Joyce Frieden

MONTREAL – Prescribing antidepressants to children comes with its own set of challenges, Dr. Neil S. Kaye said at the annual meeting of the American Academy of Psychiatry and the Law.

For one thing, it's difficult to comply with the visit schedule suggested by the Food and Drug Administration, said Dr. Kaye, a psychiatrist in private practice in Wilmington, Del.

The agency's “Medication Guide: About Using Antidepressants in Children and Teenagers” recommends: “After starting an antidepressant, your child should generally see his or her health care provider:

▸ Once a week for the first 4 weeks.

▸ Every 2 weeks for the next 4 weeks.

▸ After taking the antidepressant for 12 weeks.

▸ More often if problems or questions arise.”

After 12 weeks, “we get to become providers again,” Dr. Kaye said, noting that the visit schedule goes back to whatever the physician thinks is appropriate.

“You'll see it's almost impossible to comply” with that schedule for the first 12 weeks, Dr. Kaye said. “Nobody has enough time slots; there aren't enough doctors available; and managed care does not really want to pay for that.”

Dr. Kaye wrote to one senator complaining about the recommendations. “He said … his office's view after contacting the FDA was that the FDA didn't really intend for that to be what is said and done, even though it's what they've written,” Dr. Kaye said.

Doctors need to make themselves available to parents whose children are taking these drugs, Dr. Kaye continued. “When you look at cases that have been litigated, one of the major issues is doctors and their staffs not returning phone calls in a timely manner,” he said.

“That breeds anger, that breeds malpractice, that breeds bad outcomes. We need to return patients' [and parents'] calls. It sounds simple, but it needs to be said.”

Physicians also need to alert parents that their children may get worse initially, “either because of the drug or because the drug has not yet started and the disorder is still going on,” he said.

“And we need to let everyone know what [side effects] to watch for,” including akathisias, restlessness, and induction of hypomania.

Dr. Kaye noted that the media have really jumped on the story of problems with prescribing antidepressants. “As of Sept. 8, there were more than 3.6 million Internet articles on this topic,” he said. “This is hot.”

Unfortunately, the media have done an effective job of scaring people away from antidepressants, according to Dr. Kaye, who has consulting arrangements with many pharmaceutical companies.

“Twenty-five percent of people surveyed say that antidepressants are harmful to someone who's depressed and suicidal,” Dr. Kaye said. “That's a big number of people who will be driven away from what could be life-saving treatment because of the hype and what the media has done.”

How have physicians responded to the hype? “We're scared,” he said, noting that there has been a big drop in the number of antidepressants being prescribed.

And the number of doctors willing to prescribe them seems to be decreasing as well.

“Pediatricians and primary care doctors are saying, 'This is too litigious; we're not going near this–you have to see a specialist,' Dr. Kaye said. “And of course there aren't enough psychiatrists to take on those patients in a timely manner, so a crisis is being developed, without a doubt.”

A study released last year by Medco Health Systems Inc., the pharmacy benefit manager, showed a 10% dropoff in prescribing antidepressants for patients younger than 18 years in 2004.

Medco reported that no difference was seen in the dropoff rate between primary care physicians and psychiatrists.

MONTREAL – Prescribing antidepressants to children comes with its own set of challenges, Dr. Neil S. Kaye said at the annual meeting of the American Academy of Psychiatry and the Law.

For one thing, it's difficult to comply with the visit schedule suggested by the Food and Drug Administration, said Dr. Kaye, a psychiatrist in private practice in Wilmington, Del.

The agency's “Medication Guide: About Using Antidepressants in Children and Teenagers” recommends: “After starting an antidepressant, your child should generally see his or her health care provider:

▸ Once a week for the first 4 weeks.

▸ Every 2 weeks for the next 4 weeks.

▸ After taking the antidepressant for 12 weeks.

▸ More often if problems or questions arise.”

After 12 weeks, “we get to become providers again,” Dr. Kaye said, noting that the visit schedule goes back to whatever the physician thinks is appropriate.

“You'll see it's almost impossible to comply” with that schedule for the first 12 weeks, Dr. Kaye said. “Nobody has enough time slots; there aren't enough doctors available; and managed care does not really want to pay for that.”

Dr. Kaye wrote to one senator complaining about the recommendations. “He said … his office's view after contacting the FDA was that the FDA didn't really intend for that to be what is said and done, even though it's what they've written,” Dr. Kaye said.

Doctors need to make themselves available to parents whose children are taking these drugs, Dr. Kaye continued. “When you look at cases that have been litigated, one of the major issues is doctors and their staffs not returning phone calls in a timely manner,” he said.

“That breeds anger, that breeds malpractice, that breeds bad outcomes. We need to return patients' [and parents'] calls. It sounds simple, but it needs to be said.”

Physicians also need to alert parents that their children may get worse initially, “either because of the drug or because the drug has not yet started and the disorder is still going on,” he said.

“And we need to let everyone know what [side effects] to watch for,” including akathisias, restlessness, and induction of hypomania.

Dr. Kaye noted that the media have really jumped on the story of problems with prescribing antidepressants. “As of Sept. 8, there were more than 3.6 million Internet articles on this topic,” he said. “This is hot.”

Unfortunately, the media have done an effective job of scaring people away from antidepressants, according to Dr. Kaye, who has consulting arrangements with many pharmaceutical companies.

“Twenty-five percent of people surveyed say that antidepressants are harmful to someone who's depressed and suicidal,” Dr. Kaye said. “That's a big number of people who will be driven away from what could be life-saving treatment because of the hype and what the media has done.”

How have physicians responded to the hype? “We're scared,” he said, noting that there has been a big drop in the number of antidepressants being prescribed.

And the number of doctors willing to prescribe them seems to be decreasing as well.

“Pediatricians and primary care doctors are saying, 'This is too litigious; we're not going near this–you have to see a specialist,' Dr. Kaye said. “And of course there aren't enough psychiatrists to take on those patients in a timely manner, so a crisis is being developed, without a doubt.”

A study released last year by Medco Health Systems Inc., the pharmacy benefit manager, showed a 10% dropoff in prescribing antidepressants for patients younger than 18 years in 2004.

Medco reported that no difference was seen in the dropoff rate between primary care physicians and psychiatrists.

MONTREAL – Prescribing antidepressants to children comes with its own set of challenges, Dr. Neil S. Kaye said at the annual meeting of the American Academy of Psychiatry and the Law.

For one thing, it's difficult to comply with the visit schedule suggested by the Food and Drug Administration, said Dr. Kaye, a psychiatrist in private practice in Wilmington, Del.

The agency's “Medication Guide: About Using Antidepressants in Children and Teenagers” recommends: “After starting an antidepressant, your child should generally see his or her health care provider:

▸ Once a week for the first 4 weeks.

▸ Every 2 weeks for the next 4 weeks.

▸ After taking the antidepressant for 12 weeks.

▸ More often if problems or questions arise.”

After 12 weeks, “we get to become providers again,” Dr. Kaye said, noting that the visit schedule goes back to whatever the physician thinks is appropriate.

“You'll see it's almost impossible to comply” with that schedule for the first 12 weeks, Dr. Kaye said. “Nobody has enough time slots; there aren't enough doctors available; and managed care does not really want to pay for that.”

Dr. Kaye wrote to one senator complaining about the recommendations. “He said … his office's view after contacting the FDA was that the FDA didn't really intend for that to be what is said and done, even though it's what they've written,” Dr. Kaye said.

Doctors need to make themselves available to parents whose children are taking these drugs, Dr. Kaye continued. “When you look at cases that have been litigated, one of the major issues is doctors and their staffs not returning phone calls in a timely manner,” he said.

“That breeds anger, that breeds malpractice, that breeds bad outcomes. We need to return patients' [and parents'] calls. It sounds simple, but it needs to be said.”

Physicians also need to alert parents that their children may get worse initially, “either because of the drug or because the drug has not yet started and the disorder is still going on,” he said.

“And we need to let everyone know what [side effects] to watch for,” including akathisias, restlessness, and induction of hypomania.

Dr. Kaye noted that the media have really jumped on the story of problems with prescribing antidepressants. “As of Sept. 8, there were more than 3.6 million Internet articles on this topic,” he said. “This is hot.”

Unfortunately, the media have done an effective job of scaring people away from antidepressants, according to Dr. Kaye, who has consulting arrangements with many pharmaceutical companies.

“Twenty-five percent of people surveyed say that antidepressants are harmful to someone who's depressed and suicidal,” Dr. Kaye said. “That's a big number of people who will be driven away from what could be life-saving treatment because of the hype and what the media has done.”

How have physicians responded to the hype? “We're scared,” he said, noting that there has been a big drop in the number of antidepressants being prescribed.

And the number of doctors willing to prescribe them seems to be decreasing as well.

“Pediatricians and primary care doctors are saying, 'This is too litigious; we're not going near this–you have to see a specialist,' Dr. Kaye said. “And of course there aren't enough psychiatrists to take on those patients in a timely manner, so a crisis is being developed, without a doubt.”

A study released last year by Medco Health Systems Inc., the pharmacy benefit manager, showed a 10% dropoff in prescribing antidepressants for patients younger than 18 years in 2004.

Medco reported that no difference was seen in the dropoff rate between primary care physicians and psychiatrists.

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 “Consumer's 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.'”

Although health care in this country 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 vital need is to “demystify” the health care industry, Mr. Tyson said. “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 “Consumer's 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.'”

Although health care in this country 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 vital need is to “demystify” the health care industry, Mr. Tyson said. “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 “Consumer's 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.'”

Although health care in this country 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 vital need is to “demystify” the health care industry, Mr. Tyson said. “The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value.”

WASHINGTON — Aiming for computerization of physician order entry at health care institutions isn't the right course to take, Dr. Stephen T. Lawless said at a health care congress sponsored by the Wall Street Journal and CNBC.

"That's the wrong goal," said Dr. Lawless, chief knowledge and quality officer at Nemours, a Wilmington, Del., pediatric subspecialty practice with about 1 million patient encounters per year. "The right goal is NPOE—no physician order entry. Just tell us what you want and we'll have the best person [enter] it for you."

With this caveat, computerized order entry still remains an important tool in reducing medication errors, said Dr. Lawless, also professor of pediatrics at Jefferson Medical College, Philadelphia.

He said that the hospital where he practices—the Alfred I. DuPont Hospital for Children, Wilmington—partnered with a large pharmacy chain and asked the pharmacy to find the errors in the hospital's handwritten prescriptions.

Of handwritten prescriptions, 35%–40% had errors, he said. "Of those, 53% had legibility problems, 36% had issues with completeness, and 11% had content errors."

The hospital's use of electronic prescribing has eliminated legibility errors, but that still leaves the other half of the errors to be resolved, he said. That's where the "decision support" piece comes in, which has encountered some resistance from providers. "We're forcing people by saying, 'You've picked this drug at this time, at this dose, at this range. Thank you very much.' It's very hard to make people do that."

Dr. Lawless said measures such as checklists are resisted by the medical community because "we all think it's about health care professionals being industrialized. I'm saying it's [about] health care craftsmen fighting being professionalized."

WASHINGTON — Aiming for computerization of physician order entry at health care institutions isn't the right course to take, Dr. Stephen T. Lawless said at a health care congress sponsored by the Wall Street Journal and CNBC.

"That's the wrong goal," said Dr. Lawless, chief knowledge and quality officer at Nemours, a Wilmington, Del., pediatric subspecialty practice with about 1 million patient encounters per year. "The right goal is NPOE—no physician order entry. Just tell us what you want and we'll have the best person [enter] it for you."

With this caveat, computerized order entry still remains an important tool in reducing medication errors, said Dr. Lawless, also professor of pediatrics at Jefferson Medical College, Philadelphia.

He said that the hospital where he practices—the Alfred I. DuPont Hospital for Children, Wilmington—partnered with a large pharmacy chain and asked the pharmacy to find the errors in the hospital's handwritten prescriptions.

Of handwritten prescriptions, 35%–40% had errors, he said. "Of those, 53% had legibility problems, 36% had issues with completeness, and 11% had content errors."

The hospital's use of electronic prescribing has eliminated legibility errors, but that still leaves the other half of the errors to be resolved, he said. That's where the "decision support" piece comes in, which has encountered some resistance from providers. "We're forcing people by saying, 'You've picked this drug at this time, at this dose, at this range. Thank you very much.' It's very hard to make people do that."

Dr. Lawless said measures such as checklists are resisted by the medical community because "we all think it's about health care professionals being industrialized. I'm saying it's [about] health care craftsmen fighting being professionalized."

WASHINGTON — Aiming for computerization of physician order entry at health care institutions isn't the right course to take, Dr. Stephen T. Lawless said at a health care congress sponsored by the Wall Street Journal and CNBC.

"That's the wrong goal," said Dr. Lawless, chief knowledge and quality officer at Nemours, a Wilmington, Del., pediatric subspecialty practice with about 1 million patient encounters per year. "The right goal is NPOE—no physician order entry. Just tell us what you want and we'll have the best person [enter] it for you."

With this caveat, computerized order entry still remains an important tool in reducing medication errors, said Dr. Lawless, also professor of pediatrics at Jefferson Medical College, Philadelphia.

He said that the hospital where he practices—the Alfred I. DuPont Hospital for Children, Wilmington—partnered with a large pharmacy chain and asked the pharmacy to find the errors in the hospital's handwritten prescriptions.

Of handwritten prescriptions, 35%–40% had errors, he said. "Of those, 53% had legibility problems, 36% had issues with completeness, and 11% had content errors."

The hospital's use of electronic prescribing has eliminated legibility errors, but that still leaves the other half of the errors to be resolved, he said. That's where the "decision support" piece comes in, which has encountered some resistance from providers. "We're forcing people by saying, 'You've picked this drug at this time, at this dose, at this range. Thank you very much.' It's very hard to make people do that."

Dr. Lawless said measures such as checklists are resisted by the medical community because "we all think it's about health care professionals being industrialized. I'm saying it's [about] health care craftsmen fighting being professionalized."

WASHINGTON — Provider groups are behind the curve when it comes to anticipating acceptance of pay-for-performance programs, Jeff Flick said at a health care congress sponsored by the Wall Street Journal and CNBC.

Take, for instance, the Premier Hospital Quality Incentive Demonstration program funded by the Centers for Medicare and Medicaid Services, under which hospitals report data on 34 quality measures, said Mr. Flick, the CMS regional administrator in San Francisco.

The program gives a bonus each year to the 20% of hospitals with the highest score, but those who have not improved a certain amount after 3 years are penalized, he said.

When the program was launched several years ago, "The American Hospital Association said, 'No hospital is going to do this,'" Mr. Flick said. "Hospitals are afraid to even report information about quality, but the idea that they could be penalized financially … the [AHA] thought it would never happen. But there were 300 hospitals on board immediately."

Similarly, the American Medical Association recently said it did not support CMS's new physician voluntary reporting program, under which physicians would volunteer to report 36 pieces of data on their practices. The AMA's opposition "is not a shock; those kinds of organizations are very nervous about this," said Mr. Flick. "But it is a very important step that CMS is taking, and it is physicians saying, 'I want to report information because I'd like to know if my performance varies in a significant way from my peers.'"

Many physicians are ready to start focusing on quality, he continued. "They want to publish information, they want to know how they compare, they want to be paid based on performance. That doesn't mean the AMA is necessarily going to support it."

The program uses G-codes to enter the data, which can make for a bit of a hassle for physicians not familiar with them. "If every physician in this country had an [electronic health record], this would be easy; I think this would be done," he said. "Today we would be really paying based on performance. Maybe just thinking about the G-codes will drive people into an EHR."

WASHINGTON — Provider groups are behind the curve when it comes to anticipating acceptance of pay-for-performance programs, Jeff Flick said at a health care congress sponsored by the Wall Street Journal and CNBC.

Take, for instance, the Premier Hospital Quality Incentive Demonstration program funded by the Centers for Medicare and Medicaid Services, under which hospitals report data on 34 quality measures, said Mr. Flick, the CMS regional administrator in San Francisco.

The program gives a bonus each year to the 20% of hospitals with the highest score, but those who have not improved a certain amount after 3 years are penalized, he said.

When the program was launched several years ago, "The American Hospital Association said, 'No hospital is going to do this,'" Mr. Flick said. "Hospitals are afraid to even report information about quality, but the idea that they could be penalized financially … the [AHA] thought it would never happen. But there were 300 hospitals on board immediately."

Similarly, the American Medical Association recently said it did not support CMS's new physician voluntary reporting program, under which physicians would volunteer to report 36 pieces of data on their practices. The AMA's opposition "is not a shock; those kinds of organizations are very nervous about this," said Mr. Flick. "But it is a very important step that CMS is taking, and it is physicians saying, 'I want to report information because I'd like to know if my performance varies in a significant way from my peers.'"

Many physicians are ready to start focusing on quality, he continued. "They want to publish information, they want to know how they compare, they want to be paid based on performance. That doesn't mean the AMA is necessarily going to support it."

The program uses G-codes to enter the data, which can make for a bit of a hassle for physicians not familiar with them. "If every physician in this country had an [electronic health record], this would be easy; I think this would be done," he said. "Today we would be really paying based on performance. Maybe just thinking about the G-codes will drive people into an EHR."

WASHINGTON — Provider groups are behind the curve when it comes to anticipating acceptance of pay-for-performance programs, Jeff Flick said at a health care congress sponsored by the Wall Street Journal and CNBC.

Take, for instance, the Premier Hospital Quality Incentive Demonstration program funded by the Centers for Medicare and Medicaid Services, under which hospitals report data on 34 quality measures, said Mr. Flick, the CMS regional administrator in San Francisco.

The program gives a bonus each year to the 20% of hospitals with the highest score, but those who have not improved a certain amount after 3 years are penalized, he said.

When the program was launched several years ago, "The American Hospital Association said, 'No hospital is going to do this,'" Mr. Flick said. "Hospitals are afraid to even report information about quality, but the idea that they could be penalized financially … the [AHA] thought it would never happen. But there were 300 hospitals on board immediately."

Similarly, the American Medical Association recently said it did not support CMS's new physician voluntary reporting program, under which physicians would volunteer to report 36 pieces of data on their practices. The AMA's opposition "is not a shock; those kinds of organizations are very nervous about this," said Mr. Flick. "But it is a very important step that CMS is taking, and it is physicians saying, 'I want to report information because I'd like to know if my performance varies in a significant way from my peers.'"

Many physicians are ready to start focusing on quality, he continued. "They want to publish information, they want to know how they compare, they want to be paid based on performance. That doesn't mean the AMA is necessarily going to support it."

The program uses G-codes to enter the data, which can make for a bit of a hassle for physicians not familiar with them. "If every physician in this country had an [electronic health record], this would be easy; I think this would be done," he said. "Today we would be really paying based on performance. Maybe just thinking about the G-codes will drive people into an EHR."

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."

A better method would be having 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' 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."

A better method would be having 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' 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."

A better method would be having 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' 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."

The experience of the drug discount card program that Medicare beneficiaries participated in prior to the launch of the Medicare drug benefit offers some lessons for the Centers for Medicare and Medicaid Services, the Government Accountability Office said in two reports.

In its first report, the GAO said that although the Centers for Medicare and Medicaid Services (CMS) had identified and corrected some problems with the entities that sponsored the drug cards, it also “had some limitations with respect to the timeliness of oversight activities and the guidance provided to sponsors.”

For instance, the report noted, “CMS finalized guidance on how drug card sponsors should report data on price concessions from manufacturers and pharmacies in November 2004, about 5 months after the program began.

According to CMS, as of August 2005, the overall quality of that data remained questionable, with problems such as outliers and missing data.”

The report also noted that a CMS contractor requested two preenrollment information packets from six drug card sponsors.

“All the packets were noncompliant with program requirements,” the report said. “Most packets were missing materials required by CMS and some materials had not been previously approved for distribution by the CMS contractor. The contractor never received several requested packets.” CMS told the GAO that it had worked with the sponsors to resolve the problems.

For its part, CMS said in a letter to the GAO that the report “did not paint a full picture of the depth and breadth of the actual monitoring and oversight activities.” Dr. Mark B. McClellan, CMS administrator, acknowledged that with the discount card program, “We have learned many valuable lessons that will inform our future efforts as we plan for the drug benefit in 2006.”

The second report looked at CMS's beneficiary and outreach education efforts for the discount card program. In general, the GAO found that “CMS's efforts did not consistently provide information that was clear, accurate, and accessible, and they collectively fell short of conveying program features.” The report did add, however, that the GAO got this impression by looking at assessments that CMS has done on its own programs, and “these assessments acknowledge the actions taken by CMS to address some of these problems.”

Beneficiary confusion about the discount card program was a particular problem, the report said. In spite of CMS's outreach efforts, “Beneficiaries confused the drug card with the 2006 prescription drug benefit, and some beneficiaries did not enroll because they were under the impression that Medicare would be sending them a card. Furthermore, the concept of a private drug card sponsor was difficult for many beneficiaries to understand.”

Beneficiaries also were confused about eligibility, the report said. CMS's own research found that some beneficiaries might not have enrolled because they thought they were not eligible for the discount cards.

“Specifically, many beneficiaries incorrectly thought that the drug card was only for low-income people, and those who likely qualified for the $600 in transitional assistance did not believe they qualified for it, even after having the income criteria explained to them,” the report noted.

In response to the second report, Dr. McClellan said that it, like the first report, did not address the “full picture of the depth and breadth of the actual activities undertaken.” Dr. McClellan said that the number of education and outreach activities was “unprecedented for a program of limited duration.”

As he did in responding to the first report, Dr. McClellan said that the lessons learned from this portion of the discount card program would be applied to the drug benefit. But he also added, “From a public service perspective, the most important question about the drug discount card is whether the program provided discounts and access to prescription drugs for any beneficiary who wanted help. The answer is yes, immediately.”

The reports are available at www.gao.gov

The experience of the drug discount card program that Medicare beneficiaries participated in prior to the launch of the Medicare drug benefit offers some lessons for the Centers for Medicare and Medicaid Services, the Government Accountability Office said in two reports.

In its first report, the GAO said that although the Centers for Medicare and Medicaid Services (CMS) had identified and corrected some problems with the entities that sponsored the drug cards, it also “had some limitations with respect to the timeliness of oversight activities and the guidance provided to sponsors.”

For instance, the report noted, “CMS finalized guidance on how drug card sponsors should report data on price concessions from manufacturers and pharmacies in November 2004, about 5 months after the program began.

According to CMS, as of August 2005, the overall quality of that data remained questionable, with problems such as outliers and missing data.”

The report also noted that a CMS contractor requested two preenrollment information packets from six drug card sponsors.

“All the packets were noncompliant with program requirements,” the report said. “Most packets were missing materials required by CMS and some materials had not been previously approved for distribution by the CMS contractor. The contractor never received several requested packets.” CMS told the GAO that it had worked with the sponsors to resolve the problems.

For its part, CMS said in a letter to the GAO that the report “did not paint a full picture of the depth and breadth of the actual monitoring and oversight activities.” Dr. Mark B. McClellan, CMS administrator, acknowledged that with the discount card program, “We have learned many valuable lessons that will inform our future efforts as we plan for the drug benefit in 2006.”

The second report looked at CMS's beneficiary and outreach education efforts for the discount card program. In general, the GAO found that “CMS's efforts did not consistently provide information that was clear, accurate, and accessible, and they collectively fell short of conveying program features.” The report did add, however, that the GAO got this impression by looking at assessments that CMS has done on its own programs, and “these assessments acknowledge the actions taken by CMS to address some of these problems.”

Beneficiary confusion about the discount card program was a particular problem, the report said. In spite of CMS's outreach efforts, “Beneficiaries confused the drug card with the 2006 prescription drug benefit, and some beneficiaries did not enroll because they were under the impression that Medicare would be sending them a card. Furthermore, the concept of a private drug card sponsor was difficult for many beneficiaries to understand.”

Beneficiaries also were confused about eligibility, the report said. CMS's own research found that some beneficiaries might not have enrolled because they thought they were not eligible for the discount cards.

“Specifically, many beneficiaries incorrectly thought that the drug card was only for low-income people, and those who likely qualified for the $600 in transitional assistance did not believe they qualified for it, even after having the income criteria explained to them,” the report noted.

In response to the second report, Dr. McClellan said that it, like the first report, did not address the “full picture of the depth and breadth of the actual activities undertaken.” Dr. McClellan said that the number of education and outreach activities was “unprecedented for a program of limited duration.”

As he did in responding to the first report, Dr. McClellan said that the lessons learned from this portion of the discount card program would be applied to the drug benefit. But he also added, “From a public service perspective, the most important question about the drug discount card is whether the program provided discounts and access to prescription drugs for any beneficiary who wanted help. The answer is yes, immediately.”

The reports are available at www.gao.gov

The experience of the drug discount card program that Medicare beneficiaries participated in prior to the launch of the Medicare drug benefit offers some lessons for the Centers for Medicare and Medicaid Services, the Government Accountability Office said in two reports.

In its first report, the GAO said that although the Centers for Medicare and Medicaid Services (CMS) had identified and corrected some problems with the entities that sponsored the drug cards, it also “had some limitations with respect to the timeliness of oversight activities and the guidance provided to sponsors.”

For instance, the report noted, “CMS finalized guidance on how drug card sponsors should report data on price concessions from manufacturers and pharmacies in November 2004, about 5 months after the program began.

According to CMS, as of August 2005, the overall quality of that data remained questionable, with problems such as outliers and missing data.”

The report also noted that a CMS contractor requested two preenrollment information packets from six drug card sponsors.

“All the packets were noncompliant with program requirements,” the report said. “Most packets were missing materials required by CMS and some materials had not been previously approved for distribution by the CMS contractor. The contractor never received several requested packets.” CMS told the GAO that it had worked with the sponsors to resolve the problems.

For its part, CMS said in a letter to the GAO that the report “did not paint a full picture of the depth and breadth of the actual monitoring and oversight activities.” Dr. Mark B. McClellan, CMS administrator, acknowledged that with the discount card program, “We have learned many valuable lessons that will inform our future efforts as we plan for the drug benefit in 2006.”

The second report looked at CMS's beneficiary and outreach education efforts for the discount card program. In general, the GAO found that “CMS's efforts did not consistently provide information that was clear, accurate, and accessible, and they collectively fell short of conveying program features.” The report did add, however, that the GAO got this impression by looking at assessments that CMS has done on its own programs, and “these assessments acknowledge the actions taken by CMS to address some of these problems.”

Beneficiary confusion about the discount card program was a particular problem, the report said. In spite of CMS's outreach efforts, “Beneficiaries confused the drug card with the 2006 prescription drug benefit, and some beneficiaries did not enroll because they were under the impression that Medicare would be sending them a card. Furthermore, the concept of a private drug card sponsor was difficult for many beneficiaries to understand.”

Beneficiaries also were confused about eligibility, the report said. CMS's own research found that some beneficiaries might not have enrolled because they thought they were not eligible for the discount cards.

“Specifically, many beneficiaries incorrectly thought that the drug card was only for low-income people, and those who likely qualified for the $600 in transitional assistance did not believe they qualified for it, even after having the income criteria explained to them,” the report noted.

In response to the second report, Dr. McClellan said that it, like the first report, did not address the “full picture of the depth and breadth of the actual activities undertaken.” Dr. McClellan said that the number of education and outreach activities was “unprecedented for a program of limited duration.”

As he did in responding to the first report, Dr. McClellan said that the lessons learned from this portion of the discount card program would be applied to the drug benefit. But he also added, “From a public service perspective, the most important question about the drug discount card is whether the program provided discounts and access to prescription drugs for any beneficiary who wanted help. The answer is yes, immediately.”

The reports are available at www.gao.gov

WASHINGTON — Aiming for computerization of physician order entry at health care institutions isn't the right course to take, Dr. Stephen T. Lawless said at a health care congress sponsored by the Wall Street Journal and CNBC.

“That's the wrong goal,” said Dr. Lawless, who is chief knowledge and quality officer at Nemours, a Wilmington, Del., pediatric subspecialty practice with about 1 million patient encounters per year. “The right goal is NPOE—no physician order entry. Just tell us what you want and we'll have the best person [enter] it for you.”

With this caveat, computerized order entry still remains an important tool in reducing medication errors, said Dr. Lawless, who also is professor of pediatrics at Jefferson Medical College, Philadelphia.

He said that the hospital where he practices—the Alfred I. DuPont Hospital for Children, Wilmington—partnered with a large pharmacy chain and asked the pharmacy to find the errors in the hospital's handwritten prescriptions.

Of the handwritten prescriptions, 35%–40% had errors, he said. “Of those, 53% had legibility problems, 36% had issues with completeness, and 11% had content errors.”

The hospital's use of electronic prescribing has eliminated legibility errors, but that still leaves the other half of the errors to be resolved, he said. That's where the “decision support” piece comes in, which has encountered some resistance.

On further analysis, hospital officials found that most errors occurred at three different times of the day: 6 a.m. to 8 a.m., 5 p.m. to 6 p.m., and around midnight, he continued. “What goes on around those periods of time? Handoffs or dinner.”

In a handoff in an airline cockpit or in the military, “you would not have these errors because there's a discipline put into it,” Dr. Lawless said. But “discipline” measures such as checklists are often resisted by the medical community because “we all think it's about health care professionals being industrialized. I'm saying it's [about] health care craftsmen fighting being professionalized.”

WASHINGTON — Aiming for computerization of physician order entry at health care institutions isn't the right course to take, Dr. Stephen T. Lawless said at a health care congress sponsored by the Wall Street Journal and CNBC.

“That's the wrong goal,” said Dr. Lawless, who is chief knowledge and quality officer at Nemours, a Wilmington, Del., pediatric subspecialty practice with about 1 million patient encounters per year. “The right goal is NPOE—no physician order entry. Just tell us what you want and we'll have the best person [enter] it for you.”

With this caveat, computerized order entry still remains an important tool in reducing medication errors, said Dr. Lawless, who also is professor of pediatrics at Jefferson Medical College, Philadelphia.

He said that the hospital where he practices—the Alfred I. DuPont Hospital for Children, Wilmington—partnered with a large pharmacy chain and asked the pharmacy to find the errors in the hospital's handwritten prescriptions.

Of the handwritten prescriptions, 35%–40% had errors, he said. “Of those, 53% had legibility problems, 36% had issues with completeness, and 11% had content errors.”

The hospital's use of electronic prescribing has eliminated legibility errors, but that still leaves the other half of the errors to be resolved, he said. That's where the “decision support” piece comes in, which has encountered some resistance.

On further analysis, hospital officials found that most errors occurred at three different times of the day: 6 a.m. to 8 a.m., 5 p.m. to 6 p.m., and around midnight, he continued. “What goes on around those periods of time? Handoffs or dinner.”

In a handoff in an airline cockpit or in the military, “you would not have these errors because there's a discipline put into it,” Dr. Lawless said. But “discipline” measures such as checklists are often resisted by the medical community because “we all think it's about health care professionals being industrialized. I'm saying it's [about] health care craftsmen fighting being professionalized.”

WASHINGTON — Aiming for computerization of physician order entry at health care institutions isn't the right course to take, Dr. Stephen T. Lawless said at a health care congress sponsored by the Wall Street Journal and CNBC.

“That's the wrong goal,” said Dr. Lawless, who is chief knowledge and quality officer at Nemours, a Wilmington, Del., pediatric subspecialty practice with about 1 million patient encounters per year. “The right goal is NPOE—no physician order entry. Just tell us what you want and we'll have the best person [enter] it for you.”

With this caveat, computerized order entry still remains an important tool in reducing medication errors, said Dr. Lawless, who also is professor of pediatrics at Jefferson Medical College, Philadelphia.

He said that the hospital where he practices—the Alfred I. DuPont Hospital for Children, Wilmington—partnered with a large pharmacy chain and asked the pharmacy to find the errors in the hospital's handwritten prescriptions.

Of the handwritten prescriptions, 35%–40% had errors, he said. “Of those, 53% had legibility problems, 36% had issues with completeness, and 11% had content errors.”

The hospital's use of electronic prescribing has eliminated legibility errors, but that still leaves the other half of the errors to be resolved, he said. That's where the “decision support” piece comes in, which has encountered some resistance.

On further analysis, hospital officials found that most errors occurred at three different times of the day: 6 a.m. to 8 a.m., 5 p.m. to 6 p.m., and around midnight, he continued. “What goes on around those periods of time? Handoffs or dinner.”

In a handoff in an airline cockpit or in the military, “you would not have these errors because there's a discipline put into it,” Dr. Lawless said. But “discipline” measures such as checklists are often resisted by the medical community because “we all think it's about health care professionals being industrialized. I'm saying it's [about] health care craftsmen fighting being professionalized.”

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?”

By lumping the responders 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,'” Dr. Collins said. “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. We can do better than that.”

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 to other parts of the world,” 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.

“In the space of just 3 years, the HapMap has delivered this remarkable picture of how DNA variation has occurred across all chromosomes,” he said. “This has been a gold mine of information for people trying to unravel the genetic contributions of diabetes, heart disease, mental illness, blindness, and a whole host of conditions that fill up our hospitals and our clinics.”

If medical researchers really want to know how genetic variation affects predisposition to illness, “we're going to need more data, and the good news is, in another 2 or 3 years, we're going to have a lot more data on this subject and will be much more poised to do something about it,” he said.

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?”

By lumping the responders 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,'” Dr. Collins said. “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. We can do better than that.”

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 to other parts of the world,” 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.

“In the space of just 3 years, the HapMap has delivered this remarkable picture of how DNA variation has occurred across all chromosomes,” he said. “This has been a gold mine of information for people trying to unravel the genetic contributions of diabetes, heart disease, mental illness, blindness, and a whole host of conditions that fill up our hospitals and our clinics.”

If medical researchers really want to know how genetic variation affects predisposition to illness, “we're going to need more data, and the good news is, in another 2 or 3 years, we're going to have a lot more data on this subject and will be much more poised to do something about it,” he said.

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?”

By lumping the responders 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,'” Dr. Collins said. “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. We can do better than that.”

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 to other parts of the world,” 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.

“In the space of just 3 years, the HapMap has delivered this remarkable picture of how DNA variation has occurred across all chromosomes,” he said. “This has been a gold mine of information for people trying to unravel the genetic contributions of diabetes, heart disease, mental illness, blindness, and a whole host of conditions that fill up our hospitals and our clinics.”

If medical researchers really want to know how genetic variation affects predisposition to illness, “we're going to need more data, and the good news is, in another 2 or 3 years, we're going to have a lot more data on this subject and will be much more poised to do something about it,” he said.

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

Medicare and its beneficiaries could save $8.2 billion under the new Medicare drug benefit if beneficiaries were prescribed generic statins for cholesterol reduction instead of name brands, according to a study from Consumers Union and Consumer Reports.

The cost of statins to Medicare and its beneficiaries is expected to be $14 billion in 2007, but could be cut to $5.8 billion if seniors received the generic drugs instead, according to the report. “For the Medicare drug benefit to continue without breaking the federal budget, it will be critical that medicines are prescribed based on their effectiveness and track record, not on advertising campaigns,” said Gail Shearer of Consumer Reports.

The report also notes that monthly statin prescriptions rose 2.6% overall between the period from November 2004 to April 2005 and the period from May 2005 to October 2005. Some brand-name statins such as Lescol and Pravachol saw their prescriptions decline, while generic lovastatin prescriptions increased 15.2%, “a positive sign that doctors and payers are becoming more cost conscious.”

In its analysis, the report assumes that not everyone will be able to switch to the generic statins. For instance, it assumes a 100% switch from Zocor to generic simvastatin when Zocor goes off patent this June, and a 50% switch from other statins to generic simvastatin. It also assumes that all Medicare beneficiaries on Lipitor who need only modest cholesterol reduction will be able to switch to generic lovastatin.

Prices for most statin drugs rose modestly during the study period, but some statin price increases exceeded the general inflation rate of 3.5%. For instance, Lipitor rose about 6%, while Pravachol rose about 7% (both increases reflect an averaging of all dose strengths), the study noted.

Medicare and its beneficiaries could save $8.2 billion under the new Medicare drug benefit if beneficiaries were prescribed generic statins for cholesterol reduction instead of name brands, according to a study from Consumers Union and Consumer Reports.

The cost of statins to Medicare and its beneficiaries is expected to be $14 billion in 2007, but could be cut to $5.8 billion if seniors received the generic drugs instead, according to the report. “For the Medicare drug benefit to continue without breaking the federal budget, it will be critical that medicines are prescribed based on their effectiveness and track record, not on advertising campaigns,” said Gail Shearer of Consumer Reports.

The report also notes that monthly statin prescriptions rose 2.6% overall between the period from November 2004 to April 2005 and the period from May 2005 to October 2005. Some brand-name statins such as Lescol and Pravachol saw their prescriptions decline, while generic lovastatin prescriptions increased 15.2%, “a positive sign that doctors and payers are becoming more cost conscious.”

In its analysis, the report assumes that not everyone will be able to switch to the generic statins. For instance, it assumes a 100% switch from Zocor to generic simvastatin when Zocor goes off patent this June, and a 50% switch from other statins to generic simvastatin. It also assumes that all Medicare beneficiaries on Lipitor who need only modest cholesterol reduction will be able to switch to generic lovastatin.

Prices for most statin drugs rose modestly during the study period, but some statin price increases exceeded the general inflation rate of 3.5%. For instance, Lipitor rose about 6%, while Pravachol rose about 7% (both increases reflect an averaging of all dose strengths), the study noted.

Medicare and its beneficiaries could save $8.2 billion under the new Medicare drug benefit if beneficiaries were prescribed generic statins for cholesterol reduction instead of name brands, according to a study from Consumers Union and Consumer Reports.

The cost of statins to Medicare and its beneficiaries is expected to be $14 billion in 2007, but could be cut to $5.8 billion if seniors received the generic drugs instead, according to the report. “For the Medicare drug benefit to continue without breaking the federal budget, it will be critical that medicines are prescribed based on their effectiveness and track record, not on advertising campaigns,” said Gail Shearer of Consumer Reports.

The report also notes that monthly statin prescriptions rose 2.6% overall between the period from November 2004 to April 2005 and the period from May 2005 to October 2005. Some brand-name statins such as Lescol and Pravachol saw their prescriptions decline, while generic lovastatin prescriptions increased 15.2%, “a positive sign that doctors and payers are becoming more cost conscious.”

In its analysis, the report assumes that not everyone will be able to switch to the generic statins. For instance, it assumes a 100% switch from Zocor to generic simvastatin when Zocor goes off patent this June, and a 50% switch from other statins to generic simvastatin. It also assumes that all Medicare beneficiaries on Lipitor who need only modest cholesterol reduction will be able to switch to generic lovastatin.

Prices for most statin drugs rose modestly during the study period, but some statin price increases exceeded the general inflation rate of 3.5%. For instance, Lipitor rose about 6%, while Pravachol rose about 7% (both increases reflect an averaging of all dose strengths), the study noted.

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 did good work]. 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.'”

Although health care in this country 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 said. “The average consumer does not really 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 did good work]. 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.'”

Although health care in this country 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 said. “The average consumer does not really 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 did good work]. 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.'”

Although health care in this country 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 said. “The average consumer does not really know how to define [its] value.”