menus is legal. Judge Richard Holwell of the U.S. District Court for the Southern District of New York threw out a claim by the New York State Restaurant Association that the regulation was preempted by a federal law, the Nutrition Labeling and Education Act of 1990. New York City officials argued that since the federal law “does not seek to impose or regulate the mandatory disclosure of nutrition information by restaurants, the new regulation is not preempted by the federal statute.” The court agreed with the city, and also found that “the required disclosure of caloric information is reasonably related to the government's interest in providing consumers with accurate nutritional information and therefore does not unduly infringe on the First Amendment rights of [restaurant association] members,” the judge wrote. The American Diabetes Association applauded the decision. “We strongly support the court's ruling in favor of upholding this important measure to protect consumers,” said Dr. John Buse, president of medicine and science at the ADA. “If individuals are expected to make informed, healthy food choices, we must give them the nutritional tools they need to do so.”

Health Sector Biggest Lobby

The health care industry was the biggest spender when it came to lobbying Congress in 2007. Pharmaceutical, medical device, physician, and hospital groups spent $227 million, a larger tally than for any other sector, according to the Center for Responsive Politics, a Washington-based watchdog group. Of individual lobbying concerns, the U.S. Chamber of Commerce was No. 1, spending $53 million on in-house and external personnel, the center reported. Close behind was General Electric ($24 million), followed by the Pharmaceutical Research and Manufacturers of America ($23 million), the American Medical Association ($22 million), and the American Hospital Association ($20 million). Broken out by industries, the pharmaceutical sector has spent more on lobbying than any other industry in the last decade, laying out an accumulated $1.3 billion since 1997, according to the center. The data are taken from official lobbying reports that are submitted to the Senate Office of Public Records. The figures do not include other spending that is still aimed at influencing policy, the center noted in its report.

Cancer Info New to Exubera Label

Pfizer has updated its U.S. label for Exubera (insulin human [rDNA origin] inhalation powder) to include information about lung cancer. The company reported last month that over the course of its clinical trials, 6 of the 4,740 Exubera-treated patients developed lung cancer, compared with 1 of 4,292 patients not treated with the drug. Pfizer also received a postmarketing report of lung cancer in one Exubera patient. The labeling update notes that all patients who developed lung cancer had a prior history of cigarette smoking, and that there were too few cases to determine whether the development of lung cancer was related to the use of Exubera. Pfizer discontinued marketing Exubera in October 2007 because of poor sales. After Pfizer announced the labeling change, Nektar Therapeutics, which had been working on an inhaled insulin product, announced that it had stopped development of its product. “The concern over this new data analysis from ongoing clinical trials has resulted in the termination of all negotiations with potential partners,” said Howard W. Robin, company president. “Fortunately, over the past year Nektar has significantly transformed its business, moving away from inhaled insulin.”

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“I think past history shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

Dr. Himmelstein added, however, that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well. We had a charismatic president [John F. Kennedy] elected in 1960 who did not have very bold social programs that he proposed, yet he triggered a very broad outpouring of sentiment that succeeded in passing major social initiatives.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, said Dr. Davis. “Those are good jobs.”

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response to the recession,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although the recession is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. The federal government “would have more money because suddenly [they] don't have [health care] tax credits for employers … And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “I'm an optimist—I think it's always dark before it gets really dark, but then it gets lighter,” said Mr. Miller, who favors a free-market approach to health care. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care.”

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

'The pain is broadening far beyond the poor…. That's the condition for political change.' DR. HIMMELSTEIN

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“I think past history shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

Dr. Himmelstein added, however, that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well. We had a charismatic president [John F. Kennedy] elected in 1960 who did not have very bold social programs that he proposed, yet he triggered a very broad outpouring of sentiment that succeeded in passing major social initiatives.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, said Dr. Davis. “Those are good jobs.”

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response to the recession,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although the recession is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. The federal government “would have more money because suddenly [they] don't have [health care] tax credits for employers … And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “I'm an optimist—I think it's always dark before it gets really dark, but then it gets lighter,” said Mr. Miller, who favors a free-market approach to health care. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care.”

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

'The pain is broadening far beyond the poor…. That's the condition for political change.' DR. HIMMELSTEIN

ARLINGTON, VA. — Health care reform can be achieved even in difficult economic times, several speakers said at the annual meeting of the Association of Health Care Journalists.

“I think past history shows us that major social initiatives do happen exactly at a time of major economic crisis,” said Dr. David U. Himmelstein of the department of medicine at Harvard Medical School, Boston, and cofounder of Physicians for a National Health Program, a group that advocates for a single-payer health care system. “The New Deal is the outstanding example of that. We're facing a period where our country can't afford the health care system we have at present, and the pain is broadening far beyond the poor into the middle classes. … That's the condition for political change.”

Dr. Himmelstein added, however, that the change probably will not come from Washington. “Political leadership has become the ultimate oxymoron. Demand from outside Washington can actually move this country as well. We had a charismatic president [John F. Kennedy] elected in 1960 who did not have very bold social programs that he proposed, yet he triggered a very broad outpouring of sentiment that succeeded in passing major social initiatives.”

Karen Davis, Ph.D., president of the Commonwealth Fund, a health policy research organization in New York, noted that during hard economic times, “people really get worried about health concerns, so the demand for their political leaders to do something about it grows whenever the economy tanks.” However, states are less able to meet those increased demands “because sales tax revenues go down and unemployment compensation costs go up.”

During the current downturn, federal lawmakers decided to give people tax rebates, but another way to stimulate the economy would have been to invest in the health sector, said Dr. Davis. “Those are good jobs.”

She criticized the Bush administration's decision to limit funding for the State Children's Health Insurance Program and other programs funded by the states and the federal government during this period. “It was the wrong response to the recession,” she said. “We ought to have a countercyclical matching rate built into those programs, so that when the economy tanks, the federal government could pay more of the costs,” reducing the burden on states.

Julie Barnes, deputy director of the health policy program at the New America Foundation, a nonpartisan Washington think tank, agreed that reform is possible during a downturn. Although the recession is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said. “They're the ones we need to look at to determine how health benefits fit into health care costs.”

Although it might be a scary idea, “what if we took employers out of the health care benefit business and pooled individuals instead?” she suggested. The federal government “would have more money because suddenly [they] don't have [health care] tax credits for employers … And wages can go up.”

Tom Miller, resident fellow at the American Enterprise Institute, a public policy research organization in Washington, was less hopeful about the prospect of reform. “I'm an optimist—I think it's always dark before it gets really dark, but then it gets lighter,” said Mr. Miller, who favors a free-market approach to health care. “In the short term, I wouldn't expect a lot of moving around. … We're not going to have any mandate after 2 years of thrashing around debate in Congress. We're going to get some marginal incentives that can provide a little additional assistance so some folks can get some more care.”

He added, however, that Congress “is going to rewrite a good bit of the tax code in the next few years, and health care is going to get less in tax subsidies than it did before. As a result of that, we may rationalize the approach to tax financing of care.”

'The pain is broadening far beyond the poor…. That's the condition for political change.' DR. HIMMELSTEIN