Joyce Frieden

While Guidant Corp., the troubled maker of implantable cardioverter defibrillators, struggles to repair its reputation and salvage its acquisition by Johnson & Johnson, physicians are finding it increasingly difficult to convince patients of the benefits of ICDs.

“It is more common now for a patient to say that they are concerned about whether or not they should have an ICD implanted because of problems they have read about, so I'm having to spend more time explaining the very small risk of the device compared to the huge benefit,” said Dr. Stephen C. Hammill, director of heart rhythm services at the Mayo Clinic, Rochester, Minn. “That's a longer discussion now. My concern is that it's deterred people from even pursuing it with the doctor.”

In May, the Food and Drug Administration began investigating reports that Guidant failed to notify physicians for several years that one of its devices had short-circuited in some patients.

In November, New York State Attorney General Eliot Spitzer filed suit against the company in federal court, alleging, “In April and November 2002, Guidant made manufacturing changes to the Prizm 1861 defibrillator intended to remedy the systemic defect and prevent the short-circuiting and resulting catastrophic failure of the device. Despite making these design changes, Guidant continued to sell Prizm 1861 defibrillators that had been manufactured before April 2002. Guidant did not disclose to physicians and patients that these devices contained a serious design flaw that had been corrected in later devices.”

A few days later, Johnson & Johnson, which had agreed to buy Guidant in a deal valued at more than $25 billion, announced that it was reconsidering the deal. Guidant sued Johnson & Johnson in federal court to force it to complete the buyout. However, Guidant also noted in its 10-Q filing to the Securities and Exchange Commission the same day that the SEC was investigating the company “related to certain of [Guidant's] product disclosures and trading in Guidant stock.”

In the same 10-Q report, Guidant also announced that it had received three requests for information from the attorneys general of Arizona, Illinois, and Oregon relating to whether the company violated any state laws in connection with its ICDs, and that 31 other states and the District of Columbia “are cooperating in these [requests].” The company also is under scrutiny from the U.S. attorney's office in Boston “concerning marketing practices for pacemakers, ICDs, leads, and related products,” according to the filing.

Eventually, Johnson & Johnson agreed to buy Guidant at a reduced price, lowering the value of the deal to $19 billion. “We are delighted that our companies have reached an according,” Johnson & Johnson CEO William C. Weldon said in a statement.

While all this is going on at Guidant, device makers and physicians alike are trying to figure out exactly what level of postmarket reporting is needed for problems with ICDs.

“If people want notification about [every] model that has a malfunction, you're going to be hearing about essentially every model of every device,” Dr. William Maisel, director of the pacemaker and ICD service at Beth Israel Deaconess Medical Center, Boston, said at a meeting sponsored by the Heart Rhythm Society that was held in cooperation with the FDA.

These disclosure issues will become more prominent as medical device companies' sales volumes increase, said Thomas Gunderson, senior research analyst at Piper Jaffray & Co., a Minneapolis-based investment banking firm. “You can't have a '1-in-10,000' problem until you start selling 10,000 products. In the old days, these companies didn't. Now they do, and they're going to have to provide more data.”

This is especially important in the type of market that device companies now find themselves in, he added. “What you don't want to do in a tight oligopoly with large margins is lose consumer confidence.”

And indeed, in mid-November, Guidant issued a 153-page report listing outcomes for all of its devices. The company noted that the report was being published “in response to the medical community's call for more detailed description of device performance and access to product performance information. … We understand that lives depend on our products, and that we must seize every opportunity for continuous quality improvement. The detail in this report is meant to provide an open window into this process.”

The report “looks like a fire hose of information,” Mr. Gunderson said. “It will be difficult to complain that physicians, patients, Wall Street, and the media are not being provided enough data.”

The Guidant report is available online at www.guidant.com/physician/ppr

While Guidant Corp., the troubled maker of implantable cardioverter defibrillators, struggles to repair its reputation and salvage its acquisition by Johnson & Johnson, physicians are finding it increasingly difficult to convince patients of the benefits of ICDs.

“It is more common now for a patient to say that they are concerned about whether or not they should have an ICD implanted because of problems they have read about, so I'm having to spend more time explaining the very small risk of the device compared to the huge benefit,” said Dr. Stephen C. Hammill, director of heart rhythm services at the Mayo Clinic, Rochester, Minn. “That's a longer discussion now. My concern is that it's deterred people from even pursuing it with the doctor.”

In May, the Food and Drug Administration began investigating reports that Guidant failed to notify physicians for several years that one of its devices had short-circuited in some patients.

In November, New York State Attorney General Eliot Spitzer filed suit against the company in federal court, alleging, “In April and November 2002, Guidant made manufacturing changes to the Prizm 1861 defibrillator intended to remedy the systemic defect and prevent the short-circuiting and resulting catastrophic failure of the device. Despite making these design changes, Guidant continued to sell Prizm 1861 defibrillators that had been manufactured before April 2002. Guidant did not disclose to physicians and patients that these devices contained a serious design flaw that had been corrected in later devices.”

A few days later, Johnson & Johnson, which had agreed to buy Guidant in a deal valued at more than $25 billion, announced that it was reconsidering the deal. Guidant sued Johnson & Johnson in federal court to force it to complete the buyout. However, Guidant also noted in its 10-Q filing to the Securities and Exchange Commission the same day that the SEC was investigating the company “related to certain of [Guidant's] product disclosures and trading in Guidant stock.”

In the same 10-Q report, Guidant also announced that it had received three requests for information from the attorneys general of Arizona, Illinois, and Oregon relating to whether the company violated any state laws in connection with its ICDs, and that 31 other states and the District of Columbia “are cooperating in these [requests].” The company also is under scrutiny from the U.S. attorney's office in Boston “concerning marketing practices for pacemakers, ICDs, leads, and related products,” according to the filing.

Eventually, Johnson & Johnson agreed to buy Guidant at a reduced price, lowering the value of the deal to $19 billion. “We are delighted that our companies have reached an according,” Johnson & Johnson CEO William C. Weldon said in a statement.

While all this is going on at Guidant, device makers and physicians alike are trying to figure out exactly what level of postmarket reporting is needed for problems with ICDs.

“If people want notification about [every] model that has a malfunction, you're going to be hearing about essentially every model of every device,” Dr. William Maisel, director of the pacemaker and ICD service at Beth Israel Deaconess Medical Center, Boston, said at a meeting sponsored by the Heart Rhythm Society that was held in cooperation with the FDA.

These disclosure issues will become more prominent as medical device companies' sales volumes increase, said Thomas Gunderson, senior research analyst at Piper Jaffray & Co., a Minneapolis-based investment banking firm. “You can't have a '1-in-10,000' problem until you start selling 10,000 products. In the old days, these companies didn't. Now they do, and they're going to have to provide more data.”

This is especially important in the type of market that device companies now find themselves in, he added. “What you don't want to do in a tight oligopoly with large margins is lose consumer confidence.”

And indeed, in mid-November, Guidant issued a 153-page report listing outcomes for all of its devices. The company noted that the report was being published “in response to the medical community's call for more detailed description of device performance and access to product performance information. … We understand that lives depend on our products, and that we must seize every opportunity for continuous quality improvement. The detail in this report is meant to provide an open window into this process.”

The report “looks like a fire hose of information,” Mr. Gunderson said. “It will be difficult to complain that physicians, patients, Wall Street, and the media are not being provided enough data.”

The Guidant report is available online at www.guidant.com/physician/ppr

While Guidant Corp., the troubled maker of implantable cardioverter defibrillators, struggles to repair its reputation and salvage its acquisition by Johnson & Johnson, physicians are finding it increasingly difficult to convince patients of the benefits of ICDs.

“It is more common now for a patient to say that they are concerned about whether or not they should have an ICD implanted because of problems they have read about, so I'm having to spend more time explaining the very small risk of the device compared to the huge benefit,” said Dr. Stephen C. Hammill, director of heart rhythm services at the Mayo Clinic, Rochester, Minn. “That's a longer discussion now. My concern is that it's deterred people from even pursuing it with the doctor.”

In May, the Food and Drug Administration began investigating reports that Guidant failed to notify physicians for several years that one of its devices had short-circuited in some patients.

In November, New York State Attorney General Eliot Spitzer filed suit against the company in federal court, alleging, “In April and November 2002, Guidant made manufacturing changes to the Prizm 1861 defibrillator intended to remedy the systemic defect and prevent the short-circuiting and resulting catastrophic failure of the device. Despite making these design changes, Guidant continued to sell Prizm 1861 defibrillators that had been manufactured before April 2002. Guidant did not disclose to physicians and patients that these devices contained a serious design flaw that had been corrected in later devices.”

A few days later, Johnson & Johnson, which had agreed to buy Guidant in a deal valued at more than $25 billion, announced that it was reconsidering the deal. Guidant sued Johnson & Johnson in federal court to force it to complete the buyout. However, Guidant also noted in its 10-Q filing to the Securities and Exchange Commission the same day that the SEC was investigating the company “related to certain of [Guidant's] product disclosures and trading in Guidant stock.”

In the same 10-Q report, Guidant also announced that it had received three requests for information from the attorneys general of Arizona, Illinois, and Oregon relating to whether the company violated any state laws in connection with its ICDs, and that 31 other states and the District of Columbia “are cooperating in these [requests].” The company also is under scrutiny from the U.S. attorney's office in Boston “concerning marketing practices for pacemakers, ICDs, leads, and related products,” according to the filing.

Eventually, Johnson & Johnson agreed to buy Guidant at a reduced price, lowering the value of the deal to $19 billion. “We are delighted that our companies have reached an according,” Johnson & Johnson CEO William C. Weldon said in a statement.

While all this is going on at Guidant, device makers and physicians alike are trying to figure out exactly what level of postmarket reporting is needed for problems with ICDs.

“If people want notification about [every] model that has a malfunction, you're going to be hearing about essentially every model of every device,” Dr. William Maisel, director of the pacemaker and ICD service at Beth Israel Deaconess Medical Center, Boston, said at a meeting sponsored by the Heart Rhythm Society that was held in cooperation with the FDA.

These disclosure issues will become more prominent as medical device companies' sales volumes increase, said Thomas Gunderson, senior research analyst at Piper Jaffray & Co., a Minneapolis-based investment banking firm. “You can't have a '1-in-10,000' problem until you start selling 10,000 products. In the old days, these companies didn't. Now they do, and they're going to have to provide more data.”

This is especially important in the type of market that device companies now find themselves in, he added. “What you don't want to do in a tight oligopoly with large margins is lose consumer confidence.”

And indeed, in mid-November, Guidant issued a 153-page report listing outcomes for all of its devices. The company noted that the report was being published “in response to the medical community's call for more detailed description of device performance and access to product performance information. … We understand that lives depend on our products, and that we must seize every opportunity for continuous quality improvement. The detail in this report is meant to provide an open window into this process.”

The report “looks like a fire hose of information,” Mr. Gunderson said. “It will be difficult to complain that physicians, patients, Wall Street, and the media are not being provided enough data.”

The Guidant report is available online at www.guidant.com/physician/ppr

MONTREAL – Outpatient commitment can be a useful tool if it is implemented for a long enough period and combined with more frequent services, Dr. Marvin S. Swartz said at the annual meeting of the American Academy of Psychiatry and the Law.

“We do show that outpatient commitment exerts an effect over and above enhanced services,” said Dr. Swartz, who is head of social and community psychiatry at Duke University Medical Center, Durham, N.C. “But if you give outpatient commitment without enhanced services, it has no effect.”

Forty-one states have outpatient commitment statutes, Dr. Swartz said. These laws allow courts to mandate that outpatient psychiatry patients attend treatment sessions. If patients refuse to go to the sessions, health care providers can enlist the aid of law enforcement authorities to bring the patients in.

In a study Dr. Swartz and his colleagues conducted with 331 patients who had recently been hospitalized for a mental illness, patients who had more than 6 months of outpatient commitment were less likely to be readmitted to the hospital compared with those who had less than 6 months' worth. In addition, those who had 6 months or more of outpatient commitment had a lower mean number of hospital stays and a much lower number of average days in the hospital–8 days versus 30 days–compared with those either in the control group or with less than 6 months of outpatient commitment.

“This is a significant effect of outpatient commitment,” Dr. Swartz said. “Most of the effect was among folks with psychotic disorders such as schizoaffective disorder and schizophrenia, as opposed to mood disorders or bipolar disorders.”

Those who were violent in the past and had 6 months or more of outpatient commitment were also less likely to be violent, he added.

Overall, “treatment adherence improved with outpatient commitment, and outpatient commitment can reduce violence, victimization, and family strain, and can improve medication adherence and quality of life,” he said.

But outpatient commitment is just a single point on the spectrum of leverage psychiatrists can use to get patients to come for treatment, noted Dr. Paul Appelbaum, chair of psychiatry at Columbia University, New York. Other leverage points include housing, money, and, in some cases, control over parole, he said.

Child custody is another example; a provider might say: “'We'll support your regaining custody of your child, or having more unsupervised visits, but we really can't do that in good conscience … unless you're coming to treatment regularly,'” he said. “Outpatient commitment is one piece of the entire spectrum of coercion or leverage applied to people in outpatient settings.”

Although outpatient commitment causes lots of controversy because of its coercive aspects, that's the wrong thing to focus on, according to Stephen J. Morse, Ph.D., professor of psychology and law in psychiatry at the University of Pennsylvania, Philadelphia. Dr. Morse noted that there are 25 million people in the United States suffering from schizophrenic disorder, serious or moderate major depressive disorder, or bipolar disorder.

“Now how many doctoral and clinical psychologists and psychiatrists are there? About 90,000 altogether,” he said. “That's one treating professional for every 232 people” suffering from just those three conditions; assuming only half would consent to voluntary outpatient treatment, that would still be one provider for every 116 people–and that doesn't take into account people who suffer from other disorders and assumes all providers would be spending 100% of their time on patient care.

“Suppose we said to 25 million people, 'We can help keep you out of hospital, help you get along with your family, help keep you out of the criminal justice system; we can do all those things for you if you just come for at least 6 months, three times a week.' You couldn't begin to treat all the people who would accept under those conditions,” Dr. Morse said. “Why are we talking about coercion of one sort of another when what we ought to talk about is forcing the legislature to produce the services that would make coercion not necessary?”

MONTREAL – Outpatient commitment can be a useful tool if it is implemented for a long enough period and combined with more frequent services, Dr. Marvin S. Swartz said at the annual meeting of the American Academy of Psychiatry and the Law.

“We do show that outpatient commitment exerts an effect over and above enhanced services,” said Dr. Swartz, who is head of social and community psychiatry at Duke University Medical Center, Durham, N.C. “But if you give outpatient commitment without enhanced services, it has no effect.”

Forty-one states have outpatient commitment statutes, Dr. Swartz said. These laws allow courts to mandate that outpatient psychiatry patients attend treatment sessions. If patients refuse to go to the sessions, health care providers can enlist the aid of law enforcement authorities to bring the patients in.

In a study Dr. Swartz and his colleagues conducted with 331 patients who had recently been hospitalized for a mental illness, patients who had more than 6 months of outpatient commitment were less likely to be readmitted to the hospital compared with those who had less than 6 months' worth. In addition, those who had 6 months or more of outpatient commitment had a lower mean number of hospital stays and a much lower number of average days in the hospital–8 days versus 30 days–compared with those either in the control group or with less than 6 months of outpatient commitment.

“This is a significant effect of outpatient commitment,” Dr. Swartz said. “Most of the effect was among folks with psychotic disorders such as schizoaffective disorder and schizophrenia, as opposed to mood disorders or bipolar disorders.”

Those who were violent in the past and had 6 months or more of outpatient commitment were also less likely to be violent, he added.

Overall, “treatment adherence improved with outpatient commitment, and outpatient commitment can reduce violence, victimization, and family strain, and can improve medication adherence and quality of life,” he said.

But outpatient commitment is just a single point on the spectrum of leverage psychiatrists can use to get patients to come for treatment, noted Dr. Paul Appelbaum, chair of psychiatry at Columbia University, New York. Other leverage points include housing, money, and, in some cases, control over parole, he said.

Child custody is another example; a provider might say: “'We'll support your regaining custody of your child, or having more unsupervised visits, but we really can't do that in good conscience … unless you're coming to treatment regularly,'” he said. “Outpatient commitment is one piece of the entire spectrum of coercion or leverage applied to people in outpatient settings.”

Although outpatient commitment causes lots of controversy because of its coercive aspects, that's the wrong thing to focus on, according to Stephen J. Morse, Ph.D., professor of psychology and law in psychiatry at the University of Pennsylvania, Philadelphia. Dr. Morse noted that there are 25 million people in the United States suffering from schizophrenic disorder, serious or moderate major depressive disorder, or bipolar disorder.

“Now how many doctoral and clinical psychologists and psychiatrists are there? About 90,000 altogether,” he said. “That's one treating professional for every 232 people” suffering from just those three conditions; assuming only half would consent to voluntary outpatient treatment, that would still be one provider for every 116 people–and that doesn't take into account people who suffer from other disorders and assumes all providers would be spending 100% of their time on patient care.

“Suppose we said to 25 million people, 'We can help keep you out of hospital, help you get along with your family, help keep you out of the criminal justice system; we can do all those things for you if you just come for at least 6 months, three times a week.' You couldn't begin to treat all the people who would accept under those conditions,” Dr. Morse said. “Why are we talking about coercion of one sort of another when what we ought to talk about is forcing the legislature to produce the services that would make coercion not necessary?”

MONTREAL – Outpatient commitment can be a useful tool if it is implemented for a long enough period and combined with more frequent services, Dr. Marvin S. Swartz said at the annual meeting of the American Academy of Psychiatry and the Law.

“We do show that outpatient commitment exerts an effect over and above enhanced services,” said Dr. Swartz, who is head of social and community psychiatry at Duke University Medical Center, Durham, N.C. “But if you give outpatient commitment without enhanced services, it has no effect.”

Forty-one states have outpatient commitment statutes, Dr. Swartz said. These laws allow courts to mandate that outpatient psychiatry patients attend treatment sessions. If patients refuse to go to the sessions, health care providers can enlist the aid of law enforcement authorities to bring the patients in.

In a study Dr. Swartz and his colleagues conducted with 331 patients who had recently been hospitalized for a mental illness, patients who had more than 6 months of outpatient commitment were less likely to be readmitted to the hospital compared with those who had less than 6 months' worth. In addition, those who had 6 months or more of outpatient commitment had a lower mean number of hospital stays and a much lower number of average days in the hospital–8 days versus 30 days–compared with those either in the control group or with less than 6 months of outpatient commitment.

“This is a significant effect of outpatient commitment,” Dr. Swartz said. “Most of the effect was among folks with psychotic disorders such as schizoaffective disorder and schizophrenia, as opposed to mood disorders or bipolar disorders.”

Those who were violent in the past and had 6 months or more of outpatient commitment were also less likely to be violent, he added.

Overall, “treatment adherence improved with outpatient commitment, and outpatient commitment can reduce violence, victimization, and family strain, and can improve medication adherence and quality of life,” he said.

But outpatient commitment is just a single point on the spectrum of leverage psychiatrists can use to get patients to come for treatment, noted Dr. Paul Appelbaum, chair of psychiatry at Columbia University, New York. Other leverage points include housing, money, and, in some cases, control over parole, he said.

Child custody is another example; a provider might say: “'We'll support your regaining custody of your child, or having more unsupervised visits, but we really can't do that in good conscience … unless you're coming to treatment regularly,'” he said. “Outpatient commitment is one piece of the entire spectrum of coercion or leverage applied to people in outpatient settings.”

Although outpatient commitment causes lots of controversy because of its coercive aspects, that's the wrong thing to focus on, according to Stephen J. Morse, Ph.D., professor of psychology and law in psychiatry at the University of Pennsylvania, Philadelphia. Dr. Morse noted that there are 25 million people in the United States suffering from schizophrenic disorder, serious or moderate major depressive disorder, or bipolar disorder.

“Now how many doctoral and clinical psychologists and psychiatrists are there? About 90,000 altogether,” he said. “That's one treating professional for every 232 people” suffering from just those three conditions; assuming only half would consent to voluntary outpatient treatment, that would still be one provider for every 116 people–and that doesn't take into account people who suffer from other disorders and assumes all providers would be spending 100% of their time on patient care.

“Suppose we said to 25 million people, 'We can help keep you out of hospital, help you get along with your family, help keep you out of the criminal justice system; we can do all those things for you if you just come for at least 6 months, three times a week.' You couldn't begin to treat all the people who would accept under those conditions,” Dr. Morse said. “Why are we talking about coercion of one sort of another when what we ought to talk about is forcing the legislature to produce the services that would make coercion not necessary?”

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

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

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

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

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

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

“The health care system is pitiful when it comes to public information,” said Mr. Scully, now senior counsel at Alston & Bird LLP, a Washington law firm. “As much as people avoid it and fight it, it works to change behavior. I've never run across any instance where providers, as much as they didn't like it when they were forced to share information, didn't come back a year or two later and say, 'You know what? It's worked out pretty well, it's changed my behavior, and it wasn't that hard 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 continued. “The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value.”

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

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

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

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

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

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

“The health care system is pitiful when it comes to public information,” said Mr. Scully, now senior counsel at Alston & Bird LLP, a Washington law firm. “As much as people avoid it and fight it, it works to change behavior. I've never run across any instance where providers, as much as they didn't like it when they were forced to share information, didn't come back a year or two later and say, 'You know what? It's worked out pretty well, it's changed my behavior, and it wasn't that hard 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 continued. “The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value.”

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

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

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

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

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

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

“The health care system is pitiful when it comes to public information,” said Mr. Scully, now senior counsel at Alston & Bird LLP, a Washington law firm. “As much as people avoid it and fight it, it works to change behavior. I've never run across any instance where providers, as much as they didn't like it when they were forced to share information, didn't come back a year or two later and say, 'You know what? It's worked out pretty well, it's changed my behavior, and it wasn't that hard 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 continued. “The average consumer does not know how to measure [health care] and really doesn't know how to define [its] value.”

Alcohol Ads, Underage Drinking

Youth people who see more alcohol advertisements end up drinking more, according to a study published in the January issue of the Archives of Pediatric and Adolescent Medicine (2006;160:18–24). Researchers from the University of Connecticut, Farmington, and their colleagues randomly sampled more than 1,800 people aged 15–26 about their drinking habits and their viewing of alcohol advertisements; each subject was interviewed four times during a 21-month period. The researchers found that individuals who were exposed to one more TV, radio, or magazine advertisement per month on average than other individuals had 1% more alcoholic drinks per month. They also found that for every additional dollar per capita spent on advertising in a particular media market, respondents consumed 3% more alcoholic beverages per month. The findings “call into question the industry's argument that its roughly $1.8 billion in measured media expenditures per year have no impact on underage drinking,” David H. Jerningan, Ph.D., of Georgetown University's Center on Alcohol Marketing and Youth, Washington, wrote in an accompanying editorial. “The fact that young people … were more likely to drink more over time in environments with more alcohol advertising, even when controlling for alcohol sales in those environments, suggests that it is exposure to alcohol advertising that contributes to the drinking, rather than the reverse.”

Parity Law Extended

The law requiring employers to provide the same caps on mental health coverage as they do for physical health coverage has been extended for another year. The Mental Health Parity Act, which does not apply to substance abuse or chemical dependency benefits, says that group health plans offering mental health benefits cannot set annual or lifetime dollar limits on mental health benefits that are lower than any dollar limits for medical and surgical benefits. Plans that have no annual or lifetime limits on medical and surgical benefits may not impose dollar limits on mental health benefits either.

Mental Health Screening Snapshot

More than half the states provide education or information to primary care providers to help them focus on young children's early mental health development, according to a survey from the National Academy for State Health Policy (NASHP). As part of the Assuring Better Child Health and Development program, NASHP surveyed Medicaid, maternal and child health, and children's mental health agencies in all 50 states and the District of Columbia to gather information on how states were addressing the mental health development of children aged birth to 3 years. Various resources were available in the states to assist primary care providers who identify a child in need of further assessment or in-house follow-up, the survey found. Mental health consultation was mentioned most frequently (48%), followed by state-funded care coordinators (33%), public health nursing consultation (30%), and lists of organizations for physician referrals (27%). However, “these low percentages suggest that none of these resources are readily available,” the survey indicated. Providers also raised concerns regarding screening for social and emotional development, such as a lack of referral resources, insufficient payment, and a lack of expertise.

Behaviors Leading to Death

By the time they enter adulthood, a large percentage of American youth have already begun the behaviors that lead to preventable causes of death, according to a study from the Carolina Population Center and the University of North Carolina at Chapel Hill. Researchers studied a nationally representative sample of more than 14,000 young adults; they were first interviewed from 1994 to 1995 when they ranged in age from 12 to 19 years, and again in 2001 and 2002, when their age range was 19 to 26 years. The researchers found that for nearly all groups surveyed, diet, obesity, and access to health care worsened; tobacco, alcohol, and illicit drug use and the likelihood of acquiring a sexually transmitted disease increased as the youths reached adulthood. “Whether the trends will continue as they age, we don't know,” said Kathleen M. Harris, Ph.D., the study's principal investigator. “But it doesn't bode well for their future health.” One statistic that doesn't bode well: The proportion of young white female respondents reporting no weekly physical exercise was 5% during adolescence, but grew to 46% in early adulthood. The study appears in the January issue of the Archives of Pediatric and Adolescent Medicine (2006;160:74–81).

Money for Psychiatric Hospitals

Inpatient psychiatric facilities would receive an average 4.2% increase in their Medicare payments under a proposal from the Centers for Medicare and Medicaid Services. The proposed rule would affect about 1,800 facilities, including certified psychiatric units in general acute care hospitals. Freestanding government psychiatric hospitals would receive the largest share of the increase, the agency said. “We believe the changes we are proposing today will support the continued improvement in quality of care for Medicare beneficiaries with severe psychiatric disorders,” said CMS Administrator Dr. Mark B. McClellan. “Appropriate inpatient psychiatric care often can make it possible for these beneficiaries to return to their homes or to less restrictive settings.” CMS will accept comments on the proposed rule until March 14; a final rule will be published later in the spring. The increase will affect all discharges occurring on or after July 1.

Alcohol Ads, Underage Drinking

Youth people who see more alcohol advertisements end up drinking more, according to a study published in the January issue of the Archives of Pediatric and Adolescent Medicine (2006;160:18–24). Researchers from the University of Connecticut, Farmington, and their colleagues randomly sampled more than 1,800 people aged 15–26 about their drinking habits and their viewing of alcohol advertisements; each subject was interviewed four times during a 21-month period. The researchers found that individuals who were exposed to one more TV, radio, or magazine advertisement per month on average than other individuals had 1% more alcoholic drinks per month. They also found that for every additional dollar per capita spent on advertising in a particular media market, respondents consumed 3% more alcoholic beverages per month. The findings “call into question the industry's argument that its roughly $1.8 billion in measured media expenditures per year have no impact on underage drinking,” David H. Jerningan, Ph.D., of Georgetown University's Center on Alcohol Marketing and Youth, Washington, wrote in an accompanying editorial. “The fact that young people … were more likely to drink more over time in environments with more alcohol advertising, even when controlling for alcohol sales in those environments, suggests that it is exposure to alcohol advertising that contributes to the drinking, rather than the reverse.”

Parity Law Extended

The law requiring employers to provide the same caps on mental health coverage as they do for physical health coverage has been extended for another year. The Mental Health Parity Act, which does not apply to substance abuse or chemical dependency benefits, says that group health plans offering mental health benefits cannot set annual or lifetime dollar limits on mental health benefits that are lower than any dollar limits for medical and surgical benefits. Plans that have no annual or lifetime limits on medical and surgical benefits may not impose dollar limits on mental health benefits either.

Mental Health Screening Snapshot

More than half the states provide education or information to primary care providers to help them focus on young children's early mental health development, according to a survey from the National Academy for State Health Policy (NASHP). As part of the Assuring Better Child Health and Development program, NASHP surveyed Medicaid, maternal and child health, and children's mental health agencies in all 50 states and the District of Columbia to gather information on how states were addressing the mental health development of children aged birth to 3 years. Various resources were available in the states to assist primary care providers who identify a child in need of further assessment or in-house follow-up, the survey found. Mental health consultation was mentioned most frequently (48%), followed by state-funded care coordinators (33%), public health nursing consultation (30%), and lists of organizations for physician referrals (27%). However, “these low percentages suggest that none of these resources are readily available,” the survey indicated. Providers also raised concerns regarding screening for social and emotional development, such as a lack of referral resources, insufficient payment, and a lack of expertise.

Behaviors Leading to Death

By the time they enter adulthood, a large percentage of American youth have already begun the behaviors that lead to preventable causes of death, according to a study from the Carolina Population Center and the University of North Carolina at Chapel Hill. Researchers studied a nationally representative sample of more than 14,000 young adults; they were first interviewed from 1994 to 1995 when they ranged in age from 12 to 19 years, and again in 2001 and 2002, when their age range was 19 to 26 years. The researchers found that for nearly all groups surveyed, diet, obesity, and access to health care worsened; tobacco, alcohol, and illicit drug use and the likelihood of acquiring a sexually transmitted disease increased as the youths reached adulthood. “Whether the trends will continue as they age, we don't know,” said Kathleen M. Harris, Ph.D., the study's principal investigator. “But it doesn't bode well for their future health.” One statistic that doesn't bode well: The proportion of young white female respondents reporting no weekly physical exercise was 5% during adolescence, but grew to 46% in early adulthood. The study appears in the January issue of the Archives of Pediatric and Adolescent Medicine (2006;160:74–81).

Money for Psychiatric Hospitals

Inpatient psychiatric facilities would receive an average 4.2% increase in their Medicare payments under a proposal from the Centers for Medicare and Medicaid Services. The proposed rule would affect about 1,800 facilities, including certified psychiatric units in general acute care hospitals. Freestanding government psychiatric hospitals would receive the largest share of the increase, the agency said. “We believe the changes we are proposing today will support the continued improvement in quality of care for Medicare beneficiaries with severe psychiatric disorders,” said CMS Administrator Dr. Mark B. McClellan. “Appropriate inpatient psychiatric care often can make it possible for these beneficiaries to return to their homes or to less restrictive settings.” CMS will accept comments on the proposed rule until March 14; a final rule will be published later in the spring. The increase will affect all discharges occurring on or after July 1.

Alcohol Ads, Underage Drinking

Youth people who see more alcohol advertisements end up drinking more, according to a study published in the January issue of the Archives of Pediatric and Adolescent Medicine (2006;160:18–24). Researchers from the University of Connecticut, Farmington, and their colleagues randomly sampled more than 1,800 people aged 15–26 about their drinking habits and their viewing of alcohol advertisements; each subject was interviewed four times during a 21-month period. The researchers found that individuals who were exposed to one more TV, radio, or magazine advertisement per month on average than other individuals had 1% more alcoholic drinks per month. They also found that for every additional dollar per capita spent on advertising in a particular media market, respondents consumed 3% more alcoholic beverages per month. The findings “call into question the industry's argument that its roughly $1.8 billion in measured media expenditures per year have no impact on underage drinking,” David H. Jerningan, Ph.D., of Georgetown University's Center on Alcohol Marketing and Youth, Washington, wrote in an accompanying editorial. “The fact that young people … were more likely to drink more over time in environments with more alcohol advertising, even when controlling for alcohol sales in those environments, suggests that it is exposure to alcohol advertising that contributes to the drinking, rather than the reverse.”

Parity Law Extended

The law requiring employers to provide the same caps on mental health coverage as they do for physical health coverage has been extended for another year. The Mental Health Parity Act, which does not apply to substance abuse or chemical dependency benefits, says that group health plans offering mental health benefits cannot set annual or lifetime dollar limits on mental health benefits that are lower than any dollar limits for medical and surgical benefits. Plans that have no annual or lifetime limits on medical and surgical benefits may not impose dollar limits on mental health benefits either.

Mental Health Screening Snapshot

More than half the states provide education or information to primary care providers to help them focus on young children's early mental health development, according to a survey from the National Academy for State Health Policy (NASHP). As part of the Assuring Better Child Health and Development program, NASHP surveyed Medicaid, maternal and child health, and children's mental health agencies in all 50 states and the District of Columbia to gather information on how states were addressing the mental health development of children aged birth to 3 years. Various resources were available in the states to assist primary care providers who identify a child in need of further assessment or in-house follow-up, the survey found. Mental health consultation was mentioned most frequently (48%), followed by state-funded care coordinators (33%), public health nursing consultation (30%), and lists of organizations for physician referrals (27%). However, “these low percentages suggest that none of these resources are readily available,” the survey indicated. Providers also raised concerns regarding screening for social and emotional development, such as a lack of referral resources, insufficient payment, and a lack of expertise.

Behaviors Leading to Death

By the time they enter adulthood, a large percentage of American youth have already begun the behaviors that lead to preventable causes of death, according to a study from the Carolina Population Center and the University of North Carolina at Chapel Hill. Researchers studied a nationally representative sample of more than 14,000 young adults; they were first interviewed from 1994 to 1995 when they ranged in age from 12 to 19 years, and again in 2001 and 2002, when their age range was 19 to 26 years. The researchers found that for nearly all groups surveyed, diet, obesity, and access to health care worsened; tobacco, alcohol, and illicit drug use and the likelihood of acquiring a sexually transmitted disease increased as the youths reached adulthood. “Whether the trends will continue as they age, we don't know,” said Kathleen M. Harris, Ph.D., the study's principal investigator. “But it doesn't bode well for their future health.” One statistic that doesn't bode well: The proportion of young white female respondents reporting no weekly physical exercise was 5% during adolescence, but grew to 46% in early adulthood. The study appears in the January issue of the Archives of Pediatric and Adolescent Medicine (2006;160:74–81).

Money for Psychiatric Hospitals

Inpatient psychiatric facilities would receive an average 4.2% increase in their Medicare payments under a proposal from the Centers for Medicare and Medicaid Services. The proposed rule would affect about 1,800 facilities, including certified psychiatric units in general acute care hospitals. Freestanding government psychiatric hospitals would receive the largest share of the increase, the agency said. “We believe the changes we are proposing today will support the continued improvement in quality of care for Medicare beneficiaries with severe psychiatric disorders,” said CMS Administrator Dr. Mark B. McClellan. “Appropriate inpatient psychiatric care often can make it possible for these beneficiaries to return to their homes or to less restrictive settings.” CMS will accept comments on the proposed rule until March 14; a final rule will be published later in the spring. The increase will affect all discharges occurring on or after July 1.

The Medicare program 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, director of the Best Buy Drugs project for 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.

In addition to switching to generics, cutting copayments for cholesterol drugs might also save money for the health care system, according to a study from Rand Corporation. The study, which was published in the January issue of the American Journal of Managed Care, looked at the 6.3 million adults with Medicare or private coverage and simulated the impact of a plan with varied copayments. Researchers found that with smaller copayments, patients were more likely to take their medications and, as a result, suffered fewer complications from high cholesterol. Cutting the copayments could save the health care system more than $1 billion a year in medical costs, the study found.

The Medicare program 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, director of the Best Buy Drugs project for 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.

In addition to switching to generics, cutting copayments for cholesterol drugs might also save money for the health care system, according to a study from Rand Corporation. The study, which was published in the January issue of the American Journal of Managed Care, looked at the 6.3 million adults with Medicare or private coverage and simulated the impact of a plan with varied copayments. Researchers found that with smaller copayments, patients were more likely to take their medications and, as a result, suffered fewer complications from high cholesterol. Cutting the copayments could save the health care system more than $1 billion a year in medical costs, the study found.

The Medicare program 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, director of the Best Buy Drugs project for 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.

In addition to switching to generics, cutting copayments for cholesterol drugs might also save money for the health care system, according to a study from Rand Corporation. The study, which was published in the January issue of the American Journal of Managed Care, looked at the 6.3 million adults with Medicare or private coverage and simulated the impact of a plan with varied copayments. Researchers found that with smaller copayments, patients were more likely to take their medications and, as a result, suffered fewer complications from high cholesterol. Cutting the copayments could save the health care system more than $1 billion a year in medical costs, the study found.

WASHINGTON — Members of the Practicing Physician Advisory Council are asking if Medicare should do more to identify and correct underpayments.

At a recent council meeting, PPAC members wanted to know why a new demonstration program from the Centers for Medicare and Medicaid Services rewards contractors financially for finding money owed to the Medicare program, but not for finding money that Medicare has underpaid to physicians.

Under the Recovery Audit Contractors program, three contractors hired by CMS look for overpayments and underpayments made by Medicare to physicians and hospitals, and try to recover the overpayments. The program, which began last spring, operates in the three states with the largest Medicare beneficiary populations: California, Florida, and New York.

The contractors are paid a percentage of what they collect in overpayments, but there is no similar incentive for finding underpayments. That's because it would require Medicare to pay money over and above the amount of the underpayment, “and that's money going out of the [Medicare] trust fund, not going back in,” Gerald Walters, director of the financial services group at CMS, told PPAC members.

Council member Dr. Peter D. Grimm, a radiation oncologist in Seattle, said he would gladly give some of the underpayment money he was due back to the contractor. “If you found $100 of mine, I'd give you $5, I'll tell you that much,” he said. “I think physicians would not be opposed to [paying].”

Mr. Walters said that idea had been suggested to him before, but under the terms of the demonstration program, “if even one person says, 'I'm not going to pay, give me my money,' I can't do it.”

Council member Dr. Barbara L. McAneny, a clinical oncologist in Albuquerque, noted that there is a “cottage industry” of companies that volunteer to review physicians' claims, find examples of undercoding, and help the physicians resubmit the claims for more money.

Council chair Dr. Ronald D. Castellanos, a urologist in Cape Coral, Fla., said he had spoken with one of the contractors who “definitely had sent out demand letters [to providers], but had not found any underpayments.” Mr. Walters said that CMS “believes it has found a way to incentivize” the contractors to target underpayments, but he did not elaborate further.

Once an underpayment has been identified, the contractor must notify the appropriate Medicare carrier, which will adjust the claim and pay the provider.

WASHINGTON — Members of the Practicing Physician Advisory Council are asking if Medicare should do more to identify and correct underpayments.

At a recent council meeting, PPAC members wanted to know why a new demonstration program from the Centers for Medicare and Medicaid Services rewards contractors financially for finding money owed to the Medicare program, but not for finding money that Medicare has underpaid to physicians.

Under the Recovery Audit Contractors program, three contractors hired by CMS look for overpayments and underpayments made by Medicare to physicians and hospitals, and try to recover the overpayments. The program, which began last spring, operates in the three states with the largest Medicare beneficiary populations: California, Florida, and New York.

The contractors are paid a percentage of what they collect in overpayments, but there is no similar incentive for finding underpayments. That's because it would require Medicare to pay money over and above the amount of the underpayment, “and that's money going out of the [Medicare] trust fund, not going back in,” Gerald Walters, director of the financial services group at CMS, told PPAC members.

Council member Dr. Peter D. Grimm, a radiation oncologist in Seattle, said he would gladly give some of the underpayment money he was due back to the contractor. “If you found $100 of mine, I'd give you $5, I'll tell you that much,” he said. “I think physicians would not be opposed to [paying].”

Mr. Walters said that idea had been suggested to him before, but under the terms of the demonstration program, “if even one person says, 'I'm not going to pay, give me my money,' I can't do it.”

Council member Dr. Barbara L. McAneny, a clinical oncologist in Albuquerque, noted that there is a “cottage industry” of companies that volunteer to review physicians' claims, find examples of undercoding, and help the physicians resubmit the claims for more money.

Council chair Dr. Ronald D. Castellanos, a urologist in Cape Coral, Fla., said he had spoken with one of the contractors who “definitely had sent out demand letters [to providers], but had not found any underpayments.” Mr. Walters said that CMS “believes it has found a way to incentivize” the contractors to target underpayments, but he did not elaborate further.

Once an underpayment has been identified, the contractor must notify the appropriate Medicare carrier, which will adjust the claim and pay the provider.

WASHINGTON — Members of the Practicing Physician Advisory Council are asking if Medicare should do more to identify and correct underpayments.

At a recent council meeting, PPAC members wanted to know why a new demonstration program from the Centers for Medicare and Medicaid Services rewards contractors financially for finding money owed to the Medicare program, but not for finding money that Medicare has underpaid to physicians.

Under the Recovery Audit Contractors program, three contractors hired by CMS look for overpayments and underpayments made by Medicare to physicians and hospitals, and try to recover the overpayments. The program, which began last spring, operates in the three states with the largest Medicare beneficiary populations: California, Florida, and New York.

The contractors are paid a percentage of what they collect in overpayments, but there is no similar incentive for finding underpayments. That's because it would require Medicare to pay money over and above the amount of the underpayment, “and that's money going out of the [Medicare] trust fund, not going back in,” Gerald Walters, director of the financial services group at CMS, told PPAC members.

Council member Dr. Peter D. Grimm, a radiation oncologist in Seattle, said he would gladly give some of the underpayment money he was due back to the contractor. “If you found $100 of mine, I'd give you $5, I'll tell you that much,” he said. “I think physicians would not be opposed to [paying].”

Mr. Walters said that idea had been suggested to him before, but under the terms of the demonstration program, “if even one person says, 'I'm not going to pay, give me my money,' I can't do it.”

Council member Dr. Barbara L. McAneny, a clinical oncologist in Albuquerque, noted that there is a “cottage industry” of companies that volunteer to review physicians' claims, find examples of undercoding, and help the physicians resubmit the claims for more money.

Council chair Dr. Ronald D. Castellanos, a urologist in Cape Coral, Fla., said he had spoken with one of the contractors who “definitely had sent out demand letters [to providers], but had not found any underpayments.” Mr. Walters said that CMS “believes it has found a way to incentivize” the contractors to target underpayments, but he did not elaborate further.

Once an underpayment has been identified, the contractor must notify the appropriate Medicare carrier, which will adjust the claim and pay the provider.

WASHINGTON — Electronic health records make good business sense for physicians, even for those in small- and medium-sized medical groups, Stefanos Zenios, Ph.D., said at a health care congress sponsored by the Wall Street Journal and CNBC.

"There is a perception that there's no business case for adopting electronic health records in small or midsize medical groups," said Dr. Zenios, professor of operations, information, and technology at Stanford (Calif.) University. However, that's not the case if one considers the economic data carefully, he said.

Like any other investment, electronic health records (EHRs) have both short-term and long-term costs. "Initial costs are $43,000 per full-time equivalent [FTE], including software and hardware and productivity losses," he said, citing a recent study (Health Affairs 2005;24:1127–37).

However, the same study also showed an $18,000 increase in revenue per FTE due to better billing and better follow-up on patients, he added. And by the fourth year, the return on investment is 31%.

"If you would take all money you are spending to install and maintain the system, and put it in the bank, on average you would be making 5%–7% [in interest]. Even if you put it in the stock market in the 1990s, you would be making 10% on that money … not even the venture capitalists can see returns as high [as 31%]. So that's a compelling financial case, which primarily comes from better billing," he said.

Better data mining is another way practices can increase revenue. For instance, one 26-member cardiology group in North Carolina used EHR data to look for patients at risk of sudden coronary death. Out of 80,000 patient records, they found nearly 300 patients who were candidates for primary prevention and more than 1,400 patients who were candidates for secondary prevention.

This then translated into more than 1,300 consultations, 900 echocardiograms, 500 T-wave tests, and 500 implantable cardioverter defibrillator implantations. That had a clinical impact of averting 37 sudden cardiac deaths each year, and a financial impact of $2.8 million in additional revenue to the practice, Dr. Zenios said.

Finally, those who are early adopters of EHRs can put practices at a competitive advantage. Dr Zenios cited another study that showed EHRs could bring a total estimated savings to the entire health care system of $245 billion. Of that, an estimated $23 billion would come in the form of fewer physician visits (Health Affairs 2005;24:1103–17).

In the face of this possible reduction in business, if all small- and medium-sized medical practices invested in EHRs, no one's share of the shrinking outpatient market would change, Dr. Zenios said. But if only some groups invested in them, "they would gain an advantage" because of increases in practice efficiency, while their competitors' market share will go down. "To protect your business, it may make sense to have an EHR."

Like any other investment, installing an EHR is not risk-free, Dr. Zenios warned. He offered several suggestions to help physicians better manage the risks involved:

▸ Redundancy, redundancy, redundancy. "People put a new information technology system in place, and the next morning they turn off their previous system," he said. "It doesn't make sense. It's costly to have both systems in place, but that protects you. For 3–6 months, there has to be some redundancy."

▸ Assess the ability of the system to improve your billing processes. For example, the system may be able to flag procedures for which physicians are routinely underbilling and bill them at the proper level.

▸ Assess the system's capability to take advantage of all the data that are going to become available. "Some innovative practices are using this capability to deliver better quality of care to their patients and improve their revenue," he said.

WASHINGTON — Electronic health records make good business sense for physicians, even for those in small- and medium-sized medical groups, Stefanos Zenios, Ph.D., said at a health care congress sponsored by the Wall Street Journal and CNBC.

"There is a perception that there's no business case for adopting electronic health records in small or midsize medical groups," said Dr. Zenios, professor of operations, information, and technology at Stanford (Calif.) University. However, that's not the case if one considers the economic data carefully, he said.

Like any other investment, electronic health records (EHRs) have both short-term and long-term costs. "Initial costs are $43,000 per full-time equivalent [FTE], including software and hardware and productivity losses," he said, citing a recent study (Health Affairs 2005;24:1127–37).

However, the same study also showed an $18,000 increase in revenue per FTE due to better billing and better follow-up on patients, he added. And by the fourth year, the return on investment is 31%.

"If you would take all money you are spending to install and maintain the system, and put it in the bank, on average you would be making 5%–7% [in interest]. Even if you put it in the stock market in the 1990s, you would be making 10% on that money … not even the venture capitalists can see returns as high [as 31%]. So that's a compelling financial case, which primarily comes from better billing," he said.

Better data mining is another way practices can increase revenue. For instance, one 26-member cardiology group in North Carolina used EHR data to look for patients at risk of sudden coronary death. Out of 80,000 patient records, they found nearly 300 patients who were candidates for primary prevention and more than 1,400 patients who were candidates for secondary prevention.

This then translated into more than 1,300 consultations, 900 echocardiograms, 500 T-wave tests, and 500 implantable cardioverter defibrillator implantations. That had a clinical impact of averting 37 sudden cardiac deaths each year, and a financial impact of $2.8 million in additional revenue to the practice, Dr. Zenios said.

Finally, those who are early adopters of EHRs can put practices at a competitive advantage. Dr Zenios cited another study that showed EHRs could bring a total estimated savings to the entire health care system of $245 billion. Of that, an estimated $23 billion would come in the form of fewer physician visits (Health Affairs 2005;24:1103–17).

In the face of this possible reduction in business, if all small- and medium-sized medical practices invested in EHRs, no one's share of the shrinking outpatient market would change, Dr. Zenios said. But if only some groups invested in them, "they would gain an advantage" because of increases in practice efficiency, while their competitors' market share will go down. "To protect your business, it may make sense to have an EHR."

Like any other investment, installing an EHR is not risk-free, Dr. Zenios warned. He offered several suggestions to help physicians better manage the risks involved:

▸ Redundancy, redundancy, redundancy. "People put a new information technology system in place, and the next morning they turn off their previous system," he said. "It doesn't make sense. It's costly to have both systems in place, but that protects you. For 3–6 months, there has to be some redundancy."

▸ Assess the ability of the system to improve your billing processes. For example, the system may be able to flag procedures for which physicians are routinely underbilling and bill them at the proper level.

▸ Assess the system's capability to take advantage of all the data that are going to become available. "Some innovative practices are using this capability to deliver better quality of care to their patients and improve their revenue," he said.

WASHINGTON — Electronic health records make good business sense for physicians, even for those in small- and medium-sized medical groups, Stefanos Zenios, Ph.D., said at a health care congress sponsored by the Wall Street Journal and CNBC.

"There is a perception that there's no business case for adopting electronic health records in small or midsize medical groups," said Dr. Zenios, professor of operations, information, and technology at Stanford (Calif.) University. However, that's not the case if one considers the economic data carefully, he said.

Like any other investment, electronic health records (EHRs) have both short-term and long-term costs. "Initial costs are $43,000 per full-time equivalent [FTE], including software and hardware and productivity losses," he said, citing a recent study (Health Affairs 2005;24:1127–37).

However, the same study also showed an $18,000 increase in revenue per FTE due to better billing and better follow-up on patients, he added. And by the fourth year, the return on investment is 31%.

"If you would take all money you are spending to install and maintain the system, and put it in the bank, on average you would be making 5%–7% [in interest]. Even if you put it in the stock market in the 1990s, you would be making 10% on that money … not even the venture capitalists can see returns as high [as 31%]. So that's a compelling financial case, which primarily comes from better billing," he said.

Better data mining is another way practices can increase revenue. For instance, one 26-member cardiology group in North Carolina used EHR data to look for patients at risk of sudden coronary death. Out of 80,000 patient records, they found nearly 300 patients who were candidates for primary prevention and more than 1,400 patients who were candidates for secondary prevention.

This then translated into more than 1,300 consultations, 900 echocardiograms, 500 T-wave tests, and 500 implantable cardioverter defibrillator implantations. That had a clinical impact of averting 37 sudden cardiac deaths each year, and a financial impact of $2.8 million in additional revenue to the practice, Dr. Zenios said.

Finally, those who are early adopters of EHRs can put practices at a competitive advantage. Dr Zenios cited another study that showed EHRs could bring a total estimated savings to the entire health care system of $245 billion. Of that, an estimated $23 billion would come in the form of fewer physician visits (Health Affairs 2005;24:1103–17).

In the face of this possible reduction in business, if all small- and medium-sized medical practices invested in EHRs, no one's share of the shrinking outpatient market would change, Dr. Zenios said. But if only some groups invested in them, "they would gain an advantage" because of increases in practice efficiency, while their competitors' market share will go down. "To protect your business, it may make sense to have an EHR."

Like any other investment, installing an EHR is not risk-free, Dr. Zenios warned. He offered several suggestions to help physicians better manage the risks involved:

▸ Redundancy, redundancy, redundancy. "People put a new information technology system in place, and the next morning they turn off their previous system," he said. "It doesn't make sense. It's costly to have both systems in place, but that protects you. For 3–6 months, there has to be some redundancy."

▸ Assess the ability of the system to improve your billing processes. For example, the system may be able to flag procedures for which physicians are routinely underbilling and bill them at the proper level.

▸ Assess the system's capability to take advantage of all the data that are going to become available. "Some innovative practices are using this capability to deliver better quality of care to their patients and improve their revenue," he said.

WASHINGTON — Physicians are often reluctant to leap into an electronic health record system because of its complexity and the expense involved, Dr. Daniel Sands said at a health care congress sponsored by the Wall Street Journal and CNBC.

“If you're a doctor, what do you do? How do you get that [EHR] if you can't take the one big leap?” he said.

One way to start is by using electronic communications with patients and with office staff, he said. “Why don't you get rid of those stupid yellow Post-It notes you use for phone messages? A simple step like that is a good way to get people engaged with technology,” said Dr. Sands of Harvard University, Boston.

Electronic prescribing is another way to bridge the gap, said Dr. Sands, who is also chief medical officer of ZixCorp, a Newton, Mass., company that sells electronic prescribing software. Medications can be prescribed using various electronic devices, including desktop and laptop computers, handhelds, and even mobile phones. Studies have shown that electronic prescribing can reduce medication errors substantially, therefore “this should be the standard of care,” he said.

Another step is to use online clinical reference materials, Dr. Sands continued. “We have lots of data showing that physicians are often faced with questions when taking care of patients, and they can't find the answers because they don't have time, so they just move on. And that's really scary.”

Rather than looking for answers “in a book that's out of date as soon as it's printed, maybe looking online would be a great place to start,” Dr. Sands said.

WASHINGTON — Physicians are often reluctant to leap into an electronic health record system because of its complexity and the expense involved, Dr. Daniel Sands said at a health care congress sponsored by the Wall Street Journal and CNBC.

“If you're a doctor, what do you do? How do you get that [EHR] if you can't take the one big leap?” he said.

One way to start is by using electronic communications with patients and with office staff, he said. “Why don't you get rid of those stupid yellow Post-It notes you use for phone messages? A simple step like that is a good way to get people engaged with technology,” said Dr. Sands of Harvard University, Boston.

Electronic prescribing is another way to bridge the gap, said Dr. Sands, who is also chief medical officer of ZixCorp, a Newton, Mass., company that sells electronic prescribing software. Medications can be prescribed using various electronic devices, including desktop and laptop computers, handhelds, and even mobile phones. Studies have shown that electronic prescribing can reduce medication errors substantially, therefore “this should be the standard of care,” he said.

Another step is to use online clinical reference materials, Dr. Sands continued. “We have lots of data showing that physicians are often faced with questions when taking care of patients, and they can't find the answers because they don't have time, so they just move on. And that's really scary.”

Rather than looking for answers “in a book that's out of date as soon as it's printed, maybe looking online would be a great place to start,” Dr. Sands said.

WASHINGTON — Physicians are often reluctant to leap into an electronic health record system because of its complexity and the expense involved, Dr. Daniel Sands said at a health care congress sponsored by the Wall Street Journal and CNBC.

“If you're a doctor, what do you do? How do you get that [EHR] if you can't take the one big leap?” he said.

One way to start is by using electronic communications with patients and with office staff, he said. “Why don't you get rid of those stupid yellow Post-It notes you use for phone messages? A simple step like that is a good way to get people engaged with technology,” said Dr. Sands of Harvard University, Boston.

Electronic prescribing is another way to bridge the gap, said Dr. Sands, who is also chief medical officer of ZixCorp, a Newton, Mass., company that sells electronic prescribing software. Medications can be prescribed using various electronic devices, including desktop and laptop computers, handhelds, and even mobile phones. Studies have shown that electronic prescribing can reduce medication errors substantially, therefore “this should be the standard of care,” he said.

Another step is to use online clinical reference materials, Dr. Sands continued. “We have lots of data showing that physicians are often faced with questions when taking care of patients, and they can't find the answers because they don't have time, so they just move on. And that's really scary.”

Rather than looking for answers “in a book that's out of date as soon as it's printed, maybe looking online would be a great place to start,” Dr. Sands said.

WASHINGTON — Use of illegal drugs among adolescents continues to decline modestly, but abuse of some prescription drugs is increasing, according to a survey of 49,000 students in 400 secondary schools nationwide.

Overall, the use of any illicit drug in the past 12 months is down by more than a third since 1996 among eighth graders and by just under a quarter among 10th graders, according to the survey. The decline is smaller among 12th graders—about 10%.

“Today is another great day for America's teens, it's a really bad day for the drug traffickers trading on them, and it's a particularly bad day for those who falsely claim we are losing the battle against drugs,” Karen P. Tandy, administrator of the Drug Enforcement Administration, said at a press briefing on the survey sponsored by the National Institute on Drug Abuse.

Principal investigator Lloyd Johnston, Ph.D., noted that although declines in illicit drug use among 10th and 12th graders were not dramatic this year, “they are dramatic over a long period of time. Their use of marijuana and illicit drugs other than marijuana is down for the fourth year in a row.”

Overall, “several specific drugs showed declines this year which were statistically significant in one or more grades: those include amphetamines—including methamphetamines—steroids, and alcohol,” said Dr. Johnston, who is a distinguished senior research scientist at the University of Michigan's Institute for Social Research, in Ann Arbor. “The drop in methamphetamine use would seem to defy conventional wisdom because we've heard so much about the meth epidemic spreading. I don't want to say that it's not, but it's certainly not spreading among secondary school students.”

But all the news is not rosy, especially when it comes to abuse of prescription medications. For instance, nonmedical use of OxyContin by 12th graders in the past year rose from 4% in 2002 to 5.5% in 2005, a statistically significant difference. The increase “is something I think we need to deal with,” Dr. Johnston said.

The nonmedical use of Vicodin among 12th graders rose slightly from last year—to 9.5% from 9.3%—but was down from 10.5% in 2003.

NIDA director Dr. Nora D. Volkow speculated on where teens might be getting prescription drugs.

“Kids can get it directly from a Web site; you just need a credit card,” she said. “But there are also people who may be buying it in larger [quantities] and then distributing it. And then there are those patients who may be going to different physicians asking for prescription medications, and then those [drugs] are diverted,” said Dr. Volkow.

The vast majority of prescription drug abuse is probably not starting out from home, said John P. Walters, director of the Office of National Drug Control Policy. “When you see levels of Vicodin use of 1 in 10 high school seniors, I don't believe they're [stealing] them out of their parents' medicine cabinet. No doubt there is some of that, but the quantities we're talking about are not sustainable with simply pulling … one or two pills out of a bottle. We also have detected organized criminal groups that are providing pills out of the drug supply they produce.”

And the decline in overall drug use may be leveling off, judging by what trends are occurring among eighth graders, Dr. Johnston said.

“Eighth graders were first to show increase in drug use in the early 1990s, and they gave us an early warning that problems were about to emerge. They were also the first to show the beginning of a turnaround in drug use in the mid-1990s. Now they appear to be first to possibly signal an end of decline in mid-2000s, in that their cigarette use did not decline this year, their use of marijuana did not decline, and their use of illicit drugs other than marijuana did not decline. This is a divergence from other grades.”

The study also looked at perceived availability of various illicit drugs. Amyl nitrite and butyl nitrite were among those judged hardest to get, with only 19% of 12th graders saying they would be “easy” or “fairly easy” to acquire.

At the other end of the spectrum, 85% of 12th graders said marijuana would be easy or fairly easy to get, a percentage that has remained relatively constant for the entire 30 years of the survey.

The fact that the marijuana number has remained relatively unchanged “just shows that the war on drugs is failing and we need another way,” Aaron Houston, director of government relations for the Marijuana Policy Project, said in an interview after he had listened to the briefing. “Our current policy guarantees that marijuana will be available to young adults because it keeps it in the black market. If we were to control and regulate marijuana and bring it out of the black market, we might be able to control it like we have tobacco.”

WASHINGTON — Use of illegal drugs among adolescents continues to decline modestly, but abuse of some prescription drugs is increasing, according to a survey of 49,000 students in 400 secondary schools nationwide.

Overall, the use of any illicit drug in the past 12 months is down by more than a third since 1996 among eighth graders and by just under a quarter among 10th graders, according to the survey. The decline is smaller among 12th graders—about 10%.

“Today is another great day for America's teens, it's a really bad day for the drug traffickers trading on them, and it's a particularly bad day for those who falsely claim we are losing the battle against drugs,” Karen P. Tandy, administrator of the Drug Enforcement Administration, said at a press briefing on the survey sponsored by the National Institute on Drug Abuse.

Principal investigator Lloyd Johnston, Ph.D., noted that although declines in illicit drug use among 10th and 12th graders were not dramatic this year, “they are dramatic over a long period of time. Their use of marijuana and illicit drugs other than marijuana is down for the fourth year in a row.”

Overall, “several specific drugs showed declines this year which were statistically significant in one or more grades: those include amphetamines—including methamphetamines—steroids, and alcohol,” said Dr. Johnston, who is a distinguished senior research scientist at the University of Michigan's Institute for Social Research, in Ann Arbor. “The drop in methamphetamine use would seem to defy conventional wisdom because we've heard so much about the meth epidemic spreading. I don't want to say that it's not, but it's certainly not spreading among secondary school students.”

But all the news is not rosy, especially when it comes to abuse of prescription medications. For instance, nonmedical use of OxyContin by 12th graders in the past year rose from 4% in 2002 to 5.5% in 2005, a statistically significant difference. The increase “is something I think we need to deal with,” Dr. Johnston said.

The nonmedical use of Vicodin among 12th graders rose slightly from last year—to 9.5% from 9.3%—but was down from 10.5% in 2003.

NIDA director Dr. Nora D. Volkow speculated on where teens might be getting prescription drugs.

“Kids can get it directly from a Web site; you just need a credit card,” she said. “But there are also people who may be buying it in larger [quantities] and then distributing it. And then there are those patients who may be going to different physicians asking for prescription medications, and then those [drugs] are diverted,” said Dr. Volkow.

The vast majority of prescription drug abuse is probably not starting out from home, said John P. Walters, director of the Office of National Drug Control Policy. “When you see levels of Vicodin use of 1 in 10 high school seniors, I don't believe they're [stealing] them out of their parents' medicine cabinet. No doubt there is some of that, but the quantities we're talking about are not sustainable with simply pulling … one or two pills out of a bottle. We also have detected organized criminal groups that are providing pills out of the drug supply they produce.”

And the decline in overall drug use may be leveling off, judging by what trends are occurring among eighth graders, Dr. Johnston said.

“Eighth graders were first to show increase in drug use in the early 1990s, and they gave us an early warning that problems were about to emerge. They were also the first to show the beginning of a turnaround in drug use in the mid-1990s. Now they appear to be first to possibly signal an end of decline in mid-2000s, in that their cigarette use did not decline this year, their use of marijuana did not decline, and their use of illicit drugs other than marijuana did not decline. This is a divergence from other grades.”

The study also looked at perceived availability of various illicit drugs. Amyl nitrite and butyl nitrite were among those judged hardest to get, with only 19% of 12th graders saying they would be “easy” or “fairly easy” to acquire.

At the other end of the spectrum, 85% of 12th graders said marijuana would be easy or fairly easy to get, a percentage that has remained relatively constant for the entire 30 years of the survey.

The fact that the marijuana number has remained relatively unchanged “just shows that the war on drugs is failing and we need another way,” Aaron Houston, director of government relations for the Marijuana Policy Project, said in an interview after he had listened to the briefing. “Our current policy guarantees that marijuana will be available to young adults because it keeps it in the black market. If we were to control and regulate marijuana and bring it out of the black market, we might be able to control it like we have tobacco.”

WASHINGTON — Use of illegal drugs among adolescents continues to decline modestly, but abuse of some prescription drugs is increasing, according to a survey of 49,000 students in 400 secondary schools nationwide.

Overall, the use of any illicit drug in the past 12 months is down by more than a third since 1996 among eighth graders and by just under a quarter among 10th graders, according to the survey. The decline is smaller among 12th graders—about 10%.

“Today is another great day for America's teens, it's a really bad day for the drug traffickers trading on them, and it's a particularly bad day for those who falsely claim we are losing the battle against drugs,” Karen P. Tandy, administrator of the Drug Enforcement Administration, said at a press briefing on the survey sponsored by the National Institute on Drug Abuse.

Principal investigator Lloyd Johnston, Ph.D., noted that although declines in illicit drug use among 10th and 12th graders were not dramatic this year, “they are dramatic over a long period of time. Their use of marijuana and illicit drugs other than marijuana is down for the fourth year in a row.”

Overall, “several specific drugs showed declines this year which were statistically significant in one or more grades: those include amphetamines—including methamphetamines—steroids, and alcohol,” said Dr. Johnston, who is a distinguished senior research scientist at the University of Michigan's Institute for Social Research, in Ann Arbor. “The drop in methamphetamine use would seem to defy conventional wisdom because we've heard so much about the meth epidemic spreading. I don't want to say that it's not, but it's certainly not spreading among secondary school students.”

But all the news is not rosy, especially when it comes to abuse of prescription medications. For instance, nonmedical use of OxyContin by 12th graders in the past year rose from 4% in 2002 to 5.5% in 2005, a statistically significant difference. The increase “is something I think we need to deal with,” Dr. Johnston said.

The nonmedical use of Vicodin among 12th graders rose slightly from last year—to 9.5% from 9.3%—but was down from 10.5% in 2003.

NIDA director Dr. Nora D. Volkow speculated on where teens might be getting prescription drugs.

“Kids can get it directly from a Web site; you just need a credit card,” she said. “But there are also people who may be buying it in larger [quantities] and then distributing it. And then there are those patients who may be going to different physicians asking for prescription medications, and then those [drugs] are diverted,” said Dr. Volkow.

The vast majority of prescription drug abuse is probably not starting out from home, said John P. Walters, director of the Office of National Drug Control Policy. “When you see levels of Vicodin use of 1 in 10 high school seniors, I don't believe they're [stealing] them out of their parents' medicine cabinet. No doubt there is some of that, but the quantities we're talking about are not sustainable with simply pulling … one or two pills out of a bottle. We also have detected organized criminal groups that are providing pills out of the drug supply they produce.”

And the decline in overall drug use may be leveling off, judging by what trends are occurring among eighth graders, Dr. Johnston said.

“Eighth graders were first to show increase in drug use in the early 1990s, and they gave us an early warning that problems were about to emerge. They were also the first to show the beginning of a turnaround in drug use in the mid-1990s. Now they appear to be first to possibly signal an end of decline in mid-2000s, in that their cigarette use did not decline this year, their use of marijuana did not decline, and their use of illicit drugs other than marijuana did not decline. This is a divergence from other grades.”

The study also looked at perceived availability of various illicit drugs. Amyl nitrite and butyl nitrite were among those judged hardest to get, with only 19% of 12th graders saying they would be “easy” or “fairly easy” to acquire.

At the other end of the spectrum, 85% of 12th graders said marijuana would be easy or fairly easy to get, a percentage that has remained relatively constant for the entire 30 years of the survey.

The fact that the marijuana number has remained relatively unchanged “just shows that the war on drugs is failing and we need another way,” Aaron Houston, director of government relations for the Marijuana Policy Project, said in an interview after he had listened to the briefing. “Our current policy guarantees that marijuana will be available to young adults because it keeps it in the black market. If we were to control and regulate marijuana and bring it out of the black market, we might be able to control it like we have tobacco.”

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 doesn't 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,” he 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 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.”

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 antidepressants are harmful to someone who's depressed and suicidal. 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,'” he 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.”

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 doesn't 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,” he 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 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.”

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 antidepressants are harmful to someone who's depressed and suicidal. 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,'” he 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.”

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 doesn't 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,” he 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 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.”

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 antidepressants are harmful to someone who's depressed and suicidal. 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,'” he 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.”