Joyce Frieden

WASHINGTON – Does your Medicare patient need a drug not on the drug plan formulary? Be forewarned: You may have to fill out pages of forms.

“There continue to be widespread reports of drug plans requiring prior authorization for beneficiaries to receive needed medication,” Sen. Hillary Rodham Clinton (D-N.Y.) said during a hearing of the U.S. Senate Special Committee on Aging. “Some reports have plans requiring forms for each drug, while others are requiring doctors to fill out forms as long as 14 pages for drugs that a beneficiary has been taking for years.”

Addressing her remarks to Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services and the hearing's first witness, Sen. Clinton continued, “Your agency's request that plans discontinue this practice does not seem to be working, based on the information we have. I hope that you will require, not request, require that the plans cease this practice and enforce that requirement.”

In his prepared testimony, Dr. McClellan noted that CMS has “developed specific procedures for timely exceptions and appeals. Using those procedures, a Medicare beneficiary can get coverage for a drug that is not on a plan's established formulary.”

He also acknowledged, however, that the plan rollout was not without problems. “We make no excuses for these problems,” he told committee members. “They are important, they are ours to solve, and we are finding and fixing them.”

Many of the problems with getting prescriptions filled occurred in the dual-eligible population–patients who qualified for both Medicare and Medicaid. “These often are the poorest and most vulnerable Americans who rely on medications to manage their chronic physical and mental illnesses,” noted committee chairman Gordon Smith (R-Ore.) “We knew there would be challenges associated with their transition from Medicaid into the new Medicare drug benefit, but it seems that perhaps not enough was done to ensure a seamless transition.”

As a result of the problems with the drug benefit, “pharmacists are not getting paid on time and have to take out loans to pay their bills and keep their doors open,” said committee member Blanche Lincoln (D-Ark.). “These problems could have been avoided.”

Sen. Clinton said the problems were so bad that she was ready to give up. “I for one believe we should scrap this and start over. We are spending hundreds of billions of dollars on an inefficient delivery of a plan that could be done in a much more cost-effective way,” she said.

But Sen. Rick Santorum (R-Pa.) disagreed. “Throwing it out would doom seniors to a situation where they would be getting less care than they are today,” he said. “We should not be flippant about casting out babies with bathwaters. The idea that we're going to once again play politics with prescription drugs … is below the dignity of this committee.”

Committee member Conrad Burns (R-Mont.) also weighed in. “We Americans are in this business that everything has to be instant–tea, coffee, everything that we do, and we're supposed to have a new program put in place and all at once it's perfect,” he said. “I would ask my colleagues [to just] get the program in place; that serves our purpose, and then we know what to fix. Right now, we don't know what to fix.”

One thing Sen. Smith said that he wants to fix is the part of the program that requires dual-eligible patients living at home or in an assisted living facility to pay copayments for drugs received under the program; currently, only dual-eligible patients in nursing homes are exempt from copayments. Sen. Smith introduced a bill eliminating the copayments for dual-eligible patients in home- or community-based care; the measure, which was cosponsored by Sen. Jeff Bingaman (D-N.M.) was still being considered at press time.

WASHINGTON – Does your Medicare patient need a drug not on the drug plan formulary? Be forewarned: You may have to fill out pages of forms.

“There continue to be widespread reports of drug plans requiring prior authorization for beneficiaries to receive needed medication,” Sen. Hillary Rodham Clinton (D-N.Y.) said during a hearing of the U.S. Senate Special Committee on Aging. “Some reports have plans requiring forms for each drug, while others are requiring doctors to fill out forms as long as 14 pages for drugs that a beneficiary has been taking for years.”

Addressing her remarks to Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services and the hearing's first witness, Sen. Clinton continued, “Your agency's request that plans discontinue this practice does not seem to be working, based on the information we have. I hope that you will require, not request, require that the plans cease this practice and enforce that requirement.”

In his prepared testimony, Dr. McClellan noted that CMS has “developed specific procedures for timely exceptions and appeals. Using those procedures, a Medicare beneficiary can get coverage for a drug that is not on a plan's established formulary.”

He also acknowledged, however, that the plan rollout was not without problems. “We make no excuses for these problems,” he told committee members. “They are important, they are ours to solve, and we are finding and fixing them.”

Many of the problems with getting prescriptions filled occurred in the dual-eligible population–patients who qualified for both Medicare and Medicaid. “These often are the poorest and most vulnerable Americans who rely on medications to manage their chronic physical and mental illnesses,” noted committee chairman Gordon Smith (R-Ore.) “We knew there would be challenges associated with their transition from Medicaid into the new Medicare drug benefit, but it seems that perhaps not enough was done to ensure a seamless transition.”

As a result of the problems with the drug benefit, “pharmacists are not getting paid on time and have to take out loans to pay their bills and keep their doors open,” said committee member Blanche Lincoln (D-Ark.). “These problems could have been avoided.”

Sen. Clinton said the problems were so bad that she was ready to give up. “I for one believe we should scrap this and start over. We are spending hundreds of billions of dollars on an inefficient delivery of a plan that could be done in a much more cost-effective way,” she said.

But Sen. Rick Santorum (R-Pa.) disagreed. “Throwing it out would doom seniors to a situation where they would be getting less care than they are today,” he said. “We should not be flippant about casting out babies with bathwaters. The idea that we're going to once again play politics with prescription drugs … is below the dignity of this committee.”

Committee member Conrad Burns (R-Mont.) also weighed in. “We Americans are in this business that everything has to be instant–tea, coffee, everything that we do, and we're supposed to have a new program put in place and all at once it's perfect,” he said. “I would ask my colleagues [to just] get the program in place; that serves our purpose, and then we know what to fix. Right now, we don't know what to fix.”

One thing Sen. Smith said that he wants to fix is the part of the program that requires dual-eligible patients living at home or in an assisted living facility to pay copayments for drugs received under the program; currently, only dual-eligible patients in nursing homes are exempt from copayments. Sen. Smith introduced a bill eliminating the copayments for dual-eligible patients in home- or community-based care; the measure, which was cosponsored by Sen. Jeff Bingaman (D-N.M.) was still being considered at press time.

WASHINGTON – Does your Medicare patient need a drug not on the drug plan formulary? Be forewarned: You may have to fill out pages of forms.

“There continue to be widespread reports of drug plans requiring prior authorization for beneficiaries to receive needed medication,” Sen. Hillary Rodham Clinton (D-N.Y.) said during a hearing of the U.S. Senate Special Committee on Aging. “Some reports have plans requiring forms for each drug, while others are requiring doctors to fill out forms as long as 14 pages for drugs that a beneficiary has been taking for years.”

Addressing her remarks to Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services and the hearing's first witness, Sen. Clinton continued, “Your agency's request that plans discontinue this practice does not seem to be working, based on the information we have. I hope that you will require, not request, require that the plans cease this practice and enforce that requirement.”

In his prepared testimony, Dr. McClellan noted that CMS has “developed specific procedures for timely exceptions and appeals. Using those procedures, a Medicare beneficiary can get coverage for a drug that is not on a plan's established formulary.”

He also acknowledged, however, that the plan rollout was not without problems. “We make no excuses for these problems,” he told committee members. “They are important, they are ours to solve, and we are finding and fixing them.”

Many of the problems with getting prescriptions filled occurred in the dual-eligible population–patients who qualified for both Medicare and Medicaid. “These often are the poorest and most vulnerable Americans who rely on medications to manage their chronic physical and mental illnesses,” noted committee chairman Gordon Smith (R-Ore.) “We knew there would be challenges associated with their transition from Medicaid into the new Medicare drug benefit, but it seems that perhaps not enough was done to ensure a seamless transition.”

As a result of the problems with the drug benefit, “pharmacists are not getting paid on time and have to take out loans to pay their bills and keep their doors open,” said committee member Blanche Lincoln (D-Ark.). “These problems could have been avoided.”

Sen. Clinton said the problems were so bad that she was ready to give up. “I for one believe we should scrap this and start over. We are spending hundreds of billions of dollars on an inefficient delivery of a plan that could be done in a much more cost-effective way,” she said.

But Sen. Rick Santorum (R-Pa.) disagreed. “Throwing it out would doom seniors to a situation where they would be getting less care than they are today,” he said. “We should not be flippant about casting out babies with bathwaters. The idea that we're going to once again play politics with prescription drugs … is below the dignity of this committee.”

Committee member Conrad Burns (R-Mont.) also weighed in. “We Americans are in this business that everything has to be instant–tea, coffee, everything that we do, and we're supposed to have a new program put in place and all at once it's perfect,” he said. “I would ask my colleagues [to just] get the program in place; that serves our purpose, and then we know what to fix. Right now, we don't know what to fix.”

One thing Sen. Smith said that he wants to fix is the part of the program that requires dual-eligible patients living at home or in an assisted living facility to pay copayments for drugs received under the program; currently, only dual-eligible patients in nursing homes are exempt from copayments. Sen. Smith introduced a bill eliminating the copayments for dual-eligible patients in home- or community-based care; the measure, which was cosponsored by Sen. Jeff Bingaman (D-N.M.) was still being considered at press time.

WASHINGTON – Health disparities won't go away until the people and institutions that play a role in creating them are held accountable, Dr. Anne C. Beal said at a meeting sponsored by the Department of Health and Human Services and the Office of Minority Health.

“When you ask physicians if racial disparities in health care exist, about 65% say no,” said Dr. Beal, senior program officer at the Commonwealth Fund. “So a lot of work needs to be done in terms of making sure we keep pushing for this agenda, that health disparities is a real issue.”

Measures of health care disparity are essentially quality measures, Dr. Beal said.

“The collection of race and ethnicity data is the basic science of disparities,” she said. Without it, “we don't know where we're going, we don't know if we're improving, and we don't know if interventions we're trying to implement are making a difference.”

Although health care quality measures were not initially designed to measure disparities, “if you take standard quality measures and stratify them by race and ethnicity, it allows you to identify racial disparities and what I call 'potential accountability,'” she said.

For example, many people have heard that the infant mortality rate is higher for African Americans than it is for whites. “However, there's no sense of ownership when you hear that,” Dr. Beal said. “You sit there and say, 'Um, um, um, that is a shame that we have this.'” But if a physician gets a report that says his Latino patients are not getting immunized at the same rate as his African American patients, “then [he] has a sense of ownership and a sense of responsibility for those results,” she said.

There are several problems with collecting racial and ethnic data, however. One of the problems is how it's done. Dr. Beal quoted a study by Romana Hasnain-Wynia, Ph.D., vice-president for research at the Health Research and Education Trust, which found that 79% of hospitals were collecting racial and ethnic data. However, nearly half of the hospitals collecting the data said the categorization was made by “an admitting clerk, based on observation.”

It would be better to have patients self-identify, she continued. “In the emergency room or admitting area, there is a variety of other tasks you have to complete, not least of which is getting that all-important insurance card, so trying to ask about the patient's race probably falls very low on the list. But in order for us to see how we're doing, we need to develop standards not only in terms of the categories we use, but even with how we ask the question.”

That includes which racial categories to list. “I'm still amazed that in the United States, there are people using 'black, white, and other' as categories,” Dr. Beal said. “Only 80% of hospitals even include a Latino designation.”

Ignatius Bao, director of culturally competent health systems at The California Endowment, said providers should pay more attention to the variety of racial and ethnic groups. He noted that the Department of Health and Human Services is far behind in complying with standards issued in 1997 by the Office of Management and Budget that list a variety of racial categories government agencies are supposed to document when they issue data.

“I would argue, especially on behalf of Asian Americans, Pacific Islanders, and Native Americans, that we need to do better than these standards. We need to disaggregate the data even further,” Mr. Bao said. “But at the very beginning, every time HHS puts out data, it should have these categories, and if it doesn't, HHS should explain why the data are not there.”

Racial and ethnic designations also need to be made part of any electronic health record (EHR) system, Dr. Beal noted. “One of my concerns is that because it's really not high on the agenda of EHR [developers], 10, 15, or 20 years from now we're going to be right back where we started. If we build it in right now, we'll be able to have this capacity moving forward.”

WASHINGTON – Health disparities won't go away until the people and institutions that play a role in creating them are held accountable, Dr. Anne C. Beal said at a meeting sponsored by the Department of Health and Human Services and the Office of Minority Health.

“When you ask physicians if racial disparities in health care exist, about 65% say no,” said Dr. Beal, senior program officer at the Commonwealth Fund. “So a lot of work needs to be done in terms of making sure we keep pushing for this agenda, that health disparities is a real issue.”

Measures of health care disparity are essentially quality measures, Dr. Beal said.

“The collection of race and ethnicity data is the basic science of disparities,” she said. Without it, “we don't know where we're going, we don't know if we're improving, and we don't know if interventions we're trying to implement are making a difference.”

Although health care quality measures were not initially designed to measure disparities, “if you take standard quality measures and stratify them by race and ethnicity, it allows you to identify racial disparities and what I call 'potential accountability,'” she said.

For example, many people have heard that the infant mortality rate is higher for African Americans than it is for whites. “However, there's no sense of ownership when you hear that,” Dr. Beal said. “You sit there and say, 'Um, um, um, that is a shame that we have this.'” But if a physician gets a report that says his Latino patients are not getting immunized at the same rate as his African American patients, “then [he] has a sense of ownership and a sense of responsibility for those results,” she said.

There are several problems with collecting racial and ethnic data, however. One of the problems is how it's done. Dr. Beal quoted a study by Romana Hasnain-Wynia, Ph.D., vice-president for research at the Health Research and Education Trust, which found that 79% of hospitals were collecting racial and ethnic data. However, nearly half of the hospitals collecting the data said the categorization was made by “an admitting clerk, based on observation.”

It would be better to have patients self-identify, she continued. “In the emergency room or admitting area, there is a variety of other tasks you have to complete, not least of which is getting that all-important insurance card, so trying to ask about the patient's race probably falls very low on the list. But in order for us to see how we're doing, we need to develop standards not only in terms of the categories we use, but even with how we ask the question.”

That includes which racial categories to list. “I'm still amazed that in the United States, there are people using 'black, white, and other' as categories,” Dr. Beal said. “Only 80% of hospitals even include a Latino designation.”

Ignatius Bao, director of culturally competent health systems at The California Endowment, said providers should pay more attention to the variety of racial and ethnic groups. He noted that the Department of Health and Human Services is far behind in complying with standards issued in 1997 by the Office of Management and Budget that list a variety of racial categories government agencies are supposed to document when they issue data.

“I would argue, especially on behalf of Asian Americans, Pacific Islanders, and Native Americans, that we need to do better than these standards. We need to disaggregate the data even further,” Mr. Bao said. “But at the very beginning, every time HHS puts out data, it should have these categories, and if it doesn't, HHS should explain why the data are not there.”

Racial and ethnic designations also need to be made part of any electronic health record (EHR) system, Dr. Beal noted. “One of my concerns is that because it's really not high on the agenda of EHR [developers], 10, 15, or 20 years from now we're going to be right back where we started. If we build it in right now, we'll be able to have this capacity moving forward.”

WASHINGTON – Health disparities won't go away until the people and institutions that play a role in creating them are held accountable, Dr. Anne C. Beal said at a meeting sponsored by the Department of Health and Human Services and the Office of Minority Health.

“When you ask physicians if racial disparities in health care exist, about 65% say no,” said Dr. Beal, senior program officer at the Commonwealth Fund. “So a lot of work needs to be done in terms of making sure we keep pushing for this agenda, that health disparities is a real issue.”

Measures of health care disparity are essentially quality measures, Dr. Beal said.

“The collection of race and ethnicity data is the basic science of disparities,” she said. Without it, “we don't know where we're going, we don't know if we're improving, and we don't know if interventions we're trying to implement are making a difference.”

Although health care quality measures were not initially designed to measure disparities, “if you take standard quality measures and stratify them by race and ethnicity, it allows you to identify racial disparities and what I call 'potential accountability,'” she said.

For example, many people have heard that the infant mortality rate is higher for African Americans than it is for whites. “However, there's no sense of ownership when you hear that,” Dr. Beal said. “You sit there and say, 'Um, um, um, that is a shame that we have this.'” But if a physician gets a report that says his Latino patients are not getting immunized at the same rate as his African American patients, “then [he] has a sense of ownership and a sense of responsibility for those results,” she said.

There are several problems with collecting racial and ethnic data, however. One of the problems is how it's done. Dr. Beal quoted a study by Romana Hasnain-Wynia, Ph.D., vice-president for research at the Health Research and Education Trust, which found that 79% of hospitals were collecting racial and ethnic data. However, nearly half of the hospitals collecting the data said the categorization was made by “an admitting clerk, based on observation.”

It would be better to have patients self-identify, she continued. “In the emergency room or admitting area, there is a variety of other tasks you have to complete, not least of which is getting that all-important insurance card, so trying to ask about the patient's race probably falls very low on the list. But in order for us to see how we're doing, we need to develop standards not only in terms of the categories we use, but even with how we ask the question.”

That includes which racial categories to list. “I'm still amazed that in the United States, there are people using 'black, white, and other' as categories,” Dr. Beal said. “Only 80% of hospitals even include a Latino designation.”

Ignatius Bao, director of culturally competent health systems at The California Endowment, said providers should pay more attention to the variety of racial and ethnic groups. He noted that the Department of Health and Human Services is far behind in complying with standards issued in 1997 by the Office of Management and Budget that list a variety of racial categories government agencies are supposed to document when they issue data.

“I would argue, especially on behalf of Asian Americans, Pacific Islanders, and Native Americans, that we need to do better than these standards. We need to disaggregate the data even further,” Mr. Bao said. “But at the very beginning, every time HHS puts out data, it should have these categories, and if it doesn't, HHS should explain why the data are not there.”

Racial and ethnic designations also need to be made part of any electronic health record (EHR) system, Dr. Beal noted. “One of my concerns is that because it's really not high on the agenda of EHR [developers], 10, 15, or 20 years from now we're going to be right back where we started. If we build it in right now, we'll be able to have this capacity moving forward.”

A survey from the National Association of Counties paints a bleak picture of the toll that methamphetamine abuse is taking on the nation's emergency departments, at least in public and regional hospitals.

The survey of 200 emergency department officials in 39 states found that 73% of emergency departments saw increases in ED visits involving methamphetamine in the last five years, including 94% of hospitals in counties with a population ranging from 50,000 to 100,000. In Nebraska alone, 94% of EDs reported that up to 10% of their visits involve methamphetamine abuse.

Methamphetamine was also the top illicit drug seen in presentations of emergency department patients, according to 47% of respondents. Marijuana came in a distant second, at 16%, followed closely by cocaine at 15%. On the issue of what EDs recommended for these patients upon discharge, 58% of respondents said they referred them to private treatment programs, 53% referred to hospital treatment programs, and 39% said they referred to county treatment programs. Four percent said they made no referrals.

The survey also asked about the insurance status of methamphetamine abusers. Overall, 83% of respondents reported that during the last 3 years, patients presenting to the ED with meth-related conditions were often uninsured, and 81% said if they had insurance, they were often underinsured. As a result, the survey said, 56% of hospitals report that costs have increased at their facilities because of meth abuse.

A second survey released the same day involved substance abuse treatment facilities. Researchers interviewed 200 behavioral health directors in 26 states and the District of Columbia and found that 69% of respondents said the need for treatment programs has been increasing due to methamphetamine, including 90% of respondents in Texas and 86% of respondents in Maryland.

Some providers note, however, that although the methamphetamine problem clearly is widespread, the statistics in the hospital ED survey may not be representative of the nation as a whole. “My town is a heroin town,” said Dr. Jon Mark Hirshon, of the division of emergency medicine at the University of Maryland, in Baltimore, and chair of the American College of Emergency Physicians' public health committee. “That's what I see.”

But the National Association of Counties wasn't trying to be representative of all hospital EDs nationwide, according to Tom Goodman, public affairs director for the association. “We believe it's representative, but we're trying to show the effect of methamphetamine abuse on public hospitals, so it's representative of that,” he said. “The bigger factor people have to consider is that 83% of those [ED] officials said the people coming in needing treatment related to meth were uninsured. If that's the case, [public hospitals are] where they go, because private hospitals will probably turn them away.”

Mr. Goodman agreed that methamphetamine abuse is not a big problem on the East Coast. “It's possible it could grow, but it's not necessarily an urban problem at this point, although it is in the West and the Midwest.”

Whatever its shortcomings, the study does point up that the substance abuse problem is contributing to the continued overcrowding of emergency departments, Dr. Hirshon said.

Methamphetamine abuse is an emergency visit that is preventable, “and we need to address these problems in a better fashion. We need to give people resources, so they can get off of drugs and stay off. There needs to be increased public investment to deal with these problems,” he said.

A survey from the National Association of Counties paints a bleak picture of the toll that methamphetamine abuse is taking on the nation's emergency departments, at least in public and regional hospitals.

The survey of 200 emergency department officials in 39 states found that 73% of emergency departments saw increases in ED visits involving methamphetamine in the last five years, including 94% of hospitals in counties with a population ranging from 50,000 to 100,000. In Nebraska alone, 94% of EDs reported that up to 10% of their visits involve methamphetamine abuse.

Methamphetamine was also the top illicit drug seen in presentations of emergency department patients, according to 47% of respondents. Marijuana came in a distant second, at 16%, followed closely by cocaine at 15%. On the issue of what EDs recommended for these patients upon discharge, 58% of respondents said they referred them to private treatment programs, 53% referred to hospital treatment programs, and 39% said they referred to county treatment programs. Four percent said they made no referrals.

The survey also asked about the insurance status of methamphetamine abusers. Overall, 83% of respondents reported that during the last 3 years, patients presenting to the ED with meth-related conditions were often uninsured, and 81% said if they had insurance, they were often underinsured. As a result, the survey said, 56% of hospitals report that costs have increased at their facilities because of meth abuse.

A second survey released the same day involved substance abuse treatment facilities. Researchers interviewed 200 behavioral health directors in 26 states and the District of Columbia and found that 69% of respondents said the need for treatment programs has been increasing due to methamphetamine, including 90% of respondents in Texas and 86% of respondents in Maryland.

Some providers note, however, that although the methamphetamine problem clearly is widespread, the statistics in the hospital ED survey may not be representative of the nation as a whole. “My town is a heroin town,” said Dr. Jon Mark Hirshon, of the division of emergency medicine at the University of Maryland, in Baltimore, and chair of the American College of Emergency Physicians' public health committee. “That's what I see.”

But the National Association of Counties wasn't trying to be representative of all hospital EDs nationwide, according to Tom Goodman, public affairs director for the association. “We believe it's representative, but we're trying to show the effect of methamphetamine abuse on public hospitals, so it's representative of that,” he said. “The bigger factor people have to consider is that 83% of those [ED] officials said the people coming in needing treatment related to meth were uninsured. If that's the case, [public hospitals are] where they go, because private hospitals will probably turn them away.”

Mr. Goodman agreed that methamphetamine abuse is not a big problem on the East Coast. “It's possible it could grow, but it's not necessarily an urban problem at this point, although it is in the West and the Midwest.”

Whatever its shortcomings, the study does point up that the substance abuse problem is contributing to the continued overcrowding of emergency departments, Dr. Hirshon said.

Methamphetamine abuse is an emergency visit that is preventable, “and we need to address these problems in a better fashion. We need to give people resources, so they can get off of drugs and stay off. There needs to be increased public investment to deal with these problems,” he said.

A survey from the National Association of Counties paints a bleak picture of the toll that methamphetamine abuse is taking on the nation's emergency departments, at least in public and regional hospitals.

The survey of 200 emergency department officials in 39 states found that 73% of emergency departments saw increases in ED visits involving methamphetamine in the last five years, including 94% of hospitals in counties with a population ranging from 50,000 to 100,000. In Nebraska alone, 94% of EDs reported that up to 10% of their visits involve methamphetamine abuse.

Methamphetamine was also the top illicit drug seen in presentations of emergency department patients, according to 47% of respondents. Marijuana came in a distant second, at 16%, followed closely by cocaine at 15%. On the issue of what EDs recommended for these patients upon discharge, 58% of respondents said they referred them to private treatment programs, 53% referred to hospital treatment programs, and 39% said they referred to county treatment programs. Four percent said they made no referrals.

The survey also asked about the insurance status of methamphetamine abusers. Overall, 83% of respondents reported that during the last 3 years, patients presenting to the ED with meth-related conditions were often uninsured, and 81% said if they had insurance, they were often underinsured. As a result, the survey said, 56% of hospitals report that costs have increased at their facilities because of meth abuse.

A second survey released the same day involved substance abuse treatment facilities. Researchers interviewed 200 behavioral health directors in 26 states and the District of Columbia and found that 69% of respondents said the need for treatment programs has been increasing due to methamphetamine, including 90% of respondents in Texas and 86% of respondents in Maryland.

Some providers note, however, that although the methamphetamine problem clearly is widespread, the statistics in the hospital ED survey may not be representative of the nation as a whole. “My town is a heroin town,” said Dr. Jon Mark Hirshon, of the division of emergency medicine at the University of Maryland, in Baltimore, and chair of the American College of Emergency Physicians' public health committee. “That's what I see.”

But the National Association of Counties wasn't trying to be representative of all hospital EDs nationwide, according to Tom Goodman, public affairs director for the association. “We believe it's representative, but we're trying to show the effect of methamphetamine abuse on public hospitals, so it's representative of that,” he said. “The bigger factor people have to consider is that 83% of those [ED] officials said the people coming in needing treatment related to meth were uninsured. If that's the case, [public hospitals are] where they go, because private hospitals will probably turn them away.”

Mr. Goodman agreed that methamphetamine abuse is not a big problem on the East Coast. “It's possible it could grow, but it's not necessarily an urban problem at this point, although it is in the West and the Midwest.”

Whatever its shortcomings, the study does point up that the substance abuse problem is contributing to the continued overcrowding of emergency departments, Dr. Hirshon said.

Methamphetamine abuse is an emergency visit that is preventable, “and we need to address these problems in a better fashion. We need to give people resources, so they can get off of drugs and stay off. There needs to be increased public investment to deal with these problems,” he said.

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, he said, noting that the cost of poor-quality care was spread throughout the health care system.

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.

Outpatient costs rose significantly last year, Mr. Rodgers said. “Those are the services that are really growing rapidly.” The increase in outpatient services accounted for more than a third of the 8.8% increase in premiums, he noted.

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 said. Part of the stabilization will likely be due to consumers having to pay more for their health care costs and becoming more aware of prices as a result, he 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, he said, noting that the cost of poor-quality care was spread throughout the health care system.

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.

Outpatient costs rose significantly last year, Mr. Rodgers said. “Those are the services that are really growing rapidly.” The increase in outpatient services accounted for more than a third of the 8.8% increase in premiums, he noted.

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 said. Part of the stabilization will likely be due to consumers having to pay more for their health care costs and becoming more aware of prices as a result, he 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, he said, noting that the cost of poor-quality care was spread throughout the health care system.

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.

Outpatient costs rose significantly last year, Mr. Rodgers said. “Those are the services that are really growing rapidly.” The increase in outpatient services accounted for more than a third of the 8.8% increase in premiums, he noted.

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

WASHINGTON — Although consumer-driven health care puts much more decision making in the hands of consumers, there is still a role for employers and insurers, several speakers said at a meeting on health care competition sponsored by Health Affairs journal and the Center for Studying Health System Change.

Employers will have a role because “as there's labor competition for offering health benefits, we have to offer health plans,” said Dr. Robert Galvin, director of corporate health care programs for General Electric. “You're going to see much more [emphasis] on financial incentives for employees staying healthy and making [good] choices on doctors and hospitals and health plans.”

Another role for employers—although it gets denigrated a bit—is providing access to meaningful, usable, and accurate information “as long as the market isn't working on its own, and it certainly isn't today,” Dr. Galvin said. “This is a responsibility of ours to keep driving at.”

He noted that within GE, officials believe “if information is not readable, it isn't going to be read.” In light of that philosophy, the company has come up with a “health index” that tells employees things such as how healthy they are, compared with how healthy they want to be; how much money is in their wellness account; and when it's time to schedule their children's physicals.

Although employers can act as intermediaries, insurers also have a role, said Dr. Samuel Nussbaum, executive vice president and chief medical officer at WellPoint Inc., a multistate Blue Cross and Blue Shield company based in Indianapolis. One of their roles is to make consumers more aware of how much their choices are costing them.

“Most Americans consider health care an entitlement, not a consumer product,” Dr. Nussbaum said. “And consumers are insulated from the true costs of health care services and products. So a prerequisite for health care competition is to have accurate, usable information about cost and quality.”

Insurers also can help steer patients to higher-quality providers, and that means making sure the networks they are in are of high quality, he continued. “It's not effective enough to have 20% high-quality providers because [consumers] can't all get to those high-quality providers … [or] travel around the country for care.”

In addition to helping consumers with purchasing decisions, WellPoint also tries to help consumers decide on treatments by making evidence available on its Web site. “We do this with academic physicians and specialty societies,” Dr. Nussbaum said.

Health plans also can make it beneficial to consumers to get more information, he said. For example, in one of WellPoint's consumer-driven health plans that uses a health reimbursement account, “we pay consumers more to take health risk assessments, we pay them more to enroll in personal health coaching programs in disease and care management, and we pay them more to graduate.”

And the early results are promising. “You can see the reduction in pharmacy costs of 15% and an increase in preventive care spending; 5% of total medical expenses are going to preventive services rather than only 2% or 3%,” he said.

WellPoint also has a database patients can consult when they are about to undergo a procedure. “You can go online and learn about a condition and compare hospital quality, so if you are in Los Angeles and require bypass graft surgery, you can find out whether it should be done at UCLA Medical Center or Cedars-Sinai, how many procedures they do, and what their outcomes are,” Dr. Nussbaum said.

To be the consumers' trusted choice as an intermediary in consumer-driven health care, “we need consistent standards of measurement and transparency in cost and quality,” he concluded.

WASHINGTON — Although consumer-driven health care puts much more decision making in the hands of consumers, there is still a role for employers and insurers, several speakers said at a meeting on health care competition sponsored by Health Affairs journal and the Center for Studying Health System Change.

Employers will have a role because “as there's labor competition for offering health benefits, we have to offer health plans,” said Dr. Robert Galvin, director of corporate health care programs for General Electric. “You're going to see much more [emphasis] on financial incentives for employees staying healthy and making [good] choices on doctors and hospitals and health plans.”

Another role for employers—although it gets denigrated a bit—is providing access to meaningful, usable, and accurate information “as long as the market isn't working on its own, and it certainly isn't today,” Dr. Galvin said. “This is a responsibility of ours to keep driving at.”

He noted that within GE, officials believe “if information is not readable, it isn't going to be read.” In light of that philosophy, the company has come up with a “health index” that tells employees things such as how healthy they are, compared with how healthy they want to be; how much money is in their wellness account; and when it's time to schedule their children's physicals.

Although employers can act as intermediaries, insurers also have a role, said Dr. Samuel Nussbaum, executive vice president and chief medical officer at WellPoint Inc., a multistate Blue Cross and Blue Shield company based in Indianapolis. One of their roles is to make consumers more aware of how much their choices are costing them.

“Most Americans consider health care an entitlement, not a consumer product,” Dr. Nussbaum said. “And consumers are insulated from the true costs of health care services and products. So a prerequisite for health care competition is to have accurate, usable information about cost and quality.”

Insurers also can help steer patients to higher-quality providers, and that means making sure the networks they are in are of high quality, he continued. “It's not effective enough to have 20% high-quality providers because [consumers] can't all get to those high-quality providers … [or] travel around the country for care.”

In addition to helping consumers with purchasing decisions, WellPoint also tries to help consumers decide on treatments by making evidence available on its Web site. “We do this with academic physicians and specialty societies,” Dr. Nussbaum said.

Health plans also can make it beneficial to consumers to get more information, he said. For example, in one of WellPoint's consumer-driven health plans that uses a health reimbursement account, “we pay consumers more to take health risk assessments, we pay them more to enroll in personal health coaching programs in disease and care management, and we pay them more to graduate.”

And the early results are promising. “You can see the reduction in pharmacy costs of 15% and an increase in preventive care spending; 5% of total medical expenses are going to preventive services rather than only 2% or 3%,” he said.

WellPoint also has a database patients can consult when they are about to undergo a procedure. “You can go online and learn about a condition and compare hospital quality, so if you are in Los Angeles and require bypass graft surgery, you can find out whether it should be done at UCLA Medical Center or Cedars-Sinai, how many procedures they do, and what their outcomes are,” Dr. Nussbaum said.

To be the consumers' trusted choice as an intermediary in consumer-driven health care, “we need consistent standards of measurement and transparency in cost and quality,” he concluded.

WASHINGTON — Although consumer-driven health care puts much more decision making in the hands of consumers, there is still a role for employers and insurers, several speakers said at a meeting on health care competition sponsored by Health Affairs journal and the Center for Studying Health System Change.

Employers will have a role because “as there's labor competition for offering health benefits, we have to offer health plans,” said Dr. Robert Galvin, director of corporate health care programs for General Electric. “You're going to see much more [emphasis] on financial incentives for employees staying healthy and making [good] choices on doctors and hospitals and health plans.”

Another role for employers—although it gets denigrated a bit—is providing access to meaningful, usable, and accurate information “as long as the market isn't working on its own, and it certainly isn't today,” Dr. Galvin said. “This is a responsibility of ours to keep driving at.”

He noted that within GE, officials believe “if information is not readable, it isn't going to be read.” In light of that philosophy, the company has come up with a “health index” that tells employees things such as how healthy they are, compared with how healthy they want to be; how much money is in their wellness account; and when it's time to schedule their children's physicals.

Although employers can act as intermediaries, insurers also have a role, said Dr. Samuel Nussbaum, executive vice president and chief medical officer at WellPoint Inc., a multistate Blue Cross and Blue Shield company based in Indianapolis. One of their roles is to make consumers more aware of how much their choices are costing them.

“Most Americans consider health care an entitlement, not a consumer product,” Dr. Nussbaum said. “And consumers are insulated from the true costs of health care services and products. So a prerequisite for health care competition is to have accurate, usable information about cost and quality.”

Insurers also can help steer patients to higher-quality providers, and that means making sure the networks they are in are of high quality, he continued. “It's not effective enough to have 20% high-quality providers because [consumers] can't all get to those high-quality providers … [or] travel around the country for care.”

In addition to helping consumers with purchasing decisions, WellPoint also tries to help consumers decide on treatments by making evidence available on its Web site. “We do this with academic physicians and specialty societies,” Dr. Nussbaum said.

Health plans also can make it beneficial to consumers to get more information, he said. For example, in one of WellPoint's consumer-driven health plans that uses a health reimbursement account, “we pay consumers more to take health risk assessments, we pay them more to enroll in personal health coaching programs in disease and care management, and we pay them more to graduate.”

And the early results are promising. “You can see the reduction in pharmacy costs of 15% and an increase in preventive care spending; 5% of total medical expenses are going to preventive services rather than only 2% or 3%,” he said.

WellPoint also has a database patients can consult when they are about to undergo a procedure. “You can go online and learn about a condition and compare hospital quality, so if you are in Los Angeles and require bypass graft surgery, you can find out whether it should be done at UCLA Medical Center or Cedars-Sinai, how many procedures they do, and what their outcomes are,” Dr. Nussbaum said.

To be the consumers' trusted choice as an intermediary in consumer-driven health care, “we need consistent standards of measurement and transparency in cost and quality,” he concluded.

The fill rate for internal medicine positions increased slightly for this year's resident match, but the American College of Physicians remained concerned about what appeared to be a decreased level of interest in general internal medicine.

This year, 4,735 internal medicine residency positions were offered. Of those, 97.9% were filled, with slightly more than half—56.3%—filled by U.S. medical graduates. In 2005, 97.2% of slots were filled, although a slightly higher number of positions were offered (4,768).

“We're not as much concerned about internal medicine overall if you look at all the subspecialties,” said Dr. Steven E. Weinberger, senior vice president for medical knowledge and education at the American College of Physicians, in Philadelphia. “The concern is with the number of people going into primary care.”

Match Day itself doesn't reveal how many medical students plan to go into internal medicine subspecialties instead of primary care, “in part because a lot of them don't know yet,” Dr. Weinberger noted.

But the ACP also gives residents a questionnaire asking about their plans. “In 1998, 54% of graduating residents were choosing to go into general internal medicine. The comparable number for residents graduating in 2005 was only 20%,” he said. “With the aging of Baby Boomers who have more complex chronic diseases, it's going to be harder to find people to coordinate their care, so that's going to be a concern.”

As for the relatively low number of U.S. graduates choosing internal medicine, Dr. Weinberger said there were two reasons for that. “One is financial: It tends to be procedural-based specialties and subspecialties that have much higher reimbursement rates than primary care,” he said. “The so-called cognitive specialties have not been reimbursed as well, which is part of our whole dysfunctional payment system.”

Perceived lifestyle issues also play a part. “Medical students are going into things they view as having more regular hours and a better lifestyle,” he said. “Some of that is attributed to 'Generation Y' having a different set of values and priorities than an older generation of physicians had. I don't know whether that is truly the case or not, but people do say lifestyle is an issue.”

That view was echoed by the National Resident Matching Program (NRMP), which runs Match Day. In a statement, NRMP noted that graduates continued their increasing interest in “lifestyle” specialties that are considered to have more reasonable work hours. For example, 100% of first-year dermatology residency slots were filled, with U.S. seniors filling 93.3% of the slots. In anesthesiology, 97% of the positions were filled, including more than 80% by U.S. seniors.

The ACP is trying to address some of these issues, Dr. Weinberger said. First, the college is developing the concept of the “advanced medical home,” which would identify physicians who can provide comprehensive care for chronically ill complex patients. These physicians work in teams that coordinate all care for these patients, integrating an understanding of cardiology problems, gastrointestinal problems, and other conditions. The concept includes an endorsement of reimbursement changes to help provide funding for these practices, he said.

The ACP is not the only organization concerned about primary care reimbursement. The American Academy of Family Physicians is working with the Centers for Medicare and Medicaid Services to increase the number of relative value units Medicare assigns to evaluation and management codes; that would increase the payment rates for many services provided to Medicare beneficiaries, said AAFP President Larry Fields. “We hope to see some efforts come to fruition fairly soon.”

The ACP also is beginning to redesign internal medicine outpatient training, Dr. Weinberger said. “When residents go through training, they don't have particularly good ambulatory experiences.”

One issue is that outpatient training is only one afternoon a week. To go to the outpatient clinic, residents must leave the inpatients they are caring for, which leaves many feeling conflicted and wanting to just get the clinic over with, Dr. Weinberger said. “If they don't have a great ambulatory experience during training, they are less likely to want to go into it.”

Another possible factor in the declining interest in primary care careers has been the rise of hospitalists, he added. “Of the people not interested in a specialty, a reasonable number are deciding to go into hospital medicine versus ambulatory medicine.” In the resident survey, 12% of respondents said they were planning to become hospitalists, compared with 20% who said they would go into general internal medicine. “So [the hospitalists] are catching up.”

Overall, more than 26,000 seniors graduating from medical schools—including more than 15,000 U.S. seniors—participated in the match. Nearly 22% of available slots were in internal medicine, making it the largest specialty, according to the NRMP. Family practice had 2,711 slots; 85.1% of those were filled, a slight increase over last year. The filled positions include 41.4% filled by U.S. seniors.

Pediatrics was also popular, with 96.5% of its 2,288 slots filled; 72.9% were filled by U.S. seniors. And ob.gyn. continued its upward trend, with 97.9% of its slots filled, 72.4% of them by U.S. seniors. Otolaryngology was new to the match this year, and got off to a good start: 98% of the 264 slots offered were filled, 92% by U.S. medical school seniors. General surgery also was popular, with all but 1 of its 1,047 slots filled, 83.3% by U.S. seniors.

The fill rate for internal medicine positions increased slightly for this year's resident match, but the American College of Physicians remained concerned about what appeared to be a decreased level of interest in general internal medicine.

This year, 4,735 internal medicine residency positions were offered. Of those, 97.9% were filled, with slightly more than half—56.3%—filled by U.S. medical graduates. In 2005, 97.2% of slots were filled, although a slightly higher number of positions were offered (4,768).

“We're not as much concerned about internal medicine overall if you look at all the subspecialties,” said Dr. Steven E. Weinberger, senior vice president for medical knowledge and education at the American College of Physicians, in Philadelphia. “The concern is with the number of people going into primary care.”

Match Day itself doesn't reveal how many medical students plan to go into internal medicine subspecialties instead of primary care, “in part because a lot of them don't know yet,” Dr. Weinberger noted.

But the ACP also gives residents a questionnaire asking about their plans. “In 1998, 54% of graduating residents were choosing to go into general internal medicine. The comparable number for residents graduating in 2005 was only 20%,” he said. “With the aging of Baby Boomers who have more complex chronic diseases, it's going to be harder to find people to coordinate their care, so that's going to be a concern.”

As for the relatively low number of U.S. graduates choosing internal medicine, Dr. Weinberger said there were two reasons for that. “One is financial: It tends to be procedural-based specialties and subspecialties that have much higher reimbursement rates than primary care,” he said. “The so-called cognitive specialties have not been reimbursed as well, which is part of our whole dysfunctional payment system.”

Perceived lifestyle issues also play a part. “Medical students are going into things they view as having more regular hours and a better lifestyle,” he said. “Some of that is attributed to 'Generation Y' having a different set of values and priorities than an older generation of physicians had. I don't know whether that is truly the case or not, but people do say lifestyle is an issue.”

That view was echoed by the National Resident Matching Program (NRMP), which runs Match Day. In a statement, NRMP noted that graduates continued their increasing interest in “lifestyle” specialties that are considered to have more reasonable work hours. For example, 100% of first-year dermatology residency slots were filled, with U.S. seniors filling 93.3% of the slots. In anesthesiology, 97% of the positions were filled, including more than 80% by U.S. seniors.

The ACP is trying to address some of these issues, Dr. Weinberger said. First, the college is developing the concept of the “advanced medical home,” which would identify physicians who can provide comprehensive care for chronically ill complex patients. These physicians work in teams that coordinate all care for these patients, integrating an understanding of cardiology problems, gastrointestinal problems, and other conditions. The concept includes an endorsement of reimbursement changes to help provide funding for these practices, he said.

The ACP is not the only organization concerned about primary care reimbursement. The American Academy of Family Physicians is working with the Centers for Medicare and Medicaid Services to increase the number of relative value units Medicare assigns to evaluation and management codes; that would increase the payment rates for many services provided to Medicare beneficiaries, said AAFP President Larry Fields. “We hope to see some efforts come to fruition fairly soon.”

The ACP also is beginning to redesign internal medicine outpatient training, Dr. Weinberger said. “When residents go through training, they don't have particularly good ambulatory experiences.”

One issue is that outpatient training is only one afternoon a week. To go to the outpatient clinic, residents must leave the inpatients they are caring for, which leaves many feeling conflicted and wanting to just get the clinic over with, Dr. Weinberger said. “If they don't have a great ambulatory experience during training, they are less likely to want to go into it.”

Another possible factor in the declining interest in primary care careers has been the rise of hospitalists, he added. “Of the people not interested in a specialty, a reasonable number are deciding to go into hospital medicine versus ambulatory medicine.” In the resident survey, 12% of respondents said they were planning to become hospitalists, compared with 20% who said they would go into general internal medicine. “So [the hospitalists] are catching up.”

Overall, more than 26,000 seniors graduating from medical schools—including more than 15,000 U.S. seniors—participated in the match. Nearly 22% of available slots were in internal medicine, making it the largest specialty, according to the NRMP. Family practice had 2,711 slots; 85.1% of those were filled, a slight increase over last year. The filled positions include 41.4% filled by U.S. seniors.

Pediatrics was also popular, with 96.5% of its 2,288 slots filled; 72.9% were filled by U.S. seniors. And ob.gyn. continued its upward trend, with 97.9% of its slots filled, 72.4% of them by U.S. seniors. Otolaryngology was new to the match this year, and got off to a good start: 98% of the 264 slots offered were filled, 92% by U.S. medical school seniors. General surgery also was popular, with all but 1 of its 1,047 slots filled, 83.3% by U.S. seniors.

The fill rate for internal medicine positions increased slightly for this year's resident match, but the American College of Physicians remained concerned about what appeared to be a decreased level of interest in general internal medicine.

This year, 4,735 internal medicine residency positions were offered. Of those, 97.9% were filled, with slightly more than half—56.3%—filled by U.S. medical graduates. In 2005, 97.2% of slots were filled, although a slightly higher number of positions were offered (4,768).

“We're not as much concerned about internal medicine overall if you look at all the subspecialties,” said Dr. Steven E. Weinberger, senior vice president for medical knowledge and education at the American College of Physicians, in Philadelphia. “The concern is with the number of people going into primary care.”

Match Day itself doesn't reveal how many medical students plan to go into internal medicine subspecialties instead of primary care, “in part because a lot of them don't know yet,” Dr. Weinberger noted.

But the ACP also gives residents a questionnaire asking about their plans. “In 1998, 54% of graduating residents were choosing to go into general internal medicine. The comparable number for residents graduating in 2005 was only 20%,” he said. “With the aging of Baby Boomers who have more complex chronic diseases, it's going to be harder to find people to coordinate their care, so that's going to be a concern.”

As for the relatively low number of U.S. graduates choosing internal medicine, Dr. Weinberger said there were two reasons for that. “One is financial: It tends to be procedural-based specialties and subspecialties that have much higher reimbursement rates than primary care,” he said. “The so-called cognitive specialties have not been reimbursed as well, which is part of our whole dysfunctional payment system.”

Perceived lifestyle issues also play a part. “Medical students are going into things they view as having more regular hours and a better lifestyle,” he said. “Some of that is attributed to 'Generation Y' having a different set of values and priorities than an older generation of physicians had. I don't know whether that is truly the case or not, but people do say lifestyle is an issue.”

That view was echoed by the National Resident Matching Program (NRMP), which runs Match Day. In a statement, NRMP noted that graduates continued their increasing interest in “lifestyle” specialties that are considered to have more reasonable work hours. For example, 100% of first-year dermatology residency slots were filled, with U.S. seniors filling 93.3% of the slots. In anesthesiology, 97% of the positions were filled, including more than 80% by U.S. seniors.

The ACP is trying to address some of these issues, Dr. Weinberger said. First, the college is developing the concept of the “advanced medical home,” which would identify physicians who can provide comprehensive care for chronically ill complex patients. These physicians work in teams that coordinate all care for these patients, integrating an understanding of cardiology problems, gastrointestinal problems, and other conditions. The concept includes an endorsement of reimbursement changes to help provide funding for these practices, he said.

The ACP is not the only organization concerned about primary care reimbursement. The American Academy of Family Physicians is working with the Centers for Medicare and Medicaid Services to increase the number of relative value units Medicare assigns to evaluation and management codes; that would increase the payment rates for many services provided to Medicare beneficiaries, said AAFP President Larry Fields. “We hope to see some efforts come to fruition fairly soon.”

The ACP also is beginning to redesign internal medicine outpatient training, Dr. Weinberger said. “When residents go through training, they don't have particularly good ambulatory experiences.”

One issue is that outpatient training is only one afternoon a week. To go to the outpatient clinic, residents must leave the inpatients they are caring for, which leaves many feeling conflicted and wanting to just get the clinic over with, Dr. Weinberger said. “If they don't have a great ambulatory experience during training, they are less likely to want to go into it.”

Another possible factor in the declining interest in primary care careers has been the rise of hospitalists, he added. “Of the people not interested in a specialty, a reasonable number are deciding to go into hospital medicine versus ambulatory medicine.” In the resident survey, 12% of respondents said they were planning to become hospitalists, compared with 20% who said they would go into general internal medicine. “So [the hospitalists] are catching up.”

Overall, more than 26,000 seniors graduating from medical schools—including more than 15,000 U.S. seniors—participated in the match. Nearly 22% of available slots were in internal medicine, making it the largest specialty, according to the NRMP. Family practice had 2,711 slots; 85.1% of those were filled, a slight increase over last year. The filled positions include 41.4% filled by U.S. seniors.

Pediatrics was also popular, with 96.5% of its 2,288 slots filled; 72.9% were filled by U.S. seniors. And ob.gyn. continued its upward trend, with 97.9% of its slots filled, 72.4% of them by U.S. seniors. Otolaryngology was new to the match this year, and got off to a good start: 98% of the 264 slots offered were filled, 92% by U.S. medical school seniors. General surgery also was popular, with all but 1 of its 1,047 slots filled, 83.3% by U.S. seniors.

WASHINGTON — The lists of "best doctors" published in magazines may not be all they're cracked up to be, several speakers said at a health care competition conference sponsored by Health Affairs journal and the Center for Studying Health System Change.

"Outcomes are much more difficult to measure in health care" than in other industries like auto repair or roofing, said Robert Krughoff, president and founder of the Center for the Study of Services, which publishes the service-rating magazine "Consumers' Checkbook" in several cities nationwide. "Consumers know right away if [the plumber is good]. With a health care provider, they may not know until 5 or 10 years out."

Further, an outcome cannot always be attributed to the intervention of the health care provider, he said. And because of health insurance, consumers often are insulated from the true costs of care, so it's hard to talk about who provides the best value for the money.

Taking a regional approach to physician rating could have value, Mr. Krughoff suggested. "Patients would report their experience with physicians—they would tell how well the physician listens, how well he or she coordinates care, and whether they are good at working with patients to devise acceptable prevention behaviors," he said.

The cost of doing such a survey would be a concern, but Mr. Krughoff said he thought it could be done for less than $200 per physician and it wouldn't have to be done annually, although a physician should be able to pay for a re-survey if he or she made improvements to the practice.

Tom Scully, former administrator of the Centers for Medicare and Medicaid Services, agreed that information is key to getting patients involved as consumers.

"The health care system is pitiful when it comes to public information," said Mr. Scully, now senior counsel at Alston & Bird LLP, a Washington law firm. "As much as people avoid it and fight it, it works to change behavior. I've never run across any instance where providers, as much as they didn't like it when they were forced to share information, didn't come back a year or two later and say, 'You know what? It's worked out pretty well, it's changed my behavior, and it wasn't that difficult after all.'"

While health care will never be a pure market economy, "in some sense supply and demand will help, and there is no way to have supply and demand if you don't send consumers information and give them some understanding of what they're buying and what the relative price and quality is," Mr. Scully said. The problem is getting providers to provide the information, and the best way to do that is with monetary incentives.

For example, when CMS wanted hospitals to voluntarily report on 10 quality measures, "we put through a little teeny thing [into the Medicare budget legislation] that said, 'It's totally voluntary; you don't have to give us the 10 measures, but if you don't, we'll volunteer to pay four-tenths of a percent less of the market-basket rate" for hospital costs, he said. "We went from zero compliance to 99% compliance in a year. I personally believe as a Republican that you shouldn't mandate anything—just voluntarily pay people less if they don't behave right."

That may work for health care providers, but the health care industry alone can't make patients better consumers, said Bernard Tyson, senior vice president for brand strategy and management for Kaiser Foundation Health Plan. "There isn't a health care system in place today that can support that kind of consumer interaction and behavior," he said. "It will take forces outside the industry itself to enforce that change. Two outside forces that can really help move this are government and employers."

One thing that must be done is to "demystify" the health care industry, Mr. Tyson continued. "The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value."

WASHINGTON — The lists of "best doctors" published in magazines may not be all they're cracked up to be, several speakers said at a health care competition conference sponsored by Health Affairs journal and the Center for Studying Health System Change.

"Outcomes are much more difficult to measure in health care" than in other industries like auto repair or roofing, said Robert Krughoff, president and founder of the Center for the Study of Services, which publishes the service-rating magazine "Consumers' Checkbook" in several cities nationwide. "Consumers know right away if [the plumber is good]. With a health care provider, they may not know until 5 or 10 years out."

Further, an outcome cannot always be attributed to the intervention of the health care provider, he said. And because of health insurance, consumers often are insulated from the true costs of care, so it's hard to talk about who provides the best value for the money.

Taking a regional approach to physician rating could have value, Mr. Krughoff suggested. "Patients would report their experience with physicians—they would tell how well the physician listens, how well he or she coordinates care, and whether they are good at working with patients to devise acceptable prevention behaviors," he said.

The cost of doing such a survey would be a concern, but Mr. Krughoff said he thought it could be done for less than $200 per physician and it wouldn't have to be done annually, although a physician should be able to pay for a re-survey if he or she made improvements to the practice.

Tom Scully, former administrator of the Centers for Medicare and Medicaid Services, agreed that information is key to getting patients involved as consumers.

"The health care system is pitiful when it comes to public information," said Mr. Scully, now senior counsel at Alston & Bird LLP, a Washington law firm. "As much as people avoid it and fight it, it works to change behavior. I've never run across any instance where providers, as much as they didn't like it when they were forced to share information, didn't come back a year or two later and say, 'You know what? It's worked out pretty well, it's changed my behavior, and it wasn't that difficult after all.'"

While health care will never be a pure market economy, "in some sense supply and demand will help, and there is no way to have supply and demand if you don't send consumers information and give them some understanding of what they're buying and what the relative price and quality is," Mr. Scully said. The problem is getting providers to provide the information, and the best way to do that is with monetary incentives.

For example, when CMS wanted hospitals to voluntarily report on 10 quality measures, "we put through a little teeny thing [into the Medicare budget legislation] that said, 'It's totally voluntary; you don't have to give us the 10 measures, but if you don't, we'll volunteer to pay four-tenths of a percent less of the market-basket rate" for hospital costs, he said. "We went from zero compliance to 99% compliance in a year. I personally believe as a Republican that you shouldn't mandate anything—just voluntarily pay people less if they don't behave right."

That may work for health care providers, but the health care industry alone can't make patients better consumers, said Bernard Tyson, senior vice president for brand strategy and management for Kaiser Foundation Health Plan. "There isn't a health care system in place today that can support that kind of consumer interaction and behavior," he said. "It will take forces outside the industry itself to enforce that change. Two outside forces that can really help move this are government and employers."

One thing that must be done is to "demystify" the health care industry, Mr. Tyson continued. "The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value."

WASHINGTON — The lists of "best doctors" published in magazines may not be all they're cracked up to be, several speakers said at a health care competition conference sponsored by Health Affairs journal and the Center for Studying Health System Change.

"Outcomes are much more difficult to measure in health care" than in other industries like auto repair or roofing, said Robert Krughoff, president and founder of the Center for the Study of Services, which publishes the service-rating magazine "Consumers' Checkbook" in several cities nationwide. "Consumers know right away if [the plumber is good]. With a health care provider, they may not know until 5 or 10 years out."

Further, an outcome cannot always be attributed to the intervention of the health care provider, he said. And because of health insurance, consumers often are insulated from the true costs of care, so it's hard to talk about who provides the best value for the money.

Taking a regional approach to physician rating could have value, Mr. Krughoff suggested. "Patients would report their experience with physicians—they would tell how well the physician listens, how well he or she coordinates care, and whether they are good at working with patients to devise acceptable prevention behaviors," he said.

The cost of doing such a survey would be a concern, but Mr. Krughoff said he thought it could be done for less than $200 per physician and it wouldn't have to be done annually, although a physician should be able to pay for a re-survey if he or she made improvements to the practice.

Tom Scully, former administrator of the Centers for Medicare and Medicaid Services, agreed that information is key to getting patients involved as consumers.

"The health care system is pitiful when it comes to public information," said Mr. Scully, now senior counsel at Alston & Bird LLP, a Washington law firm. "As much as people avoid it and fight it, it works to change behavior. I've never run across any instance where providers, as much as they didn't like it when they were forced to share information, didn't come back a year or two later and say, 'You know what? It's worked out pretty well, it's changed my behavior, and it wasn't that difficult after all.'"

While health care will never be a pure market economy, "in some sense supply and demand will help, and there is no way to have supply and demand if you don't send consumers information and give them some understanding of what they're buying and what the relative price and quality is," Mr. Scully said. The problem is getting providers to provide the information, and the best way to do that is with monetary incentives.

For example, when CMS wanted hospitals to voluntarily report on 10 quality measures, "we put through a little teeny thing [into the Medicare budget legislation] that said, 'It's totally voluntary; you don't have to give us the 10 measures, but if you don't, we'll volunteer to pay four-tenths of a percent less of the market-basket rate" for hospital costs, he said. "We went from zero compliance to 99% compliance in a year. I personally believe as a Republican that you shouldn't mandate anything—just voluntarily pay people less if they don't behave right."

That may work for health care providers, but the health care industry alone can't make patients better consumers, said Bernard Tyson, senior vice president for brand strategy and management for Kaiser Foundation Health Plan. "There isn't a health care system in place today that can support that kind of consumer interaction and behavior," he said. "It will take forces outside the industry itself to enforce that change. Two outside forces that can really help move this are government and employers."

One thing that must be done is to "demystify" the health care industry, Mr. Tyson continued. "The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value."

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.

Outpatient costs rose significantly last year, Mr. Rodgers said. "Those are the services that are really growing rapidly." The increase in outpatient services accounted for more than a third of the 8.8% increase in premiums, he noted.

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 due to consumers having to pay more for their health care costs and becoming more aware of prices as a result, he 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.

Outpatient costs rose significantly last year, Mr. Rodgers said. "Those are the services that are really growing rapidly." The increase in outpatient services accounted for more than a third of the 8.8% increase in premiums, he noted.

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 due to consumers having to pay more for their health care costs and becoming more aware of prices as a result, he 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.

Outpatient costs rose significantly last year, Mr. Rodgers said. "Those are the services that are really growing rapidly." The increase in outpatient services accounted for more than a third of the 8.8% increase in premiums, he noted.

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 due to consumers having to pay more for their health care costs and becoming more aware of prices as a result, he added.

WASHINGTON — Drugs like BiDil that target a particular racial or ethnic group do not represent the best approach for looking at health disparities, Dr. Francis S. Collins said at a meeting sponsored by the Department of Health and Human Services and the Office of Minority Health.

"It is a good thing that we have a drug that treats individuals with congestive heart failure and clearly improves their survival," said Dr. Collins, director of the National Human Genome Research Institute, in Bethesda, Md. "But are we sure that this came about in a way that actually makes the most sense? Are we sure this drug would not have benefited other groups?"

Although the original clinical trial for BiDil (fixed-dose isosorbide dinitrate and hydralazine) appeared to show that only African Americans clearly benefited from the drug, "it was a relatively modest-sized study, and there could very well have been some benefit in others," Dr. Collins said. "Are we sure that this has anything to do with being African American, or could it be that since African Americans tend to have heart failure on the basis of hypertension, that this [study] says this drug works for hypertensive heart failure and not as well for heart failure from coronary artery disease, which is perhaps more common in other groups?"

With the responders lumped into the category of a racial group, "there's a real risk that this will be interpreted as, 'Oh, well, that means black people really are biologically different. After all, there is this drug that only works for them,'" said Dr. Collins. "That is unjustified by the science that's been done here."

More drugs like BiDil may be coming, but "I don't think this is where we want to go," he said. "I think we want to go in the direction of figuring out, 'Okay, if this drug works for some people and not others, why is that? What specific DNA variants are responsible for the variation in response?' Let's check the individuals and find out whether they're likely to respond to the drug or not, and not use this very murky and potentially misleading and damaging proxy called race, and pretend that we're practicing really upscale medicine."

Part of the problem with using racial groups to explain health disparities is that race is hard to define, Dr. Collins noted. "First you have to decide exactly what you mean by race. Race has so much baggage; it carries with it connotations of history and discrimination, culture and society, and dietary practices. It carries a little bit of ancestral geography, of course, but that is probably in the minority of what most people are actually thinking of when the term race appears in the census," he said.

Another problem with separating people into races is that the genetic makeup of all humans is actually quite similar, said Dr. Collins, who leads the Human Genome Project. He noted that people are 99.9% the same, genetically speaking.

"We are much more alike … than most other species on the planet. There's more diversity in a small group of chimpanzees living on one hillside than there is in the entire human race, because we're so new on the scene."

Most of the variation in the human genome over the last 100,000 years "relates to the ways in which those genes were spread as those people migrated out of Africa," he said. And while genomics may play a role in the reasons for health disparities, "it is almost always in concert with environmental factors."

When new mutations have occurred, for the most part they appear and then disappear, according to Dr. Collins. One exception to that, however, is any mutation that gave people a selective advantage. Skin color is an example.

"If you're dark skinned in a northern climate where there's not as much sun exposure, you're likely to get rickets, and someone with rickets will have a difficult time in childbirth," he said. "Whereas, if you have light skin at the equator, you're going to end up with a very high risk of skin cancer."

The way that lighter-skinned people evolved from their starting point as black Africans just proves the fact that "we white people are actually mutants," he added.

Now that the Human Genome Project and other private groups have decoded the human genome, researchers are focusing on the 0.1% of the genome that varies among individuals.

Dr. Collins is currently managing the International HapMap Project, a cooperative effort among researchers in six countries to build a catalog of human genetic variation.

Information on the International HapMap Project can be found online at www.hapmap.org

WASHINGTON — Drugs like BiDil that target a particular racial or ethnic group do not represent the best approach for looking at health disparities, Dr. Francis S. Collins said at a meeting sponsored by the Department of Health and Human Services and the Office of Minority Health.

"It is a good thing that we have a drug that treats individuals with congestive heart failure and clearly improves their survival," said Dr. Collins, director of the National Human Genome Research Institute, in Bethesda, Md. "But are we sure that this came about in a way that actually makes the most sense? Are we sure this drug would not have benefited other groups?"

Although the original clinical trial for BiDil (fixed-dose isosorbide dinitrate and hydralazine) appeared to show that only African Americans clearly benefited from the drug, "it was a relatively modest-sized study, and there could very well have been some benefit in others," Dr. Collins said. "Are we sure that this has anything to do with being African American, or could it be that since African Americans tend to have heart failure on the basis of hypertension, that this [study] says this drug works for hypertensive heart failure and not as well for heart failure from coronary artery disease, which is perhaps more common in other groups?"

With the responders lumped into the category of a racial group, "there's a real risk that this will be interpreted as, 'Oh, well, that means black people really are biologically different. After all, there is this drug that only works for them,'" said Dr. Collins. "That is unjustified by the science that's been done here."

More drugs like BiDil may be coming, but "I don't think this is where we want to go," he said. "I think we want to go in the direction of figuring out, 'Okay, if this drug works for some people and not others, why is that? What specific DNA variants are responsible for the variation in response?' Let's check the individuals and find out whether they're likely to respond to the drug or not, and not use this very murky and potentially misleading and damaging proxy called race, and pretend that we're practicing really upscale medicine."

Part of the problem with using racial groups to explain health disparities is that race is hard to define, Dr. Collins noted. "First you have to decide exactly what you mean by race. Race has so much baggage; it carries with it connotations of history and discrimination, culture and society, and dietary practices. It carries a little bit of ancestral geography, of course, but that is probably in the minority of what most people are actually thinking of when the term race appears in the census," he said.

Another problem with separating people into races is that the genetic makeup of all humans is actually quite similar, said Dr. Collins, who leads the Human Genome Project. He noted that people are 99.9% the same, genetically speaking.

"We are much more alike … than most other species on the planet. There's more diversity in a small group of chimpanzees living on one hillside than there is in the entire human race, because we're so new on the scene."

Most of the variation in the human genome over the last 100,000 years "relates to the ways in which those genes were spread as those people migrated out of Africa," he said. And while genomics may play a role in the reasons for health disparities, "it is almost always in concert with environmental factors."

When new mutations have occurred, for the most part they appear and then disappear, according to Dr. Collins. One exception to that, however, is any mutation that gave people a selective advantage. Skin color is an example.

"If you're dark skinned in a northern climate where there's not as much sun exposure, you're likely to get rickets, and someone with rickets will have a difficult time in childbirth," he said. "Whereas, if you have light skin at the equator, you're going to end up with a very high risk of skin cancer."

The way that lighter-skinned people evolved from their starting point as black Africans just proves the fact that "we white people are actually mutants," he added.

Now that the Human Genome Project and other private groups have decoded the human genome, researchers are focusing on the 0.1% of the genome that varies among individuals.

Dr. Collins is currently managing the International HapMap Project, a cooperative effort among researchers in six countries to build a catalog of human genetic variation.

Information on the International HapMap Project can be found online at www.hapmap.org

WASHINGTON — Drugs like BiDil that target a particular racial or ethnic group do not represent the best approach for looking at health disparities, Dr. Francis S. Collins said at a meeting sponsored by the Department of Health and Human Services and the Office of Minority Health.

"It is a good thing that we have a drug that treats individuals with congestive heart failure and clearly improves their survival," said Dr. Collins, director of the National Human Genome Research Institute, in Bethesda, Md. "But are we sure that this came about in a way that actually makes the most sense? Are we sure this drug would not have benefited other groups?"

Although the original clinical trial for BiDil (fixed-dose isosorbide dinitrate and hydralazine) appeared to show that only African Americans clearly benefited from the drug, "it was a relatively modest-sized study, and there could very well have been some benefit in others," Dr. Collins said. "Are we sure that this has anything to do with being African American, or could it be that since African Americans tend to have heart failure on the basis of hypertension, that this [study] says this drug works for hypertensive heart failure and not as well for heart failure from coronary artery disease, which is perhaps more common in other groups?"

With the responders lumped into the category of a racial group, "there's a real risk that this will be interpreted as, 'Oh, well, that means black people really are biologically different. After all, there is this drug that only works for them,'" said Dr. Collins. "That is unjustified by the science that's been done here."

More drugs like BiDil may be coming, but "I don't think this is where we want to go," he said. "I think we want to go in the direction of figuring out, 'Okay, if this drug works for some people and not others, why is that? What specific DNA variants are responsible for the variation in response?' Let's check the individuals and find out whether they're likely to respond to the drug or not, and not use this very murky and potentially misleading and damaging proxy called race, and pretend that we're practicing really upscale medicine."

Part of the problem with using racial groups to explain health disparities is that race is hard to define, Dr. Collins noted. "First you have to decide exactly what you mean by race. Race has so much baggage; it carries with it connotations of history and discrimination, culture and society, and dietary practices. It carries a little bit of ancestral geography, of course, but that is probably in the minority of what most people are actually thinking of when the term race appears in the census," he said.

Another problem with separating people into races is that the genetic makeup of all humans is actually quite similar, said Dr. Collins, who leads the Human Genome Project. He noted that people are 99.9% the same, genetically speaking.

"We are much more alike … than most other species on the planet. There's more diversity in a small group of chimpanzees living on one hillside than there is in the entire human race, because we're so new on the scene."

Most of the variation in the human genome over the last 100,000 years "relates to the ways in which those genes were spread as those people migrated out of Africa," he said. And while genomics may play a role in the reasons for health disparities, "it is almost always in concert with environmental factors."

When new mutations have occurred, for the most part they appear and then disappear, according to Dr. Collins. One exception to that, however, is any mutation that gave people a selective advantage. Skin color is an example.

"If you're dark skinned in a northern climate where there's not as much sun exposure, you're likely to get rickets, and someone with rickets will have a difficult time in childbirth," he said. "Whereas, if you have light skin at the equator, you're going to end up with a very high risk of skin cancer."

The way that lighter-skinned people evolved from their starting point as black Africans just proves the fact that "we white people are actually mutants," he added.

Now that the Human Genome Project and other private groups have decoded the human genome, researchers are focusing on the 0.1% of the genome that varies among individuals.

Dr. Collins is currently managing the International HapMap Project, a cooperative effort among researchers in six countries to build a catalog of human genetic variation.

Information on the International HapMap Project can be found online at www.hapmap.org

WASHINGTON — Although consumer-driven health care puts much more decision making in the hands of consumers, employers and insurers still have a role to play, several speakers said at a meeting on health care competition sponsored by Health Affairs journal and the Center for Studying Health System Change.

Employers will have a role because "as there's labor competition for offering health benefits, we have to offer health plans," said Dr. Robert Galvin, director of corporate health care programs for General Electric. "You're going to see much more [emphasis] on financial incentives for employees staying healthy and making [good] choices on doctors and hospitals and health plans."

Another role for employers—although it gets denigrated a bit—is providing access to meaningful, usable, and accurate information "as long as the market isn't working on its own, and it certainly isn't today," Dr. Galvin said. "This is a responsibility of ours to keep driving at."

He noted that within GE, officials believe "if information is not readable, it isn't going to be read." In light of that philosophy, the company has come up with a "health index" that tells employees things such as how healthy they are, compared with how healthy they want to be; how much money is in their wellness account; and when it's time to schedule their children's physicals. It also can include a scorecard about the providers they use.

This information could be integrated into employee e-mail accounts—a sort of "You've Got Health" idea, Dr. Galvin said. "It's not that this is information you don't know about, it's that it's more usable because it's part of people's everyday life."

Although employers can act as intermediaries, insurers also have a role, said Dr. Samuel Nussbaum, executive vice president and chief medical officer at WellPoint Inc., a multistate Blue Cross and Blue Shield company based in Indianapolis. One of their roles is to make consumers more aware of how much their choices are costing them.

"Most Americans consider health care an entitlement, not a consumer product," Dr. Nussbaum said. "And consumers are insulated from the true costs of health care services and products. So a prerequisite for health care competition is to have accurate, usable information about cost and quality."

Insurers also can help steer patients to higher-quality providers, and that means making sure the networks they are in are of high quality, he continued. "It's not effective enough to have 20% high-quality providers because [consumers] can't all get to those high-quality providers … [or] travel around the country for care."

In addition to helping consumers with purchasing decisions, WellPoint also tries to help consumers decide on treatments by making evidence available on its Web site. "We do this with academic physicians and specialty societies," Dr. Nussbaum said.

Health plans also can make it beneficial to consumers to get more information, he said. For example, in one of WellPoint's consumer-driven health plans that uses a health reimbursement account, "we pay consumers more to take health risk assessments, we pay them more to enroll in personal health coaching programs in disease and care management, and we pay them more to graduate."

And the early results are promising. "You can see the reduction in pharmacy costs of 15% and an increase in preventive care spending; 5% of total medical expenses are going to preventive services rather than only 2% or 3%," Dr. Nussbaum said.

WellPoint also has a database patients can consult when they are about to undergo a procedure. "You can go online and learn about a condition and compare hospital quality, so if you are in Los Angeles and require bypass graft surgery, you can find out whether it should be done at UCLA Medical Center or Cedars-Sinai, how many procedures they do, and what their outcomes are."

To be the consumers' trusted choice as an intermediary in consumer-driven health care, "we need consistent standards of measurement and transparency in cost and quality," he concluded. "As we do this and adopt consumer-friendly tools with the right benefit design, and work with delivery systems to be organized around centers of excellence, … we can drive true change in our health care system."

WASHINGTON — Although consumer-driven health care puts much more decision making in the hands of consumers, employers and insurers still have a role to play, several speakers said at a meeting on health care competition sponsored by Health Affairs journal and the Center for Studying Health System Change.

Employers will have a role because "as there's labor competition for offering health benefits, we have to offer health plans," said Dr. Robert Galvin, director of corporate health care programs for General Electric. "You're going to see much more [emphasis] on financial incentives for employees staying healthy and making [good] choices on doctors and hospitals and health plans."

Another role for employers—although it gets denigrated a bit—is providing access to meaningful, usable, and accurate information "as long as the market isn't working on its own, and it certainly isn't today," Dr. Galvin said. "This is a responsibility of ours to keep driving at."

He noted that within GE, officials believe "if information is not readable, it isn't going to be read." In light of that philosophy, the company has come up with a "health index" that tells employees things such as how healthy they are, compared with how healthy they want to be; how much money is in their wellness account; and when it's time to schedule their children's physicals. It also can include a scorecard about the providers they use.

This information could be integrated into employee e-mail accounts—a sort of "You've Got Health" idea, Dr. Galvin said. "It's not that this is information you don't know about, it's that it's more usable because it's part of people's everyday life."

Although employers can act as intermediaries, insurers also have a role, said Dr. Samuel Nussbaum, executive vice president and chief medical officer at WellPoint Inc., a multistate Blue Cross and Blue Shield company based in Indianapolis. One of their roles is to make consumers more aware of how much their choices are costing them.

"Most Americans consider health care an entitlement, not a consumer product," Dr. Nussbaum said. "And consumers are insulated from the true costs of health care services and products. So a prerequisite for health care competition is to have accurate, usable information about cost and quality."

Insurers also can help steer patients to higher-quality providers, and that means making sure the networks they are in are of high quality, he continued. "It's not effective enough to have 20% high-quality providers because [consumers] can't all get to those high-quality providers … [or] travel around the country for care."

In addition to helping consumers with purchasing decisions, WellPoint also tries to help consumers decide on treatments by making evidence available on its Web site. "We do this with academic physicians and specialty societies," Dr. Nussbaum said.

Health plans also can make it beneficial to consumers to get more information, he said. For example, in one of WellPoint's consumer-driven health plans that uses a health reimbursement account, "we pay consumers more to take health risk assessments, we pay them more to enroll in personal health coaching programs in disease and care management, and we pay them more to graduate."

And the early results are promising. "You can see the reduction in pharmacy costs of 15% and an increase in preventive care spending; 5% of total medical expenses are going to preventive services rather than only 2% or 3%," Dr. Nussbaum said.

WellPoint also has a database patients can consult when they are about to undergo a procedure. "You can go online and learn about a condition and compare hospital quality, so if you are in Los Angeles and require bypass graft surgery, you can find out whether it should be done at UCLA Medical Center or Cedars-Sinai, how many procedures they do, and what their outcomes are."

To be the consumers' trusted choice as an intermediary in consumer-driven health care, "we need consistent standards of measurement and transparency in cost and quality," he concluded. "As we do this and adopt consumer-friendly tools with the right benefit design, and work with delivery systems to be organized around centers of excellence, … we can drive true change in our health care system."

WASHINGTON — Although consumer-driven health care puts much more decision making in the hands of consumers, employers and insurers still have a role to play, several speakers said at a meeting on health care competition sponsored by Health Affairs journal and the Center for Studying Health System Change.

Employers will have a role because "as there's labor competition for offering health benefits, we have to offer health plans," said Dr. Robert Galvin, director of corporate health care programs for General Electric. "You're going to see much more [emphasis] on financial incentives for employees staying healthy and making [good] choices on doctors and hospitals and health plans."

Another role for employers—although it gets denigrated a bit—is providing access to meaningful, usable, and accurate information "as long as the market isn't working on its own, and it certainly isn't today," Dr. Galvin said. "This is a responsibility of ours to keep driving at."

He noted that within GE, officials believe "if information is not readable, it isn't going to be read." In light of that philosophy, the company has come up with a "health index" that tells employees things such as how healthy they are, compared with how healthy they want to be; how much money is in their wellness account; and when it's time to schedule their children's physicals. It also can include a scorecard about the providers they use.

This information could be integrated into employee e-mail accounts—a sort of "You've Got Health" idea, Dr. Galvin said. "It's not that this is information you don't know about, it's that it's more usable because it's part of people's everyday life."

Although employers can act as intermediaries, insurers also have a role, said Dr. Samuel Nussbaum, executive vice president and chief medical officer at WellPoint Inc., a multistate Blue Cross and Blue Shield company based in Indianapolis. One of their roles is to make consumers more aware of how much their choices are costing them.

"Most Americans consider health care an entitlement, not a consumer product," Dr. Nussbaum said. "And consumers are insulated from the true costs of health care services and products. So a prerequisite for health care competition is to have accurate, usable information about cost and quality."

Insurers also can help steer patients to higher-quality providers, and that means making sure the networks they are in are of high quality, he continued. "It's not effective enough to have 20% high-quality providers because [consumers] can't all get to those high-quality providers … [or] travel around the country for care."

In addition to helping consumers with purchasing decisions, WellPoint also tries to help consumers decide on treatments by making evidence available on its Web site. "We do this with academic physicians and specialty societies," Dr. Nussbaum said.

Health plans also can make it beneficial to consumers to get more information, he said. For example, in one of WellPoint's consumer-driven health plans that uses a health reimbursement account, "we pay consumers more to take health risk assessments, we pay them more to enroll in personal health coaching programs in disease and care management, and we pay them more to graduate."

And the early results are promising. "You can see the reduction in pharmacy costs of 15% and an increase in preventive care spending; 5% of total medical expenses are going to preventive services rather than only 2% or 3%," Dr. Nussbaum said.

WellPoint also has a database patients can consult when they are about to undergo a procedure. "You can go online and learn about a condition and compare hospital quality, so if you are in Los Angeles and require bypass graft surgery, you can find out whether it should be done at UCLA Medical Center or Cedars-Sinai, how many procedures they do, and what their outcomes are."

To be the consumers' trusted choice as an intermediary in consumer-driven health care, "we need consistent standards of measurement and transparency in cost and quality," he concluded. "As we do this and adopt consumer-friendly tools with the right benefit design, and work with delivery systems to be organized around centers of excellence, … we can drive true change in our health care system."