Joyce Frieden

WASHINGTON — Knowing which Medicare managed care plans provide high-quality care is a good idea, but Medicare beneficiaries will need more information to figure out which providers to see within a particular plan, Glenn M. Hackbarth, J.D., said at a meeting of the Medicare Payment Advisory Commission.

In Boston, for instance, "If you're a Medicare beneficiary trying to get good health care, knowing that Harvard Pilgrim Health Care is ranked number one doesn't tell you at all where to go within the Harvard Pilgrim network to get really outstanding care," said Mr. Hackbarth, a Bend, Ore., health care consultant who is chairman of MedPAC. "That's something that needs to be understood about plan rankings."

The commission staff ranked about 150 Medicare Advantage plans, which are managed care plans offered to Medicare beneficiaries. Senior analyst Niall Brennan presented their work.

To assess the plans, staff members looked at plan scores on nine different measures within the Health Plan Employer Data and Information Set (HEDIS) database. The researchers looked only at HMO plans; PPO and fee-for-service programs within Medicare Advantage were excluded because they weren't required to report on all HEDIS measures.

Measures included breast cancer screening, β-blocker treatment after a heart attack, antidepressant medication management, hypertension management, osteoporosis management, cholesterol management, follow-up after mental illness, and colorectal cancer screening. One additional measure, diabetes care, counted double in the scoring, Mr. Brennan said.

Scores were calculated based on how well each plan did compared with other plans—for instance, a plan that scored above the 90th percentile on a particular measure received 1 point, while a plan that scored between the 75th and 90th percentile received a 0.88. Ten points constituted a perfect score.

Mr. Brennan noted that the total scores of the plans the staff evaluated ranged from 1.2 to 9.8. And different measures had very different levels of result. For example, "giving β-blockers after a heart attack is a well established quality measure, and plans tend to score very highly on it," he said. "Other measures [such as osteoporosis management] are a little lower and more widely dispersed."

In general, bigger plans seemed to perform better, with plans that had more than 50,000 enrollees having an average HEDIS score of 7.5 compared with an average of 5.7 for plans with fewer than 10,000 enrollees. Not-for-profit plans had slightly higher scores than did for-profit plans. And while there was not a lot of geographic variation, Boston area plans did score "significantly higher" in terms of quality, Mr. Brennan said.

Scores also appeared to remain stable over time: 74% of the plans in the lowest quartile in 2003 remained in the lowest quartile in 2004. "The results of our analysis are quite interesting, and highlight the need for a pay-for-performance program in Medicare Advantage, and the feasibility of using HEDIS data for differentiating among Medicare Advantage plans," he said.

MedPAC commissioners, however, were not sure how useful the scores would be, especially if the quality data were supposed to be used as the basis for a pay-for-performance plan. "If this looks like a good measure for implementing a pay-for-performance program, I'd like to step back and say that it isn't," said Commission Vice-Chair Robert D. Reischauer, Ph.D., president of the Urban Institute.

Mr. Hackbarth noted that beneficiaries needed to look at more than just managed care plans. For plan data to be really useful, "beneficiaries ought to be able to compare plan offerings and choices to the ambient level of quality of fee-for-service Medicare in that same community," he said. "We're moving in the right direction, but there are a host of questions about how you do these things."

WASHINGTON — Knowing which Medicare managed care plans provide high-quality care is a good idea, but Medicare beneficiaries will need more information to figure out which providers to see within a particular plan, Glenn M. Hackbarth, J.D., said at a meeting of the Medicare Payment Advisory Commission.

In Boston, for instance, "If you're a Medicare beneficiary trying to get good health care, knowing that Harvard Pilgrim Health Care is ranked number one doesn't tell you at all where to go within the Harvard Pilgrim network to get really outstanding care," said Mr. Hackbarth, a Bend, Ore., health care consultant who is chairman of MedPAC. "That's something that needs to be understood about plan rankings."

The commission staff ranked about 150 Medicare Advantage plans, which are managed care plans offered to Medicare beneficiaries. Senior analyst Niall Brennan presented their work.

To assess the plans, staff members looked at plan scores on nine different measures within the Health Plan Employer Data and Information Set (HEDIS) database. The researchers looked only at HMO plans; PPO and fee-for-service programs within Medicare Advantage were excluded because they weren't required to report on all HEDIS measures.

Measures included breast cancer screening, β-blocker treatment after a heart attack, antidepressant medication management, hypertension management, osteoporosis management, cholesterol management, follow-up after mental illness, and colorectal cancer screening. One additional measure, diabetes care, counted double in the scoring, Mr. Brennan said.

Scores were calculated based on how well each plan did compared with other plans—for instance, a plan that scored above the 90th percentile on a particular measure received 1 point, while a plan that scored between the 75th and 90th percentile received a 0.88. Ten points constituted a perfect score.

Mr. Brennan noted that the total scores of the plans the staff evaluated ranged from 1.2 to 9.8. And different measures had very different levels of result. For example, "giving β-blockers after a heart attack is a well established quality measure, and plans tend to score very highly on it," he said. "Other measures [such as osteoporosis management] are a little lower and more widely dispersed."

In general, bigger plans seemed to perform better, with plans that had more than 50,000 enrollees having an average HEDIS score of 7.5 compared with an average of 5.7 for plans with fewer than 10,000 enrollees. Not-for-profit plans had slightly higher scores than did for-profit plans. And while there was not a lot of geographic variation, Boston area plans did score "significantly higher" in terms of quality, Mr. Brennan said.

Scores also appeared to remain stable over time: 74% of the plans in the lowest quartile in 2003 remained in the lowest quartile in 2004. "The results of our analysis are quite interesting, and highlight the need for a pay-for-performance program in Medicare Advantage, and the feasibility of using HEDIS data for differentiating among Medicare Advantage plans," he said.

MedPAC commissioners, however, were not sure how useful the scores would be, especially if the quality data were supposed to be used as the basis for a pay-for-performance plan. "If this looks like a good measure for implementing a pay-for-performance program, I'd like to step back and say that it isn't," said Commission Vice-Chair Robert D. Reischauer, Ph.D., president of the Urban Institute.

Mr. Hackbarth noted that beneficiaries needed to look at more than just managed care plans. For plan data to be really useful, "beneficiaries ought to be able to compare plan offerings and choices to the ambient level of quality of fee-for-service Medicare in that same community," he said. "We're moving in the right direction, but there are a host of questions about how you do these things."

WASHINGTON — Knowing which Medicare managed care plans provide high-quality care is a good idea, but Medicare beneficiaries will need more information to figure out which providers to see within a particular plan, Glenn M. Hackbarth, J.D., said at a meeting of the Medicare Payment Advisory Commission.

In Boston, for instance, "If you're a Medicare beneficiary trying to get good health care, knowing that Harvard Pilgrim Health Care is ranked number one doesn't tell you at all where to go within the Harvard Pilgrim network to get really outstanding care," said Mr. Hackbarth, a Bend, Ore., health care consultant who is chairman of MedPAC. "That's something that needs to be understood about plan rankings."

The commission staff ranked about 150 Medicare Advantage plans, which are managed care plans offered to Medicare beneficiaries. Senior analyst Niall Brennan presented their work.

To assess the plans, staff members looked at plan scores on nine different measures within the Health Plan Employer Data and Information Set (HEDIS) database. The researchers looked only at HMO plans; PPO and fee-for-service programs within Medicare Advantage were excluded because they weren't required to report on all HEDIS measures.

Measures included breast cancer screening, β-blocker treatment after a heart attack, antidepressant medication management, hypertension management, osteoporosis management, cholesterol management, follow-up after mental illness, and colorectal cancer screening. One additional measure, diabetes care, counted double in the scoring, Mr. Brennan said.

Scores were calculated based on how well each plan did compared with other plans—for instance, a plan that scored above the 90th percentile on a particular measure received 1 point, while a plan that scored between the 75th and 90th percentile received a 0.88. Ten points constituted a perfect score.

Mr. Brennan noted that the total scores of the plans the staff evaluated ranged from 1.2 to 9.8. And different measures had very different levels of result. For example, "giving β-blockers after a heart attack is a well established quality measure, and plans tend to score very highly on it," he said. "Other measures [such as osteoporosis management] are a little lower and more widely dispersed."

In general, bigger plans seemed to perform better, with plans that had more than 50,000 enrollees having an average HEDIS score of 7.5 compared with an average of 5.7 for plans with fewer than 10,000 enrollees. Not-for-profit plans had slightly higher scores than did for-profit plans. And while there was not a lot of geographic variation, Boston area plans did score "significantly higher" in terms of quality, Mr. Brennan said.

Scores also appeared to remain stable over time: 74% of the plans in the lowest quartile in 2003 remained in the lowest quartile in 2004. "The results of our analysis are quite interesting, and highlight the need for a pay-for-performance program in Medicare Advantage, and the feasibility of using HEDIS data for differentiating among Medicare Advantage plans," he said.

MedPAC commissioners, however, were not sure how useful the scores would be, especially if the quality data were supposed to be used as the basis for a pay-for-performance plan. "If this looks like a good measure for implementing a pay-for-performance program, I'd like to step back and say that it isn't," said Commission Vice-Chair Robert D. Reischauer, Ph.D., president of the Urban Institute.

Mr. Hackbarth noted that beneficiaries needed to look at more than just managed care plans. For plan data to be really useful, "beneficiaries ought to be able to compare plan offerings and choices to the ambient level of quality of fee-for-service Medicare in that same community," he said. "We're moving in the right direction, but there are a host of questions about how you do these things."

The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html

WASHINGTON — The issues of aging, dementia, and long-term care merit formation of a presidential commission, the President's Council on Bioethics suggests in a new report.

At its recent meeting in Washington, the commission heard from Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, who said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a health care system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and making less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown University, Washington, told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home- and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system to ease the burden on caregivers than are currently in place, Dr. Friedlander said.

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Peter Rabins, M.D., codirector of geriatric psychiatry and neuropsychiatry at Hopkins, said there was another element of the long-term care system that was worth considering. “Probably about 1 million or so people now live in assisted living, and studies just completed by [myself and colleagues] show that, just as in nursing homes, about two-thirds of individuals in assisted living have dementia,” he said.

As a result, “all the relatively mild dementia cases are in assisted living and what has happened in nursing homes is that they now treat the very advanced patients,” he said. “So nursing homes have changed very dramatically. I think that's very important to keep in mind.”

Leon Kass, M.D., American Enterprise Institute, retired as council chair at the September meeting.

The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html

WASHINGTON — The issues of aging, dementia, and long-term care merit formation of a presidential commission, the President's Council on Bioethics suggests in a new report.

At its recent meeting in Washington, the commission heard from Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, who said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a health care system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and making less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown University, Washington, told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home- and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system to ease the burden on caregivers than are currently in place, Dr. Friedlander said.

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Peter Rabins, M.D., codirector of geriatric psychiatry and neuropsychiatry at Hopkins, said there was another element of the long-term care system that was worth considering. “Probably about 1 million or so people now live in assisted living, and studies just completed by [myself and colleagues] show that, just as in nursing homes, about two-thirds of individuals in assisted living have dementia,” he said.

As a result, “all the relatively mild dementia cases are in assisted living and what has happened in nursing homes is that they now treat the very advanced patients,” he said. “So nursing homes have changed very dramatically. I think that's very important to keep in mind.”

Leon Kass, M.D., American Enterprise Institute, retired as council chair at the September meeting.

The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html

WASHINGTON — The issues of aging, dementia, and long-term care merit formation of a presidential commission, the President's Council on Bioethics suggests in a new report.

At its recent meeting in Washington, the commission heard from Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, who said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a health care system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and making less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown University, Washington, told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home- and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system to ease the burden on caregivers than are currently in place, Dr. Friedlander said.

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Peter Rabins, M.D., codirector of geriatric psychiatry and neuropsychiatry at Hopkins, said there was another element of the long-term care system that was worth considering. “Probably about 1 million or so people now live in assisted living, and studies just completed by [myself and colleagues] show that, just as in nursing homes, about two-thirds of individuals in assisted living have dementia,” he said.

As a result, “all the relatively mild dementia cases are in assisted living and what has happened in nursing homes is that they now treat the very advanced patients,” he said. “So nursing homes have changed very dramatically. I think that's very important to keep in mind.”

Leon Kass, M.D., American Enterprise Institute, retired as council chair at the September meeting.

Now Playing: Vascular Neurology

The results are in: 225 neurologists have passed the first certification exam for the new subspecialty of vascular neurology. “The new subspecialty reflects the growth of cerebrovascular disease as an independent area of medical expertise,” Harold P. Adams Jr., M.D., and colleagues said in announcing the test results in the October issue of Stroke. The authors note that the new certificates are valid for 10 years; to retain certification, physicians “will periodically have to complete an [American Board of Psychiatry and Neurology] maintenance of certification process, including taking another examination.” The next scheduled certification examination will take place in June 2006. Meanwhile, the Accreditation Council for Graduate Medical Education has endorsed fellowship training in vascular neurology; after the 2009 examination, only those neurologists who have completed an ACGME-accredited program will be eligible for certification.

Neurology Council Gets New Members

Health and Human Services Secretary Michael O. Leavitt has appointed three new members to the National Advisory Neurological Disorders and Stroke Council, the major advisory panel of the National Institute of Neurological Disorders and Stroke. The new members, who will serve through July 2009, are Robi Blumenstein, president of MRSSI Inc., a company that provides consulting and grant-making services to foundations researching Huntington's disease; Helen Mayberg, M.D., professor of psychiatry and neurology at Emory University; and Laura Ment, M.D., professor of pediatrics and neurology at Yale University. Mr. Leavitt also announced that council member Patrick Pullicino, M.D., Ph.D., professor and chairman of neurosciences at the University of Medicine and Dentistry of New Jersey, will serve on the council for an additional year.

Anticonvulsant Education

The Epilepsy Foundation is telling women of childbearing age who take anticonvulsant medications to talk with their doctors about their treatment options. The group issued a “call to action” in an effort to make women aware of the risks to the fetus from these drugs. Since the risks from these drugs occur early in pregnancy and about half of pregnancies in the United States are unplanned, it leaves women unprepared, according to the Epilepsy Foundation. The call to action “places a sense of urgency for all women of childbearing age to reevaluate their current drug treatment,” Eric Hargis, president of the Epilepsy Foundation, said in a statement. This call to action is part of a larger effort to educate women about reducing the risks associated with anticonvulsant drugs, according to the group. More than 56 million prescriptions were written last year for anticonvulsants, making it the fifth most prescribed class of medications, according to the Epilepsy Foundation.

New Medicare Registries

The Centers for Medicare and Medicaid Services has announced that it is starting two new registries: one on carotid stents and the other on fluorodeoxyglucose PET scans for dementia and neurodegenerative diseases. The carotid artery stent registry will “collect and maintain data on patients to review determinations of 'reasonable and necessary' with respect to … patients who are at high risk for [carotid endarterectomy],” CMS said in a Sept. 20 Federal Register notice. As for the PET scans, the Oct. 13 Federal Register notice pointed out that although CMS has found sufficient evidence to deem PET scans no longer experimental, “the evidence was insufficient to reach a conclusion that FDG PET is reasonable and necessary in all instances. A sufficient inference of benefit, however, can be drawn to support limited coverage if certain safeguards for patients are provided.” Both regulations are available from

www.gpoaccess.gov/fr/index.html

Voters Doubt Congress on Health

Roughly two-thirds of voters think Congress has not made much progress on helping those without health insurance, and is not likely to make much more in the next 5–10 years, according to a survey of 800 likely voters sponsored by Ceasefire on Health Care, a group whose aim is to stimulate dialogue on health care between Republican and Democratic policy makers. Overall, poll respondents listed their top four health care priorities as making sure all U.S. children have access to basic health care, guaranteeing health care to every U.S. citizen, providing better preventive health care to all Americans, and helping control the amount of out-of-pocket health care costs. “Probably the most interesting result in this study is that 88% of those surveyed want Congress to compromise on the issue of the uninsured,” said former Sen. John Breaux (D-La.), who is leading the group.

Now Playing: Vascular Neurology

The results are in: 225 neurologists have passed the first certification exam for the new subspecialty of vascular neurology. “The new subspecialty reflects the growth of cerebrovascular disease as an independent area of medical expertise,” Harold P. Adams Jr., M.D., and colleagues said in announcing the test results in the October issue of Stroke. The authors note that the new certificates are valid for 10 years; to retain certification, physicians “will periodically have to complete an [American Board of Psychiatry and Neurology] maintenance of certification process, including taking another examination.” The next scheduled certification examination will take place in June 2006. Meanwhile, the Accreditation Council for Graduate Medical Education has endorsed fellowship training in vascular neurology; after the 2009 examination, only those neurologists who have completed an ACGME-accredited program will be eligible for certification.

Neurology Council Gets New Members

Health and Human Services Secretary Michael O. Leavitt has appointed three new members to the National Advisory Neurological Disorders and Stroke Council, the major advisory panel of the National Institute of Neurological Disorders and Stroke. The new members, who will serve through July 2009, are Robi Blumenstein, president of MRSSI Inc., a company that provides consulting and grant-making services to foundations researching Huntington's disease; Helen Mayberg, M.D., professor of psychiatry and neurology at Emory University; and Laura Ment, M.D., professor of pediatrics and neurology at Yale University. Mr. Leavitt also announced that council member Patrick Pullicino, M.D., Ph.D., professor and chairman of neurosciences at the University of Medicine and Dentistry of New Jersey, will serve on the council for an additional year.

Anticonvulsant Education

The Epilepsy Foundation is telling women of childbearing age who take anticonvulsant medications to talk with their doctors about their treatment options. The group issued a “call to action” in an effort to make women aware of the risks to the fetus from these drugs. Since the risks from these drugs occur early in pregnancy and about half of pregnancies in the United States are unplanned, it leaves women unprepared, according to the Epilepsy Foundation. The call to action “places a sense of urgency for all women of childbearing age to reevaluate their current drug treatment,” Eric Hargis, president of the Epilepsy Foundation, said in a statement. This call to action is part of a larger effort to educate women about reducing the risks associated with anticonvulsant drugs, according to the group. More than 56 million prescriptions were written last year for anticonvulsants, making it the fifth most prescribed class of medications, according to the Epilepsy Foundation.

New Medicare Registries

The Centers for Medicare and Medicaid Services has announced that it is starting two new registries: one on carotid stents and the other on fluorodeoxyglucose PET scans for dementia and neurodegenerative diseases. The carotid artery stent registry will “collect and maintain data on patients to review determinations of 'reasonable and necessary' with respect to … patients who are at high risk for [carotid endarterectomy],” CMS said in a Sept. 20 Federal Register notice. As for the PET scans, the Oct. 13 Federal Register notice pointed out that although CMS has found sufficient evidence to deem PET scans no longer experimental, “the evidence was insufficient to reach a conclusion that FDG PET is reasonable and necessary in all instances. A sufficient inference of benefit, however, can be drawn to support limited coverage if certain safeguards for patients are provided.” Both regulations are available from

www.gpoaccess.gov/fr/index.html

Voters Doubt Congress on Health

Roughly two-thirds of voters think Congress has not made much progress on helping those without health insurance, and is not likely to make much more in the next 5–10 years, according to a survey of 800 likely voters sponsored by Ceasefire on Health Care, a group whose aim is to stimulate dialogue on health care between Republican and Democratic policy makers. Overall, poll respondents listed their top four health care priorities as making sure all U.S. children have access to basic health care, guaranteeing health care to every U.S. citizen, providing better preventive health care to all Americans, and helping control the amount of out-of-pocket health care costs. “Probably the most interesting result in this study is that 88% of those surveyed want Congress to compromise on the issue of the uninsured,” said former Sen. John Breaux (D-La.), who is leading the group.

Now Playing: Vascular Neurology

The results are in: 225 neurologists have passed the first certification exam for the new subspecialty of vascular neurology. “The new subspecialty reflects the growth of cerebrovascular disease as an independent area of medical expertise,” Harold P. Adams Jr., M.D., and colleagues said in announcing the test results in the October issue of Stroke. The authors note that the new certificates are valid for 10 years; to retain certification, physicians “will periodically have to complete an [American Board of Psychiatry and Neurology] maintenance of certification process, including taking another examination.” The next scheduled certification examination will take place in June 2006. Meanwhile, the Accreditation Council for Graduate Medical Education has endorsed fellowship training in vascular neurology; after the 2009 examination, only those neurologists who have completed an ACGME-accredited program will be eligible for certification.

Neurology Council Gets New Members

Health and Human Services Secretary Michael O. Leavitt has appointed three new members to the National Advisory Neurological Disorders and Stroke Council, the major advisory panel of the National Institute of Neurological Disorders and Stroke. The new members, who will serve through July 2009, are Robi Blumenstein, president of MRSSI Inc., a company that provides consulting and grant-making services to foundations researching Huntington's disease; Helen Mayberg, M.D., professor of psychiatry and neurology at Emory University; and Laura Ment, M.D., professor of pediatrics and neurology at Yale University. Mr. Leavitt also announced that council member Patrick Pullicino, M.D., Ph.D., professor and chairman of neurosciences at the University of Medicine and Dentistry of New Jersey, will serve on the council for an additional year.

Anticonvulsant Education

The Epilepsy Foundation is telling women of childbearing age who take anticonvulsant medications to talk with their doctors about their treatment options. The group issued a “call to action” in an effort to make women aware of the risks to the fetus from these drugs. Since the risks from these drugs occur early in pregnancy and about half of pregnancies in the United States are unplanned, it leaves women unprepared, according to the Epilepsy Foundation. The call to action “places a sense of urgency for all women of childbearing age to reevaluate their current drug treatment,” Eric Hargis, president of the Epilepsy Foundation, said in a statement. This call to action is part of a larger effort to educate women about reducing the risks associated with anticonvulsant drugs, according to the group. More than 56 million prescriptions were written last year for anticonvulsants, making it the fifth most prescribed class of medications, according to the Epilepsy Foundation.

New Medicare Registries

The Centers for Medicare and Medicaid Services has announced that it is starting two new registries: one on carotid stents and the other on fluorodeoxyglucose PET scans for dementia and neurodegenerative diseases. The carotid artery stent registry will “collect and maintain data on patients to review determinations of 'reasonable and necessary' with respect to … patients who are at high risk for [carotid endarterectomy],” CMS said in a Sept. 20 Federal Register notice. As for the PET scans, the Oct. 13 Federal Register notice pointed out that although CMS has found sufficient evidence to deem PET scans no longer experimental, “the evidence was insufficient to reach a conclusion that FDG PET is reasonable and necessary in all instances. A sufficient inference of benefit, however, can be drawn to support limited coverage if certain safeguards for patients are provided.” Both regulations are available from

www.gpoaccess.gov/fr/index.html

Voters Doubt Congress on Health

Roughly two-thirds of voters think Congress has not made much progress on helping those without health insurance, and is not likely to make much more in the next 5–10 years, according to a survey of 800 likely voters sponsored by Ceasefire on Health Care, a group whose aim is to stimulate dialogue on health care between Republican and Democratic policy makers. Overall, poll respondents listed their top four health care priorities as making sure all U.S. children have access to basic health care, guaranteeing health care to every U.S. citizen, providing better preventive health care to all Americans, and helping control the amount of out-of-pocket health care costs. “Probably the most interesting result in this study is that 88% of those surveyed want Congress to compromise on the issue of the uninsured,” said former Sen. John Breaux (D-La.), who is leading the group.

A Constitutional amendment specifying that marriage should be between a man and a woman would be harmful to children being raised by gay or lesbian parents, members of a pediatricians' group said in testimony before a Senate subcommittee.

At a press conference prior to the October hearing convened by the Senate Subcommittee on the Constitution, Rodney Finalle, M.D., said, “Not only is there no evidence of harm to children based on parents being the same sex, but there is considerable evidence of the benefit that comes from the security and protection which is guaranteed with marriage. Civil marriage is the social institution that promotes healthy families by conferring a powerful set of rights, benefits, and protections not obtained by other means. There's no justification from separating this group of children from other children we've chosen to protect in this way.”

Dr. Finalle, of the Children's Hospital of Philadelphia, is a member of a group calling itself the Pro-Family Pediatricians. The group has nearly 1,000 signatures on a letter to Senate Majority Leader Bill Frist, M.D., (R-Tenn.) and House Speaker Dennis Hastert (R-Ill.) calling for the defeat of the amendment, known as the Marriage Protection Amendment.

The measure poses practical problems for nonbiological gay and lesbian parents who want to visit a child in the hospital, said Ellen C. Perrin, M.D., director of the division of behavioral pediatrics at Tufts-New England Medical Center in Boston and honorary chair of Pro-Family Pediatricians. “Situations like this happen all the time, especially when the parent who is the legal parent may be out of town, is disabled, or has died,” she said. “The child is left without a parent, even though he or she has—functionally—another parent. In terms of signing for emergency surgery, the child has no legal parent who can speak for him or her.”

The amendment also will not discourage gay and lesbian couples from having children, Dr. Perrin added. “Gay and lesbian people have been raising children for many years and will continue to do so.”

Sen. Patrick Leahy (D-Vt.), ranking member of the Judiciary Committee, discouraged his colleagues from supporting the amendment. “As an American who has been married for 40 years, I am a great fan of the institution of marriage,” the senator said in a statement. “I believe it is important to encourage and to sanction committed relationships. … It would be a sad day for our nation if we amended our founding document for the first time to specifically disfavor a group of Americans. I hope that those who claim to care about healthy families will turn away from wedge politics and scapegoating so we can focus” the issues piling up on Congress' agenda.”

A Constitutional amendment specifying that marriage should be between a man and a woman would be harmful to children being raised by gay or lesbian parents, members of a pediatricians' group said in testimony before a Senate subcommittee.

At a press conference prior to the October hearing convened by the Senate Subcommittee on the Constitution, Rodney Finalle, M.D., said, “Not only is there no evidence of harm to children based on parents being the same sex, but there is considerable evidence of the benefit that comes from the security and protection which is guaranteed with marriage. Civil marriage is the social institution that promotes healthy families by conferring a powerful set of rights, benefits, and protections not obtained by other means. There's no justification from separating this group of children from other children we've chosen to protect in this way.”

Dr. Finalle, of the Children's Hospital of Philadelphia, is a member of a group calling itself the Pro-Family Pediatricians. The group has nearly 1,000 signatures on a letter to Senate Majority Leader Bill Frist, M.D., (R-Tenn.) and House Speaker Dennis Hastert (R-Ill.) calling for the defeat of the amendment, known as the Marriage Protection Amendment.

The measure poses practical problems for nonbiological gay and lesbian parents who want to visit a child in the hospital, said Ellen C. Perrin, M.D., director of the division of behavioral pediatrics at Tufts-New England Medical Center in Boston and honorary chair of Pro-Family Pediatricians. “Situations like this happen all the time, especially when the parent who is the legal parent may be out of town, is disabled, or has died,” she said. “The child is left without a parent, even though he or she has—functionally—another parent. In terms of signing for emergency surgery, the child has no legal parent who can speak for him or her.”

The amendment also will not discourage gay and lesbian couples from having children, Dr. Perrin added. “Gay and lesbian people have been raising children for many years and will continue to do so.”

Sen. Patrick Leahy (D-Vt.), ranking member of the Judiciary Committee, discouraged his colleagues from supporting the amendment. “As an American who has been married for 40 years, I am a great fan of the institution of marriage,” the senator said in a statement. “I believe it is important to encourage and to sanction committed relationships. … It would be a sad day for our nation if we amended our founding document for the first time to specifically disfavor a group of Americans. I hope that those who claim to care about healthy families will turn away from wedge politics and scapegoating so we can focus” the issues piling up on Congress' agenda.”

A Constitutional amendment specifying that marriage should be between a man and a woman would be harmful to children being raised by gay or lesbian parents, members of a pediatricians' group said in testimony before a Senate subcommittee.

At a press conference prior to the October hearing convened by the Senate Subcommittee on the Constitution, Rodney Finalle, M.D., said, “Not only is there no evidence of harm to children based on parents being the same sex, but there is considerable evidence of the benefit that comes from the security and protection which is guaranteed with marriage. Civil marriage is the social institution that promotes healthy families by conferring a powerful set of rights, benefits, and protections not obtained by other means. There's no justification from separating this group of children from other children we've chosen to protect in this way.”

Dr. Finalle, of the Children's Hospital of Philadelphia, is a member of a group calling itself the Pro-Family Pediatricians. The group has nearly 1,000 signatures on a letter to Senate Majority Leader Bill Frist, M.D., (R-Tenn.) and House Speaker Dennis Hastert (R-Ill.) calling for the defeat of the amendment, known as the Marriage Protection Amendment.

The measure poses practical problems for nonbiological gay and lesbian parents who want to visit a child in the hospital, said Ellen C. Perrin, M.D., director of the division of behavioral pediatrics at Tufts-New England Medical Center in Boston and honorary chair of Pro-Family Pediatricians. “Situations like this happen all the time, especially when the parent who is the legal parent may be out of town, is disabled, or has died,” she said. “The child is left without a parent, even though he or she has—functionally—another parent. In terms of signing for emergency surgery, the child has no legal parent who can speak for him or her.”

The amendment also will not discourage gay and lesbian couples from having children, Dr. Perrin added. “Gay and lesbian people have been raising children for many years and will continue to do so.”

Sen. Patrick Leahy (D-Vt.), ranking member of the Judiciary Committee, discouraged his colleagues from supporting the amendment. “As an American who has been married for 40 years, I am a great fan of the institution of marriage,” the senator said in a statement. “I believe it is important to encourage and to sanction committed relationships. … It would be a sad day for our nation if we amended our founding document for the first time to specifically disfavor a group of Americans. I hope that those who claim to care about healthy families will turn away from wedge politics and scapegoating so we can focus” the issues piling up on Congress' agenda.”

AA and Treatment: Best Together

Alcoholics Anonymous and treatment for alcoholism work best if started at the same time, according to a study published in the journal Alcoholism: Clinical and Experimental Research. Researchers surveyed 362 people at 1, 3, 8, and 16 years after they first sought help with alcohol abuse. Of the respondents, nearly half sought professional help at the same time as joining AA, while 25% joined AA only, and 26% only sought professional help. “Compared with individuals who initially participated only in treatment but later entered AA, those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission,” authors Rudolf H. Moos, Ph.D., and Bernice S. Moos of the Department of Veterans Affairs, Palo Alto, Calif., wrote. “Individuals who entered treatment but delayed participation in AA did not appear to obtain any additional benefit from AA.”

More Users Dependent on Meth

Although the number of actual methamphetamine users in 2004 was similar to that of 2 prior years, the number of users who met criteria for illicit drug dependence or abuse increased sharply, according to data from the Substance Abuse and Mental Health Services Administration. The statistics from the National Survey on Drug Use and Health showed that in 2004, 1.4 million people aged 12 years or older used methamphetamine in the past year, and 600,000 had used the drug in the past month, similar to 2002 and 2003. But the number of past-month users who met criteria for illicit drug dependence or abuse increased from 164,000 in 2002 to 346,000 in 2004. “Methamphetamine is undeniably a uniquely destructive drug,” SAMHSA Administrator Charles Curie said in a statement. “While rates of use have remained relatively stable over the past few years, these new findings show that an increasing proportion of methamphetamine users are developing problems of drug abuse and dependence and are in need of treatment.”

Hispanic Mental Health Initiative

The American Psychiatric Association has launched an initiative aimed at making more resources available to Hispanic patients. All information about mental health treatments and resources at

HealthyMinds.org

Groups Call for Alcohol Labeling

Two consumer groups, the National Consumers League and Shape Up America!, are calling on the federal government to require standardized labeling on alcoholic beverages similar to that appearing on packaged food and over-the-counter medications. “Even the most basic information about alcohol beverages is not required to be provided on the labels of most alcohol beverage products,” said NCL President Linda Golodner. “Just as conventional foods, dietary supplements, and nonprescription drugs are required to provide a basic minimum of information needed by consumers to make informed purchasing decisions, alcohol beverage labels should also be required to provide this information.” Information the groups would like to see on the label includes serving size, alcohol content, calories, the definition of a “standard drink,” and advice from federal dietary guidelines about moderate alcohol consumption. The two groups were responding to a request for comment from the U.S. Treasury's Alcohol and Tobacco Tax and Trade Bureau on a proposal to revise the current labeling rules.

Public Favors Electronic Records

Nearly three-fourths of Americans favor establishing a nationwide electronic information exchange to allow patient health records to be shared quickly among health professionals via the Internet, according to a survey of 800 adults sponsored by the Markle Foundation. However, 79% of respondents said it was important to make sure sharing could take place only after patients gave their permission. “Americans use digital information technology to … pay bills, book flights, and customize the music they listen to, and our research shows they now want to use health information technology to get the best care possible for themselves,” said Zoe Baird, the foundation's president. “People realize that if they or those they love are in an accident or disaster, having their medical records available at a moment's notice through secure, electronic information exchange could mean the difference between life and death.”

Voters Sour on Health Care Policy

Roughly two-thirds of voters think Congress has not made much progress on helping those without health insurance, and is not likely to make much more in the next 5–10 years, according to a survey of 800 likely voters sponsored by Ceasefire on Health Care, a group whose aim is to stimulate dialogue on health care between Republican and Democratic policy makers. Overall, poll respondents listed their top four health care priorities as making sure all U.S. children have access to basic health care, guaranteeing health care to every American citizen, providing better preventive health care to all Americans, and helping control the amount of out-of-pocket health care costs. “Probably the most interesting result in this study is that 88% of those surveyed want Congress to compromise on the issue of the uninsured,” said former Sen. John Breaux (D-La.), who is leading the group.

AA and Treatment: Best Together

Alcoholics Anonymous and treatment for alcoholism work best if started at the same time, according to a study published in the journal Alcoholism: Clinical and Experimental Research. Researchers surveyed 362 people at 1, 3, 8, and 16 years after they first sought help with alcohol abuse. Of the respondents, nearly half sought professional help at the same time as joining AA, while 25% joined AA only, and 26% only sought professional help. “Compared with individuals who initially participated only in treatment but later entered AA, those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission,” authors Rudolf H. Moos, Ph.D., and Bernice S. Moos of the Department of Veterans Affairs, Palo Alto, Calif., wrote. “Individuals who entered treatment but delayed participation in AA did not appear to obtain any additional benefit from AA.”

More Users Dependent on Meth

Although the number of actual methamphetamine users in 2004 was similar to that of 2 prior years, the number of users who met criteria for illicit drug dependence or abuse increased sharply, according to data from the Substance Abuse and Mental Health Services Administration. The statistics from the National Survey on Drug Use and Health showed that in 2004, 1.4 million people aged 12 years or older used methamphetamine in the past year, and 600,000 had used the drug in the past month, similar to 2002 and 2003. But the number of past-month users who met criteria for illicit drug dependence or abuse increased from 164,000 in 2002 to 346,000 in 2004. “Methamphetamine is undeniably a uniquely destructive drug,” SAMHSA Administrator Charles Curie said in a statement. “While rates of use have remained relatively stable over the past few years, these new findings show that an increasing proportion of methamphetamine users are developing problems of drug abuse and dependence and are in need of treatment.”

Hispanic Mental Health Initiative

The American Psychiatric Association has launched an initiative aimed at making more resources available to Hispanic patients. All information about mental health treatments and resources at

HealthyMinds.org

Groups Call for Alcohol Labeling

Two consumer groups, the National Consumers League and Shape Up America!, are calling on the federal government to require standardized labeling on alcoholic beverages similar to that appearing on packaged food and over-the-counter medications. “Even the most basic information about alcohol beverages is not required to be provided on the labels of most alcohol beverage products,” said NCL President Linda Golodner. “Just as conventional foods, dietary supplements, and nonprescription drugs are required to provide a basic minimum of information needed by consumers to make informed purchasing decisions, alcohol beverage labels should also be required to provide this information.” Information the groups would like to see on the label includes serving size, alcohol content, calories, the definition of a “standard drink,” and advice from federal dietary guidelines about moderate alcohol consumption. The two groups were responding to a request for comment from the U.S. Treasury's Alcohol and Tobacco Tax and Trade Bureau on a proposal to revise the current labeling rules.

Public Favors Electronic Records

Nearly three-fourths of Americans favor establishing a nationwide electronic information exchange to allow patient health records to be shared quickly among health professionals via the Internet, according to a survey of 800 adults sponsored by the Markle Foundation. However, 79% of respondents said it was important to make sure sharing could take place only after patients gave their permission. “Americans use digital information technology to … pay bills, book flights, and customize the music they listen to, and our research shows they now want to use health information technology to get the best care possible for themselves,” said Zoe Baird, the foundation's president. “People realize that if they or those they love are in an accident or disaster, having their medical records available at a moment's notice through secure, electronic information exchange could mean the difference between life and death.”

Voters Sour on Health Care Policy

Roughly two-thirds of voters think Congress has not made much progress on helping those without health insurance, and is not likely to make much more in the next 5–10 years, according to a survey of 800 likely voters sponsored by Ceasefire on Health Care, a group whose aim is to stimulate dialogue on health care between Republican and Democratic policy makers. Overall, poll respondents listed their top four health care priorities as making sure all U.S. children have access to basic health care, guaranteeing health care to every American citizen, providing better preventive health care to all Americans, and helping control the amount of out-of-pocket health care costs. “Probably the most interesting result in this study is that 88% of those surveyed want Congress to compromise on the issue of the uninsured,” said former Sen. John Breaux (D-La.), who is leading the group.

AA and Treatment: Best Together

Alcoholics Anonymous and treatment for alcoholism work best if started at the same time, according to a study published in the journal Alcoholism: Clinical and Experimental Research. Researchers surveyed 362 people at 1, 3, 8, and 16 years after they first sought help with alcohol abuse. Of the respondents, nearly half sought professional help at the same time as joining AA, while 25% joined AA only, and 26% only sought professional help. “Compared with individuals who initially participated only in treatment but later entered AA, those who entered treatment and AA together participated in AA longer and more frequently and were more likely to achieve remission,” authors Rudolf H. Moos, Ph.D., and Bernice S. Moos of the Department of Veterans Affairs, Palo Alto, Calif., wrote. “Individuals who entered treatment but delayed participation in AA did not appear to obtain any additional benefit from AA.”

More Users Dependent on Meth

Although the number of actual methamphetamine users in 2004 was similar to that of 2 prior years, the number of users who met criteria for illicit drug dependence or abuse increased sharply, according to data from the Substance Abuse and Mental Health Services Administration. The statistics from the National Survey on Drug Use and Health showed that in 2004, 1.4 million people aged 12 years or older used methamphetamine in the past year, and 600,000 had used the drug in the past month, similar to 2002 and 2003. But the number of past-month users who met criteria for illicit drug dependence or abuse increased from 164,000 in 2002 to 346,000 in 2004. “Methamphetamine is undeniably a uniquely destructive drug,” SAMHSA Administrator Charles Curie said in a statement. “While rates of use have remained relatively stable over the past few years, these new findings show that an increasing proportion of methamphetamine users are developing problems of drug abuse and dependence and are in need of treatment.”

Hispanic Mental Health Initiative

The American Psychiatric Association has launched an initiative aimed at making more resources available to Hispanic patients. All information about mental health treatments and resources at

HealthyMinds.org

Groups Call for Alcohol Labeling

Two consumer groups, the National Consumers League and Shape Up America!, are calling on the federal government to require standardized labeling on alcoholic beverages similar to that appearing on packaged food and over-the-counter medications. “Even the most basic information about alcohol beverages is not required to be provided on the labels of most alcohol beverage products,” said NCL President Linda Golodner. “Just as conventional foods, dietary supplements, and nonprescription drugs are required to provide a basic minimum of information needed by consumers to make informed purchasing decisions, alcohol beverage labels should also be required to provide this information.” Information the groups would like to see on the label includes serving size, alcohol content, calories, the definition of a “standard drink,” and advice from federal dietary guidelines about moderate alcohol consumption. The two groups were responding to a request for comment from the U.S. Treasury's Alcohol and Tobacco Tax and Trade Bureau on a proposal to revise the current labeling rules.

Public Favors Electronic Records

Nearly three-fourths of Americans favor establishing a nationwide electronic information exchange to allow patient health records to be shared quickly among health professionals via the Internet, according to a survey of 800 adults sponsored by the Markle Foundation. However, 79% of respondents said it was important to make sure sharing could take place only after patients gave their permission. “Americans use digital information technology to … pay bills, book flights, and customize the music they listen to, and our research shows they now want to use health information technology to get the best care possible for themselves,” said Zoe Baird, the foundation's president. “People realize that if they or those they love are in an accident or disaster, having their medical records available at a moment's notice through secure, electronic information exchange could mean the difference between life and death.”

Voters Sour on Health Care Policy

Roughly two-thirds of voters think Congress has not made much progress on helping those without health insurance, and is not likely to make much more in the next 5–10 years, according to a survey of 800 likely voters sponsored by Ceasefire on Health Care, a group whose aim is to stimulate dialogue on health care between Republican and Democratic policy makers. Overall, poll respondents listed their top four health care priorities as making sure all U.S. children have access to basic health care, guaranteeing health care to every American citizen, providing better preventive health care to all Americans, and helping control the amount of out-of-pocket health care costs. “Probably the most interesting result in this study is that 88% of those surveyed want Congress to compromise on the issue of the uninsured,” said former Sen. John Breaux (D-La.), who is leading the group.

Large health plans and other group providers will be able to treat larger numbers of opioid-dependent patients, thanks to a bill passed recently by Congress.

The measure lifts a cap that allowed practices to treat no more than 30 such patients at any time. “There has been broad acknowledgement that the 30-patient group limit doesn't make sense from a clinical perspective or any other perspective,” Nicholas Myers, director of government relations at the American Psychiatric Association, in Arlington, Va., said in an interview.

The limit, which applied to group practices and individual physicians, was a response to concern about the potential for diversion and abuse, he said. The individual physician limit remains in place.

Large health plans and other group providers will be able to treat larger numbers of opioid-dependent patients, thanks to a bill passed recently by Congress.

The measure lifts a cap that allowed practices to treat no more than 30 such patients at any time. “There has been broad acknowledgement that the 30-patient group limit doesn't make sense from a clinical perspective or any other perspective,” Nicholas Myers, director of government relations at the American Psychiatric Association, in Arlington, Va., said in an interview.

The limit, which applied to group practices and individual physicians, was a response to concern about the potential for diversion and abuse, he said. The individual physician limit remains in place.

Large health plans and other group providers will be able to treat larger numbers of opioid-dependent patients, thanks to a bill passed recently by Congress.

The measure lifts a cap that allowed practices to treat no more than 30 such patients at any time. “There has been broad acknowledgement that the 30-patient group limit doesn't make sense from a clinical perspective or any other perspective,” Nicholas Myers, director of government relations at the American Psychiatric Association, in Arlington, Va., said in an interview.

The limit, which applied to group practices and individual physicians, was a response to concern about the potential for diversion and abuse, he said. The individual physician limit remains in place.

WASHINGTON — Assisted suicide and euthanasia should not be considered for terminally ill patients, the President's Council on Bioethics suggests in a new report.

“If you say assisted suicide and euthanasia are not the way to fix these problems, you have reaffirmed the principles we affirmed in the last chapters of this report,” said Gilbert C. Meilaender, Ph.D., council member and Phyllis and Richard Dusenberg Professor of Christian Ethics at Valparaiso (Ind.) University.

“We think that euthanasia and assisted suicide are out,” agreed council member Paul McHugh, M.D., the Henry Phipps Professor of Psychiatry at Johns Hopkins University, Baltimore. “This is just an old idea that crops up again and again in society, and various people tried it, and it always fails.”

The patients who are driven to consider assisted suicide “are the people who burn out in the process of care,” said Dr. McHugh, who is also professor of mental health at the university's school of public health. “They burn out simply because doctors have been extending things too far for them, asking more than they can deliver. … Never forget that inflicting extra care on people is to ultimately burn them [out].”

Dr. McHugh said he also favored giving family caregivers tax benefits to help them financially. He added that he wished there were more role models to persuade people to think of elder care as a career. “We don't have any Florence Nightingales, any Mother Teresas to tell people this is a wonderful life.”

Council member Alfonso Gómez-Lobo, D. Phil., lauded the report but said there was more work to do on the subject. “We have to think more about the way of making a distinction between ordinary and extraordinary means,” said the Ryan Professor of Metaphysics and Moral Philosophy at Georgetown University, Washington. “It is important to affirm, on the one hand, the goodness of life. On the other hand, it's not an absolute good. It's frail and fragile, and there are moments in which we just have to open ourselves to the fact that we have to let go.”

The report also recommended establishing a presidential commission on aging, dementia, and long-term care.

“Someone might say the last thing America needs is another commission, but this commission is really set up to be unique, understanding death not as a problem to be solved but an experience to be faced,” said council member Peter Lawler, Ph.D., chairman and the Dana Professor of Government at Berry College, Mount Berry, Ga. “We as a people aren't particularly equipped to think of death as an experience to be faced. But if a commission can accomplish that, it would be quite a commission. And I'm all for that.”

At the meeting, the commission heard from Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown. Dr. Friedlander told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There also has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system than are currently in place, Dr. Friedlander said. “I think without structural changes, it is likely to be harder for caregivers in the future.”

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a healthcare system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and doing less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

The September meeting was the last one at which Leon Kass, M.D., a fellow at the American Enterprise Institute, would serve as council chairman. The new chairman is Edmund Pellegrino, M.D., professor emeritus of medicine and medical ethics at Georgetown.

The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html

WASHINGTON — Assisted suicide and euthanasia should not be considered for terminally ill patients, the President's Council on Bioethics suggests in a new report.

“If you say assisted suicide and euthanasia are not the way to fix these problems, you have reaffirmed the principles we affirmed in the last chapters of this report,” said Gilbert C. Meilaender, Ph.D., council member and Phyllis and Richard Dusenberg Professor of Christian Ethics at Valparaiso (Ind.) University.

“We think that euthanasia and assisted suicide are out,” agreed council member Paul McHugh, M.D., the Henry Phipps Professor of Psychiatry at Johns Hopkins University, Baltimore. “This is just an old idea that crops up again and again in society, and various people tried it, and it always fails.”

The patients who are driven to consider assisted suicide “are the people who burn out in the process of care,” said Dr. McHugh, who is also professor of mental health at the university's school of public health. “They burn out simply because doctors have been extending things too far for them, asking more than they can deliver. … Never forget that inflicting extra care on people is to ultimately burn them [out].”

Dr. McHugh said he also favored giving family caregivers tax benefits to help them financially. He added that he wished there were more role models to persuade people to think of elder care as a career. “We don't have any Florence Nightingales, any Mother Teresas to tell people this is a wonderful life.”

Council member Alfonso Gómez-Lobo, D. Phil., lauded the report but said there was more work to do on the subject. “We have to think more about the way of making a distinction between ordinary and extraordinary means,” said the Ryan Professor of Metaphysics and Moral Philosophy at Georgetown University, Washington. “It is important to affirm, on the one hand, the goodness of life. On the other hand, it's not an absolute good. It's frail and fragile, and there are moments in which we just have to open ourselves to the fact that we have to let go.”

The report also recommended establishing a presidential commission on aging, dementia, and long-term care.

“Someone might say the last thing America needs is another commission, but this commission is really set up to be unique, understanding death not as a problem to be solved but an experience to be faced,” said council member Peter Lawler, Ph.D., chairman and the Dana Professor of Government at Berry College, Mount Berry, Ga. “We as a people aren't particularly equipped to think of death as an experience to be faced. But if a commission can accomplish that, it would be quite a commission. And I'm all for that.”

At the meeting, the commission heard from Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown. Dr. Friedlander told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There also has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system than are currently in place, Dr. Friedlander said. “I think without structural changes, it is likely to be harder for caregivers in the future.”

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a healthcare system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and doing less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

The September meeting was the last one at which Leon Kass, M.D., a fellow at the American Enterprise Institute, would serve as council chairman. The new chairman is Edmund Pellegrino, M.D., professor emeritus of medicine and medical ethics at Georgetown.

The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html

WASHINGTON — Assisted suicide and euthanasia should not be considered for terminally ill patients, the President's Council on Bioethics suggests in a new report.

“If you say assisted suicide and euthanasia are not the way to fix these problems, you have reaffirmed the principles we affirmed in the last chapters of this report,” said Gilbert C. Meilaender, Ph.D., council member and Phyllis and Richard Dusenberg Professor of Christian Ethics at Valparaiso (Ind.) University.

“We think that euthanasia and assisted suicide are out,” agreed council member Paul McHugh, M.D., the Henry Phipps Professor of Psychiatry at Johns Hopkins University, Baltimore. “This is just an old idea that crops up again and again in society, and various people tried it, and it always fails.”

The patients who are driven to consider assisted suicide “are the people who burn out in the process of care,” said Dr. McHugh, who is also professor of mental health at the university's school of public health. “They burn out simply because doctors have been extending things too far for them, asking more than they can deliver. … Never forget that inflicting extra care on people is to ultimately burn them [out].”

Dr. McHugh said he also favored giving family caregivers tax benefits to help them financially. He added that he wished there were more role models to persuade people to think of elder care as a career. “We don't have any Florence Nightingales, any Mother Teresas to tell people this is a wonderful life.”

Council member Alfonso Gómez-Lobo, D. Phil., lauded the report but said there was more work to do on the subject. “We have to think more about the way of making a distinction between ordinary and extraordinary means,” said the Ryan Professor of Metaphysics and Moral Philosophy at Georgetown University, Washington. “It is important to affirm, on the one hand, the goodness of life. On the other hand, it's not an absolute good. It's frail and fragile, and there are moments in which we just have to open ourselves to the fact that we have to let go.”

The report also recommended establishing a presidential commission on aging, dementia, and long-term care.

“Someone might say the last thing America needs is another commission, but this commission is really set up to be unique, understanding death not as a problem to be solved but an experience to be faced,” said council member Peter Lawler, Ph.D., chairman and the Dana Professor of Government at Berry College, Mount Berry, Ga. “We as a people aren't particularly equipped to think of death as an experience to be faced. But if a commission can accomplish that, it would be quite a commission. And I'm all for that.”

At the meeting, the commission heard from Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown. Dr. Friedlander told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There also has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system than are currently in place, Dr. Friedlander said. “I think without structural changes, it is likely to be harder for caregivers in the future.”

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a healthcare system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and doing less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued. And the hospital makes money because pneumonia is a disease for which the payment often exceeds the cost of care.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

The September meeting was the last one at which Leon Kass, M.D., a fellow at the American Enterprise Institute, would serve as council chairman. The new chairman is Edmund Pellegrino, M.D., professor emeritus of medicine and medical ethics at Georgetown.

The council's report, “Taking Care: Ethical Caregiving in Our Aging Society,” can be found online at www.bioethics.gov/reports/taking_care/index.html

WASHINGTON — Hurricane Katrina has put many things on hold, including the fate of $10 billion in cuts to the Medicaid program that were proposed by a federally appointed commission.

The Medicaid Commission, which was called for by the fiscal year 2006 federal budget agreement and chartered in May by Health and Human Services Secretary Mike Leavitt, included 13 voting members and 15 nonvoting members representing a variety of interests. It was given a deadline of Sept. 1 to come up with ways to cut the money from the Medicaid budget.

After only two meetings, the commission announced its list of ways to achieve the cuts: changing the reimbursement formula for prescription drugs, tightening rules for asset transfers prior to receiving nursing home care, and allowing states to increase copayments for nonpreferred drugs. But then Hurricane Katrina left hundreds of thousands of people homeless and without a regular source of medical care, and Congress decided the need to reduce the Medicaid budget wasn't so urgent after all.

“There's no doubt that Hurricane Katrina has made it necessary to provide additional resources for the Medicaid program, and we're going to do that apart from reconciliation in the Katrina relief package that's being put together,” Sen. Chuck Grassley (R-Iowa), chair of the Senate Finance Committee, said in announcing an indefinite delay. However, he added that the changes would be voted on eventually.

With regard to the recommendation to reform the long-term care program under Medicaid, Ray Sheppach, executive director of the National Governors Association said at the August meeting that there is a “fairly sophisticated group of lawyers now who are helping people move their assets or income streams to their children or other people so they can [qualify for] Medicaid.”

To prevent people from taking advantage of some of the loopholes in the law, Mr. Sheppach said the NGA favored increasing the “lookback” period—the period during which any assets transferred would still be counted as assets for the beneficiary in determining Medicaid eligibility—from 3 to 5 years. “We also think the type of asset should be expanded so we can look at most assets, including trusts and annuities. And although it will be somewhat controversial, we believe that housing—which is an increasingly valuable asset—should also be put on the table.”

The “tiered copayments” proposal, which would allow states to implement higher copayments for nonpreferred drugs, also raised a lot of interest.

John Monahan, president of state-sponsored business at WellPoint, the for-profit California Blue Shield plan, said that he favored increased use of generic drugs. “Getting [people to increase] utilization of generics by even 5% would be an incredible savings.”

John Rugge, M.D., CEO of the Hudson Headwaters Health Network, in Glens Falls, N.Y., added that “with the psychotropic medications, there's a huge danger in [substituting] one antidepressant for another, one atypical antipsychotic for another; they clearly have to be tailored to the individual. And these are people in most need of service.”

Commission vice-chair Angus King, former governor of Maine (I), said he thought the issue could be dealt with because of the ability of the physician to override any preferred drug if it was clinically necessary to do so. He noted that in Maine, such override requests are usually filled within 72 hours.

Commission member Carol Berkowitz, M.D., president of the American Academy of Pediatrics, said she was concerned about how well such an override system would work. Dr. Berkowitz, who practices in Los Angeles, said that “in my experience it's 30–45 days before it gets approved.”

At its next meeting, scheduled for late this month, the commission is expected to begin the second phase of its work: making recommendations for long-term restructuring of the Medicaid system.

WASHINGTON — Hurricane Katrina has put many things on hold, including the fate of $10 billion in cuts to the Medicaid program that were proposed by a federally appointed commission.

The Medicaid Commission, which was called for by the fiscal year 2006 federal budget agreement and chartered in May by Health and Human Services Secretary Mike Leavitt, included 13 voting members and 15 nonvoting members representing a variety of interests. It was given a deadline of Sept. 1 to come up with ways to cut the money from the Medicaid budget.

After only two meetings, the commission announced its list of ways to achieve the cuts: changing the reimbursement formula for prescription drugs, tightening rules for asset transfers prior to receiving nursing home care, and allowing states to increase copayments for nonpreferred drugs. But then Hurricane Katrina left hundreds of thousands of people homeless and without a regular source of medical care, and Congress decided the need to reduce the Medicaid budget wasn't so urgent after all.

“There's no doubt that Hurricane Katrina has made it necessary to provide additional resources for the Medicaid program, and we're going to do that apart from reconciliation in the Katrina relief package that's being put together,” Sen. Chuck Grassley (R-Iowa), chair of the Senate Finance Committee, said in announcing an indefinite delay. However, he added that the changes would be voted on eventually.

With regard to the recommendation to reform the long-term care program under Medicaid, Ray Sheppach, executive director of the National Governors Association said at the August meeting that there is a “fairly sophisticated group of lawyers now who are helping people move their assets or income streams to their children or other people so they can [qualify for] Medicaid.”

To prevent people from taking advantage of some of the loopholes in the law, Mr. Sheppach said the NGA favored increasing the “lookback” period—the period during which any assets transferred would still be counted as assets for the beneficiary in determining Medicaid eligibility—from 3 to 5 years. “We also think the type of asset should be expanded so we can look at most assets, including trusts and annuities. And although it will be somewhat controversial, we believe that housing—which is an increasingly valuable asset—should also be put on the table.”

The “tiered copayments” proposal, which would allow states to implement higher copayments for nonpreferred drugs, also raised a lot of interest.

John Monahan, president of state-sponsored business at WellPoint, the for-profit California Blue Shield plan, said that he favored increased use of generic drugs. “Getting [people to increase] utilization of generics by even 5% would be an incredible savings.”

John Rugge, M.D., CEO of the Hudson Headwaters Health Network, in Glens Falls, N.Y., added that “with the psychotropic medications, there's a huge danger in [substituting] one antidepressant for another, one atypical antipsychotic for another; they clearly have to be tailored to the individual. And these are people in most need of service.”

Commission vice-chair Angus King, former governor of Maine (I), said he thought the issue could be dealt with because of the ability of the physician to override any preferred drug if it was clinically necessary to do so. He noted that in Maine, such override requests are usually filled within 72 hours.

Commission member Carol Berkowitz, M.D., president of the American Academy of Pediatrics, said she was concerned about how well such an override system would work. Dr. Berkowitz, who practices in Los Angeles, said that “in my experience it's 30–45 days before it gets approved.”

At its next meeting, scheduled for late this month, the commission is expected to begin the second phase of its work: making recommendations for long-term restructuring of the Medicaid system.

WASHINGTON — Hurricane Katrina has put many things on hold, including the fate of $10 billion in cuts to the Medicaid program that were proposed by a federally appointed commission.

The Medicaid Commission, which was called for by the fiscal year 2006 federal budget agreement and chartered in May by Health and Human Services Secretary Mike Leavitt, included 13 voting members and 15 nonvoting members representing a variety of interests. It was given a deadline of Sept. 1 to come up with ways to cut the money from the Medicaid budget.

After only two meetings, the commission announced its list of ways to achieve the cuts: changing the reimbursement formula for prescription drugs, tightening rules for asset transfers prior to receiving nursing home care, and allowing states to increase copayments for nonpreferred drugs. But then Hurricane Katrina left hundreds of thousands of people homeless and without a regular source of medical care, and Congress decided the need to reduce the Medicaid budget wasn't so urgent after all.

“There's no doubt that Hurricane Katrina has made it necessary to provide additional resources for the Medicaid program, and we're going to do that apart from reconciliation in the Katrina relief package that's being put together,” Sen. Chuck Grassley (R-Iowa), chair of the Senate Finance Committee, said in announcing an indefinite delay. However, he added that the changes would be voted on eventually.

With regard to the recommendation to reform the long-term care program under Medicaid, Ray Sheppach, executive director of the National Governors Association said at the August meeting that there is a “fairly sophisticated group of lawyers now who are helping people move their assets or income streams to their children or other people so they can [qualify for] Medicaid.”

To prevent people from taking advantage of some of the loopholes in the law, Mr. Sheppach said the NGA favored increasing the “lookback” period—the period during which any assets transferred would still be counted as assets for the beneficiary in determining Medicaid eligibility—from 3 to 5 years. “We also think the type of asset should be expanded so we can look at most assets, including trusts and annuities. And although it will be somewhat controversial, we believe that housing—which is an increasingly valuable asset—should also be put on the table.”

The “tiered copayments” proposal, which would allow states to implement higher copayments for nonpreferred drugs, also raised a lot of interest.

John Monahan, president of state-sponsored business at WellPoint, the for-profit California Blue Shield plan, said that he favored increased use of generic drugs. “Getting [people to increase] utilization of generics by even 5% would be an incredible savings.”

John Rugge, M.D., CEO of the Hudson Headwaters Health Network, in Glens Falls, N.Y., added that “with the psychotropic medications, there's a huge danger in [substituting] one antidepressant for another, one atypical antipsychotic for another; they clearly have to be tailored to the individual. And these are people in most need of service.”

Commission vice-chair Angus King, former governor of Maine (I), said he thought the issue could be dealt with because of the ability of the physician to override any preferred drug if it was clinically necessary to do so. He noted that in Maine, such override requests are usually filled within 72 hours.

Commission member Carol Berkowitz, M.D., president of the American Academy of Pediatrics, said she was concerned about how well such an override system would work. Dr. Berkowitz, who practices in Los Angeles, said that “in my experience it's 30–45 days before it gets approved.”

At its next meeting, scheduled for late this month, the commission is expected to begin the second phase of its work: making recommendations for long-term restructuring of the Medicaid system.

Medicare's decision to increase payment for stroke patients who receive tissue plasminogen activator likely will result in more stroke centers, but experts are divided over whether it will mean better care for patients.

“It's a great step forward,” said William Barsan, M.D., professor and chair of emergency medicine at the University of Michigan, Ann Arbor. “This has been something in the works for a long time. We identified this as an issue that needed to be addressed soon after TPA was released.”

Currently, the Centers for Medicare and Medicaid Services pays hospitals the same amount—about $5,700—under its diagnosis-related group (DRG) payment system for treating a stroke patient, regardless of whether TPA is used. But under a proposed regulation issued in August, CMS would develop a new DRG called “acute ischemic stroke with use of thrombolytic agents.”

Although TPA costs about $2,000 per dose, the new DRG would pay hospitals about $6,000 more for these patients. That's because patients who receive TPA generally are sicker overall than other stroke patients, and often require more intensive treatment and longer hospital stays, according to a CMS spokeswoman.

That logic is further explained in the proposed regulation. The regulation's authors wrote that when they reviewed average charges for stroke patients, “we noted that the average standardized charges for all patients in DRG 14 ['Intracranial Hemorrhage or Cerebral Infarction'] were $18,997, but that the subset of 2,085 cases in which TPA was used had average standardized charges of $35,128.” As a result, “we are changing the structure of stroke DRGs not to award higher payment for a specific drug, but to recognize the need for better overall care for this group of patients.”

In addition to getting TPA to more patients, this change also will save CMS money if it goes through, said Joseph Broderick, M.D., professor and chair of neurology at the University of Cincinnati. “If you can keep patients out of rehabilitation and nursing homes because you improve things on the front end, you save Medicare and the health system money,” Dr. Broderick said.

But Jerome Hoffman, M.D., professor of medicine and emergency medicine at the University of California, Los Angeles, is not so sure that giving more stroke patients TPA is a good idea. “There is not good evidence that TPA is beneficial in patients with stroke,” he said. “It probably helps a few people and hurts a few people, and the balance is really unclear.”

Aside from the issue of which patients should receive TPA, the increased payment will encourage hospitals to put more money into treating stroke patients, according to Dr. Broderick. “A lot of hospitals have not seen a reason why they should put more resources into [treating] strokes when, in essence, these kinds of patients are going to cost them money.”

Now that they're being paid more for these patients, “more administrators will say, 'Why don't we have a stroke center? Why don't we have more patients who are treated with TPA?'” he said. “If they are going to get paid almost twice as much money, that's an incentive to see why the system is not working, why someone isn't taking the initiative.”

But new financial incentives for hospitals may have little impact on what some experts say is fundamentally a clinical obstacle.

It's not that hospitals don't want to provide patients with proper care, said Dr. Barsan, but it takes a lot of effort to make TPA treatment work efficiently, especially because there is only a 3-hour window for administration once the stroke has occurred.

The 3-hour window is a big issue, Dr. Hoffman concurred. “Many people who are having a stroke wake up with symptoms, so it's hard to tell when they were last normal,” he said. “So most people are outside the 3-hour window.”

A survey Dr. Barsan and colleagues performed of more than 1,100 emergency physicians found that while 60% of respondents said they were “very likely” or “likely” to use TPA in an ideal setting with an appropriate patient and access to the proper equipment and personnel, another 24% of respondents said they would be unlikely to use the drug, and 16% said they were “uncertain” about the matter (Ann. Emerg. Med. 2005;46:56–60). Of this combined group, nearly two-thirds said they were concerned about a possible brain hemorrhage, another 23% listed lack of benefit from the drug, and 12% said they would not use it for both reasons.

Then there are the practical issues. “Ideally, you would have a 'door-to-needle' time of 60 minutes,” Dr. Barsan said. This would require first rapidly identifying the patient when he or she arrives in the emergency department, then doing an exam and determining that the patient did have a stroke, and finally sending the patient for a CT scan to make sure it is not a hemorrhagic stroke, he said.

Even in the best of circumstances, all of this takes a while, Dr. Barsan said. That process can be made even longer if the required specialists are on call but not on site, because it can mean another 30–40 minutes to get them in, he added.

In the end, if the drug is used within strict guidelines, “I don't think it will matter all that much in terms of harm or benefit to patients,” Dr. Hoffman added. “But when you put monetary or legal incentives on people to use it, and they use it a lot more because they think they're supposed to, it could be harmful.”

Dr. Broderick noted that the proposed regulation was largely the result of the combined efforts of several medical organizations, including the American Academy of Neurology, the American Stroke Association, and the National Association of EMS Physicians. “This is a team effort of a lot of organizations who are very passionate about stroke care,” he said. “To CMS's credit, they really listened well and made an informed and well-articulated decision.”

Medicare's decision to increase payment for stroke patients who receive tissue plasminogen activator likely will result in more stroke centers, but experts are divided over whether it will mean better care for patients.

“It's a great step forward,” said William Barsan, M.D., professor and chair of emergency medicine at the University of Michigan, Ann Arbor. “This has been something in the works for a long time. We identified this as an issue that needed to be addressed soon after TPA was released.”

Currently, the Centers for Medicare and Medicaid Services pays hospitals the same amount—about $5,700—under its diagnosis-related group (DRG) payment system for treating a stroke patient, regardless of whether TPA is used. But under a proposed regulation issued in August, CMS would develop a new DRG called “acute ischemic stroke with use of thrombolytic agents.”

Although TPA costs about $2,000 per dose, the new DRG would pay hospitals about $6,000 more for these patients. That's because patients who receive TPA generally are sicker overall than other stroke patients, and often require more intensive treatment and longer hospital stays, according to a CMS spokeswoman.

That logic is further explained in the proposed regulation. The regulation's authors wrote that when they reviewed average charges for stroke patients, “we noted that the average standardized charges for all patients in DRG 14 ['Intracranial Hemorrhage or Cerebral Infarction'] were $18,997, but that the subset of 2,085 cases in which TPA was used had average standardized charges of $35,128.” As a result, “we are changing the structure of stroke DRGs not to award higher payment for a specific drug, but to recognize the need for better overall care for this group of patients.”

In addition to getting TPA to more patients, this change also will save CMS money if it goes through, said Joseph Broderick, M.D., professor and chair of neurology at the University of Cincinnati. “If you can keep patients out of rehabilitation and nursing homes because you improve things on the front end, you save Medicare and the health system money,” Dr. Broderick said.

But Jerome Hoffman, M.D., professor of medicine and emergency medicine at the University of California, Los Angeles, is not so sure that giving more stroke patients TPA is a good idea. “There is not good evidence that TPA is beneficial in patients with stroke,” he said. “It probably helps a few people and hurts a few people, and the balance is really unclear.”

Aside from the issue of which patients should receive TPA, the increased payment will encourage hospitals to put more money into treating stroke patients, according to Dr. Broderick. “A lot of hospitals have not seen a reason why they should put more resources into [treating] strokes when, in essence, these kinds of patients are going to cost them money.”

Now that they're being paid more for these patients, “more administrators will say, 'Why don't we have a stroke center? Why don't we have more patients who are treated with TPA?'” he said. “If they are going to get paid almost twice as much money, that's an incentive to see why the system is not working, why someone isn't taking the initiative.”

But new financial incentives for hospitals may have little impact on what some experts say is fundamentally a clinical obstacle.

It's not that hospitals don't want to provide patients with proper care, said Dr. Barsan, but it takes a lot of effort to make TPA treatment work efficiently, especially because there is only a 3-hour window for administration once the stroke has occurred.

The 3-hour window is a big issue, Dr. Hoffman concurred. “Many people who are having a stroke wake up with symptoms, so it's hard to tell when they were last normal,” he said. “So most people are outside the 3-hour window.”

A survey Dr. Barsan and colleagues performed of more than 1,100 emergency physicians found that while 60% of respondents said they were “very likely” or “likely” to use TPA in an ideal setting with an appropriate patient and access to the proper equipment and personnel, another 24% of respondents said they would be unlikely to use the drug, and 16% said they were “uncertain” about the matter (Ann. Emerg. Med. 2005;46:56–60). Of this combined group, nearly two-thirds said they were concerned about a possible brain hemorrhage, another 23% listed lack of benefit from the drug, and 12% said they would not use it for both reasons.

Then there are the practical issues. “Ideally, you would have a 'door-to-needle' time of 60 minutes,” Dr. Barsan said. This would require first rapidly identifying the patient when he or she arrives in the emergency department, then doing an exam and determining that the patient did have a stroke, and finally sending the patient for a CT scan to make sure it is not a hemorrhagic stroke, he said.

Even in the best of circumstances, all of this takes a while, Dr. Barsan said. That process can be made even longer if the required specialists are on call but not on site, because it can mean another 30–40 minutes to get them in, he added.

In the end, if the drug is used within strict guidelines, “I don't think it will matter all that much in terms of harm or benefit to patients,” Dr. Hoffman added. “But when you put monetary or legal incentives on people to use it, and they use it a lot more because they think they're supposed to, it could be harmful.”

Dr. Broderick noted that the proposed regulation was largely the result of the combined efforts of several medical organizations, including the American Academy of Neurology, the American Stroke Association, and the National Association of EMS Physicians. “This is a team effort of a lot of organizations who are very passionate about stroke care,” he said. “To CMS's credit, they really listened well and made an informed and well-articulated decision.”

Medicare's decision to increase payment for stroke patients who receive tissue plasminogen activator likely will result in more stroke centers, but experts are divided over whether it will mean better care for patients.

“It's a great step forward,” said William Barsan, M.D., professor and chair of emergency medicine at the University of Michigan, Ann Arbor. “This has been something in the works for a long time. We identified this as an issue that needed to be addressed soon after TPA was released.”

Currently, the Centers for Medicare and Medicaid Services pays hospitals the same amount—about $5,700—under its diagnosis-related group (DRG) payment system for treating a stroke patient, regardless of whether TPA is used. But under a proposed regulation issued in August, CMS would develop a new DRG called “acute ischemic stroke with use of thrombolytic agents.”

Although TPA costs about $2,000 per dose, the new DRG would pay hospitals about $6,000 more for these patients. That's because patients who receive TPA generally are sicker overall than other stroke patients, and often require more intensive treatment and longer hospital stays, according to a CMS spokeswoman.

That logic is further explained in the proposed regulation. The regulation's authors wrote that when they reviewed average charges for stroke patients, “we noted that the average standardized charges for all patients in DRG 14 ['Intracranial Hemorrhage or Cerebral Infarction'] were $18,997, but that the subset of 2,085 cases in which TPA was used had average standardized charges of $35,128.” As a result, “we are changing the structure of stroke DRGs not to award higher payment for a specific drug, but to recognize the need for better overall care for this group of patients.”

In addition to getting TPA to more patients, this change also will save CMS money if it goes through, said Joseph Broderick, M.D., professor and chair of neurology at the University of Cincinnati. “If you can keep patients out of rehabilitation and nursing homes because you improve things on the front end, you save Medicare and the health system money,” Dr. Broderick said.

But Jerome Hoffman, M.D., professor of medicine and emergency medicine at the University of California, Los Angeles, is not so sure that giving more stroke patients TPA is a good idea. “There is not good evidence that TPA is beneficial in patients with stroke,” he said. “It probably helps a few people and hurts a few people, and the balance is really unclear.”

Aside from the issue of which patients should receive TPA, the increased payment will encourage hospitals to put more money into treating stroke patients, according to Dr. Broderick. “A lot of hospitals have not seen a reason why they should put more resources into [treating] strokes when, in essence, these kinds of patients are going to cost them money.”

Now that they're being paid more for these patients, “more administrators will say, 'Why don't we have a stroke center? Why don't we have more patients who are treated with TPA?'” he said. “If they are going to get paid almost twice as much money, that's an incentive to see why the system is not working, why someone isn't taking the initiative.”

But new financial incentives for hospitals may have little impact on what some experts say is fundamentally a clinical obstacle.

It's not that hospitals don't want to provide patients with proper care, said Dr. Barsan, but it takes a lot of effort to make TPA treatment work efficiently, especially because there is only a 3-hour window for administration once the stroke has occurred.

The 3-hour window is a big issue, Dr. Hoffman concurred. “Many people who are having a stroke wake up with symptoms, so it's hard to tell when they were last normal,” he said. “So most people are outside the 3-hour window.”

A survey Dr. Barsan and colleagues performed of more than 1,100 emergency physicians found that while 60% of respondents said they were “very likely” or “likely” to use TPA in an ideal setting with an appropriate patient and access to the proper equipment and personnel, another 24% of respondents said they would be unlikely to use the drug, and 16% said they were “uncertain” about the matter (Ann. Emerg. Med. 2005;46:56–60). Of this combined group, nearly two-thirds said they were concerned about a possible brain hemorrhage, another 23% listed lack of benefit from the drug, and 12% said they would not use it for both reasons.

Then there are the practical issues. “Ideally, you would have a 'door-to-needle' time of 60 minutes,” Dr. Barsan said. This would require first rapidly identifying the patient when he or she arrives in the emergency department, then doing an exam and determining that the patient did have a stroke, and finally sending the patient for a CT scan to make sure it is not a hemorrhagic stroke, he said.

Even in the best of circumstances, all of this takes a while, Dr. Barsan said. That process can be made even longer if the required specialists are on call but not on site, because it can mean another 30–40 minutes to get them in, he added.

In the end, if the drug is used within strict guidelines, “I don't think it will matter all that much in terms of harm or benefit to patients,” Dr. Hoffman added. “But when you put monetary or legal incentives on people to use it, and they use it a lot more because they think they're supposed to, it could be harmful.”

Dr. Broderick noted that the proposed regulation was largely the result of the combined efforts of several medical organizations, including the American Academy of Neurology, the American Stroke Association, and the National Association of EMS Physicians. “This is a team effort of a lot of organizations who are very passionate about stroke care,” he said. “To CMS's credit, they really listened well and made an informed and well-articulated decision.”

WASHINGTON — Assisted suicide and euthanasia should not be considered for terminally ill patients, the President's Council on Bioethics suggests in a soon to be released report.

“If you say assisted suicide and euthanasia are not the way to fix these problems, you have reaffirmed the principles we affirmed in the last chapters of this report,” said Gilbert C. Meilaender, Ph.D., council member and Phyllis and Richard Dusenberg Professor of Christian Ethics at Valparaiso (Ind.) University.

“We think that euthanasia and assisted suicide are out,” agreed council member Paul McHugh, M.D., the Henry Phipps Professor of Psychiatry at Johns Hopkins University, Baltimore. “This is just an old idea that crops up again and again in society, and various people tried it, and it always fails.”

The patients who are driven to consider assisted suicide “are the people who burn out in the process of care,” said Dr. McHugh, who is also professor of mental health at the university's school of public health. “They burn out simply because doctors have been extending things too far for them, asking more than they can deliver. … Never forget that inflicting extra care on people is to ultimately burn them [out].”

Dr. McHugh said he also favored giving family caregivers tax benefits to help them financially. He added that he wished there were more role models to persuade people to think of elder care as a career. “We don't have any Florence Nightingales, any Mother Teresas to tell people this is a wonderful life.”

Council member Alfonso Gómez-Lobo, D. Phil., lauded the report but said there was more work to do on the subject. “We have to think more about the way of making a distinction between ordinary and extraordinary means,” said the Ryan Professor of Metaphysics and Moral Philosophy at Georgetown University, Washington. “It is important to affirm, on the one hand, the goodness of life. On the other hand, it's not an absolute good. It's frail and fragile, and there are moments in which we just have to open ourselves to the fact that we have to let go.”

The council also recommended establishing a presidential commission on aging, dementia, and long-term care.

“Someone might say the last thing America needs is another commission, but this commission is really set up to be unique, understanding death not as a problem to be solved but an experience to be faced,” said council member Peter Lawler, Ph.D., chairman and the Dana Professor of Government at Berry College, Mount Berry, Ga. “We as a people aren't particularly equipped to think of death as an experience to be faced. But if a commission can accomplish that, it would be quite a commission. And I'm all for that.”

At the meeting, the commission heard from Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown. Dr. Friedlander told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There also has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system than are currently in place, Dr. Friedlander said. “I think without structural changes, it is likely to be harder for caregivers in the future.”

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a healthcare system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and doing less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

The September meeting was the last one at which Leon Kass, M.D., a fellow at the American Enterprise Institute, would serve as council chairman. The new chairman is Edmund Pellegrino, M.D., professor emeritus of medicine and medical ethics at Georgetown.

WASHINGTON — Assisted suicide and euthanasia should not be considered for terminally ill patients, the President's Council on Bioethics suggests in a soon to be released report.

“If you say assisted suicide and euthanasia are not the way to fix these problems, you have reaffirmed the principles we affirmed in the last chapters of this report,” said Gilbert C. Meilaender, Ph.D., council member and Phyllis and Richard Dusenberg Professor of Christian Ethics at Valparaiso (Ind.) University.

“We think that euthanasia and assisted suicide are out,” agreed council member Paul McHugh, M.D., the Henry Phipps Professor of Psychiatry at Johns Hopkins University, Baltimore. “This is just an old idea that crops up again and again in society, and various people tried it, and it always fails.”

The patients who are driven to consider assisted suicide “are the people who burn out in the process of care,” said Dr. McHugh, who is also professor of mental health at the university's school of public health. “They burn out simply because doctors have been extending things too far for them, asking more than they can deliver. … Never forget that inflicting extra care on people is to ultimately burn them [out].”

Dr. McHugh said he also favored giving family caregivers tax benefits to help them financially. He added that he wished there were more role models to persuade people to think of elder care as a career. “We don't have any Florence Nightingales, any Mother Teresas to tell people this is a wonderful life.”

Council member Alfonso Gómez-Lobo, D. Phil., lauded the report but said there was more work to do on the subject. “We have to think more about the way of making a distinction between ordinary and extraordinary means,” said the Ryan Professor of Metaphysics and Moral Philosophy at Georgetown University, Washington. “It is important to affirm, on the one hand, the goodness of life. On the other hand, it's not an absolute good. It's frail and fragile, and there are moments in which we just have to open ourselves to the fact that we have to let go.”

The council also recommended establishing a presidential commission on aging, dementia, and long-term care.

“Someone might say the last thing America needs is another commission, but this commission is really set up to be unique, understanding death not as a problem to be solved but an experience to be faced,” said council member Peter Lawler, Ph.D., chairman and the Dana Professor of Government at Berry College, Mount Berry, Ga. “We as a people aren't particularly equipped to think of death as an experience to be faced. But if a commission can accomplish that, it would be quite a commission. And I'm all for that.”

At the meeting, the commission heard from Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown. Dr. Friedlander told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There also has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system than are currently in place, Dr. Friedlander said. “I think without structural changes, it is likely to be harder for caregivers in the future.”

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a healthcare system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and doing less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

The September meeting was the last one at which Leon Kass, M.D., a fellow at the American Enterprise Institute, would serve as council chairman. The new chairman is Edmund Pellegrino, M.D., professor emeritus of medicine and medical ethics at Georgetown.

WASHINGTON — Assisted suicide and euthanasia should not be considered for terminally ill patients, the President's Council on Bioethics suggests in a soon to be released report.

“If you say assisted suicide and euthanasia are not the way to fix these problems, you have reaffirmed the principles we affirmed in the last chapters of this report,” said Gilbert C. Meilaender, Ph.D., council member and Phyllis and Richard Dusenberg Professor of Christian Ethics at Valparaiso (Ind.) University.

“We think that euthanasia and assisted suicide are out,” agreed council member Paul McHugh, M.D., the Henry Phipps Professor of Psychiatry at Johns Hopkins University, Baltimore. “This is just an old idea that crops up again and again in society, and various people tried it, and it always fails.”

The patients who are driven to consider assisted suicide “are the people who burn out in the process of care,” said Dr. McHugh, who is also professor of mental health at the university's school of public health. “They burn out simply because doctors have been extending things too far for them, asking more than they can deliver. … Never forget that inflicting extra care on people is to ultimately burn them [out].”

Dr. McHugh said he also favored giving family caregivers tax benefits to help them financially. He added that he wished there were more role models to persuade people to think of elder care as a career. “We don't have any Florence Nightingales, any Mother Teresas to tell people this is a wonderful life.”

Council member Alfonso Gómez-Lobo, D. Phil., lauded the report but said there was more work to do on the subject. “We have to think more about the way of making a distinction between ordinary and extraordinary means,” said the Ryan Professor of Metaphysics and Moral Philosophy at Georgetown University, Washington. “It is important to affirm, on the one hand, the goodness of life. On the other hand, it's not an absolute good. It's frail and fragile, and there are moments in which we just have to open ourselves to the fact that we have to let go.”

The council also recommended establishing a presidential commission on aging, dementia, and long-term care.

“Someone might say the last thing America needs is another commission, but this commission is really set up to be unique, understanding death not as a problem to be solved but an experience to be faced,” said council member Peter Lawler, Ph.D., chairman and the Dana Professor of Government at Berry College, Mount Berry, Ga. “We as a people aren't particularly equipped to think of death as an experience to be faced. But if a commission can accomplish that, it would be quite a commission. And I'm all for that.”

At the meeting, the commission heard from Robert Friedlander, Ph.D., director of the Center for an Aging Society at Georgetown. Dr. Friedlander told the council that although most of the caregiving for elderly patients is provided at home—often by family members—three-quarters of the money spent on caregiving is spent at institutions. This is partly because institutional long-term care is a mandated benefit under Medicaid, whereas home- and community-based care is not.

But “there have been tremendous efforts on the part of states to move care out of the nursing home,” especially since states think care is cheaper outside of institutions, he said. “This rebalancing has meant that in the period from 1991 to 2001, the expenditures in home and community-based care in Medicaid have more than tripled, from $6.2 billion to $22.2 billion.”

There also has been movement toward changing the financing of long-term care. “The past 6–8 years, most of the focus has been on tax credits for caregivers and more public incentives for the purchase of long-term care insurance,” Dr. Friedlander explained.

More fundamental changes need to be made to the long-term care financing system than are currently in place, Dr. Friedlander said. “I think without structural changes, it is likely to be harder for caregivers in the future.”

Further, things will only get worse as baby boomers live longer, and there are fewer children to support and care for them. “I would call these the best of times. I think when we get to the real crisis, these are going to look like the good old days.”

Greg Sachs, M.D., chief of the section of geriatrics at the University of Chicago, said that when it came to caring for dementia patients, he was “less worried about the advancing number of people and smaller numbers of caregivers … and much more worried about the propensity to overtreat, to not provide good end-of-life care, and in fact, to have a healthcare system that is particularly ill-suited for the ongoing care of people with dementia.”

Current financial incentives don't encourage the idea of letting dementia patients die peacefully at a nursing home, Dr. Sachs said. “When the [nursing home] patient has pneumonia and is getting close to dying, the nursing home has to provide more care … but they are not reimbursed more. Depending on where they are and if the patient is on Medicaid, if they send the patient to the hospital they can actually be paid a 'bed-hold,' and they are actually making money while the patient is in the hospital, rather than losing money from having to provide additional care.”

In addition, the physician, instead of being paid at a lower rate and doing less frequent visits, “hospitalizes the patient and makes more money by seeing the patient on a daily basis and gets reimbursed at a higher rate,” he continued.

“All the financial incentives are aligned for this patient to be transferred to the hospital rather than being cared for in the nursing home and being allowed to die peacefully,” he said.

The September meeting was the last one at which Leon Kass, M.D., a fellow at the American Enterprise Institute, would serve as council chairman. The new chairman is Edmund Pellegrino, M.D., professor emeritus of medicine and medical ethics at Georgetown.