Joyce Frieden

BALTIMORE — Targeting medicines at particular racial categories “is a misguided approach, and what we should be pursuing is attribute-based medicine,” Sharona Hoffman said at the annual meeting of the American Society of Law, Medicine, and Ethics.

One example of a medicine targeted at racial categories is BiDil (fixed-dose isosorbide dinitrate and hydralazine), a heart failure drug that was approved specifically for use in blacks. Some experts have concluded that a good response to BiDil has more to do with attributes and genes than it does with racial identity.

Patient attributes that might be considered relevant for assessing disease vulnerability or treatment responses include genetic variations or alleles that might be more common for people who are of one ancestral origin rather than others but could still cross population lines. “Then there are other factors such as diet, exercise, stress level, and exposure to toxins” that play into treatment response, said Ms. Hoffman, a professor of law at Case Western Reserve University in Cleveland.

“The Human Genome Project showed us that race is not a biologically valid or genetically valid concept, and therefore the emergence of 'race-based' medicine is both perplexing and troubling,” she said at the meeting, which was cosponsored by the University of Maryland. “Race doesn't mean much of anything” from a genetic perspective because “99.9% of genes are identical for all humans,” and in the remaining 0.1%, 90%–95% of genetic variations are found at equal rates in every population.

Society also has difficulty defining race, with legal definitions of race varying from one state to another, Ms. Hoffman said. The race categories listed in the U.S. Census also change every decade. Almost 7 million people checked off more than one race in the 2000 census, she noted. “If you ask people to self-identify, they may say they're African American when they are really of mixed race. And visual observation is even more misleading.”

In addition to these problems, using “race-based” medicine may exacerbate health disparities, because “it's possible doctors may try to specialize in treating blacks or whites,” said Ms. Hoffman. That may violate federal or state antidiscrimination laws.

Instead of pursuing race-based protocols, Ms. Hoffman recommended designing attribute-based trial protocols, and having institutional review boards and scientific review boards subject them to special scrutiny.

“Consider the genetic variations and the psychosocial, economic, cultural, environmental, and other factors, which you can measure or ask about—stress, diet, exercise, exposure to toxins, and cultural and religious barriers to treatment compliance,” she said. “Maybe people aren't doing well because they are not following the protocol—because they either don't understand it [due to] a language barrier, or they have religious beliefs that prevent them from doing some of the things you need them to do.”

Also, be aware of the limits of self-identification or identification through visual observation. “Don't use skin color as a proxy. What questions do you need to ask? Do you need to do further genetic testing?” Ms. Hoffman said. “It's very hard to tell what ancestry people have if you don't ask specific questions.”

BALTIMORE — Targeting medicines at particular racial categories “is a misguided approach, and what we should be pursuing is attribute-based medicine,” Sharona Hoffman said at the annual meeting of the American Society of Law, Medicine, and Ethics.

One example of a medicine targeted at racial categories is BiDil (fixed-dose isosorbide dinitrate and hydralazine), a heart failure drug that was approved specifically for use in blacks. Some experts have concluded that a good response to BiDil has more to do with attributes and genes than it does with racial identity.

Patient attributes that might be considered relevant for assessing disease vulnerability or treatment responses include genetic variations or alleles that might be more common for people who are of one ancestral origin rather than others but could still cross population lines. “Then there are other factors such as diet, exercise, stress level, and exposure to toxins” that play into treatment response, said Ms. Hoffman, a professor of law at Case Western Reserve University in Cleveland.

“The Human Genome Project showed us that race is not a biologically valid or genetically valid concept, and therefore the emergence of 'race-based' medicine is both perplexing and troubling,” she said at the meeting, which was cosponsored by the University of Maryland. “Race doesn't mean much of anything” from a genetic perspective because “99.9% of genes are identical for all humans,” and in the remaining 0.1%, 90%–95% of genetic variations are found at equal rates in every population.

Society also has difficulty defining race, with legal definitions of race varying from one state to another, Ms. Hoffman said. The race categories listed in the U.S. Census also change every decade. Almost 7 million people checked off more than one race in the 2000 census, she noted. “If you ask people to self-identify, they may say they're African American when they are really of mixed race. And visual observation is even more misleading.”

In addition to these problems, using “race-based” medicine may exacerbate health disparities, because “it's possible doctors may try to specialize in treating blacks or whites,” said Ms. Hoffman. That may violate federal or state antidiscrimination laws.

Instead of pursuing race-based protocols, Ms. Hoffman recommended designing attribute-based trial protocols, and having institutional review boards and scientific review boards subject them to special scrutiny.

“Consider the genetic variations and the psychosocial, economic, cultural, environmental, and other factors, which you can measure or ask about—stress, diet, exercise, exposure to toxins, and cultural and religious barriers to treatment compliance,” she said. “Maybe people aren't doing well because they are not following the protocol—because they either don't understand it [due to] a language barrier, or they have religious beliefs that prevent them from doing some of the things you need them to do.”

Also, be aware of the limits of self-identification or identification through visual observation. “Don't use skin color as a proxy. What questions do you need to ask? Do you need to do further genetic testing?” Ms. Hoffman said. “It's very hard to tell what ancestry people have if you don't ask specific questions.”

BALTIMORE — Targeting medicines at particular racial categories “is a misguided approach, and what we should be pursuing is attribute-based medicine,” Sharona Hoffman said at the annual meeting of the American Society of Law, Medicine, and Ethics.

One example of a medicine targeted at racial categories is BiDil (fixed-dose isosorbide dinitrate and hydralazine), a heart failure drug that was approved specifically for use in blacks. Some experts have concluded that a good response to BiDil has more to do with attributes and genes than it does with racial identity.

Patient attributes that might be considered relevant for assessing disease vulnerability or treatment responses include genetic variations or alleles that might be more common for people who are of one ancestral origin rather than others but could still cross population lines. “Then there are other factors such as diet, exercise, stress level, and exposure to toxins” that play into treatment response, said Ms. Hoffman, a professor of law at Case Western Reserve University in Cleveland.

“The Human Genome Project showed us that race is not a biologically valid or genetically valid concept, and therefore the emergence of 'race-based' medicine is both perplexing and troubling,” she said at the meeting, which was cosponsored by the University of Maryland. “Race doesn't mean much of anything” from a genetic perspective because “99.9% of genes are identical for all humans,” and in the remaining 0.1%, 90%–95% of genetic variations are found at equal rates in every population.

Society also has difficulty defining race, with legal definitions of race varying from one state to another, Ms. Hoffman said. The race categories listed in the U.S. Census also change every decade. Almost 7 million people checked off more than one race in the 2000 census, she noted. “If you ask people to self-identify, they may say they're African American when they are really of mixed race. And visual observation is even more misleading.”

In addition to these problems, using “race-based” medicine may exacerbate health disparities, because “it's possible doctors may try to specialize in treating blacks or whites,” said Ms. Hoffman. That may violate federal or state antidiscrimination laws.

Instead of pursuing race-based protocols, Ms. Hoffman recommended designing attribute-based trial protocols, and having institutional review boards and scientific review boards subject them to special scrutiny.

“Consider the genetic variations and the psychosocial, economic, cultural, environmental, and other factors, which you can measure or ask about—stress, diet, exercise, exposure to toxins, and cultural and religious barriers to treatment compliance,” she said. “Maybe people aren't doing well because they are not following the protocol—because they either don't understand it [due to] a language barrier, or they have religious beliefs that prevent them from doing some of the things you need them to do.”

Also, be aware of the limits of self-identification or identification through visual observation. “Don't use skin color as a proxy. What questions do you need to ask? Do you need to do further genetic testing?” Ms. Hoffman said. “It's very hard to tell what ancestry people have if you don't ask specific questions.”

WASHINGTON — The mumps outbreak that occurred in Iowa earlier this year is not necessarily the end of the illness in the United States, Dr. Anne Schuchat said at a press briefing sponsored by the National Foundation for Infectious Diseases.

The Iowa outbreak was the biggest in 20 years, “but that doesn't mean it's the last time we'll be seeing mumps,” said Dr. Schuchat, who is director of the National Immunization Program at the Centers for Disease Control and Prevention, Atlanta.

The mumps vaccine was first licensed in 1967 and has been very successful for the most part, said Dr. Schuchat. But that changed in March 2006, when the outbreak began; Iowa had more than 200 cases, “which was almost as many cases as would [normally] have been recorded throughout the entire United States.”

By June 20th, Iowa had 1,921 reported cases; by early July, a total of 4,600 cases had been reported nationwide, she added. Much of the outbreak occurred in eight states: Iowa, Kansas, Nebraska, South Dakota, Wisconsin, Illinois, Missouri, and Pennsylvania.

The clinical illness involved in the outbreak was primarily mild: 80% of the cases featured parotitis, and there were a few cases of meningitis, 59 cases of orchitis, and more than 40 hospitalizations. No deaths were confirmed with the outbreak.

While there are no simple answers to what caused the outbreak, investigators think it may have begun with an unrecognized importation, possibly from the United Kingdom, which had a large mumps outbreak in 2004–2005 involving about 70,000 cases. “The strain that is circulating in our mumps outbreak is identical to the strain from [the U.K.], but that strain is also common in a number of other places where mumps vaccination is not as strong as we have here in the United States,” Dr. Schuchat said.

The Iowa outbreak started with a group of college students, and may have been helped to spread by the college student lifestyle, said Dr. Schuchat. “I don't like to think about what happens in colleges, but we know the way people live in college and the way they socialize can lead to high transmission of infections.

“We also know college students in America have a lower two-dose vaccine coverage than do [students in] high schools or elementary schools,” she said. “That's just a fact of life because we changed our recommendations for the two-dose schedule in 1989, and had pretty good follow-up in terms of school entry, but college students were older and didn't necessarily get that second dose before they went off to college.”

Delayed recognition of the outbreak also may have given it a chance to take off and spread to a lot of colleges and states, Dr. Schuchat continued. “Why did we have delayed recognition? [This occurred] partly because physicians and parents and kids aren't that familiar with mumps anymore, and partly because some of the presentations were atypical. They weren't that jaw swelling that people know; there were other respiratory presentations.”

Another possible factor in the spread of the outbreak is the overall effectiveness of the vaccine itself. “The vaccine is good, but not great,” she said. “When you get two doses of mumps vaccine, we think 90% of people are protected, but it's not 100%. So 10% of people, even those who have good immune systems and get the most vaccine, will still be vulnerable to mumps if they get exposed to the virus.”

Dr. Schuchat stressed that the outbreak could have been much worse. “We have a very high measles-mumps-rubella vaccine coverage level, and the vaccine effectiveness of the two-dose schedule probably prevented thousands and thousands of cases.”

Investigators also think the disease was milder than it might otherwise have been, “because it was occurring in people who had one or two doses and may have not gotten the more severe forms of mumps even though they were adults and in an age group where it might occur,” she added.

WASHINGTON — The mumps outbreak that occurred in Iowa earlier this year is not necessarily the end of the illness in the United States, Dr. Anne Schuchat said at a press briefing sponsored by the National Foundation for Infectious Diseases.

The Iowa outbreak was the biggest in 20 years, “but that doesn't mean it's the last time we'll be seeing mumps,” said Dr. Schuchat, who is director of the National Immunization Program at the Centers for Disease Control and Prevention, Atlanta.

The mumps vaccine was first licensed in 1967 and has been very successful for the most part, said Dr. Schuchat. But that changed in March 2006, when the outbreak began; Iowa had more than 200 cases, “which was almost as many cases as would [normally] have been recorded throughout the entire United States.”

By June 20th, Iowa had 1,921 reported cases; by early July, a total of 4,600 cases had been reported nationwide, she added. Much of the outbreak occurred in eight states: Iowa, Kansas, Nebraska, South Dakota, Wisconsin, Illinois, Missouri, and Pennsylvania.

The clinical illness involved in the outbreak was primarily mild: 80% of the cases featured parotitis, and there were a few cases of meningitis, 59 cases of orchitis, and more than 40 hospitalizations. No deaths were confirmed with the outbreak.

While there are no simple answers to what caused the outbreak, investigators think it may have begun with an unrecognized importation, possibly from the United Kingdom, which had a large mumps outbreak in 2004–2005 involving about 70,000 cases. “The strain that is circulating in our mumps outbreak is identical to the strain from [the U.K.], but that strain is also common in a number of other places where mumps vaccination is not as strong as we have here in the United States,” Dr. Schuchat said.

The Iowa outbreak started with a group of college students, and may have been helped to spread by the college student lifestyle, said Dr. Schuchat. “I don't like to think about what happens in colleges, but we know the way people live in college and the way they socialize can lead to high transmission of infections.

“We also know college students in America have a lower two-dose vaccine coverage than do [students in] high schools or elementary schools,” she said. “That's just a fact of life because we changed our recommendations for the two-dose schedule in 1989, and had pretty good follow-up in terms of school entry, but college students were older and didn't necessarily get that second dose before they went off to college.”

Delayed recognition of the outbreak also may have given it a chance to take off and spread to a lot of colleges and states, Dr. Schuchat continued. “Why did we have delayed recognition? [This occurred] partly because physicians and parents and kids aren't that familiar with mumps anymore, and partly because some of the presentations were atypical. They weren't that jaw swelling that people know; there were other respiratory presentations.”

Another possible factor in the spread of the outbreak is the overall effectiveness of the vaccine itself. “The vaccine is good, but not great,” she said. “When you get two doses of mumps vaccine, we think 90% of people are protected, but it's not 100%. So 10% of people, even those who have good immune systems and get the most vaccine, will still be vulnerable to mumps if they get exposed to the virus.”

Dr. Schuchat stressed that the outbreak could have been much worse. “We have a very high measles-mumps-rubella vaccine coverage level, and the vaccine effectiveness of the two-dose schedule probably prevented thousands and thousands of cases.”

Investigators also think the disease was milder than it might otherwise have been, “because it was occurring in people who had one or two doses and may have not gotten the more severe forms of mumps even though they were adults and in an age group where it might occur,” she added.

WASHINGTON — The mumps outbreak that occurred in Iowa earlier this year is not necessarily the end of the illness in the United States, Dr. Anne Schuchat said at a press briefing sponsored by the National Foundation for Infectious Diseases.

The Iowa outbreak was the biggest in 20 years, “but that doesn't mean it's the last time we'll be seeing mumps,” said Dr. Schuchat, who is director of the National Immunization Program at the Centers for Disease Control and Prevention, Atlanta.

The mumps vaccine was first licensed in 1967 and has been very successful for the most part, said Dr. Schuchat. But that changed in March 2006, when the outbreak began; Iowa had more than 200 cases, “which was almost as many cases as would [normally] have been recorded throughout the entire United States.”

By June 20th, Iowa had 1,921 reported cases; by early July, a total of 4,600 cases had been reported nationwide, she added. Much of the outbreak occurred in eight states: Iowa, Kansas, Nebraska, South Dakota, Wisconsin, Illinois, Missouri, and Pennsylvania.

The clinical illness involved in the outbreak was primarily mild: 80% of the cases featured parotitis, and there were a few cases of meningitis, 59 cases of orchitis, and more than 40 hospitalizations. No deaths were confirmed with the outbreak.

While there are no simple answers to what caused the outbreak, investigators think it may have begun with an unrecognized importation, possibly from the United Kingdom, which had a large mumps outbreak in 2004–2005 involving about 70,000 cases. “The strain that is circulating in our mumps outbreak is identical to the strain from [the U.K.], but that strain is also common in a number of other places where mumps vaccination is not as strong as we have here in the United States,” Dr. Schuchat said.

The Iowa outbreak started with a group of college students, and may have been helped to spread by the college student lifestyle, said Dr. Schuchat. “I don't like to think about what happens in colleges, but we know the way people live in college and the way they socialize can lead to high transmission of infections.

“We also know college students in America have a lower two-dose vaccine coverage than do [students in] high schools or elementary schools,” she said. “That's just a fact of life because we changed our recommendations for the two-dose schedule in 1989, and had pretty good follow-up in terms of school entry, but college students were older and didn't necessarily get that second dose before they went off to college.”

Delayed recognition of the outbreak also may have given it a chance to take off and spread to a lot of colleges and states, Dr. Schuchat continued. “Why did we have delayed recognition? [This occurred] partly because physicians and parents and kids aren't that familiar with mumps anymore, and partly because some of the presentations were atypical. They weren't that jaw swelling that people know; there were other respiratory presentations.”

Another possible factor in the spread of the outbreak is the overall effectiveness of the vaccine itself. “The vaccine is good, but not great,” she said. “When you get two doses of mumps vaccine, we think 90% of people are protected, but it's not 100%. So 10% of people, even those who have good immune systems and get the most vaccine, will still be vulnerable to mumps if they get exposed to the virus.”

Dr. Schuchat stressed that the outbreak could have been much worse. “We have a very high measles-mumps-rubella vaccine coverage level, and the vaccine effectiveness of the two-dose schedule probably prevented thousands and thousands of cases.”

Investigators also think the disease was milder than it might otherwise have been, “because it was occurring in people who had one or two doses and may have not gotten the more severe forms of mumps even though they were adults and in an age group where it might occur,” she added.

WASHINGTON — If you don't like medically "unbelievable" edits, how about medically "unusual" ones?

Members of the Practicing Physicians Advisory Council (PPAC), which advises the Centers for Medicare and Medicaid Services (CMS) on issues of interest to physicians, were upset about the name of the proposed Medically Unbelievable Edits program, which aims to find obvious errors in Medicare claims—for example, a claim for doing a hysterectomy on a male patient.

" 'Unbelievable' is a value judgment," PPAC member Dr. Peter Grimm, a radiation oncologist from Seattle, said at a recent council meeting. "You're going to get immediate reaction from people, so changing that word to 'unusual' doesn't change your [acronym] and really accurately describes what you're trying to do."

PPAC member Dr. M. LeRoy Sprang, an Evanston, Ill., ob.gyn., had another idea. "How about 'medically unexpected?' It's a softer word, and it really covers what you want to do. It's just not as obnoxious as 'unbelievable.'"

The program in question is designed to detect implausible Medicare claims submissions and avert inappropriate claims payment, according to Lisa Zone, director of the program integrity group at the CMS Office of Financial Management.

"I realize that this is an unfortunate title," she said. "We are trying to install edits to detect true errors in the system."

A recent CMS report found that Medicare's national paid claims error rate was 5.1%, "and we know that 1.7% is related to improper coding or billing errors," Ms. Zone said. "When you look at the federal dollars expended in the coding error class, it's in the billions of dollars."

The comment period for the proposed program ended on June 19, and Ms. Zone noted that "given that we've [already] heard from various provider organizations about the MUEs out there today for comment, we are not going to be going forward with the MUEs as they are."

Instead, the office will look at the edits as a whole and make decisions on the best way to move forward. Initially, Ms. Zone's office will concentrate on developing edits to catch "anatomical" errors, such as procedures performed on the wrong body part. Then, they will address edits for typographical errors—someone bills for 500 units instead of 5, for example.

After making those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a "test period" beforehand, Ms. Zone said. The testing will include an appeals process as well as the use of modifiers. Implementation will be in a "staged" approach, starting with the anatomical and typographical edits.

"We're very interested in what you have to say," Ms. Zone told the council. "We want to have those edits detect errors within the claims processing system, but in no way do we want the edits to affect medical practice or payment policy."

Ms. Zone noted that doctors who make errors will not be on any "hit list."

"Certainly, if we see a group or provider who was hitting edits more frequently than anyone else, then a contractor might decide to do some education or medical reviews for someone who was having problems submitting claims correctly, but that would be found based on data analysis," she said.

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, told Ms. Zone that "there is considerably more angst in the medical community about this issue than may immediately appear." He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

For example, one possible edit would return a claim if a surgeon took out two spleens in the same patient on the same day. "I'm not a surgeon, but [I know that] there are some people who do have accessory spleens, and it is conceivable that you might have to take out a second spleen," he said. "I really think you need to come up with a modifier for situations that don't appear to be straightforward before you bring this [system] out."

Thomas Gustafson, Ph.D., deputy director of the agency's Center for Medicare Management, seemed sympathetic to the modifier idea. "Insofar as we're capturing inversions of numbers or stuff like that, which are true coding errors, everybody should be able to agree with that," he said. "We then need to isolate those cases that are not essentially expected to arise in the routine practice of medicine. We've got to have some way of addressing that, some modifier or something of that sort."

He added that although CMS expects to save some money with the MUE initiative, "that's not what's driving this … The intent is truly to try to take care of the hysterectomies on men and those kinds of circumstances and try to do it in a sophisticated way so that we're not interfering with the practice of medicine to a noticeable extent."

WASHINGTON — If you don't like medically "unbelievable" edits, how about medically "unusual" ones?

Members of the Practicing Physicians Advisory Council (PPAC), which advises the Centers for Medicare and Medicaid Services (CMS) on issues of interest to physicians, were upset about the name of the proposed Medically Unbelievable Edits program, which aims to find obvious errors in Medicare claims—for example, a claim for doing a hysterectomy on a male patient.

" 'Unbelievable' is a value judgment," PPAC member Dr. Peter Grimm, a radiation oncologist from Seattle, said at a recent council meeting. "You're going to get immediate reaction from people, so changing that word to 'unusual' doesn't change your [acronym] and really accurately describes what you're trying to do."

PPAC member Dr. M. LeRoy Sprang, an Evanston, Ill., ob.gyn., had another idea. "How about 'medically unexpected?' It's a softer word, and it really covers what you want to do. It's just not as obnoxious as 'unbelievable.'"

The program in question is designed to detect implausible Medicare claims submissions and avert inappropriate claims payment, according to Lisa Zone, director of the program integrity group at the CMS Office of Financial Management.

"I realize that this is an unfortunate title," she said. "We are trying to install edits to detect true errors in the system."

A recent CMS report found that Medicare's national paid claims error rate was 5.1%, "and we know that 1.7% is related to improper coding or billing errors," Ms. Zone said. "When you look at the federal dollars expended in the coding error class, it's in the billions of dollars."

The comment period for the proposed program ended on June 19, and Ms. Zone noted that "given that we've [already] heard from various provider organizations about the MUEs out there today for comment, we are not going to be going forward with the MUEs as they are."

Instead, the office will look at the edits as a whole and make decisions on the best way to move forward. Initially, Ms. Zone's office will concentrate on developing edits to catch "anatomical" errors, such as procedures performed on the wrong body part. Then, they will address edits for typographical errors—someone bills for 500 units instead of 5, for example.

After making those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a "test period" beforehand, Ms. Zone said. The testing will include an appeals process as well as the use of modifiers. Implementation will be in a "staged" approach, starting with the anatomical and typographical edits.

"We're very interested in what you have to say," Ms. Zone told the council. "We want to have those edits detect errors within the claims processing system, but in no way do we want the edits to affect medical practice or payment policy."

Ms. Zone noted that doctors who make errors will not be on any "hit list."

"Certainly, if we see a group or provider who was hitting edits more frequently than anyone else, then a contractor might decide to do some education or medical reviews for someone who was having problems submitting claims correctly, but that would be found based on data analysis," she said.

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, told Ms. Zone that "there is considerably more angst in the medical community about this issue than may immediately appear." He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

For example, one possible edit would return a claim if a surgeon took out two spleens in the same patient on the same day. "I'm not a surgeon, but [I know that] there are some people who do have accessory spleens, and it is conceivable that you might have to take out a second spleen," he said. "I really think you need to come up with a modifier for situations that don't appear to be straightforward before you bring this [system] out."

Thomas Gustafson, Ph.D., deputy director of the agency's Center for Medicare Management, seemed sympathetic to the modifier idea. "Insofar as we're capturing inversions of numbers or stuff like that, which are true coding errors, everybody should be able to agree with that," he said. "We then need to isolate those cases that are not essentially expected to arise in the routine practice of medicine. We've got to have some way of addressing that, some modifier or something of that sort."

He added that although CMS expects to save some money with the MUE initiative, "that's not what's driving this … The intent is truly to try to take care of the hysterectomies on men and those kinds of circumstances and try to do it in a sophisticated way so that we're not interfering with the practice of medicine to a noticeable extent."

WASHINGTON — If you don't like medically "unbelievable" edits, how about medically "unusual" ones?

Members of the Practicing Physicians Advisory Council (PPAC), which advises the Centers for Medicare and Medicaid Services (CMS) on issues of interest to physicians, were upset about the name of the proposed Medically Unbelievable Edits program, which aims to find obvious errors in Medicare claims—for example, a claim for doing a hysterectomy on a male patient.

" 'Unbelievable' is a value judgment," PPAC member Dr. Peter Grimm, a radiation oncologist from Seattle, said at a recent council meeting. "You're going to get immediate reaction from people, so changing that word to 'unusual' doesn't change your [acronym] and really accurately describes what you're trying to do."

PPAC member Dr. M. LeRoy Sprang, an Evanston, Ill., ob.gyn., had another idea. "How about 'medically unexpected?' It's a softer word, and it really covers what you want to do. It's just not as obnoxious as 'unbelievable.'"

The program in question is designed to detect implausible Medicare claims submissions and avert inappropriate claims payment, according to Lisa Zone, director of the program integrity group at the CMS Office of Financial Management.

"I realize that this is an unfortunate title," she said. "We are trying to install edits to detect true errors in the system."

A recent CMS report found that Medicare's national paid claims error rate was 5.1%, "and we know that 1.7% is related to improper coding or billing errors," Ms. Zone said. "When you look at the federal dollars expended in the coding error class, it's in the billions of dollars."

The comment period for the proposed program ended on June 19, and Ms. Zone noted that "given that we've [already] heard from various provider organizations about the MUEs out there today for comment, we are not going to be going forward with the MUEs as they are."

Instead, the office will look at the edits as a whole and make decisions on the best way to move forward. Initially, Ms. Zone's office will concentrate on developing edits to catch "anatomical" errors, such as procedures performed on the wrong body part. Then, they will address edits for typographical errors—someone bills for 500 units instead of 5, for example.

After making those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a "test period" beforehand, Ms. Zone said. The testing will include an appeals process as well as the use of modifiers. Implementation will be in a "staged" approach, starting with the anatomical and typographical edits.

"We're very interested in what you have to say," Ms. Zone told the council. "We want to have those edits detect errors within the claims processing system, but in no way do we want the edits to affect medical practice or payment policy."

Ms. Zone noted that doctors who make errors will not be on any "hit list."

"Certainly, if we see a group or provider who was hitting edits more frequently than anyone else, then a contractor might decide to do some education or medical reviews for someone who was having problems submitting claims correctly, but that would be found based on data analysis," she said.

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, told Ms. Zone that "there is considerably more angst in the medical community about this issue than may immediately appear." He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

For example, one possible edit would return a claim if a surgeon took out two spleens in the same patient on the same day. "I'm not a surgeon, but [I know that] there are some people who do have accessory spleens, and it is conceivable that you might have to take out a second spleen," he said. "I really think you need to come up with a modifier for situations that don't appear to be straightforward before you bring this [system] out."

Thomas Gustafson, Ph.D., deputy director of the agency's Center for Medicare Management, seemed sympathetic to the modifier idea. "Insofar as we're capturing inversions of numbers or stuff like that, which are true coding errors, everybody should be able to agree with that," he said. "We then need to isolate those cases that are not essentially expected to arise in the routine practice of medicine. We've got to have some way of addressing that, some modifier or something of that sort."

He added that although CMS expects to save some money with the MUE initiative, "that's not what's driving this … The intent is truly to try to take care of the hysterectomies on men and those kinds of circumstances and try to do it in a sophisticated way so that we're not interfering with the practice of medicine to a noticeable extent."

PHILADELPHIA — Physicians can help Medicare beneficiaries who are trying to select a Medicare drug coverage plan, but they have to make sure they follow all the rules, Charlene L. McGinty said at the annual meeting of the American Health Lawyers Association.

The drug benefit, also known as Part D, was passed by Congress in 2003 and became effective in January 2006. Patients pay an annual deductible of $250 as well as a premium of about $35 per month, depending on the plan they choose. The plan then pays 75% of drug costs until the patient has spent $2,250. After that, in most plans, the patient has to pay the next $3,850 out of pocket; this period is known as the “doughnut hole” or “coverage gap.” Once the beneficiaries' bills hit $5,100, the plan pays 95% of any remaining drug costs for the rest of the year. Low-income beneficiaries receive a more generous benefit.

Drug plans are administered by private insurers, but of all the plans participating, 20 plans represent 90% of the market, said Ms. McGinty, a partner in an Atlanta law firm.

“The biggest group is [affiliated] with UnitedHealth Group,” she added.

There are 10 “national plans” approved by the Centers for Medicare and Medicaid Services; those plans are recommended for snowbirds who live in one place during the spring, summer, and fall but go south or west for the winter.

To help beneficiaries navigate the maze of plans, there are some things physicians are allowed to do, Ms. McGinty said. She recommended asking patients the following questions about the plans they're considering signing up with:

▸ How much is the deductible—the standard $250, or less?

▸ What about copays? Does the plan require a set copay or does it charge “coinsurance,” which means the patient must pay a certain percentage of the drug cost, whatever it is?

▸ Which pharmacies are included in the plan's pharmacy network? “Many seniors have established relationships with pharmacies and pharmacists,” said Ms. McGinty. “They may not want to change them.”

▸ What is in the formulary? Are the patients' drugs covered, or will they have to go through prior authorization or step therapy before they can get their particular medications?

One audience member pointed out that although plans are supposed to review their formularies once every 180 days, their pickup of drugs approved in 2005 was “unbelievably poor.”

If the plans base their formulary decisions on the model formulary published by the United States Pharmacopeia, that formulary is updated only once a year, he noted.

Ms. McGinty agreed that “there is a potential lag” to the new drugs coming on the model formulary, but added that each plan's pharmacy and therapeutics committee also is supposed to be keeping tracking of new drug approvals and deciding whether to add a new drug.

Off-Label Drug Use

Plans are supposed to approve off-label use as long as the use is listed in one of three drug compendia, said Greg Jones, who is with the program integrity group at the Centers for Medicare and Medicaid Services. But trying to help a patient get a drug for an off-label use not listed in a compendium will be a “trouble spot” for doctors, he conceded.

Although providers can give patients some help in choosing a drug plan—and even help low-income beneficiaries fill out the paperwork to get better benefits—“tension exists because there are limitations on what providers can say” about various drug plans, Ms. McGinty explained.

For example, providers cannot make specific plan recommendations, they can't steer an undecided enrollee to one plan over another, and they can't accept plan applications.

PHILADELPHIA — Physicians can help Medicare beneficiaries who are trying to select a Medicare drug coverage plan, but they have to make sure they follow all the rules, Charlene L. McGinty said at the annual meeting of the American Health Lawyers Association.

The drug benefit, also known as Part D, was passed by Congress in 2003 and became effective in January 2006. Patients pay an annual deductible of $250 as well as a premium of about $35 per month, depending on the plan they choose. The plan then pays 75% of drug costs until the patient has spent $2,250. After that, in most plans, the patient has to pay the next $3,850 out of pocket; this period is known as the “doughnut hole” or “coverage gap.” Once the beneficiaries' bills hit $5,100, the plan pays 95% of any remaining drug costs for the rest of the year. Low-income beneficiaries receive a more generous benefit.

Drug plans are administered by private insurers, but of all the plans participating, 20 plans represent 90% of the market, said Ms. McGinty, a partner in an Atlanta law firm.

“The biggest group is [affiliated] with UnitedHealth Group,” she added.

There are 10 “national plans” approved by the Centers for Medicare and Medicaid Services; those plans are recommended for snowbirds who live in one place during the spring, summer, and fall but go south or west for the winter.

To help beneficiaries navigate the maze of plans, there are some things physicians are allowed to do, Ms. McGinty said. She recommended asking patients the following questions about the plans they're considering signing up with:

▸ How much is the deductible—the standard $250, or less?

▸ What about copays? Does the plan require a set copay or does it charge “coinsurance,” which means the patient must pay a certain percentage of the drug cost, whatever it is?

▸ Which pharmacies are included in the plan's pharmacy network? “Many seniors have established relationships with pharmacies and pharmacists,” said Ms. McGinty. “They may not want to change them.”

▸ What is in the formulary? Are the patients' drugs covered, or will they have to go through prior authorization or step therapy before they can get their particular medications?

One audience member pointed out that although plans are supposed to review their formularies once every 180 days, their pickup of drugs approved in 2005 was “unbelievably poor.”

If the plans base their formulary decisions on the model formulary published by the United States Pharmacopeia, that formulary is updated only once a year, he noted.

Ms. McGinty agreed that “there is a potential lag” to the new drugs coming on the model formulary, but added that each plan's pharmacy and therapeutics committee also is supposed to be keeping tracking of new drug approvals and deciding whether to add a new drug.

Off-Label Drug Use

Plans are supposed to approve off-label use as long as the use is listed in one of three drug compendia, said Greg Jones, who is with the program integrity group at the Centers for Medicare and Medicaid Services. But trying to help a patient get a drug for an off-label use not listed in a compendium will be a “trouble spot” for doctors, he conceded.

Although providers can give patients some help in choosing a drug plan—and even help low-income beneficiaries fill out the paperwork to get better benefits—“tension exists because there are limitations on what providers can say” about various drug plans, Ms. McGinty explained.

For example, providers cannot make specific plan recommendations, they can't steer an undecided enrollee to one plan over another, and they can't accept plan applications.

PHILADELPHIA — Physicians can help Medicare beneficiaries who are trying to select a Medicare drug coverage plan, but they have to make sure they follow all the rules, Charlene L. McGinty said at the annual meeting of the American Health Lawyers Association.

The drug benefit, also known as Part D, was passed by Congress in 2003 and became effective in January 2006. Patients pay an annual deductible of $250 as well as a premium of about $35 per month, depending on the plan they choose. The plan then pays 75% of drug costs until the patient has spent $2,250. After that, in most plans, the patient has to pay the next $3,850 out of pocket; this period is known as the “doughnut hole” or “coverage gap.” Once the beneficiaries' bills hit $5,100, the plan pays 95% of any remaining drug costs for the rest of the year. Low-income beneficiaries receive a more generous benefit.

Drug plans are administered by private insurers, but of all the plans participating, 20 plans represent 90% of the market, said Ms. McGinty, a partner in an Atlanta law firm.

“The biggest group is [affiliated] with UnitedHealth Group,” she added.

There are 10 “national plans” approved by the Centers for Medicare and Medicaid Services; those plans are recommended for snowbirds who live in one place during the spring, summer, and fall but go south or west for the winter.

To help beneficiaries navigate the maze of plans, there are some things physicians are allowed to do, Ms. McGinty said. She recommended asking patients the following questions about the plans they're considering signing up with:

▸ How much is the deductible—the standard $250, or less?

▸ What about copays? Does the plan require a set copay or does it charge “coinsurance,” which means the patient must pay a certain percentage of the drug cost, whatever it is?

▸ Which pharmacies are included in the plan's pharmacy network? “Many seniors have established relationships with pharmacies and pharmacists,” said Ms. McGinty. “They may not want to change them.”

▸ What is in the formulary? Are the patients' drugs covered, or will they have to go through prior authorization or step therapy before they can get their particular medications?

One audience member pointed out that although plans are supposed to review their formularies once every 180 days, their pickup of drugs approved in 2005 was “unbelievably poor.”

If the plans base their formulary decisions on the model formulary published by the United States Pharmacopeia, that formulary is updated only once a year, he noted.

Ms. McGinty agreed that “there is a potential lag” to the new drugs coming on the model formulary, but added that each plan's pharmacy and therapeutics committee also is supposed to be keeping tracking of new drug approvals and deciding whether to add a new drug.

Off-Label Drug Use

Plans are supposed to approve off-label use as long as the use is listed in one of three drug compendia, said Greg Jones, who is with the program integrity group at the Centers for Medicare and Medicaid Services. But trying to help a patient get a drug for an off-label use not listed in a compendium will be a “trouble spot” for doctors, he conceded.

Although providers can give patients some help in choosing a drug plan—and even help low-income beneficiaries fill out the paperwork to get better benefits—“tension exists because there are limitations on what providers can say” about various drug plans, Ms. McGinty explained.

For example, providers cannot make specific plan recommendations, they can't steer an undecided enrollee to one plan over another, and they can't accept plan applications.

BALTIMORE — Provisions in the Deficit Reduction Act are likely to profoundly affect health care for Medicaid patients, Cindy Mann said at the annual meeting of the American Society for Law, Medicine, and Ethics.

The Deficit Reduction Act (DRA) of 2005, signed into law last February by President Bush, includes “the most significant statutory changes in the Medicaid program arguably since the late 1980s,” said Ms. Mann, who is a research professor at Georgetown University Health Policy Institute in Washington. “It really is also the first time that Congress has legislated some specific cutbacks aimed at beneficiaries.”

Many changes deal with Medicaid coverage requirements for states. The law “gives [states] very broad flexibility to move away from what has been a system of mandatory and optional benefits to a system of benchmark benefits,” said Ms. Mann, who is also executive director of the Center for Children and Families at Georgetown. “One benchmark [states can use] is any state employee plan—not the one most used in your state, or the one that has the highest enrollment of dependents, it's any state employee plan that's offered.”

States could even construct a special plan just to be a benchmark and then offer it to state employees, “and that becomes [the] standard,” she said, at the meeting cosponsored by the University of Maryland.

The other way states can formulate an acceptable plan is by getting the approval of the federal Health and Human Services secretary. The two state plan amendments now approved under the DRA—West Virginia and Kentucky—used the secretary-approved coverage option, she noted.

DRA also allows states to change benefit packages for some groups and not others, Ms. Mann said. “[States] could have one benchmark package in a rural area of the state and a different one for urban areas. It opens it up to any slice and dice a state decides it wants to do in terms of how it constructs these benchmark packages and to whom they will apply.”

A controversial change imposed by the DRA is a requirement that anyone applying for Medicaid who says they are a citizen must provide new documentation of their citizenship. “Since 1996 there's been a provision requiring documentation of immigration status, and now there are very strict rules about documentation,” she said, adding that federal guidance on how to implement this section of the law is expected shortly.

The law also allows for several demonstration projects. For example, 10 states may start Health Opportunity Accounts, which are “a little like health savings accounts for the Medicaid program,” she said. Another measure, championed by Sen. Charles Grassley (R-Iowa), is the Family Opportunity Act, which allows families to buy into Medicaid if they have severely disabled children, even if their family income is above the normal cutoff in their state for Medicaid eligibility.

Ms. Mann added that although the law contains profound changes, “it is often overstated what the changes were. In large part, what the DRA didn't do, Congress decided not to do. There was a debate about the areas of benefit guarantees for kids and there was a debate about the cost sharing. So while Congress did go a certain distance, it didn't go further than that certain distance, and I think that's an important consideration.”

BALTIMORE — Provisions in the Deficit Reduction Act are likely to profoundly affect health care for Medicaid patients, Cindy Mann said at the annual meeting of the American Society for Law, Medicine, and Ethics.

The Deficit Reduction Act (DRA) of 2005, signed into law last February by President Bush, includes “the most significant statutory changes in the Medicaid program arguably since the late 1980s,” said Ms. Mann, who is a research professor at Georgetown University Health Policy Institute in Washington. “It really is also the first time that Congress has legislated some specific cutbacks aimed at beneficiaries.”

Many changes deal with Medicaid coverage requirements for states. The law “gives [states] very broad flexibility to move away from what has been a system of mandatory and optional benefits to a system of benchmark benefits,” said Ms. Mann, who is also executive director of the Center for Children and Families at Georgetown. “One benchmark [states can use] is any state employee plan—not the one most used in your state, or the one that has the highest enrollment of dependents, it's any state employee plan that's offered.”

States could even construct a special plan just to be a benchmark and then offer it to state employees, “and that becomes [the] standard,” she said, at the meeting cosponsored by the University of Maryland.

The other way states can formulate an acceptable plan is by getting the approval of the federal Health and Human Services secretary. The two state plan amendments now approved under the DRA—West Virginia and Kentucky—used the secretary-approved coverage option, she noted.

DRA also allows states to change benefit packages for some groups and not others, Ms. Mann said. “[States] could have one benchmark package in a rural area of the state and a different one for urban areas. It opens it up to any slice and dice a state decides it wants to do in terms of how it constructs these benchmark packages and to whom they will apply.”

A controversial change imposed by the DRA is a requirement that anyone applying for Medicaid who says they are a citizen must provide new documentation of their citizenship. “Since 1996 there's been a provision requiring documentation of immigration status, and now there are very strict rules about documentation,” she said, adding that federal guidance on how to implement this section of the law is expected shortly.

The law also allows for several demonstration projects. For example, 10 states may start Health Opportunity Accounts, which are “a little like health savings accounts for the Medicaid program,” she said. Another measure, championed by Sen. Charles Grassley (R-Iowa), is the Family Opportunity Act, which allows families to buy into Medicaid if they have severely disabled children, even if their family income is above the normal cutoff in their state for Medicaid eligibility.

Ms. Mann added that although the law contains profound changes, “it is often overstated what the changes were. In large part, what the DRA didn't do, Congress decided not to do. There was a debate about the areas of benefit guarantees for kids and there was a debate about the cost sharing. So while Congress did go a certain distance, it didn't go further than that certain distance, and I think that's an important consideration.”

BALTIMORE — Provisions in the Deficit Reduction Act are likely to profoundly affect health care for Medicaid patients, Cindy Mann said at the annual meeting of the American Society for Law, Medicine, and Ethics.

The Deficit Reduction Act (DRA) of 2005, signed into law last February by President Bush, includes “the most significant statutory changes in the Medicaid program arguably since the late 1980s,” said Ms. Mann, who is a research professor at Georgetown University Health Policy Institute in Washington. “It really is also the first time that Congress has legislated some specific cutbacks aimed at beneficiaries.”

Many changes deal with Medicaid coverage requirements for states. The law “gives [states] very broad flexibility to move away from what has been a system of mandatory and optional benefits to a system of benchmark benefits,” said Ms. Mann, who is also executive director of the Center for Children and Families at Georgetown. “One benchmark [states can use] is any state employee plan—not the one most used in your state, or the one that has the highest enrollment of dependents, it's any state employee plan that's offered.”

States could even construct a special plan just to be a benchmark and then offer it to state employees, “and that becomes [the] standard,” she said, at the meeting cosponsored by the University of Maryland.

The other way states can formulate an acceptable plan is by getting the approval of the federal Health and Human Services secretary. The two state plan amendments now approved under the DRA—West Virginia and Kentucky—used the secretary-approved coverage option, she noted.

DRA also allows states to change benefit packages for some groups and not others, Ms. Mann said. “[States] could have one benchmark package in a rural area of the state and a different one for urban areas. It opens it up to any slice and dice a state decides it wants to do in terms of how it constructs these benchmark packages and to whom they will apply.”

A controversial change imposed by the DRA is a requirement that anyone applying for Medicaid who says they are a citizen must provide new documentation of their citizenship. “Since 1996 there's been a provision requiring documentation of immigration status, and now there are very strict rules about documentation,” she said, adding that federal guidance on how to implement this section of the law is expected shortly.

The law also allows for several demonstration projects. For example, 10 states may start Health Opportunity Accounts, which are “a little like health savings accounts for the Medicaid program,” she said. Another measure, championed by Sen. Charles Grassley (R-Iowa), is the Family Opportunity Act, which allows families to buy into Medicaid if they have severely disabled children, even if their family income is above the normal cutoff in their state for Medicaid eligibility.

Ms. Mann added that although the law contains profound changes, “it is often overstated what the changes were. In large part, what the DRA didn't do, Congress decided not to do. There was a debate about the areas of benefit guarantees for kids and there was a debate about the cost sharing. So while Congress did go a certain distance, it didn't go further than that certain distance, and I think that's an important consideration.”

CHICAGO — Make yourself aware of the new endocrinology diagnosis and procedure codes for this year, Dr. S. Sethu K. Reddy advised at the annual meeting of the American Association of Clinical Endocrinologists.

An important change is that the CPT code for “therapeutic, prophylactic, or diagnostic injection” is now 90772; it used to be 90872, said Dr. Reddy, chairman of coding and reimbursement for AACE. The G-code for a therapeutic or diagnostic injection, either subcutaneous or intramuscular, has been changed from G0351 to a C-code, C-8952, he said.

In addition, there are some important changes to the ICD-9 codes, said Dr. Reddy, chairman of the endocrinology, diabetes, and metabolism department at the Cleveland Clinic. For example, there is a new code, 259.5, for androgen insensitivity syndrome, and another new code, 276.50, for volume depletion of an unspecified nature; that code was expanded from 276.5 to add a fifth digit. There is also a third new code, 278.02, for overweight, he said.

New V codes include V15.88 for history of fall, V17.81 for family history of osteoporosis, and V26.31 for genetic disease carrier status testing. There is also a series of V codes related to weight: V85.0 for a body mass index (BMI) of less than 19 kg/m

Coding for diabetes education is also changing, according to Dr. Reddy. For instance, the Centers for Medicare and Medicaid Services will no longer pay for G108 (diabetes outpatient self-management training services, individual, per 30 minutes) or G109 (diabetes self-management training services, group session [two or more], per 30 minutes) codes if a registered nurse is doing the training; instead, the trainer must be a certified diabetes educator.

“If the [trainer] is not a certified diabetes educator, you may end up having to use a level 1 nurse visit,” he warned.

There is one exception to that rule: If the education program is being done by a hospital in a dedicated education room and is certified by the American Diabetes Association, registered nurses may be used as trainers, he said. The failure to include office-based practices in this exemption “is taking many office-based endocrinologists out of the loop of patient education.”

AACE also has been working on getting a code for insulin pump training, Dr. Reddy said. “We applied for a code for insulin pump training about 3 years ago. It was changed to an intensive insulin therapy code, and it finally evolved into an educational training or patient self-management code.” The advantage of this code, which is new this year, is that it can be used for other disorders such as asthma and osteoporosis.

The code for “education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes, individual patient” is 98960. There are also codes 98961 for groups of 2–4 patients and 98962 for groups of 5–8 patients. “The challenge is for AACE to develop standardized curriculum with a pretest and a posttest, and foster political support for coverage,” he said.

CHICAGO — Make yourself aware of the new endocrinology diagnosis and procedure codes for this year, Dr. S. Sethu K. Reddy advised at the annual meeting of the American Association of Clinical Endocrinologists.

An important change is that the CPT code for “therapeutic, prophylactic, or diagnostic injection” is now 90772; it used to be 90872, said Dr. Reddy, chairman of coding and reimbursement for AACE. The G-code for a therapeutic or diagnostic injection, either subcutaneous or intramuscular, has been changed from G0351 to a C-code, C-8952, he said.

In addition, there are some important changes to the ICD-9 codes, said Dr. Reddy, chairman of the endocrinology, diabetes, and metabolism department at the Cleveland Clinic. For example, there is a new code, 259.5, for androgen insensitivity syndrome, and another new code, 276.50, for volume depletion of an unspecified nature; that code was expanded from 276.5 to add a fifth digit. There is also a third new code, 278.02, for overweight, he said.

New V codes include V15.88 for history of fall, V17.81 for family history of osteoporosis, and V26.31 for genetic disease carrier status testing. There is also a series of V codes related to weight: V85.0 for a body mass index (BMI) of less than 19 kg/m

Coding for diabetes education is also changing, according to Dr. Reddy. For instance, the Centers for Medicare and Medicaid Services will no longer pay for G108 (diabetes outpatient self-management training services, individual, per 30 minutes) or G109 (diabetes self-management training services, group session [two or more], per 30 minutes) codes if a registered nurse is doing the training; instead, the trainer must be a certified diabetes educator.

“If the [trainer] is not a certified diabetes educator, you may end up having to use a level 1 nurse visit,” he warned.

There is one exception to that rule: If the education program is being done by a hospital in a dedicated education room and is certified by the American Diabetes Association, registered nurses may be used as trainers, he said. The failure to include office-based practices in this exemption “is taking many office-based endocrinologists out of the loop of patient education.”

AACE also has been working on getting a code for insulin pump training, Dr. Reddy said. “We applied for a code for insulin pump training about 3 years ago. It was changed to an intensive insulin therapy code, and it finally evolved into an educational training or patient self-management code.” The advantage of this code, which is new this year, is that it can be used for other disorders such as asthma and osteoporosis.

The code for “education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes, individual patient” is 98960. There are also codes 98961 for groups of 2–4 patients and 98962 for groups of 5–8 patients. “The challenge is for AACE to develop standardized curriculum with a pretest and a posttest, and foster political support for coverage,” he said.

CHICAGO — Make yourself aware of the new endocrinology diagnosis and procedure codes for this year, Dr. S. Sethu K. Reddy advised at the annual meeting of the American Association of Clinical Endocrinologists.

An important change is that the CPT code for “therapeutic, prophylactic, or diagnostic injection” is now 90772; it used to be 90872, said Dr. Reddy, chairman of coding and reimbursement for AACE. The G-code for a therapeutic or diagnostic injection, either subcutaneous or intramuscular, has been changed from G0351 to a C-code, C-8952, he said.

In addition, there are some important changes to the ICD-9 codes, said Dr. Reddy, chairman of the endocrinology, diabetes, and metabolism department at the Cleveland Clinic. For example, there is a new code, 259.5, for androgen insensitivity syndrome, and another new code, 276.50, for volume depletion of an unspecified nature; that code was expanded from 276.5 to add a fifth digit. There is also a third new code, 278.02, for overweight, he said.

New V codes include V15.88 for history of fall, V17.81 for family history of osteoporosis, and V26.31 for genetic disease carrier status testing. There is also a series of V codes related to weight: V85.0 for a body mass index (BMI) of less than 19 kg/m

Coding for diabetes education is also changing, according to Dr. Reddy. For instance, the Centers for Medicare and Medicaid Services will no longer pay for G108 (diabetes outpatient self-management training services, individual, per 30 minutes) or G109 (diabetes self-management training services, group session [two or more], per 30 minutes) codes if a registered nurse is doing the training; instead, the trainer must be a certified diabetes educator.

“If the [trainer] is not a certified diabetes educator, you may end up having to use a level 1 nurse visit,” he warned.

There is one exception to that rule: If the education program is being done by a hospital in a dedicated education room and is certified by the American Diabetes Association, registered nurses may be used as trainers, he said. The failure to include office-based practices in this exemption “is taking many office-based endocrinologists out of the loop of patient education.”

AACE also has been working on getting a code for insulin pump training, Dr. Reddy said. “We applied for a code for insulin pump training about 3 years ago. It was changed to an intensive insulin therapy code, and it finally evolved into an educational training or patient self-management code.” The advantage of this code, which is new this year, is that it can be used for other disorders such as asthma and osteoporosis.

The code for “education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family), each 30 minutes, individual patient” is 98960. There are also codes 98961 for groups of 2–4 patients and 98962 for groups of 5–8 patients. “The challenge is for AACE to develop standardized curriculum with a pretest and a posttest, and foster political support for coverage,” he said.

CHICAGO — Men with prostatic disease often present with symptoms of hypogonadism and are more likely to be hypogonadal, compared with patients who do not have prostatic conditions, Dr. Sherwyn L. Schwartz said in a poster presentation at the annual meeting of the American Association of Clinical Endocrinologists.

As part of the Hypogonadism in Males (HIM) study, Dr. Schwartz, an endocrinologist in private practice in San Antonio, looked at 391 men aged 45 or older who had prostatic disease and made appointments at 95 primary care centers over a 2-week period. Patients included 165 men with serum total testosterone levels of less than 300 ng/dL, defined as hypogonadal levels, and 226 men with normal serum total testosterone levels.

All patients had a single morning blood draw to test for concentrations of total testosterone, free testosterone, bioavailable testosterone, and sex hormone-binding globulin. Patients were surveyed for comorbid conditions and for signs and symptoms of hypogonadism. Dr. Schwartz compared study results in this group with results from the overall HIM study population.

In the overall study population, the percentage of hypogonadal men with a medical history of prostatic disease or disorder was 20%, similar to the 17% prevalence seen in eugonadal men. However, among the hypogonadal population not receiving testosterone therapy, the percentage of men with prostatic disease was 21%, which achieved statistical significance when compared with the prevalence in eugonadal men.

“Based on these observations, larger studies that examine the relationship between the occurrence of hypogonadal symptoms and the risk of hypogonadism … are warranted,” he concluded.

CHICAGO — Men with prostatic disease often present with symptoms of hypogonadism and are more likely to be hypogonadal, compared with patients who do not have prostatic conditions, Dr. Sherwyn L. Schwartz said in a poster presentation at the annual meeting of the American Association of Clinical Endocrinologists.

As part of the Hypogonadism in Males (HIM) study, Dr. Schwartz, an endocrinologist in private practice in San Antonio, looked at 391 men aged 45 or older who had prostatic disease and made appointments at 95 primary care centers over a 2-week period. Patients included 165 men with serum total testosterone levels of less than 300 ng/dL, defined as hypogonadal levels, and 226 men with normal serum total testosterone levels.

All patients had a single morning blood draw to test for concentrations of total testosterone, free testosterone, bioavailable testosterone, and sex hormone-binding globulin. Patients were surveyed for comorbid conditions and for signs and symptoms of hypogonadism. Dr. Schwartz compared study results in this group with results from the overall HIM study population.

In the overall study population, the percentage of hypogonadal men with a medical history of prostatic disease or disorder was 20%, similar to the 17% prevalence seen in eugonadal men. However, among the hypogonadal population not receiving testosterone therapy, the percentage of men with prostatic disease was 21%, which achieved statistical significance when compared with the prevalence in eugonadal men.

“Based on these observations, larger studies that examine the relationship between the occurrence of hypogonadal symptoms and the risk of hypogonadism … are warranted,” he concluded.

CHICAGO — Men with prostatic disease often present with symptoms of hypogonadism and are more likely to be hypogonadal, compared with patients who do not have prostatic conditions, Dr. Sherwyn L. Schwartz said in a poster presentation at the annual meeting of the American Association of Clinical Endocrinologists.

As part of the Hypogonadism in Males (HIM) study, Dr. Schwartz, an endocrinologist in private practice in San Antonio, looked at 391 men aged 45 or older who had prostatic disease and made appointments at 95 primary care centers over a 2-week period. Patients included 165 men with serum total testosterone levels of less than 300 ng/dL, defined as hypogonadal levels, and 226 men with normal serum total testosterone levels.

All patients had a single morning blood draw to test for concentrations of total testosterone, free testosterone, bioavailable testosterone, and sex hormone-binding globulin. Patients were surveyed for comorbid conditions and for signs and symptoms of hypogonadism. Dr. Schwartz compared study results in this group with results from the overall HIM study population.

In the overall study population, the percentage of hypogonadal men with a medical history of prostatic disease or disorder was 20%, similar to the 17% prevalence seen in eugonadal men. However, among the hypogonadal population not receiving testosterone therapy, the percentage of men with prostatic disease was 21%, which achieved statistical significance when compared with the prevalence in eugonadal men.

“Based on these observations, larger studies that examine the relationship between the occurrence of hypogonadal symptoms and the risk of hypogonadism … are warranted,” he concluded.

WASHINGTON — If you don't like medically “unbelievable” edits, how about medically “unusual” ones?

Members of the Practicing Physicians Advisory Council (PPAC), which advises the Centers for Medicare and Medicaid Services (CMS) on issues of interest to physicians, were upset about the name of the proposed Medically Unbelievable Edits program, which aims to find obvious errors in Medicare claims—for example, a claim for doing a hysterectomy on a male patient.

” 'Unbelievable' is a value judgment,” PPAC member Dr. Peter Grimm, a radiation oncologist from Seattle, said at a recent council meeting. “You're going to get immediate reaction from people, so changing that word to 'unusual' doesn't change your [acronym] and really accurately describes what you're trying to do.”

PPAC member Dr. M. LeRoy Sprang, an Evanston, Ill., ob.gyn. had another idea. “How about 'medically unexpected?' It's a softer word, and it really covers what you want to do. It's just not as obnoxious as 'unbelievable.'”

The program in question is designed to detect implausible Medicare claims submissions and avert inappropriate claims payment, according to Lisa Zone, director of the program integrity group at the CMS Office of Financial Management.

“I realize that this is an unfortunate title,” she said. “We are trying to install edits to detect true errors in the system.”

A recent CMS report found that Medicare's national paid claims error rate was 5.1%, “and we know that 1.7% is related to improper coding or billing errors,” Ms. Zone said. “When you look at the federal dollars expended in the coding error class, it's in the billions of dollars.”

The comment period for the proposed program ended on June 19, and Ms. Zone noted that “given that we've [already] heard from various provider organizations about the MUEs out there today for comment, we are not going to be going forward with the MUEs as they are.”

Instead, the office will look at the edits as a whole and make decisions on the best way to move forward. Initially, Ms. Zone's office will concentrate on developing edits to catch “anatomical” errors, such as procedures performed on the wrong body part. Then, they will address edits for typographical errors—someone bills for 500 units instead of 5, for example.

After making those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a “test period” beforehand, Ms. Zone said. The testing will include an appeals process as well as the use of modifiers. Implementation will be in a “staged” approach, starting with the anatomical and typographical edits. “We're very interested in what you have to say,” Ms. Zone told the council. “We want to have those edits detect errors within the claims processing system, but in no way do we want the edits to affect medical practice or payment policy.”

Ms. Zone noted that doctors who make errors will not be on any “hit list.”

“Certainly, if we see a group or provider who was hitting edits more frequently than anyone else, then a contractor might decide to do some education or medical reviews for someone who was having problems submitting claims correctly, but that would be found based on data analysis,” she said.

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, told Ms. Zone that “there is considerably more angst in the medical community about this issue than may immediately appear.” He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

For example, one possible edit would return a claim if a surgeon took out two spleens in the same patient on the same day. “I'm not a surgeon, but [I know that] there are some people who do have accessory spleens, and it is conceivable that you might have to take out a second spleen,” he said. “I really think you need to come up with a modifier for situations that don't appear to be straightforward before you bring this [system] out.”

Thomas Gustafson, Ph.D., deputy director of the Center for Medicare Management, seemed sympathetic to the modifier idea. “Insofar as we're capturing inversions of numbers or stuff like that, which are true coding errors, everybody should be able to agree with that,” he said.

WASHINGTON — If you don't like medically “unbelievable” edits, how about medically “unusual” ones?

Members of the Practicing Physicians Advisory Council (PPAC), which advises the Centers for Medicare and Medicaid Services (CMS) on issues of interest to physicians, were upset about the name of the proposed Medically Unbelievable Edits program, which aims to find obvious errors in Medicare claims—for example, a claim for doing a hysterectomy on a male patient.

” 'Unbelievable' is a value judgment,” PPAC member Dr. Peter Grimm, a radiation oncologist from Seattle, said at a recent council meeting. “You're going to get immediate reaction from people, so changing that word to 'unusual' doesn't change your [acronym] and really accurately describes what you're trying to do.”

PPAC member Dr. M. LeRoy Sprang, an Evanston, Ill., ob.gyn. had another idea. “How about 'medically unexpected?' It's a softer word, and it really covers what you want to do. It's just not as obnoxious as 'unbelievable.'”

The program in question is designed to detect implausible Medicare claims submissions and avert inappropriate claims payment, according to Lisa Zone, director of the program integrity group at the CMS Office of Financial Management.

“I realize that this is an unfortunate title,” she said. “We are trying to install edits to detect true errors in the system.”

A recent CMS report found that Medicare's national paid claims error rate was 5.1%, “and we know that 1.7% is related to improper coding or billing errors,” Ms. Zone said. “When you look at the federal dollars expended in the coding error class, it's in the billions of dollars.”

The comment period for the proposed program ended on June 19, and Ms. Zone noted that “given that we've [already] heard from various provider organizations about the MUEs out there today for comment, we are not going to be going forward with the MUEs as they are.”

Instead, the office will look at the edits as a whole and make decisions on the best way to move forward. Initially, Ms. Zone's office will concentrate on developing edits to catch “anatomical” errors, such as procedures performed on the wrong body part. Then, they will address edits for typographical errors—someone bills for 500 units instead of 5, for example.

After making those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a “test period” beforehand, Ms. Zone said. The testing will include an appeals process as well as the use of modifiers. Implementation will be in a “staged” approach, starting with the anatomical and typographical edits. “We're very interested in what you have to say,” Ms. Zone told the council. “We want to have those edits detect errors within the claims processing system, but in no way do we want the edits to affect medical practice or payment policy.”

Ms. Zone noted that doctors who make errors will not be on any “hit list.”

“Certainly, if we see a group or provider who was hitting edits more frequently than anyone else, then a contractor might decide to do some education or medical reviews for someone who was having problems submitting claims correctly, but that would be found based on data analysis,” she said.

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, told Ms. Zone that “there is considerably more angst in the medical community about this issue than may immediately appear.” He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

For example, one possible edit would return a claim if a surgeon took out two spleens in the same patient on the same day. “I'm not a surgeon, but [I know that] there are some people who do have accessory spleens, and it is conceivable that you might have to take out a second spleen,” he said. “I really think you need to come up with a modifier for situations that don't appear to be straightforward before you bring this [system] out.”

Thomas Gustafson, Ph.D., deputy director of the Center for Medicare Management, seemed sympathetic to the modifier idea. “Insofar as we're capturing inversions of numbers or stuff like that, which are true coding errors, everybody should be able to agree with that,” he said.

WASHINGTON — If you don't like medically “unbelievable” edits, how about medically “unusual” ones?

Members of the Practicing Physicians Advisory Council (PPAC), which advises the Centers for Medicare and Medicaid Services (CMS) on issues of interest to physicians, were upset about the name of the proposed Medically Unbelievable Edits program, which aims to find obvious errors in Medicare claims—for example, a claim for doing a hysterectomy on a male patient.

” 'Unbelievable' is a value judgment,” PPAC member Dr. Peter Grimm, a radiation oncologist from Seattle, said at a recent council meeting. “You're going to get immediate reaction from people, so changing that word to 'unusual' doesn't change your [acronym] and really accurately describes what you're trying to do.”

PPAC member Dr. M. LeRoy Sprang, an Evanston, Ill., ob.gyn. had another idea. “How about 'medically unexpected?' It's a softer word, and it really covers what you want to do. It's just not as obnoxious as 'unbelievable.'”

The program in question is designed to detect implausible Medicare claims submissions and avert inappropriate claims payment, according to Lisa Zone, director of the program integrity group at the CMS Office of Financial Management.

“I realize that this is an unfortunate title,” she said. “We are trying to install edits to detect true errors in the system.”

A recent CMS report found that Medicare's national paid claims error rate was 5.1%, “and we know that 1.7% is related to improper coding or billing errors,” Ms. Zone said. “When you look at the federal dollars expended in the coding error class, it's in the billions of dollars.”

The comment period for the proposed program ended on June 19, and Ms. Zone noted that “given that we've [already] heard from various provider organizations about the MUEs out there today for comment, we are not going to be going forward with the MUEs as they are.”

Instead, the office will look at the edits as a whole and make decisions on the best way to move forward. Initially, Ms. Zone's office will concentrate on developing edits to catch “anatomical” errors, such as procedures performed on the wrong body part. Then, they will address edits for typographical errors—someone bills for 500 units instead of 5, for example.

After making those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a “test period” beforehand, Ms. Zone said. The testing will include an appeals process as well as the use of modifiers. Implementation will be in a “staged” approach, starting with the anatomical and typographical edits. “We're very interested in what you have to say,” Ms. Zone told the council. “We want to have those edits detect errors within the claims processing system, but in no way do we want the edits to affect medical practice or payment policy.”

Ms. Zone noted that doctors who make errors will not be on any “hit list.”

“Certainly, if we see a group or provider who was hitting edits more frequently than anyone else, then a contractor might decide to do some education or medical reviews for someone who was having problems submitting claims correctly, but that would be found based on data analysis,” she said.

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, told Ms. Zone that “there is considerably more angst in the medical community about this issue than may immediately appear.” He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

For example, one possible edit would return a claim if a surgeon took out two spleens in the same patient on the same day. “I'm not a surgeon, but [I know that] there are some people who do have accessory spleens, and it is conceivable that you might have to take out a second spleen,” he said. “I really think you need to come up with a modifier for situations that don't appear to be straightforward before you bring this [system] out.”

Thomas Gustafson, Ph.D., deputy director of the Center for Medicare Management, seemed sympathetic to the modifier idea. “Insofar as we're capturing inversions of numbers or stuff like that, which are true coding errors, everybody should be able to agree with that,” he said.

CHICAGO — Women with polycystic ovary syndrome can have fairly advanced liver disease, Dr. Tracy L. Setji of Duke University, Durham, N.C., and colleagues said in a poster presentation at the annual meeting of the American Association of Clinical Endocrinologists.

At a university endocrinology clinic, charts were reviewed retrospectively for 275 PCOS patients with oligomenorrhea and clinical or biochemical evidence of hyperandrogenism.

Of these, 200 had no other causes of irregular menses and drank less than one alcoholic beverage daily. Aspartate aminotransferase and alanine aminotransferase levels greater than 60 U/L were seen in 15%. Patients with elevated aminotransferase levels had lower median HDL cholesterol levels (41 mg/dL vs. 50 mg/dL), higher median triglycerides (174 mg/dL vs. 129 mg/dL), and higher median fasting insulin (21 μIU/mL vs. 12 μIU/mL), compared with patients without elevated aminotransferase levels.

Liver biopsies were performed in six women with persistently high aminotransferase levels, and they were diagnosed with nonalcoholic steatohepatitis (NASH) with fibrosis. These patients had lower median HDL levels and higher median triglyceride and fasting insulin levels than did patients who did not undergo biopsy.

The study was limited by the self-reporting of alcohol consumption.

Additionally, normal liver enzyme values do not exclude the presence of liver disease, including NASH, the investigators said.

“The young age of many women with polycystic ovary syndrome and the relatively advanced stage of NASH seen on the biopsies of our patients suggest the possibility of significant risk for long-term complications from liver disease,” the authors concluded.

CHICAGO — Women with polycystic ovary syndrome can have fairly advanced liver disease, Dr. Tracy L. Setji of Duke University, Durham, N.C., and colleagues said in a poster presentation at the annual meeting of the American Association of Clinical Endocrinologists.

At a university endocrinology clinic, charts were reviewed retrospectively for 275 PCOS patients with oligomenorrhea and clinical or biochemical evidence of hyperandrogenism.

Of these, 200 had no other causes of irregular menses and drank less than one alcoholic beverage daily. Aspartate aminotransferase and alanine aminotransferase levels greater than 60 U/L were seen in 15%. Patients with elevated aminotransferase levels had lower median HDL cholesterol levels (41 mg/dL vs. 50 mg/dL), higher median triglycerides (174 mg/dL vs. 129 mg/dL), and higher median fasting insulin (21 μIU/mL vs. 12 μIU/mL), compared with patients without elevated aminotransferase levels.

Liver biopsies were performed in six women with persistently high aminotransferase levels, and they were diagnosed with nonalcoholic steatohepatitis (NASH) with fibrosis. These patients had lower median HDL levels and higher median triglyceride and fasting insulin levels than did patients who did not undergo biopsy.

The study was limited by the self-reporting of alcohol consumption.

Additionally, normal liver enzyme values do not exclude the presence of liver disease, including NASH, the investigators said.

“The young age of many women with polycystic ovary syndrome and the relatively advanced stage of NASH seen on the biopsies of our patients suggest the possibility of significant risk for long-term complications from liver disease,” the authors concluded.

CHICAGO — Women with polycystic ovary syndrome can have fairly advanced liver disease, Dr. Tracy L. Setji of Duke University, Durham, N.C., and colleagues said in a poster presentation at the annual meeting of the American Association of Clinical Endocrinologists.

At a university endocrinology clinic, charts were reviewed retrospectively for 275 PCOS patients with oligomenorrhea and clinical or biochemical evidence of hyperandrogenism.

Of these, 200 had no other causes of irregular menses and drank less than one alcoholic beverage daily. Aspartate aminotransferase and alanine aminotransferase levels greater than 60 U/L were seen in 15%. Patients with elevated aminotransferase levels had lower median HDL cholesterol levels (41 mg/dL vs. 50 mg/dL), higher median triglycerides (174 mg/dL vs. 129 mg/dL), and higher median fasting insulin (21 μIU/mL vs. 12 μIU/mL), compared with patients without elevated aminotransferase levels.

Liver biopsies were performed in six women with persistently high aminotransferase levels, and they were diagnosed with nonalcoholic steatohepatitis (NASH) with fibrosis. These patients had lower median HDL levels and higher median triglyceride and fasting insulin levels than did patients who did not undergo biopsy.

The study was limited by the self-reporting of alcohol consumption.

Additionally, normal liver enzyme values do not exclude the presence of liver disease, including NASH, the investigators said.

“The young age of many women with polycystic ovary syndrome and the relatively advanced stage of NASH seen on the biopsies of our patients suggest the possibility of significant risk for long-term complications from liver disease,” the authors concluded.

Gulf War Research

New federally funded research will test the hypothesis that veterans with Gulf War Illness have metabolic, structural, or functional changes in their basal ganglia that are not accounted for by posttraumatic stress disorder, depression, or alcoholism. This is among 24 projects that were funded by the federal government starting in fiscal year 2005 to examine the brain and nervous system function, environmental toxicology, immune function, and general health of veterans of the Gulf War. The Department of Veterans Affairs is required to report to Congress each year on the status of research into the health consequences of military service in the Persian Gulf region from Aug. 2, 1990, to July 31, 1991, said William Goldberg, Ph.D., portfolio manager of the VA's Office of Biomedical Research and Development Service. From fiscal year 1992 through 2005, the federal government has sponsored 300 research projects on Gulf War veterans' illnesses, according to the report. These annual reports are available at

www.research.va.gov/resources/pubs/pubs_individual.cfm?Category=Gulf War Reports

Moratorium on Imaging Pay Cuts

With Medicare due to slash payments for imaging services by 35%–55% in January 2007, provider organizations are rallying to delay or repeal the cuts, which call for payments for the technical component—equipment, supplies, and overhead for imaging services—to be reimbursed at the hospital outpatient payment rate if it is lower than the physician fee schedule. At a hearing of the House Energy and Commerce Health Subcommittee, Democrats and Republicans said they were concerned the reductions were enacted without public input and without any assessment of the impact on beneficiaries. The cuts were inserted into the Deficit Reduction Act during a House-Senate conference; the act was signed in February 2006. “We don't know exactly what we've done, or how well or how poorly we've done it,” said Rep. John Dingell (D-Mich.) at the hearing. H.R. 5704, sponsored by Rep. Joseph Pitts (R-Penn.), would institute a 2-year moratorium. Rep. Carolyn McCarthy (D-N.Y.) has introduced a bill that would repeal the cuts (H.R. 5238). Michael Amery, legislative counsel for the American Academy of Neurology, said that while the academy would like to see the cuts overturned, “our first priority continues to be reimbursement under the [Medicare] Sustainable Growth Rate formula.” If the imaging cuts were overturned, the academy is concerned that a physician fee reduction might be considered again in order to make things budget neutral, Mr. Amery said.

Alzheimer's Research Funding

The Alzheimer's Disease Neuroimaging Initiative—a 5-year study looking at imaging technology to improve early diagnosis and gauge the effectiveness of treatments—got a $2.1 million boost last month from the Alzheimer's Association. Officials at the association had previously granted $1 million to help fund this $60 million public-private initiative launched by the National Institute on Aging in 2004. The project is aimed at testing whether serial magnetic resonance imaging, positron emission tomography, biologic markers, and clinical and neuropsychological assessments can be used together to measure the progression of mild Alzheimer's disease and mild cognitive impairment. Researchers also will evaluate the use of PET scans with Pittsburgh Compound B (PIB). “PET/PIB technology will be a valuable addition to the study,” Dr. Samuel Gandy, chair of the Alzheimer's Association's Medical and Scientific Advisory Council, said in a statement. Researchers are currently recruiting patients for the study. Information on the study is available at

www.nia.nih.gov/Alzheimers/ResearchInformation/ClinicalTrials/ADNI.htm

Poll: Pay for Unhealthful Choices?

More than half of respondents to a Wall Street Journal/Harris Interactive poll say that people who smoke or choose not to wear seat belts should pay a higher health insurance premium than others, but most people did not feel the same way about individuals who were overweight or sedentary. Only 27% of the poll's 2,200 respondents thought that overweight people should pay more for insurance than slimmer peers; the same percentage favored having sedentary people pay more. The poll had a 3.3% margin of error.

Gulf War Research

New federally funded research will test the hypothesis that veterans with Gulf War Illness have metabolic, structural, or functional changes in their basal ganglia that are not accounted for by posttraumatic stress disorder, depression, or alcoholism. This is among 24 projects that were funded by the federal government starting in fiscal year 2005 to examine the brain and nervous system function, environmental toxicology, immune function, and general health of veterans of the Gulf War. The Department of Veterans Affairs is required to report to Congress each year on the status of research into the health consequences of military service in the Persian Gulf region from Aug. 2, 1990, to July 31, 1991, said William Goldberg, Ph.D., portfolio manager of the VA's Office of Biomedical Research and Development Service. From fiscal year 1992 through 2005, the federal government has sponsored 300 research projects on Gulf War veterans' illnesses, according to the report. These annual reports are available at

www.research.va.gov/resources/pubs/pubs_individual.cfm?Category=Gulf War Reports

Moratorium on Imaging Pay Cuts

With Medicare due to slash payments for imaging services by 35%–55% in January 2007, provider organizations are rallying to delay or repeal the cuts, which call for payments for the technical component—equipment, supplies, and overhead for imaging services—to be reimbursed at the hospital outpatient payment rate if it is lower than the physician fee schedule. At a hearing of the House Energy and Commerce Health Subcommittee, Democrats and Republicans said they were concerned the reductions were enacted without public input and without any assessment of the impact on beneficiaries. The cuts were inserted into the Deficit Reduction Act during a House-Senate conference; the act was signed in February 2006. “We don't know exactly what we've done, or how well or how poorly we've done it,” said Rep. John Dingell (D-Mich.) at the hearing. H.R. 5704, sponsored by Rep. Joseph Pitts (R-Penn.), would institute a 2-year moratorium. Rep. Carolyn McCarthy (D-N.Y.) has introduced a bill that would repeal the cuts (H.R. 5238). Michael Amery, legislative counsel for the American Academy of Neurology, said that while the academy would like to see the cuts overturned, “our first priority continues to be reimbursement under the [Medicare] Sustainable Growth Rate formula.” If the imaging cuts were overturned, the academy is concerned that a physician fee reduction might be considered again in order to make things budget neutral, Mr. Amery said.

Alzheimer's Research Funding

The Alzheimer's Disease Neuroimaging Initiative—a 5-year study looking at imaging technology to improve early diagnosis and gauge the effectiveness of treatments—got a $2.1 million boost last month from the Alzheimer's Association. Officials at the association had previously granted $1 million to help fund this $60 million public-private initiative launched by the National Institute on Aging in 2004. The project is aimed at testing whether serial magnetic resonance imaging, positron emission tomography, biologic markers, and clinical and neuropsychological assessments can be used together to measure the progression of mild Alzheimer's disease and mild cognitive impairment. Researchers also will evaluate the use of PET scans with Pittsburgh Compound B (PIB). “PET/PIB technology will be a valuable addition to the study,” Dr. Samuel Gandy, chair of the Alzheimer's Association's Medical and Scientific Advisory Council, said in a statement. Researchers are currently recruiting patients for the study. Information on the study is available at

www.nia.nih.gov/Alzheimers/ResearchInformation/ClinicalTrials/ADNI.htm

Poll: Pay for Unhealthful Choices?

More than half of respondents to a Wall Street Journal/Harris Interactive poll say that people who smoke or choose not to wear seat belts should pay a higher health insurance premium than others, but most people did not feel the same way about individuals who were overweight or sedentary. Only 27% of the poll's 2,200 respondents thought that overweight people should pay more for insurance than slimmer peers; the same percentage favored having sedentary people pay more. The poll had a 3.3% margin of error.

Gulf War Research

New federally funded research will test the hypothesis that veterans with Gulf War Illness have metabolic, structural, or functional changes in their basal ganglia that are not accounted for by posttraumatic stress disorder, depression, or alcoholism. This is among 24 projects that were funded by the federal government starting in fiscal year 2005 to examine the brain and nervous system function, environmental toxicology, immune function, and general health of veterans of the Gulf War. The Department of Veterans Affairs is required to report to Congress each year on the status of research into the health consequences of military service in the Persian Gulf region from Aug. 2, 1990, to July 31, 1991, said William Goldberg, Ph.D., portfolio manager of the VA's Office of Biomedical Research and Development Service. From fiscal year 1992 through 2005, the federal government has sponsored 300 research projects on Gulf War veterans' illnesses, according to the report. These annual reports are available at

www.research.va.gov/resources/pubs/pubs_individual.cfm?Category=Gulf War Reports

Moratorium on Imaging Pay Cuts

With Medicare due to slash payments for imaging services by 35%–55% in January 2007, provider organizations are rallying to delay or repeal the cuts, which call for payments for the technical component—equipment, supplies, and overhead for imaging services—to be reimbursed at the hospital outpatient payment rate if it is lower than the physician fee schedule. At a hearing of the House Energy and Commerce Health Subcommittee, Democrats and Republicans said they were concerned the reductions were enacted without public input and without any assessment of the impact on beneficiaries. The cuts were inserted into the Deficit Reduction Act during a House-Senate conference; the act was signed in February 2006. “We don't know exactly what we've done, or how well or how poorly we've done it,” said Rep. John Dingell (D-Mich.) at the hearing. H.R. 5704, sponsored by Rep. Joseph Pitts (R-Penn.), would institute a 2-year moratorium. Rep. Carolyn McCarthy (D-N.Y.) has introduced a bill that would repeal the cuts (H.R. 5238). Michael Amery, legislative counsel for the American Academy of Neurology, said that while the academy would like to see the cuts overturned, “our first priority continues to be reimbursement under the [Medicare] Sustainable Growth Rate formula.” If the imaging cuts were overturned, the academy is concerned that a physician fee reduction might be considered again in order to make things budget neutral, Mr. Amery said.

Alzheimer's Research Funding

The Alzheimer's Disease Neuroimaging Initiative—a 5-year study looking at imaging technology to improve early diagnosis and gauge the effectiveness of treatments—got a $2.1 million boost last month from the Alzheimer's Association. Officials at the association had previously granted $1 million to help fund this $60 million public-private initiative launched by the National Institute on Aging in 2004. The project is aimed at testing whether serial magnetic resonance imaging, positron emission tomography, biologic markers, and clinical and neuropsychological assessments can be used together to measure the progression of mild Alzheimer's disease and mild cognitive impairment. Researchers also will evaluate the use of PET scans with Pittsburgh Compound B (PIB). “PET/PIB technology will be a valuable addition to the study,” Dr. Samuel Gandy, chair of the Alzheimer's Association's Medical and Scientific Advisory Council, said in a statement. Researchers are currently recruiting patients for the study. Information on the study is available at

www.nia.nih.gov/Alzheimers/ResearchInformation/ClinicalTrials/ADNI.htm

Poll: Pay for Unhealthful Choices?

More than half of respondents to a Wall Street Journal/Harris Interactive poll say that people who smoke or choose not to wear seat belts should pay a higher health insurance premium than others, but most people did not feel the same way about individuals who were overweight or sedentary. Only 27% of the poll's 2,200 respondents thought that overweight people should pay more for insurance than slimmer peers; the same percentage favored having sedentary people pay more. The poll had a 3.3% margin of error.