Joyce Frieden

BALTIMORE — Some of the 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,” Mr. Marquis said.

“They just want to game the system a little bit, and get a little more money out of it,” he added.

Proponents believe 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. 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.

“The current [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 who can pay the fees,” she said.

BALTIMORE — Some of the 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,” Mr. Marquis said.

“They just want to game the system a little bit, and get a little more money out of it,” he added.

Proponents believe 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. 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.

“The current [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 who can pay the fees,” she said.

BALTIMORE — Some of the 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,” Mr. Marquis said.

“They just want to game the system a little bit, and get a little more money out of it,” he added.

Proponents believe 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. 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.

“The current [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 who can pay the fees,” she said.

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

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

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

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, said that “there is considerably more angst in the medical community about this issue than may immediately appear.”

He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

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

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

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

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

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

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

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

After those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a “test period” beforehand, which will include an appeals process, she said.

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

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

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

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, said that “there is considerably more angst in the medical community about this issue than may immediately appear.”

He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

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

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

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

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

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

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

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

After those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a “test period” beforehand, which will include an appeals process, she said.

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

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

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

Council member Dr. Carlos Hamilton, an endocrinologist and executive vice president for clinical affairs at the University of Texas Health Science Center in Houston, said that “there is considerably more angst in the medical community about this issue than may immediately appear.”

He noted that while the idea of using anatomical edits seems workable, there are often exceptions.

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

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

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

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

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

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

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

After those changes, the proposal will go out for more comments. The MUEs will not be implemented until at least January of next year, and there will be a “test period” beforehand, which will include an appeals process, she said.

Payment and Access to Imaging

Endocrinologists gained a powerful ally in the fight to stop impending cuts to the Medicare technical payments for in-office imaging services when the delegates to the American Medical Association's annual meeting voted in June to support the delay or repeal of the cuts. The Deficit Reduction Omnibus Reconciliation Act of 2005 (section 5102) calls for reducing the technical component payment, including the technical component of the global payment, for imaging services under the physician fee schedule if the service exceeds the hospital outpatient department payment amount under Medicare. These cuts are scheduled to take effect in January 2007 and would apply to imaging and computer-assisted imaging services, including x-rays, ultrasound, nuclear medicine, magnetic resonance imaging, computer tomography, and fluoroscopy. If the cuts go into effect, some physicians will be forced to discontinue providing in-office imaging services, which would, in turn, limit patient access and increase wait times for imaging, according to the AMA resolution. The resolution was introduced by the American Association of Clinical Endocrinologists.

Diabetes Patient Care Survey

Type 2 diabetes patients say they know a lot more about their disease than their physicians say they do, according to an online survey commissioned by the American Association of Diabetes Educators. The Harris Interactive survey of 784 adult type 2 patients and 406 primary care physicians who see at least three type 2 patients per month found that while 83% of patients who say they are on a healthy, balanced diet think they follow their health care provider's instructions on diet “well” or “very well,” only 29% of physicians believe this to be true of their type 2 patients. Also, 55% of patients surveyed didn't know their hemoglobin A_1c level, have not had it checked in the past 6 months, or are unsure if they've had it tested, according to the survey. “The survey shows a glaring information gap between what patients think they know about self-management of their disease and what doctors think patients actually know,” Dr. Sethu K. Reddy, chairman of the department of endocrinology, diabetes, and metabolism at the Cleveland Clinic, said at a press conference. The survey was sponsored by a grant from Merck & Co.

Smoking and Obesity: Bad Combo

The proportion of U.S. citizens who are both cigarette smokers and obese is higher among low-income populations, according to a study by Cheryl G. Healton, Dr.P.H., of Columbia University and colleagues. The researchers used data from a national health interview survey of more than 29,000 adults to estimate how many people were both smokers and obese. They found that overall, 5.3% of men and 4.2% of women were both—about 9 million people altogether. “This proportion is higher in African Americans than in other racial or ethnic groups,” the authors wrote. “A greater proportion of people with lower income and education levels smoke and are obese.” The authors called for treatments to be developed to target this patient group. The study was funded by the American Legacy Foundation; Dr. Healton is the group's president and CEO.

Global Diabetes Campaign

The International Diabetes Federation has launched a global campaign to highlight the “alarming rise” of diabetes worldwide and encourage government support for a United Nations resolution on diabetes. The “Unite for Diabetes” campaign will try to get a resolution passed on or around World Diabetes Day on Nov. 14, 2007. “The number of people living with diabetes is expected to grow to 350 million in less than 20 years if action is not taken,” the campaign noted in a press release. “If nothing is done, diabetes will place severe economic, social, and health burdens on the countries that can least afford it.” Dr. Martin Silink, president-elect of the federation, noted that “The diabetes epidemic will overwhelm health care resources everywhere if governments do not wake up and take action now.”

Rapid Response Teams Cut Deaths

An 18-month campaign to get hospitals to adopt quality control measures has saved more than 100,000 lives. That's according to estimates by the Institute for Healthcare Improvement, the nonprofit organization behind the campaign. The IHI bases its estimates on raw mortality data from inpatient admissions only, which is submitted to the organization by participating hospitals. So far, at least 3,000 hospitals have signed up to participate. They agreed to implement some or all of a checklist of six quality improvement initiatives, including establishing rapid response teams that are activated when a patient's condition is deemed to be worsening.

Payment and Access to Imaging

Endocrinologists gained a powerful ally in the fight to stop impending cuts to the Medicare technical payments for in-office imaging services when the delegates to the American Medical Association's annual meeting voted in June to support the delay or repeal of the cuts. The Deficit Reduction Omnibus Reconciliation Act of 2005 (section 5102) calls for reducing the technical component payment, including the technical component of the global payment, for imaging services under the physician fee schedule if the service exceeds the hospital outpatient department payment amount under Medicare. These cuts are scheduled to take effect in January 2007 and would apply to imaging and computer-assisted imaging services, including x-rays, ultrasound, nuclear medicine, magnetic resonance imaging, computer tomography, and fluoroscopy. If the cuts go into effect, some physicians will be forced to discontinue providing in-office imaging services, which would, in turn, limit patient access and increase wait times for imaging, according to the AMA resolution. The resolution was introduced by the American Association of Clinical Endocrinologists.

Diabetes Patient Care Survey

Type 2 diabetes patients say they know a lot more about their disease than their physicians say they do, according to an online survey commissioned by the American Association of Diabetes Educators. The Harris Interactive survey of 784 adult type 2 patients and 406 primary care physicians who see at least three type 2 patients per month found that while 83% of patients who say they are on a healthy, balanced diet think they follow their health care provider's instructions on diet “well” or “very well,” only 29% of physicians believe this to be true of their type 2 patients. Also, 55% of patients surveyed didn't know their hemoglobin A_1c level, have not had it checked in the past 6 months, or are unsure if they've had it tested, according to the survey. “The survey shows a glaring information gap between what patients think they know about self-management of their disease and what doctors think patients actually know,” Dr. Sethu K. Reddy, chairman of the department of endocrinology, diabetes, and metabolism at the Cleveland Clinic, said at a press conference. The survey was sponsored by a grant from Merck & Co.

Smoking and Obesity: Bad Combo

The proportion of U.S. citizens who are both cigarette smokers and obese is higher among low-income populations, according to a study by Cheryl G. Healton, Dr.P.H., of Columbia University and colleagues. The researchers used data from a national health interview survey of more than 29,000 adults to estimate how many people were both smokers and obese. They found that overall, 5.3% of men and 4.2% of women were both—about 9 million people altogether. “This proportion is higher in African Americans than in other racial or ethnic groups,” the authors wrote. “A greater proportion of people with lower income and education levels smoke and are obese.” The authors called for treatments to be developed to target this patient group. The study was funded by the American Legacy Foundation; Dr. Healton is the group's president and CEO.

Global Diabetes Campaign

The International Diabetes Federation has launched a global campaign to highlight the “alarming rise” of diabetes worldwide and encourage government support for a United Nations resolution on diabetes. The “Unite for Diabetes” campaign will try to get a resolution passed on or around World Diabetes Day on Nov. 14, 2007. “The number of people living with diabetes is expected to grow to 350 million in less than 20 years if action is not taken,” the campaign noted in a press release. “If nothing is done, diabetes will place severe economic, social, and health burdens on the countries that can least afford it.” Dr. Martin Silink, president-elect of the federation, noted that “The diabetes epidemic will overwhelm health care resources everywhere if governments do not wake up and take action now.”

Rapid Response Teams Cut Deaths

An 18-month campaign to get hospitals to adopt quality control measures has saved more than 100,000 lives. That's according to estimates by the Institute for Healthcare Improvement, the nonprofit organization behind the campaign. The IHI bases its estimates on raw mortality data from inpatient admissions only, which is submitted to the organization by participating hospitals. So far, at least 3,000 hospitals have signed up to participate. They agreed to implement some or all of a checklist of six quality improvement initiatives, including establishing rapid response teams that are activated when a patient's condition is deemed to be worsening.

Payment and Access to Imaging

Endocrinologists gained a powerful ally in the fight to stop impending cuts to the Medicare technical payments for in-office imaging services when the delegates to the American Medical Association's annual meeting voted in June to support the delay or repeal of the cuts. The Deficit Reduction Omnibus Reconciliation Act of 2005 (section 5102) calls for reducing the technical component payment, including the technical component of the global payment, for imaging services under the physician fee schedule if the service exceeds the hospital outpatient department payment amount under Medicare. These cuts are scheduled to take effect in January 2007 and would apply to imaging and computer-assisted imaging services, including x-rays, ultrasound, nuclear medicine, magnetic resonance imaging, computer tomography, and fluoroscopy. If the cuts go into effect, some physicians will be forced to discontinue providing in-office imaging services, which would, in turn, limit patient access and increase wait times for imaging, according to the AMA resolution. The resolution was introduced by the American Association of Clinical Endocrinologists.

Diabetes Patient Care Survey

Type 2 diabetes patients say they know a lot more about their disease than their physicians say they do, according to an online survey commissioned by the American Association of Diabetes Educators. The Harris Interactive survey of 784 adult type 2 patients and 406 primary care physicians who see at least three type 2 patients per month found that while 83% of patients who say they are on a healthy, balanced diet think they follow their health care provider's instructions on diet “well” or “very well,” only 29% of physicians believe this to be true of their type 2 patients. Also, 55% of patients surveyed didn't know their hemoglobin A_1c level, have not had it checked in the past 6 months, or are unsure if they've had it tested, according to the survey. “The survey shows a glaring information gap between what patients think they know about self-management of their disease and what doctors think patients actually know,” Dr. Sethu K. Reddy, chairman of the department of endocrinology, diabetes, and metabolism at the Cleveland Clinic, said at a press conference. The survey was sponsored by a grant from Merck & Co.

Smoking and Obesity: Bad Combo

The proportion of U.S. citizens who are both cigarette smokers and obese is higher among low-income populations, according to a study by Cheryl G. Healton, Dr.P.H., of Columbia University and colleagues. The researchers used data from a national health interview survey of more than 29,000 adults to estimate how many people were both smokers and obese. They found that overall, 5.3% of men and 4.2% of women were both—about 9 million people altogether. “This proportion is higher in African Americans than in other racial or ethnic groups,” the authors wrote. “A greater proportion of people with lower income and education levels smoke and are obese.” The authors called for treatments to be developed to target this patient group. The study was funded by the American Legacy Foundation; Dr. Healton is the group's president and CEO.

Global Diabetes Campaign

The International Diabetes Federation has launched a global campaign to highlight the “alarming rise” of diabetes worldwide and encourage government support for a United Nations resolution on diabetes. The “Unite for Diabetes” campaign will try to get a resolution passed on or around World Diabetes Day on Nov. 14, 2007. “The number of people living with diabetes is expected to grow to 350 million in less than 20 years if action is not taken,” the campaign noted in a press release. “If nothing is done, diabetes will place severe economic, social, and health burdens on the countries that can least afford it.” Dr. Martin Silink, president-elect of the federation, noted that “The diabetes epidemic will overwhelm health care resources everywhere if governments do not wake up and take action now.”

Rapid Response Teams Cut Deaths

An 18-month campaign to get hospitals to adopt quality control measures has saved more than 100,000 lives. That's according to estimates by the Institute for Healthcare Improvement, the nonprofit organization behind the campaign. The IHI bases its estimates on raw mortality data from inpatient admissions only, which is submitted to the organization by participating hospitals. So far, at least 3,000 hospitals have signed up to participate. They agreed to implement some or all of a checklist of six quality improvement initiatives, including establishing rapid response teams that are activated when a patient's condition is deemed to be worsening.

Handwashing with plain soap and water—not with antibacterial soaps—is still the most important way to reduce the spread of germs, according to the Canadian Paediatric Society.

The society published a position statement in an issue of Paediatrics & Child Health stating that the use of antimicrobial products is unnecessary to keep children healthy.

“You don't need to buy toys treated with antimicrobial products,” Dr. Joanne Embree, chair of the society's infectious diseases and immunization committee, said in a statement.

“When children put toys in their mouths or play with them when they are sick, simply clean them with water and soap and rinse well.”

When soap and water are not available, alcohol-based solutions or gels can be used, according to the society (J. Paediatr. Child Health 2006;11:169–73).

Handwashing with plain soap and water—not with antibacterial soaps—is still the most important way to reduce the spread of germs, according to the Canadian Paediatric Society.

The society published a position statement in an issue of Paediatrics & Child Health stating that the use of antimicrobial products is unnecessary to keep children healthy.

“You don't need to buy toys treated with antimicrobial products,” Dr. Joanne Embree, chair of the society's infectious diseases and immunization committee, said in a statement.

“When children put toys in their mouths or play with them when they are sick, simply clean them with water and soap and rinse well.”

When soap and water are not available, alcohol-based solutions or gels can be used, according to the society (J. Paediatr. Child Health 2006;11:169–73).

Handwashing with plain soap and water—not with antibacterial soaps—is still the most important way to reduce the spread of germs, according to the Canadian Paediatric Society.

The society published a position statement in an issue of Paediatrics & Child Health stating that the use of antimicrobial products is unnecessary to keep children healthy.

“You don't need to buy toys treated with antimicrobial products,” Dr. Joanne Embree, chair of the society's infectious diseases and immunization committee, said in a statement.

“When children put toys in their mouths or play with them when they are sick, simply clean them with water and soap and rinse well.”

When soap and water are not available, alcohol-based solutions or gels can be used, according to the society (J. Paediatr. Child Health 2006;11:169–73).

CHICAGO – Physicians need to help design the pay-for-performance programs that are now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care.

Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington.

“My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, according to Dr. Haywood, CMS is considering the idea that “some patients automatically are going to get excluded–excluded for noncompliance or excluded because from the standpoint of that clinician, they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure.”

CHICAGO – Physicians need to help design the pay-for-performance programs that are now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care.

Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington.

“My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, according to Dr. Haywood, CMS is considering the idea that “some patients automatically are going to get excluded–excluded for noncompliance or excluded because from the standpoint of that clinician, they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure.”

CHICAGO – Physicians need to help design the pay-for-performance programs that are now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care.

Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington.

“My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, according to Dr. Haywood, CMS is considering the idea that “some patients automatically are going to get excluded–excluded for noncompliance or excluded because from the standpoint of that clinician, they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure.”

WASHINGTON – The costs of malpractice insurance and defensive medicine account for about 10 cents of every dollar spent on health care premiums, several speakers said at a press briefing sponsored by America's Health Insurance Plans.

Medical liability and defensive medicine represented the “lion's share” of cost increases in the physician and outpatient areas, Michael Thompson, principal at the New York office of PricewaterhouseCoopers, said at the briefing.

Litigation and defensive medicine also accounted for about a third of the costs associated with poor-quality health care, said Mr. Thompson, noting that the cost of poor-quality care was spread throughout the health care system.

According to AHIP President Karen Ignagni, efforts must be made to reduce the amount of poor-quality care being given. “We have a system where 45% of what's being done is not best practice,” she said. “No public or private entity could operate at that rate.”

Overall, the rate of increase in health care premiums was 8.8% in 2004–2005, down significantly from 13.7% in 2001–2002, noted Jack Rodgers, managing director at PricewaterhouseCoopers. One factor contributing to the slowdown was a decrease in the rate of cost increases for prescription drugs, according to Mr. Thompson. “It's now trending in line with overall premiums,” he said.

Part of the reason for that decrease is employers' increasing use of three-tiered or four-tiered drug programs, in which patients pay a larger share for brand-name drugs, especially if there are generic equivalents. In 2000, only 27% of patients were in drug plans with three or more tiers; in 2004, the figure was 68%, he said. In addition, cost trends were helped by a drop in the number of state mandates that are being added each year, from 80 in 2000 to less than 40 in 2004, Mr. Thompson said.

Despite these problems, Mr. Thompson said in an interview that he did not expect premium increases to go higher next year. “We're looking at the same number or maybe a little lower,” he predicted.

Part of the stabilization will likely be tied to consumers having to pay more for their health care costs and becoming more aware of prices as a result, Mr. Thompson added.

WASHINGTON – The costs of malpractice insurance and defensive medicine account for about 10 cents of every dollar spent on health care premiums, several speakers said at a press briefing sponsored by America's Health Insurance Plans.

Medical liability and defensive medicine represented the “lion's share” of cost increases in the physician and outpatient areas, Michael Thompson, principal at the New York office of PricewaterhouseCoopers, said at the briefing.

Litigation and defensive medicine also accounted for about a third of the costs associated with poor-quality health care, said Mr. Thompson, noting that the cost of poor-quality care was spread throughout the health care system.

According to AHIP President Karen Ignagni, efforts must be made to reduce the amount of poor-quality care being given. “We have a system where 45% of what's being done is not best practice,” she said. “No public or private entity could operate at that rate.”

Overall, the rate of increase in health care premiums was 8.8% in 2004–2005, down significantly from 13.7% in 2001–2002, noted Jack Rodgers, managing director at PricewaterhouseCoopers. One factor contributing to the slowdown was a decrease in the rate of cost increases for prescription drugs, according to Mr. Thompson. “It's now trending in line with overall premiums,” he said.

Part of the reason for that decrease is employers' increasing use of three-tiered or four-tiered drug programs, in which patients pay a larger share for brand-name drugs, especially if there are generic equivalents. In 2000, only 27% of patients were in drug plans with three or more tiers; in 2004, the figure was 68%, he said. In addition, cost trends were helped by a drop in the number of state mandates that are being added each year, from 80 in 2000 to less than 40 in 2004, Mr. Thompson said.

Despite these problems, Mr. Thompson said in an interview that he did not expect premium increases to go higher next year. “We're looking at the same number or maybe a little lower,” he predicted.

Part of the stabilization will likely be tied to consumers having to pay more for their health care costs and becoming more aware of prices as a result, Mr. Thompson added.

WASHINGTON – The costs of malpractice insurance and defensive medicine account for about 10 cents of every dollar spent on health care premiums, several speakers said at a press briefing sponsored by America's Health Insurance Plans.

Medical liability and defensive medicine represented the “lion's share” of cost increases in the physician and outpatient areas, Michael Thompson, principal at the New York office of PricewaterhouseCoopers, said at the briefing.

Litigation and defensive medicine also accounted for about a third of the costs associated with poor-quality health care, said Mr. Thompson, noting that the cost of poor-quality care was spread throughout the health care system.

According to AHIP President Karen Ignagni, efforts must be made to reduce the amount of poor-quality care being given. “We have a system where 45% of what's being done is not best practice,” she said. “No public or private entity could operate at that rate.”

Overall, the rate of increase in health care premiums was 8.8% in 2004–2005, down significantly from 13.7% in 2001–2002, noted Jack Rodgers, managing director at PricewaterhouseCoopers. One factor contributing to the slowdown was a decrease in the rate of cost increases for prescription drugs, according to Mr. Thompson. “It's now trending in line with overall premiums,” he said.

Part of the reason for that decrease is employers' increasing use of three-tiered or four-tiered drug programs, in which patients pay a larger share for brand-name drugs, especially if there are generic equivalents. In 2000, only 27% of patients were in drug plans with three or more tiers; in 2004, the figure was 68%, he said. In addition, cost trends were helped by a drop in the number of state mandates that are being added each year, from 80 in 2000 to less than 40 in 2004, Mr. Thompson said.

Despite these problems, Mr. Thompson said in an interview that he did not expect premium increases to go higher next year. “We're looking at the same number or maybe a little lower,” he predicted.

Part of the stabilization will likely be tied to consumers having to pay more for their health care costs and becoming more aware of prices as a result, Mr. Thompson added.

SAMHSA Director Resigns

Charles G. Curie, administrator of the Substance Abuse and Mental Health Services Administration, is resigning effective Aug. 5. In his resignation letter to President Bush, Mr. Curie lauded the president's leadership in the New Freedom Initiative and the Access to Recovery program, which he said “cemented recovery as the new framework for public policy development in mental health and substance abuse services in this country.” He also noted that “After years of debate, we have established that individuals with cooccurring disorders should be the expectation, not the exception, in our treatment systems.” Michael J. Fitzpatrick, director of the National Alliance on Mental Illness, called Mr. Curie “a leader who has been truly committed to principles of individual dignity and recovery. He understands the needs of people living with mental illnesses, and their families, and has served as our advocate.” Mr. Curie, who was confirmed for his position in 2001, was previously deputy secretary for mental health and substance abuse services for the state of Pennsylvania.

New Inpatient Rule

A new Medicare rule for recertification for psychiatric inpatients went into effect this month, but it's not expected to have a major effect on psychiatrists. The rule requires that psychiatrists recertify psychiatric inpatients on the 12th day of their stay, rather than on the 18th day as was previously required. After that, subsequent recertifications are required at intervals established by each hospital's utilization review committee, but no less frequently than every 30 days, the rule notes. “This shouldn't have much impact, in part because lengths of stay tend to be shorter than 12 days,” said Carol Szpak, director of operations and communications at the National Association of Psychiatric Health Systems, in Washington. “The median length of stay in Medicare is somewhere around 9 days, which means at least half of the cases are shorter than that.” Changing the recertification requirement to 12 days brings psychiatry in line with other medical specialties, Ms. Szpak said.

New Detox Protocol Released

SAMHSA has released a new treatment improvement protocol (TIP 45) for detoxification and substance abuse treatment. This TIP, a revision of one published in 1995, stresses that detoxification by itself does not constitute complete substance abuse treatment and that detox patients therefore need to be connected with substance abuse treatment services. “Detoxification is one component in the continuum of health-care services for substance-related disorders,” said Mr. Curie, SAMHSA administrator. “The TIP defines detoxification as a broad process with three essential components–evaluation, stabilization, and fostering a patient's entry into treatment.” The TIP is available online at

http://store.health.org/catalog/productDetails.aspx?ProductID=17398

Licensure for Drug Sales Reps?

A proposal making its way through the Massachusetts legislature would require that pharmaceutical company sales representatives be licensed by the state, and complete continuing education programs to renew that license. The proposal passed as an amendment to the state budget and was in a joint House-Senate conference report. State Senator Mark C. Montigny, a Democrat from New Bedford, has sought to pass such a licensure requirement several times over the past few years, without success. Under the latest proposal, pharmaceutical companies–and their representatives–would also be prohibited from giving gifts, entertainment, travel, honoraria, or anything of value to physicians or public officials. Violators would be subject to a $5,000 fine and up to 2 years in jail. In a statement, Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers Association, said that licensing was unnecessary because the Food and Drug Administration already regulates promotional and educational materials and that the legislation is wrongheaded because it “seeks to impose criminal penalties on what should be viewed as the important sharing of information between pharmaceutical companies and physicians regarding the risks and benefits of medicines.”

Young Adults Lack Insurance

Adults aged 19–29 are one of the largest groups without health insurance, according to a study sponsored by the Commonwealth Fund. The number of people in that age category who were uninsured rose to 13.7 million in 2004, up 2.5 million since 2000. Although they make up only 17% of the nonelderly population, this group accounts for 30% of the nonelderly uninsured, noted Sara R. Collins, Ph.D., senior program officer at the Commonwealth Fund, and colleagues. Low-income, Hispanic, and African American patients in this age group were at higher risk of being uninsured compared with whites, the authors noted. Many of the patients had insurance until they were 18, but were dropped the following year from either their parents' private policies or public programs. Full-time college students–who often continue to be covered under their parents' private policies–are the most likely patients in this age group to maintain their insurance coverage. “Health insurance coverage of young adults would be improved by system-wide changes to expand access to and stabilize coverage among the general population,” the authors concluded. “This is a relatively low-cost group to insure: Young adults generally are healthier than older adults and therefore have far lower per capita health care expenditures.”

SAMHSA Director Resigns

Charles G. Curie, administrator of the Substance Abuse and Mental Health Services Administration, is resigning effective Aug. 5. In his resignation letter to President Bush, Mr. Curie lauded the president's leadership in the New Freedom Initiative and the Access to Recovery program, which he said “cemented recovery as the new framework for public policy development in mental health and substance abuse services in this country.” He also noted that “After years of debate, we have established that individuals with cooccurring disorders should be the expectation, not the exception, in our treatment systems.” Michael J. Fitzpatrick, director of the National Alliance on Mental Illness, called Mr. Curie “a leader who has been truly committed to principles of individual dignity and recovery. He understands the needs of people living with mental illnesses, and their families, and has served as our advocate.” Mr. Curie, who was confirmed for his position in 2001, was previously deputy secretary for mental health and substance abuse services for the state of Pennsylvania.

New Inpatient Rule

A new Medicare rule for recertification for psychiatric inpatients went into effect this month, but it's not expected to have a major effect on psychiatrists. The rule requires that psychiatrists recertify psychiatric inpatients on the 12th day of their stay, rather than on the 18th day as was previously required. After that, subsequent recertifications are required at intervals established by each hospital's utilization review committee, but no less frequently than every 30 days, the rule notes. “This shouldn't have much impact, in part because lengths of stay tend to be shorter than 12 days,” said Carol Szpak, director of operations and communications at the National Association of Psychiatric Health Systems, in Washington. “The median length of stay in Medicare is somewhere around 9 days, which means at least half of the cases are shorter than that.” Changing the recertification requirement to 12 days brings psychiatry in line with other medical specialties, Ms. Szpak said.

New Detox Protocol Released

SAMHSA has released a new treatment improvement protocol (TIP 45) for detoxification and substance abuse treatment. This TIP, a revision of one published in 1995, stresses that detoxification by itself does not constitute complete substance abuse treatment and that detox patients therefore need to be connected with substance abuse treatment services. “Detoxification is one component in the continuum of health-care services for substance-related disorders,” said Mr. Curie, SAMHSA administrator. “The TIP defines detoxification as a broad process with three essential components–evaluation, stabilization, and fostering a patient's entry into treatment.” The TIP is available online at

http://store.health.org/catalog/productDetails.aspx?ProductID=17398

Licensure for Drug Sales Reps?

A proposal making its way through the Massachusetts legislature would require that pharmaceutical company sales representatives be licensed by the state, and complete continuing education programs to renew that license. The proposal passed as an amendment to the state budget and was in a joint House-Senate conference report. State Senator Mark C. Montigny, a Democrat from New Bedford, has sought to pass such a licensure requirement several times over the past few years, without success. Under the latest proposal, pharmaceutical companies–and their representatives–would also be prohibited from giving gifts, entertainment, travel, honoraria, or anything of value to physicians or public officials. Violators would be subject to a $5,000 fine and up to 2 years in jail. In a statement, Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers Association, said that licensing was unnecessary because the Food and Drug Administration already regulates promotional and educational materials and that the legislation is wrongheaded because it “seeks to impose criminal penalties on what should be viewed as the important sharing of information between pharmaceutical companies and physicians regarding the risks and benefits of medicines.”

Young Adults Lack Insurance

Adults aged 19–29 are one of the largest groups without health insurance, according to a study sponsored by the Commonwealth Fund. The number of people in that age category who were uninsured rose to 13.7 million in 2004, up 2.5 million since 2000. Although they make up only 17% of the nonelderly population, this group accounts for 30% of the nonelderly uninsured, noted Sara R. Collins, Ph.D., senior program officer at the Commonwealth Fund, and colleagues. Low-income, Hispanic, and African American patients in this age group were at higher risk of being uninsured compared with whites, the authors noted. Many of the patients had insurance until they were 18, but were dropped the following year from either their parents' private policies or public programs. Full-time college students–who often continue to be covered under their parents' private policies–are the most likely patients in this age group to maintain their insurance coverage. “Health insurance coverage of young adults would be improved by system-wide changes to expand access to and stabilize coverage among the general population,” the authors concluded. “This is a relatively low-cost group to insure: Young adults generally are healthier than older adults and therefore have far lower per capita health care expenditures.”

SAMHSA Director Resigns

Charles G. Curie, administrator of the Substance Abuse and Mental Health Services Administration, is resigning effective Aug. 5. In his resignation letter to President Bush, Mr. Curie lauded the president's leadership in the New Freedom Initiative and the Access to Recovery program, which he said “cemented recovery as the new framework for public policy development in mental health and substance abuse services in this country.” He also noted that “After years of debate, we have established that individuals with cooccurring disorders should be the expectation, not the exception, in our treatment systems.” Michael J. Fitzpatrick, director of the National Alliance on Mental Illness, called Mr. Curie “a leader who has been truly committed to principles of individual dignity and recovery. He understands the needs of people living with mental illnesses, and their families, and has served as our advocate.” Mr. Curie, who was confirmed for his position in 2001, was previously deputy secretary for mental health and substance abuse services for the state of Pennsylvania.

New Inpatient Rule

A new Medicare rule for recertification for psychiatric inpatients went into effect this month, but it's not expected to have a major effect on psychiatrists. The rule requires that psychiatrists recertify psychiatric inpatients on the 12th day of their stay, rather than on the 18th day as was previously required. After that, subsequent recertifications are required at intervals established by each hospital's utilization review committee, but no less frequently than every 30 days, the rule notes. “This shouldn't have much impact, in part because lengths of stay tend to be shorter than 12 days,” said Carol Szpak, director of operations and communications at the National Association of Psychiatric Health Systems, in Washington. “The median length of stay in Medicare is somewhere around 9 days, which means at least half of the cases are shorter than that.” Changing the recertification requirement to 12 days brings psychiatry in line with other medical specialties, Ms. Szpak said.

New Detox Protocol Released

SAMHSA has released a new treatment improvement protocol (TIP 45) for detoxification and substance abuse treatment. This TIP, a revision of one published in 1995, stresses that detoxification by itself does not constitute complete substance abuse treatment and that detox patients therefore need to be connected with substance abuse treatment services. “Detoxification is one component in the continuum of health-care services for substance-related disorders,” said Mr. Curie, SAMHSA administrator. “The TIP defines detoxification as a broad process with three essential components–evaluation, stabilization, and fostering a patient's entry into treatment.” The TIP is available online at

http://store.health.org/catalog/productDetails.aspx?ProductID=17398

Licensure for Drug Sales Reps?

A proposal making its way through the Massachusetts legislature would require that pharmaceutical company sales representatives be licensed by the state, and complete continuing education programs to renew that license. The proposal passed as an amendment to the state budget and was in a joint House-Senate conference report. State Senator Mark C. Montigny, a Democrat from New Bedford, has sought to pass such a licensure requirement several times over the past few years, without success. Under the latest proposal, pharmaceutical companies–and their representatives–would also be prohibited from giving gifts, entertainment, travel, honoraria, or anything of value to physicians or public officials. Violators would be subject to a $5,000 fine and up to 2 years in jail. In a statement, Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers Association, said that licensing was unnecessary because the Food and Drug Administration already regulates promotional and educational materials and that the legislation is wrongheaded because it “seeks to impose criminal penalties on what should be viewed as the important sharing of information between pharmaceutical companies and physicians regarding the risks and benefits of medicines.”

Young Adults Lack Insurance

Adults aged 19–29 are one of the largest groups without health insurance, according to a study sponsored by the Commonwealth Fund. The number of people in that age category who were uninsured rose to 13.7 million in 2004, up 2.5 million since 2000. Although they make up only 17% of the nonelderly population, this group accounts for 30% of the nonelderly uninsured, noted Sara R. Collins, Ph.D., senior program officer at the Commonwealth Fund, and colleagues. Low-income, Hispanic, and African American patients in this age group were at higher risk of being uninsured compared with whites, the authors noted. Many of the patients had insurance until they were 18, but were dropped the following year from either their parents' private policies or public programs. Full-time college students–who often continue to be covered under their parents' private policies–are the most likely patients in this age group to maintain their insurance coverage. “Health insurance coverage of young adults would be improved by system-wide changes to expand access to and stabilize coverage among the general population,” the authors concluded. “This is a relatively low-cost group to insure: Young adults generally are healthier than older adults and therefore have far lower per capita health care expenditures.”

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers, or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. “My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged physicians to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, he said, CMS is considering the idea that “some patients automatically are going to get excluded—excluded for noncompliance or excluded because from the standpoint of that clinician, they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure.”

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers, or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. “My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged physicians to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, he said, CMS is considering the idea that “some patients automatically are going to get excluded—excluded for noncompliance or excluded because from the standpoint of that clinician, they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure.”

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers, or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. “My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged physicians to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, he said, CMS is considering the idea that “some patients automatically are going to get excluded—excluded for noncompliance or excluded because from the standpoint of that clinician, they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure.”

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

"What it comes down to … is there's a certain level of fear, a certain uneasiness" about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. "The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input."

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. "My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it," he said. "When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians."

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only "if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant."

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the "faulty premise" of evidence-based medicine. While the original idea behind evidence-based medicine was good, "it is being perverted to allow rationing of care," she said. Because of its insistence on having all physicians practice in the same way, "evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care."

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance "the real culprits" in the health care cost spiral.

"Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about," she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. "This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid," he said. "It's a shock to me."

But he agreed with Ms. Brase that consumers need more information to make better health care choices. "I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality."

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. "How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?" she asked.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, he said, CMS is considering the idea that some patients will automatically get excluded because "they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure."

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

"What it comes down to … is there's a certain level of fear, a certain uneasiness" about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. "The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input."

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. "My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it," he said. "When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians."

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only "if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant."

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the "faulty premise" of evidence-based medicine. While the original idea behind evidence-based medicine was good, "it is being perverted to allow rationing of care," she said. Because of its insistence on having all physicians practice in the same way, "evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care."

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance "the real culprits" in the health care cost spiral.

"Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about," she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. "This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid," he said. "It's a shock to me."

But he agreed with Ms. Brase that consumers need more information to make better health care choices. "I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality."

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. "How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?" she asked.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, he said, CMS is considering the idea that some patients will automatically get excluded because "they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure."

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

"What it comes down to … is there's a certain level of fear, a certain uneasiness" about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. "The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input."

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. "My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it," he said. "When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians."

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only "if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant."

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the "faulty premise" of evidence-based medicine. While the original idea behind evidence-based medicine was good, "it is being perverted to allow rationing of care," she said. Because of its insistence on having all physicians practice in the same way, "evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care."

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance "the real culprits" in the health care cost spiral.

"Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about," she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. "This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid," he said. "It's a shock to me."

But he agreed with Ms. Brase that consumers need more information to make better health care choices. "I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality."

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. "How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?" she asked.

Dr. Haywood said that physician input would be helpful in trying to answer that question. In the meantime, he said, CMS is considering the idea that some patients will automatically get excluded because "they've reached the therapeutic goal for a variety of reasons and won't fall into the denominator for that particular measure."

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. “My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. Meanwhile, CMS is considering the idea that “some patients automatically are going to get excluded—excluded for noncompliance or excluded because from the standpoint of that clinician.”

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. “My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. Meanwhile, CMS is considering the idea that “some patients automatically are going to get excluded—excluded for noncompliance or excluded because from the standpoint of that clinician.”

CHICAGO — Physicians need to help design the pay-for-performance programs now being initiated by Medicare and other payers or they may not like the results, Dr. Trent Haywood said at the annual meeting of the American Association of Clinical Endocrinologists.

“What it comes down to … is there's a certain level of fear, a certain uneasiness” about the program among doctors, said Dr. Haywood, who is deputy chief clinical officer at the Centers for Medicare and Medicaid Services. “The thing is for clinicians to work with us and get on board. We don't want to design a program and not have clinician input.”

Medicare currently has several pilot programs under which physician and hospital pay is based in part on patient outcomes and quality of care. Demonstrations include a project with 10 large multispecialty practices nationwide, and an oncology project in which physicians are paid to report their use of guidelines as well as outcome measures for their patients.

Dr. John Rowe, executive chairman of Aetna, made a similar comment at the Society of Hospital Medicine meeting in Washington. “My fear is that the pay-for-performance train is leaving the station, and the doctors aren't on it,” he said. “When I talk to people who buy Aetna's services [such as large employers], they get it. Corporate America is adopting the concept of pay for performance before the details are worked out, and the details have to be worked out by physicians.”

But physicians have reservations about the pay-for-performance concept. Dr. John Nelson, an American Medical Association trustee and panelist at the AACE meeting, said Medicare's pay-for-performance program would be a great opportunity for physicians to serve patients, but only “if it improves quality, if it's voluntary, and if the data are accurate, clinically meaningful, and relevant.”

However, another panelist had other ideas. Twila J. Brase, president of the Citizens' Council on Health Care, a St. Paul, Minn., group that advocates competition in health care, said that pay for performance was based on what she called the “faulty premise” of evidence-based medicine. While the original idea behind evidence-based medicine was good, “it is being perverted to allow rationing of care,” she said. Because of its insistence on having all physicians practice in the same way, “evidence-based medicine will make every doctor a managed care doctor. It will lead to budget-based care, not customized care.”

Rather than participating in pay-for-performance programs, Ms. Brase urged doctors to stop participating in Medicare and private insurance programs and instead have patients pay cash for each visit. She called Medicare and private insurance “the real culprits” in the health care cost spiral.

“Evidence-based medicine isn't about evidence. It's not even about science. It's about control. It's meant to centralize power and control outside the exam room, and if you let pay for performance and evidence-based medicine become the standard way that you do business, the only way you'll make a decent dollar working at your profession is to follow the directives of people who don't know what they're talking about,” she said to loud applause.

Dr. Haywood seemed taken aback by Ms. Brase's comments. “This is the first time I've ever been on a panel where someone advocated the abolishment of Medicare and Medicaid,” he said. “It's a shock to me.”

But he agreed with Ms. Brase that consumers need more information to make better health care choices. “I think we're moving more toward consumers having more decision-making capacity. … I do believe we're going to be providing information to consumers so that they can make some of those decisions, and hopefully that leads to better quality.”

One audience member wanted to know how CMS would deal with patients who, for one reason or another, don't meet the outcome goals. “How will CMS deal with … that 10% of the population who, come hell or high water, will never have a [hemoglobin] A_1c of 6.5%, for a variety of reasons?” she said.

Dr. Haywood said that physician input would be helpful in trying to answer that question. Meanwhile, CMS is considering the idea that “some patients automatically are going to get excluded—excluded for noncompliance or excluded because from the standpoint of that clinician.”