Joyce Frieden

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when they are deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

“This is like Travelocity for health care,” said Health and Human Services Secretary Mike Leavitt. “When people have information and they have choice, they make good choices.” Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. It included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. “There are three reasons people pick a hospital,” he said in an interview after Mr. Leavitt spoke. “They heard it was good, it's where their physician spends a lot of time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?”

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. “Every health care provider wants to provide high-quality [care],” he said. “Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up.”

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. “This is not about eliminating anyone; it's about improving everyone,” he said. “The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't.”

As for whether those hospitals that don't improve might eventually face consequences, “I hope so,” Mr. Leavitt said, noting that his tenure as HHS secretary would likely be over by the time that came to pass. “This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor—performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality.”

But it's not only hospitals and patients who can use the new data, according to Gerald Shea, assistant to the president for governmental affairs at the AFL-CIO. “This is important for physicians and other clinicians,” he said at the meeting. “We hope physicians take this information and make it part of their regular, routine discussions with their patients. … Annual checkups, semiannual checkups, regular consultations, [or] just occasional visits—there should be communication programmed into those kinds of interactions between patients and clinicians so people get a feel for what kind of data [are] available when they have to make a choice on hospitals.”

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when they are deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

“This is like Travelocity for health care,” said Health and Human Services Secretary Mike Leavitt. “When people have information and they have choice, they make good choices.” Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. It included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. “There are three reasons people pick a hospital,” he said in an interview after Mr. Leavitt spoke. “They heard it was good, it's where their physician spends a lot of time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?”

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. “Every health care provider wants to provide high-quality [care],” he said. “Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up.”

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. “This is not about eliminating anyone; it's about improving everyone,” he said. “The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't.”

As for whether those hospitals that don't improve might eventually face consequences, “I hope so,” Mr. Leavitt said, noting that his tenure as HHS secretary would likely be over by the time that came to pass. “This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor—performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality.”

But it's not only hospitals and patients who can use the new data, according to Gerald Shea, assistant to the president for governmental affairs at the AFL-CIO. “This is important for physicians and other clinicians,” he said at the meeting. “We hope physicians take this information and make it part of their regular, routine discussions with their patients. … Annual checkups, semiannual checkups, regular consultations, [or] just occasional visits—there should be communication programmed into those kinds of interactions between patients and clinicians so people get a feel for what kind of data [are] available when they have to make a choice on hospitals.”

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when they are deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

“This is like Travelocity for health care,” said Health and Human Services Secretary Mike Leavitt. “When people have information and they have choice, they make good choices.” Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. It included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. “There are three reasons people pick a hospital,” he said in an interview after Mr. Leavitt spoke. “They heard it was good, it's where their physician spends a lot of time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?”

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. “Every health care provider wants to provide high-quality [care],” he said. “Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up.”

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. “This is not about eliminating anyone; it's about improving everyone,” he said. “The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't.”

As for whether those hospitals that don't improve might eventually face consequences, “I hope so,” Mr. Leavitt said, noting that his tenure as HHS secretary would likely be over by the time that came to pass. “This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor—performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality.”

But it's not only hospitals and patients who can use the new data, according to Gerald Shea, assistant to the president for governmental affairs at the AFL-CIO. “This is important for physicians and other clinicians,” he said at the meeting. “We hope physicians take this information and make it part of their regular, routine discussions with their patients. … Annual checkups, semiannual checkups, regular consultations, [or] just occasional visits—there should be communication programmed into those kinds of interactions between patients and clinicians so people get a feel for what kind of data [are] available when they have to make a choice on hospitals.”

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 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 [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.”

Julie Barnes of 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.”

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 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 [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.”

Julie Barnes of 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.”

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 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 [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.”

Julie Barnes of 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.”

WASHINGTON — The Massachusetts health coverage plan enacted in 2006 “expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured.”

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.

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. Insurers had sought a 15% increase but settled for 10% after lengthy negotiations.

Richard Powers, program spokes-man, 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.)

Speaking at a diabetes meeting sponsored by Avalere Health, 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.

The Massachusetts 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.”

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

Details of the Massachusetts 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 requires 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. The state also exempts some residents who would normally pay the penalty from having to do so, if they are unable to find affordable coverage.

In 2007, the penalty for not having coverage was a standard $219. This year, the maximum penalty jumps to $76 per month, or $912 per year; penalties are now on a sliding scale based on the patient's income.

WASHINGTON — The Massachusetts health coverage plan enacted in 2006 “expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured.”

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.

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. Insurers had sought a 15% increase but settled for 10% after lengthy negotiations.

Richard Powers, program spokes-man, 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.)

Speaking at a diabetes meeting sponsored by Avalere Health, 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.

The Massachusetts 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.”

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

Details of the Massachusetts 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 requires 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. The state also exempts some residents who would normally pay the penalty from having to do so, if they are unable to find affordable coverage.

In 2007, the penalty for not having coverage was a standard $219. This year, the maximum penalty jumps to $76 per month, or $912 per year; penalties are now on a sliding scale based on the patient's income.

WASHINGTON — The Massachusetts health coverage plan enacted in 2006 “expanded affordable coverage to 325,000–350,000 of the [state's] estimated 550,000 uninsured.”

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.

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. Insurers had sought a 15% increase but settled for 10% after lengthy negotiations.

Richard Powers, program spokes-man, 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.)

Speaking at a diabetes meeting sponsored by Avalere Health, 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.

The Massachusetts 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.”

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

Details of the Massachusetts 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 requires 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. The state also exempts some residents who would normally pay the penalty from having to do so, if they are unable to find affordable coverage.

In 2007, the penalty for not having coverage was a standard $219. This year, the maximum penalty jumps to $76 per month, or $912 per year; penalties are now on a sliding scale based on the patient's income.

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

“This is like Travelocity for health care,” said Health and Human Services Secretary Mike Leavitt. “When people have information and they have choice, they make good choices.” Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. The survey included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. “There are three reasons people pick a hospital,” he said in an interview after Mr. Leavitt spoke. “They heard it was good, it's where their physician spends a lot of his time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?”

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. “Every health care provider wants to provide high-quality [care],” he said. “Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up.”

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. “This is not about eliminating anyone; it's about improving everyone,” he said. “The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't.”

As for whether those hospitals that don't improve might face consequences, “I hope so,” Mr. Leavitt said. “This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality.”

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

“This is like Travelocity for health care,” said Health and Human Services Secretary Mike Leavitt. “When people have information and they have choice, they make good choices.” Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. The survey included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. “There are three reasons people pick a hospital,” he said in an interview after Mr. Leavitt spoke. “They heard it was good, it's where their physician spends a lot of his time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?”

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. “Every health care provider wants to provide high-quality [care],” he said. “Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up.”

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. “This is not about eliminating anyone; it's about improving everyone,” he said. “The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't.”

As for whether those hospitals that don't improve might face consequences, “I hope so,” Mr. Leavitt said. “This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality.”

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

“This is like Travelocity for health care,” said Health and Human Services Secretary Mike Leavitt. “When people have information and they have choice, they make good choices.” Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. The survey included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) Deputy Administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. “There are three reasons people pick a hospital,” he said in an interview after Mr. Leavitt spoke. “They heard it was good, it's where their physician spends a lot of his time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?”

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. “Every health care provider wants to provide high-quality [care],” he said. “Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up.”

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. “This is not about eliminating anyone; it's about improving everyone,” he said. “The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't.”

As for whether those hospitals that don't improve might face consequences, “I hope so,” Mr. Leavitt said. “This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality.”

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, 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 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 slowing economy is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said.

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.”

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, 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 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 slowing economy is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said.

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.”

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, 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 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 slowing economy is going to affect individuals the most, “employers and businesses are in an excellent position to fix it,” she said.

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.”

PHILADELPHIA — Two new ways of dealing with end-of-life issues—default surrogates and physician-ordered life-sustaining treatment orders—are becoming more common in hospitals, according to several legal experts.

So far, 37 states have passed default surrogate regulations, aimed at naming a person who can act on behalf of an incapacitated hospital patient who does not have an advance directive, said Nina Kohn of Syracuse (N.Y.) University's College of Law. The vast majority of Americans—especially minorities, those with lower education levels, and younger patients—do not have an advance directive, noted Ms. Kohn, who spoke at a meeting of the American Society of Law, Medicine, and Ethics.

The states that have passed the default surrogate statutes “create a priority list saying if there is not an appointed surrogate, first the spouse does it, then the parent, then an adult sibling, and so on,” she explained. “The common justification is the idea that the statutes help protect wishes of the incapacitated person.”

But does that really work? Ms. Kohn and her associate Jeremy Blumenthal, also of Syracuse University, have been studying whether the laws result in the selection of the surrogates that incapacitated patients would have selected for themselves, and whether those surrogates made the decisions that those patients would have made.

They found that Americans tend to favor close family members as surrogates, which is consistent with most of the state laws. On the other hand, Ms. Kohn said, “The priority lists don't account for a number of factors predictive of surrogate selection, such as surrogate gender. Women are disproportionately selected as surrogates.” In addition, the statutes “don't do a good job of accounting for nontraditional family structures such as same-sex couples, or [situations] where people have more inclusive or more intergenerational notions of families.” This is particularly true of African Americans, who are less likely than are members of other racial groups to select a spouse or adult child as a surrogate, according to studies, she said.

As to whether the surrogates are deciding things the same way the patients would have, “we can't know for sure … because the patient is incapacitated,” she said. “But I think we can confidently say that there's real reason to be skeptical about the congruence levels being obtained.”

The literature on the subject shows that surrogates are very bad at predicting patient wishes; in addition, surrogates are not always willing to do what they know the patients would want them to do. Also, surrogates “tend to be overconfident in thinking they know more about what the patient would want than they actually do,” Ms. Kohn continued.

These problems aren't necessarily the fault of the people who wrote the statutes, however, Ms. Kohn added. “If we look at the treatment decisions of appointed surrogates, they do not appear to be significantly better.” A 2006 meta-analysis of 16 studies found that there was 69% congruence with decisions made by patient-selected surrogates compared with 68% using legally selected surrogates, “a statistical dead heat,” she noted.

Ms. Kohn had two suggestions for improving decision making by surrogates: first, having rules and statutes that move away from selecting surrogates based on familial relations, and more toward surrogates whose values are more consistent with those of the patient. And second, providing surrogates with information to better inform their decisions—for example, what a typical patient would do in a particular situation.

Another emerging tool for hospital-based end-of-life care is the physician orders for life-sustaining treatment (POLST) form, said Robert Schwartz, J.D., professor of law at the University of New Mexico, Albuquerque. These orders also go by other names: medical orders on life-sustaining treatment, medical orders on scope of treatment, or physician orders on scope of treatment.

“This is the next step from the advance directive,” Mr. Schwartz explained, noting that these forms are usually bright green or bright pink so they will be easily noticed. “These are physician orders that go in the patient's chart and provide information about the kind of patient care that should be provided.”

Usually, a POLST form addresses resuscitation issues, the extent of appropriate medical intervention, use of antibiotics, provision of nutrition and hydration, desired place of treatment, and the identity of the authorized health care provider, Mr. Schwartz said. The forms all have a place for the physician's signature, and many have a place for the patient's signature or surrogate decision maker's signature.

In a few states, the POLST form is now formally authorized by statute, and other states are looking at passing similar measures. In addition, some POLST forms are authorized by individual hospital policy, and sometimes they're authorized by networks of hospitals, Mr. Schwartz said.

But he has some reservations about the concept. “My problem with all these documents is that it seems like it's a step backwards [because] doctors are deciding these things in the hospital [rather than] patients having the authority to make these decisions. On the other hand, if patients make these decisions and they're never honored, we haven't achieved a whole lot.”

The proponents of POLST, he added, say that they “lead to the discussions between the health care provider, the families, and the patients that allow for the physician order that actually will be carried out in the hospital, so ultimately they're more effective than just having the advance directive on the front of the chart.”

PHILADELPHIA — Two new ways of dealing with end-of-life issues—default surrogates and physician-ordered life-sustaining treatment orders—are becoming more common in hospitals, according to several legal experts.

So far, 37 states have passed default surrogate regulations, aimed at naming a person who can act on behalf of an incapacitated hospital patient who does not have an advance directive, said Nina Kohn of Syracuse (N.Y.) University's College of Law. The vast majority of Americans—especially minorities, those with lower education levels, and younger patients—do not have an advance directive, noted Ms. Kohn, who spoke at a meeting of the American Society of Law, Medicine, and Ethics.

The states that have passed the default surrogate statutes “create a priority list saying if there is not an appointed surrogate, first the spouse does it, then the parent, then an adult sibling, and so on,” she explained. “The common justification is the idea that the statutes help protect wishes of the incapacitated person.”

But does that really work? Ms. Kohn and her associate Jeremy Blumenthal, also of Syracuse University, have been studying whether the laws result in the selection of the surrogates that incapacitated patients would have selected for themselves, and whether those surrogates made the decisions that those patients would have made.

They found that Americans tend to favor close family members as surrogates, which is consistent with most of the state laws. On the other hand, Ms. Kohn said, “The priority lists don't account for a number of factors predictive of surrogate selection, such as surrogate gender. Women are disproportionately selected as surrogates.” In addition, the statutes “don't do a good job of accounting for nontraditional family structures such as same-sex couples, or [situations] where people have more inclusive or more intergenerational notions of families.” This is particularly true of African Americans, who are less likely than are members of other racial groups to select a spouse or adult child as a surrogate, according to studies, she said.

As to whether the surrogates are deciding things the same way the patients would have, “we can't know for sure … because the patient is incapacitated,” she said. “But I think we can confidently say that there's real reason to be skeptical about the congruence levels being obtained.”

The literature on the subject shows that surrogates are very bad at predicting patient wishes; in addition, surrogates are not always willing to do what they know the patients would want them to do. Also, surrogates “tend to be overconfident in thinking they know more about what the patient would want than they actually do,” Ms. Kohn continued.

These problems aren't necessarily the fault of the people who wrote the statutes, however, Ms. Kohn added. “If we look at the treatment decisions of appointed surrogates, they do not appear to be significantly better.” A 2006 meta-analysis of 16 studies found that there was 69% congruence with decisions made by patient-selected surrogates compared with 68% using legally selected surrogates, “a statistical dead heat,” she noted.

Ms. Kohn had two suggestions for improving decision making by surrogates: first, having rules and statutes that move away from selecting surrogates based on familial relations, and more toward surrogates whose values are more consistent with those of the patient. And second, providing surrogates with information to better inform their decisions—for example, what a typical patient would do in a particular situation.

Another emerging tool for hospital-based end-of-life care is the physician orders for life-sustaining treatment (POLST) form, said Robert Schwartz, J.D., professor of law at the University of New Mexico, Albuquerque. These orders also go by other names: medical orders on life-sustaining treatment, medical orders on scope of treatment, or physician orders on scope of treatment.

“This is the next step from the advance directive,” Mr. Schwartz explained, noting that these forms are usually bright green or bright pink so they will be easily noticed. “These are physician orders that go in the patient's chart and provide information about the kind of patient care that should be provided.”

Usually, a POLST form addresses resuscitation issues, the extent of appropriate medical intervention, use of antibiotics, provision of nutrition and hydration, desired place of treatment, and the identity of the authorized health care provider, Mr. Schwartz said. The forms all have a place for the physician's signature, and many have a place for the patient's signature or surrogate decision maker's signature.

In a few states, the POLST form is now formally authorized by statute, and other states are looking at passing similar measures. In addition, some POLST forms are authorized by individual hospital policy, and sometimes they're authorized by networks of hospitals, Mr. Schwartz said.

But he has some reservations about the concept. “My problem with all these documents is that it seems like it's a step backwards [because] doctors are deciding these things in the hospital [rather than] patients having the authority to make these decisions. On the other hand, if patients make these decisions and they're never honored, we haven't achieved a whole lot.”

The proponents of POLST, he added, say that they “lead to the discussions between the health care provider, the families, and the patients that allow for the physician order that actually will be carried out in the hospital, so ultimately they're more effective than just having the advance directive on the front of the chart.”

PHILADELPHIA — Two new ways of dealing with end-of-life issues—default surrogates and physician-ordered life-sustaining treatment orders—are becoming more common in hospitals, according to several legal experts.

So far, 37 states have passed default surrogate regulations, aimed at naming a person who can act on behalf of an incapacitated hospital patient who does not have an advance directive, said Nina Kohn of Syracuse (N.Y.) University's College of Law. The vast majority of Americans—especially minorities, those with lower education levels, and younger patients—do not have an advance directive, noted Ms. Kohn, who spoke at a meeting of the American Society of Law, Medicine, and Ethics.

The states that have passed the default surrogate statutes “create a priority list saying if there is not an appointed surrogate, first the spouse does it, then the parent, then an adult sibling, and so on,” she explained. “The common justification is the idea that the statutes help protect wishes of the incapacitated person.”

But does that really work? Ms. Kohn and her associate Jeremy Blumenthal, also of Syracuse University, have been studying whether the laws result in the selection of the surrogates that incapacitated patients would have selected for themselves, and whether those surrogates made the decisions that those patients would have made.

They found that Americans tend to favor close family members as surrogates, which is consistent with most of the state laws. On the other hand, Ms. Kohn said, “The priority lists don't account for a number of factors predictive of surrogate selection, such as surrogate gender. Women are disproportionately selected as surrogates.” In addition, the statutes “don't do a good job of accounting for nontraditional family structures such as same-sex couples, or [situations] where people have more inclusive or more intergenerational notions of families.” This is particularly true of African Americans, who are less likely than are members of other racial groups to select a spouse or adult child as a surrogate, according to studies, she said.

As to whether the surrogates are deciding things the same way the patients would have, “we can't know for sure … because the patient is incapacitated,” she said. “But I think we can confidently say that there's real reason to be skeptical about the congruence levels being obtained.”

The literature on the subject shows that surrogates are very bad at predicting patient wishes; in addition, surrogates are not always willing to do what they know the patients would want them to do. Also, surrogates “tend to be overconfident in thinking they know more about what the patient would want than they actually do,” Ms. Kohn continued.

These problems aren't necessarily the fault of the people who wrote the statutes, however, Ms. Kohn added. “If we look at the treatment decisions of appointed surrogates, they do not appear to be significantly better.” A 2006 meta-analysis of 16 studies found that there was 69% congruence with decisions made by patient-selected surrogates compared with 68% using legally selected surrogates, “a statistical dead heat,” she noted.

Ms. Kohn had two suggestions for improving decision making by surrogates: first, having rules and statutes that move away from selecting surrogates based on familial relations, and more toward surrogates whose values are more consistent with those of the patient. And second, providing surrogates with information to better inform their decisions—for example, what a typical patient would do in a particular situation.

Another emerging tool for hospital-based end-of-life care is the physician orders for life-sustaining treatment (POLST) form, said Robert Schwartz, J.D., professor of law at the University of New Mexico, Albuquerque. These orders also go by other names: medical orders on life-sustaining treatment, medical orders on scope of treatment, or physician orders on scope of treatment.

“This is the next step from the advance directive,” Mr. Schwartz explained, noting that these forms are usually bright green or bright pink so they will be easily noticed. “These are physician orders that go in the patient's chart and provide information about the kind of patient care that should be provided.”

Usually, a POLST form addresses resuscitation issues, the extent of appropriate medical intervention, use of antibiotics, provision of nutrition and hydration, desired place of treatment, and the identity of the authorized health care provider, Mr. Schwartz said. The forms all have a place for the physician's signature, and many have a place for the patient's signature or surrogate decision maker's signature.

In a few states, the POLST form is now formally authorized by statute, and other states are looking at passing similar measures. In addition, some POLST forms are authorized by individual hospital policy, and sometimes they're authorized by networks of hospitals, Mr. Schwartz said.

But he has some reservations about the concept. “My problem with all these documents is that it seems like it's a step backwards [because] doctors are deciding these things in the hospital [rather than] patients having the authority to make these decisions. On the other hand, if patients make these decisions and they're never honored, we haven't achieved a whole lot.”

The proponents of POLST, he added, say that they “lead to the discussions between the health care provider, the families, and the patients that allow for the physician order that actually will be carried out in the hospital, so ultimately they're more effective than just having the advance directive on the front of the chart.”

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, he 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,” Dr. McDonough explained.

“They agree on absolutely nothing, except for one thing: They hate Massachusetts' ecumenical experiment,” he continued. “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.”

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

Details of Massachusetts' Coverage Plan

Under its health coverage plan, the state of Massachusetts 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 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 requires 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. The state also exempts some residents who would normally pay the penalty from having to do so, if they are unable to find affordable coverage.

In 2007, the penalty for not having coverage was a standard $219. This year, the maximum penalty jumps to $76 per month, or $912 per year; penalties are now on a sliding scale based on the individual's income. However, if a person signs up for coverage sometime during the year, he or she can stoppaying the monthly penalty, Dr. McDonough pointed out in an interview.

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, he 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,” Dr. McDonough explained.

“They agree on absolutely nothing, except for one thing: They hate Massachusetts' ecumenical experiment,” he continued. “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.”

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

Details of Massachusetts' Coverage Plan

Under its health coverage plan, the state of Massachusetts 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 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 requires 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. The state also exempts some residents who would normally pay the penalty from having to do so, if they are unable to find affordable coverage.

In 2007, the penalty for not having coverage was a standard $219. This year, the maximum penalty jumps to $76 per month, or $912 per year; penalties are now on a sliding scale based on the individual's income. However, if a person signs up for coverage sometime during the year, he or she can stoppaying the monthly penalty, Dr. McDonough pointed out in an interview.

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, he 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,” Dr. McDonough explained.

“They agree on absolutely nothing, except for one thing: They hate Massachusetts' ecumenical experiment,” he continued. “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.”

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

Details of Massachusetts' Coverage Plan

Under its health coverage plan, the state of Massachusetts 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 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 requires 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. The state also exempts some residents who would normally pay the penalty from having to do so, if they are unable to find affordable coverage.

In 2007, the penalty for not having coverage was a standard $219. This year, the maximum penalty jumps to $76 per month, or $912 per year; penalties are now on a sliding scale based on the individual's income. However, if a person signs up for coverage sometime during the year, he or she can stoppaying the monthly penalty, Dr. McDonough pointed out in an interview.

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when they are deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

"This is like Travelocity for health care," said Health and Human Services Secretary Mike Leavitt. "When people have information and they have choice, they make good choices." Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. The survey included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) deputy administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. "There are three reasons people pick a hospital," he said in an interview after Mr. Leavitt spoke. "They heard it was good, it's where their physician spends a lot of his time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?"

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. "Every health care provider wants to provide high-quality [care]," he said. "Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up."

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. "This is not about eliminating anyone; it's about improving everyone," he said. "The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't."

As for whether those hospitals that don't improve might eventually face consequences, "I hope so," Mr. Leavitt said, noting that his tenure as HHS secretary would likely be over by the time that came to pass. "This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor—performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality."

But it's not only hospitals and patients who can use the new data, according to Gerald Shea, assistant to the president for governmental affairs at the AFL-CIO. "This is important for physicians and other clinicians," he said. "Hospitalization doesn't always happen as a planned event; physicians and patients would be well served to make this a regular part of their interaction. Annual checkups, semiannual checkups, regular consultation, regular consultations, [or] just occasional visits—there should be communication programmed into those kinds of interactions between patients and clinicians so people get a feel for what kind of data [are] available when they have to make a choice on hospitals."

'This is like Travelocity for health care.' When people have information and choice they make good decisions. MR. LEAVITT

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when they are deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

"This is like Travelocity for health care," said Health and Human Services Secretary Mike Leavitt. "When people have information and they have choice, they make good choices." Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. The survey included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) deputy administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. "There are three reasons people pick a hospital," he said in an interview after Mr. Leavitt spoke. "They heard it was good, it's where their physician spends a lot of his time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?"

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. "Every health care provider wants to provide high-quality [care]," he said. "Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up."

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. "This is not about eliminating anyone; it's about improving everyone," he said. "The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't."

As for whether those hospitals that don't improve might eventually face consequences, "I hope so," Mr. Leavitt said, noting that his tenure as HHS secretary would likely be over by the time that came to pass. "This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor—performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality."

But it's not only hospitals and patients who can use the new data, according to Gerald Shea, assistant to the president for governmental affairs at the AFL-CIO. "This is important for physicians and other clinicians," he said. "Hospitalization doesn't always happen as a planned event; physicians and patients would be well served to make this a regular part of their interaction. Annual checkups, semiannual checkups, regular consultation, regular consultations, [or] just occasional visits—there should be communication programmed into those kinds of interactions between patients and clinicians so people get a feel for what kind of data [are] available when they have to make a choice on hospitals."

'This is like Travelocity for health care.' When people have information and choice they make good decisions. MR. LEAVITT

ARLINGTON, VA. — Now that the Centers for Medicare and Medicaid has added patient satisfaction data to its Hospital Compare Web site, patients will have more to consider when they are deciding which hospital to use for an elective procedure.

The Web site already included hospital-specific information on clinical measures such as antibiotic prophylaxis before surgery and aspirin upon admission for a heart attack. New patient satisfaction data include items such as nurse communication and hospital room cleanliness.

"This is like Travelocity for health care," said Health and Human Services Secretary Mike Leavitt. "When people have information and they have choice, they make good choices." Mr. Leavitt spoke at the annual meeting of the Association of Health Care Journalists.

The patient satisfaction data come from the Consumer Assessment of Healthcare Providers and Systems, a survey administered by 2,500 hospitals to patients discharged between October 2006 and June 2007. The survey included 27 questions about patients' hospital experience, including communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, and pain management.

The database also will include the volume of certain elective procedures provided at the hospital as well as what Medicare pays for those procedures.

The Centers for Medicare and Medicaid Services (CMS) deputy administrator Herb Kuhn said the information will be valuable even if patients already have selected a hospital for an elective procedure. "There are three reasons people pick a hospital," he said in an interview after Mr. Leavitt spoke. "They heard it was good, it's where their physician spends a lot of his time, or it's convenient to them. We want to add another dimension here for people to understand: Okay, if that's where you're going, what do you know about this place?"

The database also will be a good motivator for hospital improvement, Mr. Leavitt said. "Every health care provider wants to provide high-quality [care]," he said. "Wherever in health care there's robust information about quality and cost, the cost goes down and the quality goes up."

Mr. Leavitt stressed that CMS was not posting the data in order to punish hospitals that aren't performing as well as others. "This is not about eliminating anyone; it's about improving everyone," he said. "The minute a provider sees that they are at lower quality than the marketplace requires, they improve. Why? Because the market will begin to discriminate against them in a forceful and powerful way if they don't."

As for whether those hospitals that don't improve might eventually face consequences, "I hope so," Mr. Leavitt said, noting that his tenure as HHS secretary would likely be over by the time that came to pass. "This is about transparency and accountability. Without consumers and regulators and others having a means of measurement, we continue to reward mediocre—and in some cases, poor—performance. While this is not about eliminating those who are not performing well, we should certainly not assume that those who are poor performers will not be eliminated, either by the marketplace or by those who oversee quality."

But it's not only hospitals and patients who can use the new data, according to Gerald Shea, assistant to the president for governmental affairs at the AFL-CIO. "This is important for physicians and other clinicians," he said. "Hospitalization doesn't always happen as a planned event; physicians and patients would be well served to make this a regular part of their interaction. Annual checkups, semiannual checkups, regular consultation, regular consultations, [or] just occasional visits—there should be communication programmed into those kinds of interactions between patients and clinicians so people get a feel for what kind of data [are] available when they have to make a choice on hospitals."

'This is like Travelocity for health care.' When people have information and choice they make good decisions. MR. LEAVITT

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.

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. 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 wouldn't have to pay for employees' health benefits, 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."

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.

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. 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 wouldn't have to pay for employees' health benefits, 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."

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.

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. 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 wouldn't have to pay for employees' health benefits, 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."

Genomics, Health Disparities Center

The National Institutes of Health has established the Intramural Center for Genomics and Health Disparities to study how populations are affected by conditions such as obesity, diabetes, and hypertension. The center will collect and analyze genetic, clinical, lifestyle, and socioeconomic data to study a range of clinical conditions. The center will be headed by genetic epidemiologist Charles N. Rotimi, Ph.D., former director of the National Human Genome Center at Howard University, Washington. “This new center will be an NIH resource to help move research related to the complex factors underlying health disparities into the 21st century,” NIH Director Dr. Elias A. Zerhouni said in a statement. Dr. Rotimi said “the availability of tremendous expertise and the remarkable research infrastructure at NIH will make our research activities more robust and will allow us to tackle questions in ways that were not feasible in the past.”

Rx Abuse Worries Americans

The abuse of prescription drugs is as big a problem as the abuse of illegal drugs, according to respondents to a Wall Street Journal/Harris Interactive poll. Even so, less than half of those surveyed said they keep prescription medicines in a place whether others can't access them. Seventy percent said they were somewhat or very concerned about the risk of addiction associated with some prescription pain medications. The vast majority of the 2,027 adults surveyed voiced the same level of concern about drug side effects and potentially harmful interactions between pain medications and other prescriptions. About 60% of the respondents said they discuss with their physician other prescriptions they are taking when they are prescribed a new medication. Smaller numbers said they told their physician about over-the-counter medications or nutritional supplements.

Woodcock Named CDER Head

Dr. Janet Woodcock has been named director of the Federal Drug Administration's Center for Drug Evaluation and Research. Dr. Woodcock, a rheumatologist, served as director of CDER once before, in the 1990s, and has served as acting director since October 2007. The drug industry's chief lobbying group, PhRMA said it welcomed the appointment. Dr. Woodcock “has demonstrated willingness to work with diverse partners, including researchers, Congress, the White House, patients, and pharmaceutical research companies,” said a statement from the group. But Public Citizen's health research group director Dr. Sidney Wolfe said in an interview that he is “not terribly hopeful” that Dr. Woodcock will lead the center well, because she doesn't like conflict or controversy. “I don't think she's the kind of CDER director we need right now,” Dr. Wolfe said. “She is aware of a number of drugs on the market that should be taken off the market, but I don't think she has the fortitude to do something about it.” CDER is charged with assuring that safe and effective drugs—including prescription, over-the-counter, and generic products—are available to Americans.

Physicians Respond to Medicare Pay

The current uncertainty about Medicare payments to physicians is causing practices to postpone hiring staff, postpone investments in new technology, or even stop accepting new Medicare patients, according to a survey from the Medical Group Management Association. For example, 46% of respondents said that in light of the 10.6% cut in Medicare payments expected in July, they will refuse to accept new Medicare patients or limit the number of new Medicare patients. Nearly 28% said they would limit the number of appointments for Medicare patients. The pending cut could also affect the implementation of health IT systems, including e-prescribing. More than 60% of respondents said that they were more likely to postpone purchasing decisions related to e-prescribing because of the Medicare payment situation. The results are based on responses from more than 1,000 group practices, according to MGMA.

Amputations Up for Hispanics

The hospitalization rate for adult Hispanics for diabetes-related foot or leg amputations greatly increased between 2001 and 2004, according to recent data from the Agency for Healthcare Research and Quality. The rate rose from 63 admissions per 100,000 Hispanics in 2001 to nearly 80 admissions per 100,000 in 2004. During the same period, the diabetes-related amputation rate for white patients remained steady at about 28-31 admissions per 100,000 people, and among blacks decreased slightly from 113 per 100,000 people to about 104 admissions per 100,000 people. Overall, about 86,000 Americans underwent diabetes-related amputations in 2004.

Genomics, Health Disparities Center

The National Institutes of Health has established the Intramural Center for Genomics and Health Disparities to study how populations are affected by conditions such as obesity, diabetes, and hypertension. The center will collect and analyze genetic, clinical, lifestyle, and socioeconomic data to study a range of clinical conditions. The center will be headed by genetic epidemiologist Charles N. Rotimi, Ph.D., former director of the National Human Genome Center at Howard University, Washington. “This new center will be an NIH resource to help move research related to the complex factors underlying health disparities into the 21st century,” NIH Director Dr. Elias A. Zerhouni said in a statement. Dr. Rotimi said “the availability of tremendous expertise and the remarkable research infrastructure at NIH will make our research activities more robust and will allow us to tackle questions in ways that were not feasible in the past.”

Rx Abuse Worries Americans

The abuse of prescription drugs is as big a problem as the abuse of illegal drugs, according to respondents to a Wall Street Journal/Harris Interactive poll. Even so, less than half of those surveyed said they keep prescription medicines in a place whether others can't access them. Seventy percent said they were somewhat or very concerned about the risk of addiction associated with some prescription pain medications. The vast majority of the 2,027 adults surveyed voiced the same level of concern about drug side effects and potentially harmful interactions between pain medications and other prescriptions. About 60% of the respondents said they discuss with their physician other prescriptions they are taking when they are prescribed a new medication. Smaller numbers said they told their physician about over-the-counter medications or nutritional supplements.

Woodcock Named CDER Head

Dr. Janet Woodcock has been named director of the Federal Drug Administration's Center for Drug Evaluation and Research. Dr. Woodcock, a rheumatologist, served as director of CDER once before, in the 1990s, and has served as acting director since October 2007. The drug industry's chief lobbying group, PhRMA said it welcomed the appointment. Dr. Woodcock “has demonstrated willingness to work with diverse partners, including researchers, Congress, the White House, patients, and pharmaceutical research companies,” said a statement from the group. But Public Citizen's health research group director Dr. Sidney Wolfe said in an interview that he is “not terribly hopeful” that Dr. Woodcock will lead the center well, because she doesn't like conflict or controversy. “I don't think she's the kind of CDER director we need right now,” Dr. Wolfe said. “She is aware of a number of drugs on the market that should be taken off the market, but I don't think she has the fortitude to do something about it.” CDER is charged with assuring that safe and effective drugs—including prescription, over-the-counter, and generic products—are available to Americans.

Physicians Respond to Medicare Pay

The current uncertainty about Medicare payments to physicians is causing practices to postpone hiring staff, postpone investments in new technology, or even stop accepting new Medicare patients, according to a survey from the Medical Group Management Association. For example, 46% of respondents said that in light of the 10.6% cut in Medicare payments expected in July, they will refuse to accept new Medicare patients or limit the number of new Medicare patients. Nearly 28% said they would limit the number of appointments for Medicare patients. The pending cut could also affect the implementation of health IT systems, including e-prescribing. More than 60% of respondents said that they were more likely to postpone purchasing decisions related to e-prescribing because of the Medicare payment situation. The results are based on responses from more than 1,000 group practices, according to MGMA.

Amputations Up for Hispanics

The hospitalization rate for adult Hispanics for diabetes-related foot or leg amputations greatly increased between 2001 and 2004, according to recent data from the Agency for Healthcare Research and Quality. The rate rose from 63 admissions per 100,000 Hispanics in 2001 to nearly 80 admissions per 100,000 in 2004. During the same period, the diabetes-related amputation rate for white patients remained steady at about 28-31 admissions per 100,000 people, and among blacks decreased slightly from 113 per 100,000 people to about 104 admissions per 100,000 people. Overall, about 86,000 Americans underwent diabetes-related amputations in 2004.

Genomics, Health Disparities Center

The National Institutes of Health has established the Intramural Center for Genomics and Health Disparities to study how populations are affected by conditions such as obesity, diabetes, and hypertension. The center will collect and analyze genetic, clinical, lifestyle, and socioeconomic data to study a range of clinical conditions. The center will be headed by genetic epidemiologist Charles N. Rotimi, Ph.D., former director of the National Human Genome Center at Howard University, Washington. “This new center will be an NIH resource to help move research related to the complex factors underlying health disparities into the 21st century,” NIH Director Dr. Elias A. Zerhouni said in a statement. Dr. Rotimi said “the availability of tremendous expertise and the remarkable research infrastructure at NIH will make our research activities more robust and will allow us to tackle questions in ways that were not feasible in the past.”

Rx Abuse Worries Americans

The abuse of prescription drugs is as big a problem as the abuse of illegal drugs, according to respondents to a Wall Street Journal/Harris Interactive poll. Even so, less than half of those surveyed said they keep prescription medicines in a place whether others can't access them. Seventy percent said they were somewhat or very concerned about the risk of addiction associated with some prescription pain medications. The vast majority of the 2,027 adults surveyed voiced the same level of concern about drug side effects and potentially harmful interactions between pain medications and other prescriptions. About 60% of the respondents said they discuss with their physician other prescriptions they are taking when they are prescribed a new medication. Smaller numbers said they told their physician about over-the-counter medications or nutritional supplements.

Woodcock Named CDER Head

Dr. Janet Woodcock has been named director of the Federal Drug Administration's Center for Drug Evaluation and Research. Dr. Woodcock, a rheumatologist, served as director of CDER once before, in the 1990s, and has served as acting director since October 2007. The drug industry's chief lobbying group, PhRMA said it welcomed the appointment. Dr. Woodcock “has demonstrated willingness to work with diverse partners, including researchers, Congress, the White House, patients, and pharmaceutical research companies,” said a statement from the group. But Public Citizen's health research group director Dr. Sidney Wolfe said in an interview that he is “not terribly hopeful” that Dr. Woodcock will lead the center well, because she doesn't like conflict or controversy. “I don't think she's the kind of CDER director we need right now,” Dr. Wolfe said. “She is aware of a number of drugs on the market that should be taken off the market, but I don't think she has the fortitude to do something about it.” CDER is charged with assuring that safe and effective drugs—including prescription, over-the-counter, and generic products—are available to Americans.

Physicians Respond to Medicare Pay

The current uncertainty about Medicare payments to physicians is causing practices to postpone hiring staff, postpone investments in new technology, or even stop accepting new Medicare patients, according to a survey from the Medical Group Management Association. For example, 46% of respondents said that in light of the 10.6% cut in Medicare payments expected in July, they will refuse to accept new Medicare patients or limit the number of new Medicare patients. Nearly 28% said they would limit the number of appointments for Medicare patients. The pending cut could also affect the implementation of health IT systems, including e-prescribing. More than 60% of respondents said that they were more likely to postpone purchasing decisions related to e-prescribing because of the Medicare payment situation. The results are based on responses from more than 1,000 group practices, according to MGMA.

Amputations Up for Hispanics

The hospitalization rate for adult Hispanics for diabetes-related foot or leg amputations greatly increased between 2001 and 2004, according to recent data from the Agency for Healthcare Research and Quality. The rate rose from 63 admissions per 100,000 Hispanics in 2001 to nearly 80 admissions per 100,000 in 2004. During the same period, the diabetes-related amputation rate for white patients remained steady at about 28-31 admissions per 100,000 people, and among blacks decreased slightly from 113 per 100,000 people to about 104 admissions per 100,000 people. Overall, about 86,000 Americans underwent diabetes-related amputations in 2004.