Joyce Frieden

CHICAGO — Endocrinologists are “behind the curve” when it comes to treating osteoporosis, Dr. Nelson B. Watts said at the annual meeting of the American Association of Clinical Endocrinologists.

“There is roughly the same number of rheumatologists as endocrinologists in the United States,” said Dr. Watts, director of the osteoporosis and bone health program at the University of Cincinnati. “In academic centers, endocrinologists are often the 'boneheads,' but in clinical practice, rheumatologists compared with endocrinologists are twice as fast as we are in taking up ownership of densitometry or prescribing osteoporosis drugs.”

Osteoporosis groups are “in pretty good agreement” on several of the guidelines for treatment of the disorder, according to Dr. Watts, who consults for and receives grants from a number of pharmaceutical companies. “The National Osteoporosis Foundation, AACE, and the North American Menopause Society are all in agreement that patients with T scores of −1.5 or above are rarely candidates for pharmacologic treatment,” he said. “And they all agree that those with T scores of −2.5 or below should be treated even in the absence of risk factors. It's that zone in between where there's disagreement.”

The National Osteoporosis Foundation says that if the patient has risk factors for osteoporosis—such as previous fractures and advanced age—and her T score is between −1.5 and −2, the physician should go ahead and treat the patient. The doctor also should treat the patient if the T score is −2 or below, even in the absence of risk factors, the foundation says. AACE suggests treating patients whose T scores are between −1.5 and −2.5 only if risk factors are present, while the North American Menopause Society advocates no treatment if the T score is between −1.5 and −2 but suggests that patients between −2 and −2.5 should be treated if risk factors are present, Dr. Watts said.

How should physicians handle this “gray zone”? The problem with treating only patients with T scores of −2.5 or below “is that there are patients above −2.5 who actually have a fairly high 10-year probability of fracture, and unless we're smart enough to know by intuition what the right risk factors are, many of those patients aren't being treated,” said Dr. Watts.

The most recent thinking is toward moving away from T scores to something called “absolute fracture risk” or “absolute fracture probability,” he continued. “This will consider bone density, but in countries that have little or no access to bone density [measurement], this will be based solely on clinical risk factors.” In addition to age and history of fractures, other risk factors that are likely to be included are corticosteroid use, cigarette smoking, alcohol use, and rheumatoid arthritis. Also, patients who self-rate their health as poor or fair are almost twice as likely to fracture as are those who say their health is good or excellent.

Dr. Watts offered these tips on managing patients with a high fracture risk:

▸ Consider hip protectors and assistive devices. There are conflicting data on whether using hip protectors reduces the risk of fracture. But physicians who are interested in recommending them can easily find them on the Internet.

▸ Be judicious with pharmacologic therapy. Dr. Watts said bone drugs such as alendronate, raloxifene, ibandronate, risedronate, and calcitonin are only shown to reduce the risk of fracture in patients with low bone density, and are not appropriate if the risk is due to poor eyesight, poor hearing, poor balance, and muscle weakness.

▸ Advocate exercise. “Weight-bearing exercise is important,” he said. “I recommend patients walk for 30–40 minutes a session, 3–4 sessions per week.”

▸ Remember that when it comes to calcium, more is not always better. The optimal calcium intake is 1,200 mg per day for adults aged 50 and older, he noted. The average adult gets only half of what is needed from the diet, so most people do need a supplement; 700–1,000 mg per day should be adequate. But many people take too much. “I see patients who are taking in 3,000–3,500 mg of calcium per day. So I spend a fair amount of time telling patients to take less calcium by way of supplements, rather than more.”

▸ Consider recommending vitamin D. “An adequate 25-hydroxyvitamin D level is 30 ng/mL or more,” he said. “Many patients require 1,000–2,000 IU of vitamin D per day to achieve this level.”

CHICAGO — Endocrinologists are “behind the curve” when it comes to treating osteoporosis, Dr. Nelson B. Watts said at the annual meeting of the American Association of Clinical Endocrinologists.

“There is roughly the same number of rheumatologists as endocrinologists in the United States,” said Dr. Watts, director of the osteoporosis and bone health program at the University of Cincinnati. “In academic centers, endocrinologists are often the 'boneheads,' but in clinical practice, rheumatologists compared with endocrinologists are twice as fast as we are in taking up ownership of densitometry or prescribing osteoporosis drugs.”

Osteoporosis groups are “in pretty good agreement” on several of the guidelines for treatment of the disorder, according to Dr. Watts, who consults for and receives grants from a number of pharmaceutical companies. “The National Osteoporosis Foundation, AACE, and the North American Menopause Society are all in agreement that patients with T scores of −1.5 or above are rarely candidates for pharmacologic treatment,” he said. “And they all agree that those with T scores of −2.5 or below should be treated even in the absence of risk factors. It's that zone in between where there's disagreement.”

The National Osteoporosis Foundation says that if the patient has risk factors for osteoporosis—such as previous fractures and advanced age—and her T score is between −1.5 and −2, the physician should go ahead and treat the patient. The doctor also should treat the patient if the T score is −2 or below, even in the absence of risk factors, the foundation says. AACE suggests treating patients whose T scores are between −1.5 and −2.5 only if risk factors are present, while the North American Menopause Society advocates no treatment if the T score is between −1.5 and −2 but suggests that patients between −2 and −2.5 should be treated if risk factors are present, Dr. Watts said.

How should physicians handle this “gray zone”? The problem with treating only patients with T scores of −2.5 or below “is that there are patients above −2.5 who actually have a fairly high 10-year probability of fracture, and unless we're smart enough to know by intuition what the right risk factors are, many of those patients aren't being treated,” said Dr. Watts.

The most recent thinking is toward moving away from T scores to something called “absolute fracture risk” or “absolute fracture probability,” he continued. “This will consider bone density, but in countries that have little or no access to bone density [measurement], this will be based solely on clinical risk factors.” In addition to age and history of fractures, other risk factors that are likely to be included are corticosteroid use, cigarette smoking, alcohol use, and rheumatoid arthritis. Also, patients who self-rate their health as poor or fair are almost twice as likely to fracture as are those who say their health is good or excellent.

Dr. Watts offered these tips on managing patients with a high fracture risk:

▸ Consider hip protectors and assistive devices. There are conflicting data on whether using hip protectors reduces the risk of fracture. But physicians who are interested in recommending them can easily find them on the Internet.

▸ Be judicious with pharmacologic therapy. Dr. Watts said bone drugs such as alendronate, raloxifene, ibandronate, risedronate, and calcitonin are only shown to reduce the risk of fracture in patients with low bone density, and are not appropriate if the risk is due to poor eyesight, poor hearing, poor balance, and muscle weakness.

▸ Advocate exercise. “Weight-bearing exercise is important,” he said. “I recommend patients walk for 30–40 minutes a session, 3–4 sessions per week.”

▸ Remember that when it comes to calcium, more is not always better. The optimal calcium intake is 1,200 mg per day for adults aged 50 and older, he noted. The average adult gets only half of what is needed from the diet, so most people do need a supplement; 700–1,000 mg per day should be adequate. But many people take too much. “I see patients who are taking in 3,000–3,500 mg of calcium per day. So I spend a fair amount of time telling patients to take less calcium by way of supplements, rather than more.”

▸ Consider recommending vitamin D. “An adequate 25-hydroxyvitamin D level is 30 ng/mL or more,” he said. “Many patients require 1,000–2,000 IU of vitamin D per day to achieve this level.”

CHICAGO — Endocrinologists are “behind the curve” when it comes to treating osteoporosis, Dr. Nelson B. Watts said at the annual meeting of the American Association of Clinical Endocrinologists.

“There is roughly the same number of rheumatologists as endocrinologists in the United States,” said Dr. Watts, director of the osteoporosis and bone health program at the University of Cincinnati. “In academic centers, endocrinologists are often the 'boneheads,' but in clinical practice, rheumatologists compared with endocrinologists are twice as fast as we are in taking up ownership of densitometry or prescribing osteoporosis drugs.”

Osteoporosis groups are “in pretty good agreement” on several of the guidelines for treatment of the disorder, according to Dr. Watts, who consults for and receives grants from a number of pharmaceutical companies. “The National Osteoporosis Foundation, AACE, and the North American Menopause Society are all in agreement that patients with T scores of −1.5 or above are rarely candidates for pharmacologic treatment,” he said. “And they all agree that those with T scores of −2.5 or below should be treated even in the absence of risk factors. It's that zone in between where there's disagreement.”

The National Osteoporosis Foundation says that if the patient has risk factors for osteoporosis—such as previous fractures and advanced age—and her T score is between −1.5 and −2, the physician should go ahead and treat the patient. The doctor also should treat the patient if the T score is −2 or below, even in the absence of risk factors, the foundation says. AACE suggests treating patients whose T scores are between −1.5 and −2.5 only if risk factors are present, while the North American Menopause Society advocates no treatment if the T score is between −1.5 and −2 but suggests that patients between −2 and −2.5 should be treated if risk factors are present, Dr. Watts said.

How should physicians handle this “gray zone”? The problem with treating only patients with T scores of −2.5 or below “is that there are patients above −2.5 who actually have a fairly high 10-year probability of fracture, and unless we're smart enough to know by intuition what the right risk factors are, many of those patients aren't being treated,” said Dr. Watts.

The most recent thinking is toward moving away from T scores to something called “absolute fracture risk” or “absolute fracture probability,” he continued. “This will consider bone density, but in countries that have little or no access to bone density [measurement], this will be based solely on clinical risk factors.” In addition to age and history of fractures, other risk factors that are likely to be included are corticosteroid use, cigarette smoking, alcohol use, and rheumatoid arthritis. Also, patients who self-rate their health as poor or fair are almost twice as likely to fracture as are those who say their health is good or excellent.

Dr. Watts offered these tips on managing patients with a high fracture risk:

▸ Consider hip protectors and assistive devices. There are conflicting data on whether using hip protectors reduces the risk of fracture. But physicians who are interested in recommending them can easily find them on the Internet.

▸ Be judicious with pharmacologic therapy. Dr. Watts said bone drugs such as alendronate, raloxifene, ibandronate, risedronate, and calcitonin are only shown to reduce the risk of fracture in patients with low bone density, and are not appropriate if the risk is due to poor eyesight, poor hearing, poor balance, and muscle weakness.

▸ Advocate exercise. “Weight-bearing exercise is important,” he said. “I recommend patients walk for 30–40 minutes a session, 3–4 sessions per week.”

▸ Remember that when it comes to calcium, more is not always better. The optimal calcium intake is 1,200 mg per day for adults aged 50 and older, he noted. The average adult gets only half of what is needed from the diet, so most people do need a supplement; 700–1,000 mg per day should be adequate. But many people take too much. “I see patients who are taking in 3,000–3,500 mg of calcium per day. So I spend a fair amount of time telling patients to take less calcium by way of supplements, rather than more.”

▸ Consider recommending vitamin D. “An adequate 25-hydroxyvitamin D level is 30 ng/mL or more,” he said. “Many patients require 1,000–2,000 IU of vitamin D per day to achieve this level.”

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.”

In addition, “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 any more, 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 said.

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.”

In addition, “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 any more, 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 said.

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.”

In addition, “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 any more, 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 said.

WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.

Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.

With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:

▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.

▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.

▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment has been “very slow,” Ms. Magno said.

Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.

Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.

PPAC member Dr. Carlos Hamilton suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis. “Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”

The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients. “The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”

Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures. In addition, she said that CMS is considering a Senior Risk Reduction Demonstration to test the use of health risk assessments for Medicare beneficiaries under age 70.

WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.

Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.

With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:

▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.

▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.

▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment has been “very slow,” Ms. Magno said.

Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.

Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.

PPAC member Dr. Carlos Hamilton suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis. “Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”

The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients. “The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”

Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures. In addition, she said that CMS is considering a Senior Risk Reduction Demonstration to test the use of health risk assessments for Medicare beneficiaries under age 70.

WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.

Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.

With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:

▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.

▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.

▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment has been “very slow,” Ms. Magno said.

Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.

Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.

PPAC member Dr. Carlos Hamilton suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis. “Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”

The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients. “The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”

Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures. In addition, she said that CMS is considering a Senior Risk Reduction Demonstration to test the use of health risk assessments for Medicare beneficiaries under age 70.

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.

Little Help for Would-Be Suicides

Many adults with suicidal ideation don't consider getting mental health or substance abuse care, and those who do try to get care often have difficulty doing so, according to a study by Rachel Brook and colleagues at the University of California, Los Angeles, Health Services Research Center. The authors interviewed 7,800 respondents to the Healthcare for Communities survey done by the Robert Wood Johnson Foundation. They found that nearly 3.6% of U.S. adults in households with telephones reported suicidal thoughts at least once in the past 12 months. Nearly three-fourths of those respondents (74%) had a probable psychiatric disorder or substance abuse problem, and 56% perceived a need for mental health or substance abuse care, the investigators noted. Of those who perceived that they needed care, 39% did not receive any, or they received delayed care or less than they needed. “Our findings suggest a need to improve access to treatment for high-risk patients and improve provider training in caring for persons with suicide ideation,” the authors wrote. The study was published in the journal General Hospital Psychiatry.

Narcotics: Top Recreational Drug

More people started using narcotic pain relievers for nonmedical purposes in the past year than marijuana or cocaine, according to a new report from the Substance Abuse and Mental Health Services Administration. According to the report, 2.4 million people 12 years old and older started using narcotics in the year before the survey, compared with 2.1 million who started using marijuana and 1 million who started using cocaine. Of those who used pain relievers, 48% used Vicodin, Lortab, or Lorcet; 34% used Darvocet, Darvon, or Tylenol with codeine; and 20% used Percocet, Percodan, or Tylox. OxyContin was near the bottom at 8%. “The initiation rates show we must continue our efforts to help the public confront and reduce all drug abuse,” SAMHSA Administrator Charles Curie said in a statement. Data for the report came from the 2004 National Survey on Drug Use and Health.

National Depression Survey

People who suffer from depression and have limited access to mental health treatment incur an average of nearly three times the annual out-of-pocket costs for medication, psychotherapy, and other treatment costs compared with patients who have less restricted access, a survey from the National Alliance on Mental Illness shows. The Harris Interactive online survey of 3,500 people found that those with limited access spent $4,312 annually versus $1,496 for those with less restricted access. In addition, patients with limited access to treatment for their depression were nearly three times as likely to have unpaid bills more than 60 days overdue and more than twice as likely to be unable to afford the necessities of life. “This survey pinpoints exactly how lack of access to treatment harms the job prospects, financial situation, and personal relationships of people living with depression,” said NAMI medical director Dr. Ken Duckworth. The survey was funded by Wyeth Pharmaceuticals.

Postmarketing Study Failure

The Food and Drug Administration is doing a poor job of ensuring that pharmaceutical companies live up to postmarketing study commitments, according to a new report by the Department of Health and Human Services' Office of Inspector General. Among the findings: that the FDA can't easily identify if the studies are progressing or what stage they are in; and that monitoring postmarketing studies “is not a top priority at FDA.” The IG reviewed new drug applications from 1990 to 2004; 48% of those applications had at least one postmarketing study commitment for which drug makers are required to submit annual status reports. The IG found that 35% of the reports that should have been submitted in fiscal 2004 were missing or had no information on the study commitments. The IG noted that the FDA has limited enforcement power in this area, but suggested that the agency require more, and more relevant, information from drug makers. In response, FDA said it could not do that without additional regulations, but agreed that it needed to do more to improve its monitoring and to ensure that commitments are honored and that annual reports are thorough.

Group Eyes Doctor, Nurse Shortage

Experts on health care workforce issues have formed the Council on Physician and Nurse Supply. According to the council, which comes out of the University of Pennsylvania, the United States may be short by as many as 200,000 physicians and 800,000 nurses by 2020. The council plans to collect data on the physician and nurse shortage, and talk with legislators and others about how the supply can be improved. Members of the council include Dr. Richard “Buzz” Cooper and Linda Aiken, Ph.D., both of the university, as well as James Bentley, Ph.D., senior vice president for strategic policy planning at the American Hospital Association; Dr. Peter Budetti, chair of the health administration and policy department at the University of Oklahoma; Dr. David Blumenthal, director of the Institute of Health Policy at Massachusetts General Hospital; Dr. Robert Graham, professor of family medicine at the University of Cincinnati; and Dr. William Jessee, president and CEO of the Medical Group Management Association. The council is funded by AMN Healthcare, the parent company of health care staffing firm Merritt, Hawkins. Its first meeting is planned for October.

Little Help for Would-Be Suicides

Many adults with suicidal ideation don't consider getting mental health or substance abuse care, and those who do try to get care often have difficulty doing so, according to a study by Rachel Brook and colleagues at the University of California, Los Angeles, Health Services Research Center. The authors interviewed 7,800 respondents to the Healthcare for Communities survey done by the Robert Wood Johnson Foundation. They found that nearly 3.6% of U.S. adults in households with telephones reported suicidal thoughts at least once in the past 12 months. Nearly three-fourths of those respondents (74%) had a probable psychiatric disorder or substance abuse problem, and 56% perceived a need for mental health or substance abuse care, the investigators noted. Of those who perceived that they needed care, 39% did not receive any, or they received delayed care or less than they needed. “Our findings suggest a need to improve access to treatment for high-risk patients and improve provider training in caring for persons with suicide ideation,” the authors wrote. The study was published in the journal General Hospital Psychiatry.

Narcotics: Top Recreational Drug

More people started using narcotic pain relievers for nonmedical purposes in the past year than marijuana or cocaine, according to a new report from the Substance Abuse and Mental Health Services Administration. According to the report, 2.4 million people 12 years old and older started using narcotics in the year before the survey, compared with 2.1 million who started using marijuana and 1 million who started using cocaine. Of those who used pain relievers, 48% used Vicodin, Lortab, or Lorcet; 34% used Darvocet, Darvon, or Tylenol with codeine; and 20% used Percocet, Percodan, or Tylox. OxyContin was near the bottom at 8%. “The initiation rates show we must continue our efforts to help the public confront and reduce all drug abuse,” SAMHSA Administrator Charles Curie said in a statement. Data for the report came from the 2004 National Survey on Drug Use and Health.

National Depression Survey

People who suffer from depression and have limited access to mental health treatment incur an average of nearly three times the annual out-of-pocket costs for medication, psychotherapy, and other treatment costs compared with patients who have less restricted access, a survey from the National Alliance on Mental Illness shows. The Harris Interactive online survey of 3,500 people found that those with limited access spent $4,312 annually versus $1,496 for those with less restricted access. In addition, patients with limited access to treatment for their depression were nearly three times as likely to have unpaid bills more than 60 days overdue and more than twice as likely to be unable to afford the necessities of life. “This survey pinpoints exactly how lack of access to treatment harms the job prospects, financial situation, and personal relationships of people living with depression,” said NAMI medical director Dr. Ken Duckworth. The survey was funded by Wyeth Pharmaceuticals.

Postmarketing Study Failure

The Food and Drug Administration is doing a poor job of ensuring that pharmaceutical companies live up to postmarketing study commitments, according to a new report by the Department of Health and Human Services' Office of Inspector General. Among the findings: that the FDA can't easily identify if the studies are progressing or what stage they are in; and that monitoring postmarketing studies “is not a top priority at FDA.” The IG reviewed new drug applications from 1990 to 2004; 48% of those applications had at least one postmarketing study commitment for which drug makers are required to submit annual status reports. The IG found that 35% of the reports that should have been submitted in fiscal 2004 were missing or had no information on the study commitments. The IG noted that the FDA has limited enforcement power in this area, but suggested that the agency require more, and more relevant, information from drug makers. In response, FDA said it could not do that without additional regulations, but agreed that it needed to do more to improve its monitoring and to ensure that commitments are honored and that annual reports are thorough.

Group Eyes Doctor, Nurse Shortage

Experts on health care workforce issues have formed the Council on Physician and Nurse Supply. According to the council, which comes out of the University of Pennsylvania, the United States may be short by as many as 200,000 physicians and 800,000 nurses by 2020. The council plans to collect data on the physician and nurse shortage, and talk with legislators and others about how the supply can be improved. Members of the council include Dr. Richard “Buzz” Cooper and Linda Aiken, Ph.D., both of the university, as well as James Bentley, Ph.D., senior vice president for strategic policy planning at the American Hospital Association; Dr. Peter Budetti, chair of the health administration and policy department at the University of Oklahoma; Dr. David Blumenthal, director of the Institute of Health Policy at Massachusetts General Hospital; Dr. Robert Graham, professor of family medicine at the University of Cincinnati; and Dr. William Jessee, president and CEO of the Medical Group Management Association. The council is funded by AMN Healthcare, the parent company of health care staffing firm Merritt, Hawkins. Its first meeting is planned for October.

Little Help for Would-Be Suicides

Many adults with suicidal ideation don't consider getting mental health or substance abuse care, and those who do try to get care often have difficulty doing so, according to a study by Rachel Brook and colleagues at the University of California, Los Angeles, Health Services Research Center. The authors interviewed 7,800 respondents to the Healthcare for Communities survey done by the Robert Wood Johnson Foundation. They found that nearly 3.6% of U.S. adults in households with telephones reported suicidal thoughts at least once in the past 12 months. Nearly three-fourths of those respondents (74%) had a probable psychiatric disorder or substance abuse problem, and 56% perceived a need for mental health or substance abuse care, the investigators noted. Of those who perceived that they needed care, 39% did not receive any, or they received delayed care or less than they needed. “Our findings suggest a need to improve access to treatment for high-risk patients and improve provider training in caring for persons with suicide ideation,” the authors wrote. The study was published in the journal General Hospital Psychiatry.

Narcotics: Top Recreational Drug

More people started using narcotic pain relievers for nonmedical purposes in the past year than marijuana or cocaine, according to a new report from the Substance Abuse and Mental Health Services Administration. According to the report, 2.4 million people 12 years old and older started using narcotics in the year before the survey, compared with 2.1 million who started using marijuana and 1 million who started using cocaine. Of those who used pain relievers, 48% used Vicodin, Lortab, or Lorcet; 34% used Darvocet, Darvon, or Tylenol with codeine; and 20% used Percocet, Percodan, or Tylox. OxyContin was near the bottom at 8%. “The initiation rates show we must continue our efforts to help the public confront and reduce all drug abuse,” SAMHSA Administrator Charles Curie said in a statement. Data for the report came from the 2004 National Survey on Drug Use and Health.

National Depression Survey

People who suffer from depression and have limited access to mental health treatment incur an average of nearly three times the annual out-of-pocket costs for medication, psychotherapy, and other treatment costs compared with patients who have less restricted access, a survey from the National Alliance on Mental Illness shows. The Harris Interactive online survey of 3,500 people found that those with limited access spent $4,312 annually versus $1,496 for those with less restricted access. In addition, patients with limited access to treatment for their depression were nearly three times as likely to have unpaid bills more than 60 days overdue and more than twice as likely to be unable to afford the necessities of life. “This survey pinpoints exactly how lack of access to treatment harms the job prospects, financial situation, and personal relationships of people living with depression,” said NAMI medical director Dr. Ken Duckworth. The survey was funded by Wyeth Pharmaceuticals.

Postmarketing Study Failure

The Food and Drug Administration is doing a poor job of ensuring that pharmaceutical companies live up to postmarketing study commitments, according to a new report by the Department of Health and Human Services' Office of Inspector General. Among the findings: that the FDA can't easily identify if the studies are progressing or what stage they are in; and that monitoring postmarketing studies “is not a top priority at FDA.” The IG reviewed new drug applications from 1990 to 2004; 48% of those applications had at least one postmarketing study commitment for which drug makers are required to submit annual status reports. The IG found that 35% of the reports that should have been submitted in fiscal 2004 were missing or had no information on the study commitments. The IG noted that the FDA has limited enforcement power in this area, but suggested that the agency require more, and more relevant, information from drug makers. In response, FDA said it could not do that without additional regulations, but agreed that it needed to do more to improve its monitoring and to ensure that commitments are honored and that annual reports are thorough.

Group Eyes Doctor, Nurse Shortage

Experts on health care workforce issues have formed the Council on Physician and Nurse Supply. According to the council, which comes out of the University of Pennsylvania, the United States may be short by as many as 200,000 physicians and 800,000 nurses by 2020. The council plans to collect data on the physician and nurse shortage, and talk with legislators and others about how the supply can be improved. Members of the council include Dr. Richard “Buzz” Cooper and Linda Aiken, Ph.D., both of the university, as well as James Bentley, Ph.D., senior vice president for strategic policy planning at the American Hospital Association; Dr. Peter Budetti, chair of the health administration and policy department at the University of Oklahoma; Dr. David Blumenthal, director of the Institute of Health Policy at Massachusetts General Hospital; Dr. Robert Graham, professor of family medicine at the University of Cincinnati; and Dr. William Jessee, president and CEO of the Medical Group Management Association. The council is funded by AMN Healthcare, the parent company of health care staffing firm Merritt, Hawkins. Its first meeting is planned for October.

WASHINGTON — Two programs sponsored by the National Hispanic Medical Association aim to train more Hispanics to become physicians and to help them become leaders in the health care system.

First, the association has partnered with Meharry Medical College in Nashville, Tenn., a historically black medical school, to recruit Hispanic students for the college.

“We are all communities of color and we have to band together,” John Maupin Jr., D.D.S., president of Meharry, said at a meeting sponsored by the National Hispanic Medical Association (NHMA). “We need to be for individuals of color and individuals from poor communities of all races.”

At the meeting, representatives from Meharry and NHMA signed a memorandum of understanding, which establishes a relationship between the two organizations to expand outreach to Hispanic students. The project involves creating a model joint mentoring program, offering a summer research opportunity to a select number of potential students, and establishing a regional interview program that provides an opportunity for NHMA medical volunteers to interview students—through teleconferencing or other means—who have applied to Meharry.

“Together we ought to be able to help any number of individuals who have the opportunity to go to Meharry,” Dr. Maupin said. “I want to reach out, Meharry wants to reach out. If we come together and execute this endeavor, we'll be able to find these students.”

NHMA President Dr. Elena Rios called the memorandum “historic.” “The historically black colleges and universities of this country and the black professional world are light years ahead of the Hispanics,” she said.

“We have Hispanics serving all professions. We just don't have the boards of trustees and boards of directors that are Hispanic at our universities in this country. For the [historically black colleges and universities] to take their vision and include us, and for us to say we want to work together, this is history in the making.”

The second program is a 2-year initiative with the U.S. Department of Health and Human Services office of minority health to develop leadership training, education, and outreach programs to improve Hispanic health. The initiative's goals include recruiting Hispanics for senior-level positions at HHS and developing a national leadership training program for Hispanic doctors and public health professionals.

“We believe in developing the leadership of [Hispanic] doctors so they understand how to talk to their congressmen and policymakers in their states,” Dr. Rios said at a press conference announcing the initiative.

The association currently has two leadership-related fellowship programs, she explained. One, the NHMA leadership fellowship, trains mid-career doctors on how to be better advocates. The other one, the NHMA public health leadership fellowship, involves training Hispanic public health managers to be better leaders for the country.

NHMA board member Dr. Luis Estevez said the association's overall goals go beyond just recruiting Hispanic physicians. “We are [also] forming partnerships to try to build a pipeline to high schools and colleges to not only have more Latinos enter medical school, but also enter health professions in general, be it nursing, technological fields, or medicine,” he said.

Another place more Latinos are needed is in the health care system, especially in the top ranks, Dr. Estevez continued.

“One study done at hospital systems in New York found that [in] some of the hospitals that had up to 96 persons [at] the level of vice president and above, including the board of directors, there was not a single Hispanic, despite the fact that these hospitals—which receive federal funds, by the way—are located in Latino communities. You're not going to change the culture of the hospital unless you also affect the governance.”

WASHINGTON — Two programs sponsored by the National Hispanic Medical Association aim to train more Hispanics to become physicians and to help them become leaders in the health care system.

First, the association has partnered with Meharry Medical College in Nashville, Tenn., a historically black medical school, to recruit Hispanic students for the college.

“We are all communities of color and we have to band together,” John Maupin Jr., D.D.S., president of Meharry, said at a meeting sponsored by the National Hispanic Medical Association (NHMA). “We need to be for individuals of color and individuals from poor communities of all races.”

At the meeting, representatives from Meharry and NHMA signed a memorandum of understanding, which establishes a relationship between the two organizations to expand outreach to Hispanic students. The project involves creating a model joint mentoring program, offering a summer research opportunity to a select number of potential students, and establishing a regional interview program that provides an opportunity for NHMA medical volunteers to interview students—through teleconferencing or other means—who have applied to Meharry.

“Together we ought to be able to help any number of individuals who have the opportunity to go to Meharry,” Dr. Maupin said. “I want to reach out, Meharry wants to reach out. If we come together and execute this endeavor, we'll be able to find these students.”

NHMA President Dr. Elena Rios called the memorandum “historic.” “The historically black colleges and universities of this country and the black professional world are light years ahead of the Hispanics,” she said.

“We have Hispanics serving all professions. We just don't have the boards of trustees and boards of directors that are Hispanic at our universities in this country. For the [historically black colleges and universities] to take their vision and include us, and for us to say we want to work together, this is history in the making.”

The second program is a 2-year initiative with the U.S. Department of Health and Human Services office of minority health to develop leadership training, education, and outreach programs to improve Hispanic health. The initiative's goals include recruiting Hispanics for senior-level positions at HHS and developing a national leadership training program for Hispanic doctors and public health professionals.

“We believe in developing the leadership of [Hispanic] doctors so they understand how to talk to their congressmen and policymakers in their states,” Dr. Rios said at a press conference announcing the initiative.

The association currently has two leadership-related fellowship programs, she explained. One, the NHMA leadership fellowship, trains mid-career doctors on how to be better advocates. The other one, the NHMA public health leadership fellowship, involves training Hispanic public health managers to be better leaders for the country.

NHMA board member Dr. Luis Estevez said the association's overall goals go beyond just recruiting Hispanic physicians. “We are [also] forming partnerships to try to build a pipeline to high schools and colleges to not only have more Latinos enter medical school, but also enter health professions in general, be it nursing, technological fields, or medicine,” he said.

Another place more Latinos are needed is in the health care system, especially in the top ranks, Dr. Estevez continued.

“One study done at hospital systems in New York found that [in] some of the hospitals that had up to 96 persons [at] the level of vice president and above, including the board of directors, there was not a single Hispanic, despite the fact that these hospitals—which receive federal funds, by the way—are located in Latino communities. You're not going to change the culture of the hospital unless you also affect the governance.”

WASHINGTON — Two programs sponsored by the National Hispanic Medical Association aim to train more Hispanics to become physicians and to help them become leaders in the health care system.

First, the association has partnered with Meharry Medical College in Nashville, Tenn., a historically black medical school, to recruit Hispanic students for the college.

“We are all communities of color and we have to band together,” John Maupin Jr., D.D.S., president of Meharry, said at a meeting sponsored by the National Hispanic Medical Association (NHMA). “We need to be for individuals of color and individuals from poor communities of all races.”

At the meeting, representatives from Meharry and NHMA signed a memorandum of understanding, which establishes a relationship between the two organizations to expand outreach to Hispanic students. The project involves creating a model joint mentoring program, offering a summer research opportunity to a select number of potential students, and establishing a regional interview program that provides an opportunity for NHMA medical volunteers to interview students—through teleconferencing or other means—who have applied to Meharry.

“Together we ought to be able to help any number of individuals who have the opportunity to go to Meharry,” Dr. Maupin said. “I want to reach out, Meharry wants to reach out. If we come together and execute this endeavor, we'll be able to find these students.”

NHMA President Dr. Elena Rios called the memorandum “historic.” “The historically black colleges and universities of this country and the black professional world are light years ahead of the Hispanics,” she said.

“We have Hispanics serving all professions. We just don't have the boards of trustees and boards of directors that are Hispanic at our universities in this country. For the [historically black colleges and universities] to take their vision and include us, and for us to say we want to work together, this is history in the making.”

The second program is a 2-year initiative with the U.S. Department of Health and Human Services office of minority health to develop leadership training, education, and outreach programs to improve Hispanic health. The initiative's goals include recruiting Hispanics for senior-level positions at HHS and developing a national leadership training program for Hispanic doctors and public health professionals.

“We believe in developing the leadership of [Hispanic] doctors so they understand how to talk to their congressmen and policymakers in their states,” Dr. Rios said at a press conference announcing the initiative.

The association currently has two leadership-related fellowship programs, she explained. One, the NHMA leadership fellowship, trains mid-career doctors on how to be better advocates. The other one, the NHMA public health leadership fellowship, involves training Hispanic public health managers to be better leaders for the country.

NHMA board member Dr. Luis Estevez said the association's overall goals go beyond just recruiting Hispanic physicians. “We are [also] forming partnerships to try to build a pipeline to high schools and colleges to not only have more Latinos enter medical school, but also enter health professions in general, be it nursing, technological fields, or medicine,” he said.

Another place more Latinos are needed is in the health care system, especially in the top ranks, Dr. Estevez continued.

“One study done at hospital systems in New York found that [in] some of the hospitals that had up to 96 persons [at] the level of vice president and above, including the board of directors, there was not a single Hispanic, despite the fact that these hospitals—which receive federal funds, by the way—are located in Latino communities. You're not going to change the culture of the hospital unless you also affect the governance.”

WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.

Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.

With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:

▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.

▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.

▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment in this project has been “very slow,” Ms. Magno said.

Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.

Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.

PPAC member Dr. Carlos Hamilton said the demonstration projects “raise issues so profound that they go to the very core of our health care system.” He suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis.

“Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”

Ms. Magno agreed and noted that CMS is developing a separate demonstration project dealing with beneficiaries who are nursing home residents. The goal of the project would be “to avoid 'avoidable' hospitalizations, and to reward nursing homes for better managing care,” she said.

The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients.

“The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”

PPAC member Dr. Jeffrey Ross, a Houston physician and podiatrist, asked why CMS wasn't looking more at preventive measures.

Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures.

WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.

Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.

With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:

▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.

▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.

▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment in this project has been “very slow,” Ms. Magno said.

Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.

Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.

PPAC member Dr. Carlos Hamilton said the demonstration projects “raise issues so profound that they go to the very core of our health care system.” He suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis.

“Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”

Ms. Magno agreed and noted that CMS is developing a separate demonstration project dealing with beneficiaries who are nursing home residents. The goal of the project would be “to avoid 'avoidable' hospitalizations, and to reward nursing homes for better managing care,” she said.

The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients.

“The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”

PPAC member Dr. Jeffrey Ross, a Houston physician and podiatrist, asked why CMS wasn't looking more at preventive measures.

Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures.

WASHINGTON — Medicare has a number of demonstration projects underway to help chronically ill beneficiaries get better care, and is developing more, Linda Magno said at a meeting of the Practicing Physicians Advisory Council.

Beneficiaries with chronic illnesses are a significant part of the program's budget, said Ms. Magno, director of Medicare demonstrations for the Centers for Medicare and Medicaid Services (CMS). Although beneficiaries with five or more chronic conditions make up only 20% of all beneficiaries, they account for two-thirds of Medicare spending, she noted.

With all of the spending on this population, opportunities exist for making sure the money is spent more efficiently, Ms. Magno said. Currently, CMS has three demonstration projects going in chronic care:

▸ Medicare Coordinated Care Demonstration. In this project, which was mandated by the Balanced Budget Act of 1997, the agency is examining various care coordination models that “improve quality of services to chronically ill beneficiaries and reduce Medicare expenditures.” The Health and Human Services Secretary has discretion to continue or expand projects, Ms. Magno said, adding that currently 11 sites—a mix of urban and rural hospitals and long-term care facilities—are involved in this demonstration. Interventions include patient and provider education, prescription drug management, case management, and disease management.

▸ Care Management for High-Cost Beneficiaries. This 3-year, six-site project began last October; the last site was launched in June, Ms. Magno said. The provider groups in the demonstration put their Medicare reimbursement at risk in exchange for guaranteeing a 5% cost savings in caring for the high-cost beneficiaries involved. Services provided include physician and nurse home visits, in-home monitoring devices, electronic medical records, caregiver support, patient education, preventive care reminders, transportation services, and 24-hour nurse telephone lines.

▸ Physician Group Practice Demonstration. This demonstration was mandated in the Benefits Improvement and Protection Act of 2000, and involves giving additional payments to providers based on practice efficiency and improved management of chronically ill patients. Participants include 10 very large multispecialty group practices nationwide with a total of more than 5,000 physicians, who care for more than 200,000 Medicare beneficiaries. The project focuses on patients with diabetes, heart failure, coronary artery disease, and hypertension. Enrollment in this project has been “very slow,” Ms. Magno said.

Two more chronic disease management demonstrations are in various stages of development. The Medicare Care Management Performance Demonstration, for example, is a pay-for-performance program that will reward physicians financially for achieving quality benchmarks for chronically ill patients and for using health information technology, including using it to report quality measures electronically. This project, which is in final review, will be implemented in Arkansas, California, Massachusetts, and Utah, Ms. Magno said.

Also in development is the Medicare Health Care Quality Demonstration. This involves using payment models that give incentives for improving the quality, safety, and efficiency of care, and incorporating things like best practice guidelines, shared decision making, and cultural competence into the practice. “This [project] is really a provider-driven opportunity to redesign the delivery system, as opposed to something externally imposed through insurers and other payers,” she said. “The goal is to achieve projects designed to implement Institute of Medicine aims for improvement” known as the STEEEP principles—safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.

PPAC member Dr. Carlos Hamilton said the demonstration projects “raise issues so profound that they go to the very core of our health care system.” He suggested that many of the beneficiaries on whom Medicare spends more than $25,000 per year are probably in the last year of their lives, and that needless “ping-ponging” occurs when they are sent from the nursing home to the emergency department to the intensive care unit for, say, a case of sepsis.

“Addressing concerns about palliative care and end-of-life issues is critical if you're ever going to address the cost factors in terms of the overall health care system. If you can keep people from being transferred from the nursing home to the emergency [department] and the ICU in the middle of the night, you'll probably save a billion dollars right there.”

Ms. Magno agreed and noted that CMS is developing a separate demonstration project dealing with beneficiaries who are nursing home residents. The goal of the project would be “to avoid 'avoidable' hospitalizations, and to reward nursing homes for better managing care,” she said.

The other issue, said Dr. Hamilton, an endocrinologist who is executive vice president for external affairs at the University of Texas, Houston, has to do with lack of coordination of care for chronically ill patients.

“The primary care physician has been reduced to such a role in the system that nobody wants to [coordinate care] any more, and those that do quickly find out they can't afford to do that very effectively. So the system needs to strengthen the role of primary care physicians.”

PPAC member Dr. Jeffrey Ross, a Houston physician and podiatrist, asked why CMS wasn't looking more at preventive measures.

Ms. Magno noted that the “Welcome to Medicare” visit that new beneficiaries receive was meant to allow physicians to do a patient risk assessment and discuss preventive measures.

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 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 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," she said.

Many of the changes that the act's new provisions have created in the Medicaid program deal with Medicaid coverage requirements for the 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," she noted.

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 that states can formulate a plan that would be acceptable under the new provisions is by getting the approval of the federal Health and Human Services secretary.

The two state plan amendments now approved under the Deficit Reduction Act—West Virginia and Kentucky—used the secretary-approved coverage option, she noted.

The Deficit Reduction Act 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," she added.

A controversial change that has been imposed by the Deficit Reduction Act 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 a number of demonstration projects to be set up by the states. 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, which was championed by Sen. Charles Grassley (R-Iowa), is the Family Opportunity Act. This act allows families to buy into Medicaid if they have severely disabled children, even if their family income is higher than 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 [Deficit Reduction Act] didn't do, Congress decided not to do.

"There was a debate about the areas of benefit guarantees for children, 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 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 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," she said.

Many of the changes that the act's new provisions have created in the Medicaid program deal with Medicaid coverage requirements for the 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," she noted.

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 that states can formulate a plan that would be acceptable under the new provisions is by getting the approval of the federal Health and Human Services secretary.

The two state plan amendments now approved under the Deficit Reduction Act—West Virginia and Kentucky—used the secretary-approved coverage option, she noted.

The Deficit Reduction Act 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," she added.

A controversial change that has been imposed by the Deficit Reduction Act 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 a number of demonstration projects to be set up by the states. 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, which was championed by Sen. Charles Grassley (R-Iowa), is the Family Opportunity Act. This act allows families to buy into Medicaid if they have severely disabled children, even if their family income is higher than 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 [Deficit Reduction Act] didn't do, Congress decided not to do.

"There was a debate about the areas of benefit guarantees for children, 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 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 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," she said.

Many of the changes that the act's new provisions have created in the Medicaid program deal with Medicaid coverage requirements for the 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," she noted.

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 that states can formulate a plan that would be acceptable under the new provisions is by getting the approval of the federal Health and Human Services secretary.

The two state plan amendments now approved under the Deficit Reduction Act—West Virginia and Kentucky—used the secretary-approved coverage option, she noted.

The Deficit Reduction Act 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," she added.

A controversial change that has been imposed by the Deficit Reduction Act 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 a number of demonstration projects to be set up by the states. 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, which was championed by Sen. Charles Grassley (R-Iowa), is the Family Opportunity Act. This act allows families to buy into Medicaid if they have severely disabled children, even if their family income is higher than 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 [Deficit Reduction Act] didn't do, Congress decided not to do.

"There was a debate about the areas of benefit guarantees for children, 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 — Some physicians who embrace concierge care are ideologues who want the government and insurance companies to stop interfering in the doctor-patient relationship. And others? They're in it for the money and the lifestyle, John R. Marquis said at a meeting of the American Society of Law, Medicine, and Ethics.

"A large portion of these doctors have as their primary motive that they want to earn more money," said Mr. Marquis, a partner in a Holland, Mich., law firm. However, while money plays a big role, other factors also influence the decision, said Mr. Marquis, who helps physicians set up concierge practices.

One other big reason for the move to concierge care is lifestyle, he said. "If [I've] heard the analogy to the hamster wheel once, I've heard it a million times. 'I get up every day, I get on the hamster wheel, I run for 10 hours, I get off, and I hope to God I've seen enough patients to pay the light bill.' Concierge medicine does offer them some degree of better lifestyle as they perceive it."

Another reason physicians give is to improve patient care. "You'd be surprised at the number of physicians who list [improving patient care] as their top priority," he said. But there are two levels to the patient care issue. "Some say, 'I could practice better medicine if I spent more time with patients.' But there has been no proof of that whatsoever. I think that is bogus," said Mr. Marquis. He added that from an ethical perspective, physicians are not supposed to imply that concierge care will mean better care for their patients.

Others profess the desire to provide better preventive care, Mr. Marquis said, noting that, to him, this seemed like a legitimate reason for moving to concierge care.

"Physicians don't get paid for doing preventive care, generally speaking. You'd be surprised at the number of physicians who say, 'I really would love to see healthy patients, because I have a lot to say to them. I'd like to plan their diet, their lifestyle, get them on nonsmoking programs, and I want to be part of their lifestyle.' It sounds hokey, but I think they're being sincere when they tell me that," he said at the meeting cosponsored by the University of Maryland.

According to Mr. Marquis, there are two basic models of concierge practice. The first, practiced by the ideologues, is a "fee-for-care" model, in which the physician charges a set fee—say, $100 per month—in exchange for giving patients access to all the primary care they need, including sick visits, physicals, immunizations, and lab work. These physicians opt out of Medicare and don't bill insurance, although they may remain on some managed care panels.

The second model, used more by physicians interested in increasing their incomes, is a "fee-for-noncovered-service" model, in which the doctor charges patients a per-visit fee but also charges an annual fee for services not covered by Medicare, such as a yearly physical. "These people are driven more by money," said Mr. Marquis. "They just want to game the system a little bit, and get a little more money out of it."

Proponents also say that the type of intensive medical care provided is very good for sick people with chronic illnesses, and that the increased income ultimately will make medicine more attractive and lead more people toward a medical profession. Frank Pasquale of the Seton Hall University School of Law in Newark, N.J., agreed. Mr. Pasquale noted that concierge practices provide preventive care; "directly therapeutic" care, in which patients have the ability to jump the line and be seen the same day; and nonmedical amenities such as fluffy exam robes or a private waiting room. "The [critics] are attacking concierge care as a unitary phenomenon," Mr. Pasquale said. "I say, don't attack preventive care, but the other two [directly therapeutic care and nonmedical amenities] are a problem."

Concierge care has "amazing benefits" for the doctors and patients who participate, such as more income for the physicians and more attention for the patients, he continued. But there are also problems, such as a disruption of care relationships for patients who can't afford or don't want to join the concierge practice.

"There's the worry of the 'death spiral,' where all the better physicians will go into concierge practice and everyone who can't afford a concierge practice will be left with physicians who don't have quite as good a reputation," Mr. Pasquale said.

Proponents of concierge care say that such a disaster scenario is not likely, because concierge medicine is not apt to spread. "It's just a new product," he said.

Rather than regulating concierge care out of existence, Mr. Pasquale suggests that, instead, lawmakers tax directly therapeutic care and nonmedical amenities, and use the tax proceeds to help provide access to care for the poor.

Sandra J. Carnahan of the South Texas College of Law in Houston suggested that private insurers consider dropping concierge practices from their networks. In the case of physicians who treat Medicare patients, because taxpayer money is used to pay for the physicians' medical education, "that ought to [dictate] that they have a reasonable patient load … and physicians should not be able to use the system to choose the wealthiest, healthiest patients."

BALTIMORE — Some physicians who embrace concierge care are ideologues who want the government and insurance companies to stop interfering in the doctor-patient relationship. And others? They're in it for the money and the lifestyle, John R. Marquis said at a meeting of the American Society of Law, Medicine, and Ethics.

"A large portion of these doctors have as their primary motive that they want to earn more money," said Mr. Marquis, a partner in a Holland, Mich., law firm. However, while money plays a big role, other factors also influence the decision, said Mr. Marquis, who helps physicians set up concierge practices.

One other big reason for the move to concierge care is lifestyle, he said. "If [I've] heard the analogy to the hamster wheel once, I've heard it a million times. 'I get up every day, I get on the hamster wheel, I run for 10 hours, I get off, and I hope to God I've seen enough patients to pay the light bill.' Concierge medicine does offer them some degree of better lifestyle as they perceive it."

Another reason physicians give is to improve patient care. "You'd be surprised at the number of physicians who list [improving patient care] as their top priority," he said. But there are two levels to the patient care issue. "Some say, 'I could practice better medicine if I spent more time with patients.' But there has been no proof of that whatsoever. I think that is bogus," said Mr. Marquis. He added that from an ethical perspective, physicians are not supposed to imply that concierge care will mean better care for their patients.

Others profess the desire to provide better preventive care, Mr. Marquis said, noting that, to him, this seemed like a legitimate reason for moving to concierge care.

"Physicians don't get paid for doing preventive care, generally speaking. You'd be surprised at the number of physicians who say, 'I really would love to see healthy patients, because I have a lot to say to them. I'd like to plan their diet, their lifestyle, get them on nonsmoking programs, and I want to be part of their lifestyle.' It sounds hokey, but I think they're being sincere when they tell me that," he said at the meeting cosponsored by the University of Maryland.

According to Mr. Marquis, there are two basic models of concierge practice. The first, practiced by the ideologues, is a "fee-for-care" model, in which the physician charges a set fee—say, $100 per month—in exchange for giving patients access to all the primary care they need, including sick visits, physicals, immunizations, and lab work. These physicians opt out of Medicare and don't bill insurance, although they may remain on some managed care panels.

The second model, used more by physicians interested in increasing their incomes, is a "fee-for-noncovered-service" model, in which the doctor charges patients a per-visit fee but also charges an annual fee for services not covered by Medicare, such as a yearly physical. "These people are driven more by money," said Mr. Marquis. "They just want to game the system a little bit, and get a little more money out of it."

Proponents also say that the type of intensive medical care provided is very good for sick people with chronic illnesses, and that the increased income ultimately will make medicine more attractive and lead more people toward a medical profession. Frank Pasquale of the Seton Hall University School of Law in Newark, N.J., agreed. Mr. Pasquale noted that concierge practices provide preventive care; "directly therapeutic" care, in which patients have the ability to jump the line and be seen the same day; and nonmedical amenities such as fluffy exam robes or a private waiting room. "The [critics] are attacking concierge care as a unitary phenomenon," Mr. Pasquale said. "I say, don't attack preventive care, but the other two [directly therapeutic care and nonmedical amenities] are a problem."

Concierge care has "amazing benefits" for the doctors and patients who participate, such as more income for the physicians and more attention for the patients, he continued. But there are also problems, such as a disruption of care relationships for patients who can't afford or don't want to join the concierge practice.

"There's the worry of the 'death spiral,' where all the better physicians will go into concierge practice and everyone who can't afford a concierge practice will be left with physicians who don't have quite as good a reputation," Mr. Pasquale said.

Proponents of concierge care say that such a disaster scenario is not likely, because concierge medicine is not apt to spread. "It's just a new product," he said.

Rather than regulating concierge care out of existence, Mr. Pasquale suggests that, instead, lawmakers tax directly therapeutic care and nonmedical amenities, and use the tax proceeds to help provide access to care for the poor.

Sandra J. Carnahan of the South Texas College of Law in Houston suggested that private insurers consider dropping concierge practices from their networks. In the case of physicians who treat Medicare patients, because taxpayer money is used to pay for the physicians' medical education, "that ought to [dictate] that they have a reasonable patient load … and physicians should not be able to use the system to choose the wealthiest, healthiest patients."

BALTIMORE — Some physicians who embrace concierge care are ideologues who want the government and insurance companies to stop interfering in the doctor-patient relationship. And others? They're in it for the money and the lifestyle, John R. Marquis said at a meeting of the American Society of Law, Medicine, and Ethics.

"A large portion of these doctors have as their primary motive that they want to earn more money," said Mr. Marquis, a partner in a Holland, Mich., law firm. However, while money plays a big role, other factors also influence the decision, said Mr. Marquis, who helps physicians set up concierge practices.

One other big reason for the move to concierge care is lifestyle, he said. "If [I've] heard the analogy to the hamster wheel once, I've heard it a million times. 'I get up every day, I get on the hamster wheel, I run for 10 hours, I get off, and I hope to God I've seen enough patients to pay the light bill.' Concierge medicine does offer them some degree of better lifestyle as they perceive it."

Another reason physicians give is to improve patient care. "You'd be surprised at the number of physicians who list [improving patient care] as their top priority," he said. But there are two levels to the patient care issue. "Some say, 'I could practice better medicine if I spent more time with patients.' But there has been no proof of that whatsoever. I think that is bogus," said Mr. Marquis. He added that from an ethical perspective, physicians are not supposed to imply that concierge care will mean better care for their patients.

Others profess the desire to provide better preventive care, Mr. Marquis said, noting that, to him, this seemed like a legitimate reason for moving to concierge care.

"Physicians don't get paid for doing preventive care, generally speaking. You'd be surprised at the number of physicians who say, 'I really would love to see healthy patients, because I have a lot to say to them. I'd like to plan their diet, their lifestyle, get them on nonsmoking programs, and I want to be part of their lifestyle.' It sounds hokey, but I think they're being sincere when they tell me that," he said at the meeting cosponsored by the University of Maryland.

According to Mr. Marquis, there are two basic models of concierge practice. The first, practiced by the ideologues, is a "fee-for-care" model, in which the physician charges a set fee—say, $100 per month—in exchange for giving patients access to all the primary care they need, including sick visits, physicals, immunizations, and lab work. These physicians opt out of Medicare and don't bill insurance, although they may remain on some managed care panels.

The second model, used more by physicians interested in increasing their incomes, is a "fee-for-noncovered-service" model, in which the doctor charges patients a per-visit fee but also charges an annual fee for services not covered by Medicare, such as a yearly physical. "These people are driven more by money," said Mr. Marquis. "They just want to game the system a little bit, and get a little more money out of it."

Proponents also say that the type of intensive medical care provided is very good for sick people with chronic illnesses, and that the increased income ultimately will make medicine more attractive and lead more people toward a medical profession. Frank Pasquale of the Seton Hall University School of Law in Newark, N.J., agreed. Mr. Pasquale noted that concierge practices provide preventive care; "directly therapeutic" care, in which patients have the ability to jump the line and be seen the same day; and nonmedical amenities such as fluffy exam robes or a private waiting room. "The [critics] are attacking concierge care as a unitary phenomenon," Mr. Pasquale said. "I say, don't attack preventive care, but the other two [directly therapeutic care and nonmedical amenities] are a problem."

Concierge care has "amazing benefits" for the doctors and patients who participate, such as more income for the physicians and more attention for the patients, he continued. But there are also problems, such as a disruption of care relationships for patients who can't afford or don't want to join the concierge practice.

"There's the worry of the 'death spiral,' where all the better physicians will go into concierge practice and everyone who can't afford a concierge practice will be left with physicians who don't have quite as good a reputation," Mr. Pasquale said.

Proponents of concierge care say that such a disaster scenario is not likely, because concierge medicine is not apt to spread. "It's just a new product," he said.

Rather than regulating concierge care out of existence, Mr. Pasquale suggests that, instead, lawmakers tax directly therapeutic care and nonmedical amenities, and use the tax proceeds to help provide access to care for the poor.

Sandra J. Carnahan of the South Texas College of Law in Houston suggested that private insurers consider dropping concierge practices from their networks. In the case of physicians who treat Medicare patients, because taxpayer money is used to pay for the physicians' medical education, "that ought to [dictate] that they have a reasonable patient load … and physicians should not be able to use the system to choose the wealthiest, healthiest patients."

WASHINGTON — Medicare's pay-for-performance criterion for hemoglobin A_1c level is 9%, a value so outside the therapeutic target that endocrinologist Carlos Hamilton considers the measure to be useless.

“If we're going to ask doctors to fill out these forms, and ask them to do it for nothing, [the exercise] really needs to be meaningful,” Dr. Hamilton said at a meeting of the Practicing Physicians Advisory Council, which advises the Centers for Medicare and Medicaid Services. “If you ask them meaningless questions and then don't pay them to answer those questions, it just irritates them.”

Medicare's new Physician Voluntary Reporting Program, which began last January, rewards participating physicians with confidential feedback reports about how they are doing, compared with their peers. One of the program's 16 performance measures relates to whether patients with diabetes have hemoglobin A_1c levels at or below 9%. A hemoglobin A_1c level of 7% or less is considered to be the treatment goal by most endocrinology groups.

“You really have created so much angst on behalf of the endocrinology community,” Dr. Hamilton, who is executive vice president for external affairs at the University of Texas, Houston, told CMS representatives at the meeting. “I can't count the number of e-mails I've personally received about what this level really ought to be.

“Everyone knows that 9% or 8.6% is better than 13% or 14%, but it isn't enough better to really be important. What it ought to be is around 7%, or 6.5%, or 7.5%.”

Furthermore, just setting a single, arbitrary hemoglobin A_1c value fails to acknowledge therapeutic progress among patients with difficult-to-control diabetes, Dr. Hamilton said. “What is much more important is whether that level has come down,” he added. For example, the reporting program could ask the treating physician whether the patient's hemoglobin A_1c level is above or below 7.5%.

“If it's above 7.5%, your next question ought to be: Has this value decreased over the previous year, and has it decreased by 2 percentage points or more? If it has, and [the] value is, say, 8% or 8.5% or even 9.5%—and you've decreased it from, say, 14% to 9%—you've done a very good job. That's a much more meaningful statistic to have,” Dr. Hamilton said.

Dr. Michael Rapp, director of the quality measurement and health assessment group for the CMS's Office of Clinical Standards and Quality, told Dr. Hamilton that the CMS “is not in the business of setting up the standards. We're taking the standards given to us” by outside organizations. But he also noted that the National Committee for Quality Assurance, one of the measurement-development organizations that the CMS uses, recently proposed a quality measure for diabetes patients of less than 7% for hemoglobin A_1c. “So I think you'll see there will [soon] be a measure available for us to use which will be hemoglobin A_1c less than 7%.”

But taking this step alone only sets the goal and does not differentiate between physician quality and outcome measures in a meaningful way, Dr. Hamilton said.

“With hemoglobin A_1c, it's not a matter of, did you order the right treatment for diabetes, or did [the patients] actually get the medicine, or did they refill the medicine after a month?” he said. “It's a matter of, did they take the medication, did they take it the way you prescribed it, and did they take it consistently, not for 30 days or 90 days but for several years?

“What you're testing with hemoglobin A_1c is not just the quality of the doctor that wrote the prescription. You're testing the quality of the whole health care system in which patient compliance is by far the major component.”

WASHINGTON — Medicare's pay-for-performance criterion for hemoglobin A_1c level is 9%, a value so outside the therapeutic target that endocrinologist Carlos Hamilton considers the measure to be useless.

“If we're going to ask doctors to fill out these forms, and ask them to do it for nothing, [the exercise] really needs to be meaningful,” Dr. Hamilton said at a meeting of the Practicing Physicians Advisory Council, which advises the Centers for Medicare and Medicaid Services. “If you ask them meaningless questions and then don't pay them to answer those questions, it just irritates them.”

Medicare's new Physician Voluntary Reporting Program, which began last January, rewards participating physicians with confidential feedback reports about how they are doing, compared with their peers. One of the program's 16 performance measures relates to whether patients with diabetes have hemoglobin A_1c levels at or below 9%. A hemoglobin A_1c level of 7% or less is considered to be the treatment goal by most endocrinology groups.

“You really have created so much angst on behalf of the endocrinology community,” Dr. Hamilton, who is executive vice president for external affairs at the University of Texas, Houston, told CMS representatives at the meeting. “I can't count the number of e-mails I've personally received about what this level really ought to be.

“Everyone knows that 9% or 8.6% is better than 13% or 14%, but it isn't enough better to really be important. What it ought to be is around 7%, or 6.5%, or 7.5%.”

Furthermore, just setting a single, arbitrary hemoglobin A_1c value fails to acknowledge therapeutic progress among patients with difficult-to-control diabetes, Dr. Hamilton said. “What is much more important is whether that level has come down,” he added. For example, the reporting program could ask the treating physician whether the patient's hemoglobin A_1c level is above or below 7.5%.

“If it's above 7.5%, your next question ought to be: Has this value decreased over the previous year, and has it decreased by 2 percentage points or more? If it has, and [the] value is, say, 8% or 8.5% or even 9.5%—and you've decreased it from, say, 14% to 9%—you've done a very good job. That's a much more meaningful statistic to have,” Dr. Hamilton said.

Dr. Michael Rapp, director of the quality measurement and health assessment group for the CMS's Office of Clinical Standards and Quality, told Dr. Hamilton that the CMS “is not in the business of setting up the standards. We're taking the standards given to us” by outside organizations. But he also noted that the National Committee for Quality Assurance, one of the measurement-development organizations that the CMS uses, recently proposed a quality measure for diabetes patients of less than 7% for hemoglobin A_1c. “So I think you'll see there will [soon] be a measure available for us to use which will be hemoglobin A_1c less than 7%.”

But taking this step alone only sets the goal and does not differentiate between physician quality and outcome measures in a meaningful way, Dr. Hamilton said.

“With hemoglobin A_1c, it's not a matter of, did you order the right treatment for diabetes, or did [the patients] actually get the medicine, or did they refill the medicine after a month?” he said. “It's a matter of, did they take the medication, did they take it the way you prescribed it, and did they take it consistently, not for 30 days or 90 days but for several years?

“What you're testing with hemoglobin A_1c is not just the quality of the doctor that wrote the prescription. You're testing the quality of the whole health care system in which patient compliance is by far the major component.”

WASHINGTON — Medicare's pay-for-performance criterion for hemoglobin A_1c level is 9%, a value so outside the therapeutic target that endocrinologist Carlos Hamilton considers the measure to be useless.

“If we're going to ask doctors to fill out these forms, and ask them to do it for nothing, [the exercise] really needs to be meaningful,” Dr. Hamilton said at a meeting of the Practicing Physicians Advisory Council, which advises the Centers for Medicare and Medicaid Services. “If you ask them meaningless questions and then don't pay them to answer those questions, it just irritates them.”

Medicare's new Physician Voluntary Reporting Program, which began last January, rewards participating physicians with confidential feedback reports about how they are doing, compared with their peers. One of the program's 16 performance measures relates to whether patients with diabetes have hemoglobin A_1c levels at or below 9%. A hemoglobin A_1c level of 7% or less is considered to be the treatment goal by most endocrinology groups.

“You really have created so much angst on behalf of the endocrinology community,” Dr. Hamilton, who is executive vice president for external affairs at the University of Texas, Houston, told CMS representatives at the meeting. “I can't count the number of e-mails I've personally received about what this level really ought to be.

“Everyone knows that 9% or 8.6% is better than 13% or 14%, but it isn't enough better to really be important. What it ought to be is around 7%, or 6.5%, or 7.5%.”

Furthermore, just setting a single, arbitrary hemoglobin A_1c value fails to acknowledge therapeutic progress among patients with difficult-to-control diabetes, Dr. Hamilton said. “What is much more important is whether that level has come down,” he added. For example, the reporting program could ask the treating physician whether the patient's hemoglobin A_1c level is above or below 7.5%.

“If it's above 7.5%, your next question ought to be: Has this value decreased over the previous year, and has it decreased by 2 percentage points or more? If it has, and [the] value is, say, 8% or 8.5% or even 9.5%—and you've decreased it from, say, 14% to 9%—you've done a very good job. That's a much more meaningful statistic to have,” Dr. Hamilton said.

Dr. Michael Rapp, director of the quality measurement and health assessment group for the CMS's Office of Clinical Standards and Quality, told Dr. Hamilton that the CMS “is not in the business of setting up the standards. We're taking the standards given to us” by outside organizations. But he also noted that the National Committee for Quality Assurance, one of the measurement-development organizations that the CMS uses, recently proposed a quality measure for diabetes patients of less than 7% for hemoglobin A_1c. “So I think you'll see there will [soon] be a measure available for us to use which will be hemoglobin A_1c less than 7%.”

But taking this step alone only sets the goal and does not differentiate between physician quality and outcome measures in a meaningful way, Dr. Hamilton said.

“With hemoglobin A_1c, it's not a matter of, did you order the right treatment for diabetes, or did [the patients] actually get the medicine, or did they refill the medicine after a month?” he said. “It's a matter of, did they take the medication, did they take it the way you prescribed it, and did they take it consistently, not for 30 days or 90 days but for several years?

“What you're testing with hemoglobin A_1c is not just the quality of the doctor that wrote the prescription. You're testing the quality of the whole health care system in which patient compliance is by far the major component.”