Mary Ellen Schneider

Under an agreement among physicians, consumers, employers, and large insurers, some health plans have agreed to have their physician rating systems audited by independent experts.

The announcement comes after physicians across the country questioned the methods used by health plans to produce performance ratings for consumers.

Under the voluntary agreement, health plans would disclose their rating methods. In addition, physicians would have a chance to review their performance data and challenge it prior to publication.

“Having that transparency is a huge change,” said Dr. Douglas Henley, executive vice president of the American Academy of Family Physicians, which is supporting the agreement, known as the Patient Charter for Physician Performance Measurement, Reporting, and Tiering Programs.

Giving physicians a chance to ensure that the data is accurate makes the process fair, he said. It's also beneficial for consumers who will be able to better rely on the information provided by their health plan, Dr. Henley said.

The project was led by the Consumer-Purchaser Disclosure Project, a coalition of consumer, labor, and employer organizations that support publicly reported health performance information.

Other principles of the Patient Charter state that the measures should aim to assess whether care is safe, timely, effective, equitable, and patient centered. The measures used should also be based on national standards, preferably those endorsed by the National Quality Forum.

This agreement provides a foundation for physicians to build on, said Dr. David C. Dale, president of the American College of Physicians, another supporter. Now when any health plan establishes a physician rating system, physicians can ask whether it is standardized and how it stacks up against the requirements of the Patient Charter, he said.

The Patient Charter also has the support of the American Medical Association, the American College of Cardiology, and the American College of Surgeons.

And some heavy hitters in the insurance industry have agreed to abide by the principles of the charter, including trade group America's Health Insurance Plans (AHIP), as well as Aetna, Cigna, UnitedHealthcare, and WellPoint.

Other health plans are likely to follow suit, said Susan Pisano, AHIP spokeswoman. Third-party review of rating systems and allowing physicians to review and challenge data before they become public will likely become the industry standard, she said.

Under an agreement among physicians, consumers, employers, and large insurers, some health plans have agreed to have their physician rating systems audited by independent experts.

The announcement comes after physicians across the country questioned the methods used by health plans to produce performance ratings for consumers.

Under the voluntary agreement, health plans would disclose their rating methods. In addition, physicians would have a chance to review their performance data and challenge it prior to publication.

“Having that transparency is a huge change,” said Dr. Douglas Henley, executive vice president of the American Academy of Family Physicians, which is supporting the agreement, known as the Patient Charter for Physician Performance Measurement, Reporting, and Tiering Programs.

Giving physicians a chance to ensure that the data is accurate makes the process fair, he said. It's also beneficial for consumers who will be able to better rely on the information provided by their health plan, Dr. Henley said.

The project was led by the Consumer-Purchaser Disclosure Project, a coalition of consumer, labor, and employer organizations that support publicly reported health performance information.

Other principles of the Patient Charter state that the measures should aim to assess whether care is safe, timely, effective, equitable, and patient centered. The measures used should also be based on national standards, preferably those endorsed by the National Quality Forum.

This agreement provides a foundation for physicians to build on, said Dr. David C. Dale, president of the American College of Physicians, another supporter. Now when any health plan establishes a physician rating system, physicians can ask whether it is standardized and how it stacks up against the requirements of the Patient Charter, he said.

The Patient Charter also has the support of the American Medical Association, the American College of Cardiology, and the American College of Surgeons.

And some heavy hitters in the insurance industry have agreed to abide by the principles of the charter, including trade group America's Health Insurance Plans (AHIP), as well as Aetna, Cigna, UnitedHealthcare, and WellPoint.

Other health plans are likely to follow suit, said Susan Pisano, AHIP spokeswoman. Third-party review of rating systems and allowing physicians to review and challenge data before they become public will likely become the industry standard, she said.

Under an agreement among physicians, consumers, employers, and large insurers, some health plans have agreed to have their physician rating systems audited by independent experts.

The announcement comes after physicians across the country questioned the methods used by health plans to produce performance ratings for consumers.

Under the voluntary agreement, health plans would disclose their rating methods. In addition, physicians would have a chance to review their performance data and challenge it prior to publication.

“Having that transparency is a huge change,” said Dr. Douglas Henley, executive vice president of the American Academy of Family Physicians, which is supporting the agreement, known as the Patient Charter for Physician Performance Measurement, Reporting, and Tiering Programs.

Giving physicians a chance to ensure that the data is accurate makes the process fair, he said. It's also beneficial for consumers who will be able to better rely on the information provided by their health plan, Dr. Henley said.

The project was led by the Consumer-Purchaser Disclosure Project, a coalition of consumer, labor, and employer organizations that support publicly reported health performance information.

Other principles of the Patient Charter state that the measures should aim to assess whether care is safe, timely, effective, equitable, and patient centered. The measures used should also be based on national standards, preferably those endorsed by the National Quality Forum.

This agreement provides a foundation for physicians to build on, said Dr. David C. Dale, president of the American College of Physicians, another supporter. Now when any health plan establishes a physician rating system, physicians can ask whether it is standardized and how it stacks up against the requirements of the Patient Charter, he said.

The Patient Charter also has the support of the American Medical Association, the American College of Cardiology, and the American College of Surgeons.

And some heavy hitters in the insurance industry have agreed to abide by the principles of the charter, including trade group America's Health Insurance Plans (AHIP), as well as Aetna, Cigna, UnitedHealthcare, and WellPoint.

Other health plans are likely to follow suit, said Susan Pisano, AHIP spokeswoman. Third-party review of rating systems and allowing physicians to review and challenge data before they become public will likely become the industry standard, she said.

NEW YORK – Before starting a child on stimulants to treat attention-deficit/hyperactivity disorder, consider asking some extra questions to confirm the diagnosis and family history, Dr. Laurence L. Greenhill said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Greenhill, director of child and adolescent psychiatry at the New York State Psychiatric Institute at Columbia University, New York, presented a 10-item checklist for physicians to use as a guide before initiating stimulant therapy in children and adolescents:

▸ Is the diagnosis of ADHD accurate?

▸ Is there a history of simple tics, chronic motor tics, or Tourette syndrome? This is important to document but doesn't necessarily change the course of treatment, he said.

▸ Does the patient have comorbidities?

▸ Does the child have a history of cardiovascular problems? In May 2006, the Food and Drug Administration directed manufacturers of ADHD medications to revise their labeling to reflect concerns about adverse cardiovascular events. Since the FDA began its deliberations on this issue, there has been growing public awareness about the possible risk of cardiovascular complications, Dr. Greenhill said.

▸ Is there a family history of sudden death when young, stroke under age 40 years, or malignant hypertension? Also, does the child have a history of seeing a cardiologist or having chest pain with shortness of breath? All of these questions can serve as screening questions and should be documented in the chart, Dr. Greenhill said. “If they're all negative, most cardiologists I know don't want to see [these patients] for referrals,” he said.

▸ Is there substance abuse at home?

▸ Has there been a normal physical exam by a pediatrician in the past year?

▸ Is there a record of baseline height, weight, pulse, and blood pressure?

▸ What are the specific targets of treatment?

▸ Is the quantified ADHD severity moderate to severe?

Dr. Greenhill disclosed financial relationships with Best Practice LLC, Sepracor Inc., Eli Lilly & Co., Pfizer Inc., Johnson & Johnson, Otsuka America Inc., and McNeil Pediatrics, a division of McNeil-PPC Inc.

NEW YORK – Before starting a child on stimulants to treat attention-deficit/hyperactivity disorder, consider asking some extra questions to confirm the diagnosis and family history, Dr. Laurence L. Greenhill said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Greenhill, director of child and adolescent psychiatry at the New York State Psychiatric Institute at Columbia University, New York, presented a 10-item checklist for physicians to use as a guide before initiating stimulant therapy in children and adolescents:

▸ Is the diagnosis of ADHD accurate?

▸ Is there a history of simple tics, chronic motor tics, or Tourette syndrome? This is important to document but doesn't necessarily change the course of treatment, he said.

▸ Does the patient have comorbidities?

▸ Does the child have a history of cardiovascular problems? In May 2006, the Food and Drug Administration directed manufacturers of ADHD medications to revise their labeling to reflect concerns about adverse cardiovascular events. Since the FDA began its deliberations on this issue, there has been growing public awareness about the possible risk of cardiovascular complications, Dr. Greenhill said.

▸ Is there a family history of sudden death when young, stroke under age 40 years, or malignant hypertension? Also, does the child have a history of seeing a cardiologist or having chest pain with shortness of breath? All of these questions can serve as screening questions and should be documented in the chart, Dr. Greenhill said. “If they're all negative, most cardiologists I know don't want to see [these patients] for referrals,” he said.

▸ Is there substance abuse at home?

▸ Has there been a normal physical exam by a pediatrician in the past year?

▸ Is there a record of baseline height, weight, pulse, and blood pressure?

▸ What are the specific targets of treatment?

▸ Is the quantified ADHD severity moderate to severe?

Dr. Greenhill disclosed financial relationships with Best Practice LLC, Sepracor Inc., Eli Lilly & Co., Pfizer Inc., Johnson & Johnson, Otsuka America Inc., and McNeil Pediatrics, a division of McNeil-PPC Inc.

NEW YORK – Before starting a child on stimulants to treat attention-deficit/hyperactivity disorder, consider asking some extra questions to confirm the diagnosis and family history, Dr. Laurence L. Greenhill said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Greenhill, director of child and adolescent psychiatry at the New York State Psychiatric Institute at Columbia University, New York, presented a 10-item checklist for physicians to use as a guide before initiating stimulant therapy in children and adolescents:

▸ Is the diagnosis of ADHD accurate?

▸ Is there a history of simple tics, chronic motor tics, or Tourette syndrome? This is important to document but doesn't necessarily change the course of treatment, he said.

▸ Does the patient have comorbidities?

▸ Does the child have a history of cardiovascular problems? In May 2006, the Food and Drug Administration directed manufacturers of ADHD medications to revise their labeling to reflect concerns about adverse cardiovascular events. Since the FDA began its deliberations on this issue, there has been growing public awareness about the possible risk of cardiovascular complications, Dr. Greenhill said.

▸ Is there a family history of sudden death when young, stroke under age 40 years, or malignant hypertension? Also, does the child have a history of seeing a cardiologist or having chest pain with shortness of breath? All of these questions can serve as screening questions and should be documented in the chart, Dr. Greenhill said. “If they're all negative, most cardiologists I know don't want to see [these patients] for referrals,” he said.

▸ Is there substance abuse at home?

▸ Has there been a normal physical exam by a pediatrician in the past year?

▸ Is there a record of baseline height, weight, pulse, and blood pressure?

▸ What are the specific targets of treatment?

▸ Is the quantified ADHD severity moderate to severe?

Dr. Greenhill disclosed financial relationships with Best Practice LLC, Sepracor Inc., Eli Lilly & Co., Pfizer Inc., Johnson & Johnson, Otsuka America Inc., and McNeil Pediatrics, a division of McNeil-PPC Inc.

They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.

Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.

“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for lesser violations.

▸ Protect those who report incidents and include nonretaliation clauses into policy statements.

▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.

The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians. Over the last decade, the system has also been adopted by several large academic medical centers and community medical centers.

The information is used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improvement of communication skills. If problems continue after that, corrective action may be taken.

Overall, the Vanderbilt data suggest that about 4%–6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said. Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.

Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.

And this can lead to real safety issues for patients, she said. For example, during surgery a nurse may observe a physician break with sterile protocol when placing a subclavian central line. That nurse is in a position to stop the procedure but only if he or she feels comfortable to question the physician. Without a culture that allows for that action by the nurse, the patient is the one who suffers, Ms. Cohen said.

She advised hospital leadership to get started as soon as possible. It takes a lot of work to change the culture of an organization and to get at the root of why the bad behavior is occurring. “There is no easy fix,” she said.

At Centra Health in Lynchburg, Va., they have been operating with a practitioner code of conduct for more than a decade and over the years the leadership has tried to enforce it while still keeping the process collegial.

Dr. Chal Nunn, chief medical officer for Centra Health, said he encourages clinicians to confront inappropriate behavior on the front lines and have an informal conversation about it. Under their policy, the starting point is a conversation with the offending clinician. If the problem persists, the complaint is made in writing and the clinician is informed of the consequences.

“The whole point is to try to help the person,” Dr. Nunn said.

There are plenty of examples of policies out there. But get started now, he advised. “You just can't let it slide.”

They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.

Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.

“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for lesser violations.

▸ Protect those who report incidents and include nonretaliation clauses into policy statements.

▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.

The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians. Over the last decade, the system has also been adopted by several large academic medical centers and community medical centers.

The information is used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improvement of communication skills. If problems continue after that, corrective action may be taken.

Overall, the Vanderbilt data suggest that about 4%–6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said. Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.

Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.

And this can lead to real safety issues for patients, she said. For example, during surgery a nurse may observe a physician break with sterile protocol when placing a subclavian central line. That nurse is in a position to stop the procedure but only if he or she feels comfortable to question the physician. Without a culture that allows for that action by the nurse, the patient is the one who suffers, Ms. Cohen said.

She advised hospital leadership to get started as soon as possible. It takes a lot of work to change the culture of an organization and to get at the root of why the bad behavior is occurring. “There is no easy fix,” she said.

At Centra Health in Lynchburg, Va., they have been operating with a practitioner code of conduct for more than a decade and over the years the leadership has tried to enforce it while still keeping the process collegial.

Dr. Chal Nunn, chief medical officer for Centra Health, said he encourages clinicians to confront inappropriate behavior on the front lines and have an informal conversation about it. Under their policy, the starting point is a conversation with the offending clinician. If the problem persists, the complaint is made in writing and the clinician is informed of the consequences.

“The whole point is to try to help the person,” Dr. Nunn said.

There are plenty of examples of policies out there. But get started now, he advised. “You just can't let it slide.”

They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.

Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

The issue is so important to the Joint Commission that officials there decided to highlight it this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.

“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for lesser violations.

▸ Protect those who report incidents and include nonretaliation clauses into policy statements.

▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.

The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians. Over the last decade, the system has also been adopted by several large academic medical centers and community medical centers.

The information is used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improvement of communication skills. If problems continue after that, corrective action may be taken.

Overall, the Vanderbilt data suggest that about 4%–6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said. Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.

Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.

And this can lead to real safety issues for patients, she said. For example, during surgery a nurse may observe a physician break with sterile protocol when placing a subclavian central line. That nurse is in a position to stop the procedure but only if he or she feels comfortable to question the physician. Without a culture that allows for that action by the nurse, the patient is the one who suffers, Ms. Cohen said.

She advised hospital leadership to get started as soon as possible. It takes a lot of work to change the culture of an organization and to get at the root of why the bad behavior is occurring. “There is no easy fix,” she said.

At Centra Health in Lynchburg, Va., they have been operating with a practitioner code of conduct for more than a decade and over the years the leadership has tried to enforce it while still keeping the process collegial.

Dr. Chal Nunn, chief medical officer for Centra Health, said he encourages clinicians to confront inappropriate behavior on the front lines and have an informal conversation about it. Under their policy, the starting point is a conversation with the offending clinician. If the problem persists, the complaint is made in writing and the clinician is informed of the consequences.

“The whole point is to try to help the person,” Dr. Nunn said.

There are plenty of examples of policies out there. But get started now, he advised. “You just can't let it slide.”

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

"Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs," Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. "It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost."

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a "high-risk" pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. "We are pretty amazed at how extreme a plan Mr. McCain has staked out," said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to purchase coverage in the individual market where coverage is expensive and difficult to obtain. "Our prediction is a race to the bottom," he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of "sound science" and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research. The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election/

Sen. McCain proposes replacing tax exclusions on the value of health benefits with a tax credit. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

"Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs," Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. "It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost."

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a "high-risk" pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. "We are pretty amazed at how extreme a plan Mr. McCain has staked out," said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to purchase coverage in the individual market where coverage is expensive and difficult to obtain. "Our prediction is a race to the bottom," he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of "sound science" and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research. The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election/

Sen. McCain proposes replacing tax exclusions on the value of health benefits with a tax credit. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

"Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs," Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. "It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost."

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a "high-risk" pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. "We are pretty amazed at how extreme a plan Mr. McCain has staked out," said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to purchase coverage in the individual market where coverage is expensive and difficult to obtain. "Our prediction is a race to the bottom," he said.

And a $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

For example, Sen. McCain plans to dedicate federal research dollars on the basis of "sound science" and a put a greater emphasis on chronic disease care and management.

ACP does not endorse candidates but has performed an analysis of how the presidential candidates compare with one another on guaranteeing access to affordable coverage, providing everyone with a primary care physician, increasing investment in health information technology, reducing administrative expenses, and increasing funding for research. The side-by-side comparison is available online at www.acponline.org/advocacy/where_we_stand/election/

Sen. McCain proposes replacing tax exclusions on the value of health benefits with a tax credit. John McCain 2008/

Under an agreement among physicians, consumers, employers, and large insurers, some health plans have agreed to have their physician rating systems audited by independent experts.

The announcement comes after physicians around the country have questioned the methods used by health plans to produce the physician performance ratings for consumers.

Under the voluntary agreement, known as the Patient Charter for Physician Performance Measurement, Reporting, and Tiering Programs, health plans would disclose their rating methods. In addition, physicians would have a chance to review their performance data and challenge it prior to publication.

The project was led by the Consumer-Purchaser Disclosure Project, a coalition of consumer, labor, and employer organizations that support publicly reported health performance information.

Other principles of the Patient Charter state that the measures should aim to assess whether care is safe, timely, effective, equitable, and patient centered. The measures used should also be based on national standards, preferably those endorsed by the National Quality Forum. The principles of the Patient Charter do not apply to pure cost-comparison or shopping tools.

The Patient Charter has the support of the American Medical Association and some heavy hitters in the insurance industry have agreed to abide by the principles of the charter, including trade group America's Health Insurance Plans (AHIP), as well as Aetna, Cigna, UnitedHealthcare, and WellPoint.

Other health plans are likely to follow suit, said Susan Pisano, AHIP spokeswoman. Third-party review of rating systems and allowing physicians to review and challenge data before they become public will likely become the industry standard, she said.

“We believe strongly that consumers both want and need good information on health care quality,” Ms. Pisano said.

Now that the Patient Charter has laid down the ground rules for how clinical performance measures should be used, the next step is to ensure that physician ratings accurately reflect all the care given, because patients are generally scattered across multiple health plans. Ms. Pisano said the AHIP Foundation is studying how to aggregate data from across different plans to provide a full picture of physician quality.

Under an agreement among physicians, consumers, employers, and large insurers, some health plans have agreed to have their physician rating systems audited by independent experts.

The announcement comes after physicians around the country have questioned the methods used by health plans to produce the physician performance ratings for consumers.

Under the voluntary agreement, known as the Patient Charter for Physician Performance Measurement, Reporting, and Tiering Programs, health plans would disclose their rating methods. In addition, physicians would have a chance to review their performance data and challenge it prior to publication.

The project was led by the Consumer-Purchaser Disclosure Project, a coalition of consumer, labor, and employer organizations that support publicly reported health performance information.

Other principles of the Patient Charter state that the measures should aim to assess whether care is safe, timely, effective, equitable, and patient centered. The measures used should also be based on national standards, preferably those endorsed by the National Quality Forum. The principles of the Patient Charter do not apply to pure cost-comparison or shopping tools.

The Patient Charter has the support of the American Medical Association and some heavy hitters in the insurance industry have agreed to abide by the principles of the charter, including trade group America's Health Insurance Plans (AHIP), as well as Aetna, Cigna, UnitedHealthcare, and WellPoint.

Other health plans are likely to follow suit, said Susan Pisano, AHIP spokeswoman. Third-party review of rating systems and allowing physicians to review and challenge data before they become public will likely become the industry standard, she said.

“We believe strongly that consumers both want and need good information on health care quality,” Ms. Pisano said.

Now that the Patient Charter has laid down the ground rules for how clinical performance measures should be used, the next step is to ensure that physician ratings accurately reflect all the care given, because patients are generally scattered across multiple health plans. Ms. Pisano said the AHIP Foundation is studying how to aggregate data from across different plans to provide a full picture of physician quality.

Under an agreement among physicians, consumers, employers, and large insurers, some health plans have agreed to have their physician rating systems audited by independent experts.

The announcement comes after physicians around the country have questioned the methods used by health plans to produce the physician performance ratings for consumers.

Under the voluntary agreement, known as the Patient Charter for Physician Performance Measurement, Reporting, and Tiering Programs, health plans would disclose their rating methods. In addition, physicians would have a chance to review their performance data and challenge it prior to publication.

The project was led by the Consumer-Purchaser Disclosure Project, a coalition of consumer, labor, and employer organizations that support publicly reported health performance information.

Other principles of the Patient Charter state that the measures should aim to assess whether care is safe, timely, effective, equitable, and patient centered. The measures used should also be based on national standards, preferably those endorsed by the National Quality Forum. The principles of the Patient Charter do not apply to pure cost-comparison or shopping tools.

The Patient Charter has the support of the American Medical Association and some heavy hitters in the insurance industry have agreed to abide by the principles of the charter, including trade group America's Health Insurance Plans (AHIP), as well as Aetna, Cigna, UnitedHealthcare, and WellPoint.

Other health plans are likely to follow suit, said Susan Pisano, AHIP spokeswoman. Third-party review of rating systems and allowing physicians to review and challenge data before they become public will likely become the industry standard, she said.

“We believe strongly that consumers both want and need good information on health care quality,” Ms. Pisano said.

Now that the Patient Charter has laid down the ground rules for how clinical performance measures should be used, the next step is to ensure that physician ratings accurately reflect all the care given, because patients are generally scattered across multiple health plans. Ms. Pisano said the AHIP Foundation is studying how to aggregate data from across different plans to provide a full picture of physician quality.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011. The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006. These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years. If Congress were to provide a 0% update over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics. The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through 2017.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011. The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006. These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years. If Congress were to provide a 0% update over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics. The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through 2017.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011. The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006. These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years. If Congress were to provide a 0% update over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics. The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through 2017.

Direct-to-Consumer Genetic Testing

Patients should be fully informed about how to interpret direct-to-consumer genetic tests, which provide only the probability of developing a disease, according to a new policy statement from the American College of Medical Genetics. The organization outlined minimum requirements for the use of any genetic testing protocol, including that patients be informed about the scientific evidence on which the test is based, that a knowledgeable professional should be involved in ordering and interpreting the test, that the clinical testing laboratory is properly accredited, and that privacy concerns are addressed. “Consumers need to be cautious and always involve their health care provider, and in some cases a medical geneticist or genetic counselor, in their decisions about genetic testing, said Michael S. Watson, Ph.D., executive director of the college, in a statement. The policy statement is available at

www.acmg.net

Women Hit Hard by Uninsured Status

Women of child-bearing age are more likely to be uninsured than are Americans in general, with potentially serious consequences for their health, according to the American College of Obstetricians and Gynecologists. About 18% of Americans younger than 65 years are uninsured, compared with 20% of women 15–44 years. Uninsured women are less likely to receive clinical breast exams and tests for cervical cancer, and are more likely to be diagnosed for diseases at more advanced stages. And since women are the health care decision makers in many families, their lack of access to the health care system has even greater consequences, according to ACOG. The problem of uninsured Americans is not going away and will require the continued attention of the medical community and elected officials, Dr. Kenneth L. Noller, ACOG president, said in a statement.

Iowa to Insurers: Cover HPV Vaccine

Iowa Gov. Chet Culver (D) recently signed legislation requiring insurers to provide coverage for vaccinations against the human papillomavirus. The new law, which will take effect Jan. 1, 2009, will require insurers that provide coverage for any vaccination or immunization to also offer coverage for the HPV vaccine. The law has a different focus from many of the legislative efforts in other states, which have considered mandatory vaccination of school-aged girls.

Coping With a Malpractice Lawsuit

Despite legal advice to keep quiet about a pending medical malpractice suit, ob.gyns. need to talk about their feelings with family members, according to a statement from ACOG. In a May opinion, the college's Committee on Professional Liability advises physicians to inform family members of the lawsuit and the potential for publicity, while keeping clinical aspects confidential. Common responses to medical liability litigation include feelings of shock, outrage, denial, anxiety, guilt, shame, and despair, the opinion stated. Coping with medical professional liability litigation is an ongoing, complex process in which physicians often must struggle to regain a sense of personal identity and professional mastery as well as control of their clinical practices.” State or local medical societies and medical liability insurers may offer support groups for physicians and their families, or physicians can turn to individual professional counseling, the committee advised.

NIH Committee Gets New Members

The director of the National Institutes of Health recently appointed three new members to the institutes' Advisory Committee on Research on Women's Health. The new members are Dr. Linda C. Giudice, Dr. Nancy H. Nielsen, and Debra Toney, Ph.D. Dr. Giudice is a gynecologist and reproductive endocrinologist and chair of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. She also recently chaired the NIH Reproductive Medicine Network and currently sits on the Institute of Medicine's health sciences policy board. Dr. Nielsen, an internist, will become president of the American Medical Association in June. She is also senior associate dean of the State University of New York at Buffalo School of Medicine and Biomedical Sciences. Dr. Toney, a registered nurse who runs a licensed home health care agency, will assume the presidency of the National Black Nurses Association in August. She has more than 28 years' experience in leadership roles in family practice management, ambulatory care, and home health care. The Advisory Committee on Research on Women's Health is charged with advising the NIH director on research activities and the inclusion of women in clinical trials.

Side Effects Underreported

One in six Americans who have taken a prescription drug experienced a side effect serious enough to send them to the doctor or hospital, but only 35% of consumers said they know they can report these side effects to the FDA, according to a Consumer Reports poll. Additionally, 81% of respondents said they had seen or heard an ad for prescription drugs within the last 30 days, almost all on television. Consumers Union, the nonprofit publisher of the magazine, gave the FDA a petition signed by nearly 56,000 consumers asking that a toll-free number and Web site be included in all television drug ads so people can easily report their serious side effects. “What better way for the FDA to let consumers know how to report serious problems with their medications?” asked Consumers Union's Liz Foley in a statement.

Direct-to-Consumer Genetic Testing

Patients should be fully informed about how to interpret direct-to-consumer genetic tests, which provide only the probability of developing a disease, according to a new policy statement from the American College of Medical Genetics. The organization outlined minimum requirements for the use of any genetic testing protocol, including that patients be informed about the scientific evidence on which the test is based, that a knowledgeable professional should be involved in ordering and interpreting the test, that the clinical testing laboratory is properly accredited, and that privacy concerns are addressed. “Consumers need to be cautious and always involve their health care provider, and in some cases a medical geneticist or genetic counselor, in their decisions about genetic testing, said Michael S. Watson, Ph.D., executive director of the college, in a statement. The policy statement is available at

www.acmg.net

Women Hit Hard by Uninsured Status

Women of child-bearing age are more likely to be uninsured than are Americans in general, with potentially serious consequences for their health, according to the American College of Obstetricians and Gynecologists. About 18% of Americans younger than 65 years are uninsured, compared with 20% of women 15–44 years. Uninsured women are less likely to receive clinical breast exams and tests for cervical cancer, and are more likely to be diagnosed for diseases at more advanced stages. And since women are the health care decision makers in many families, their lack of access to the health care system has even greater consequences, according to ACOG. The problem of uninsured Americans is not going away and will require the continued attention of the medical community and elected officials, Dr. Kenneth L. Noller, ACOG president, said in a statement.

Iowa to Insurers: Cover HPV Vaccine

Iowa Gov. Chet Culver (D) recently signed legislation requiring insurers to provide coverage for vaccinations against the human papillomavirus. The new law, which will take effect Jan. 1, 2009, will require insurers that provide coverage for any vaccination or immunization to also offer coverage for the HPV vaccine. The law has a different focus from many of the legislative efforts in other states, which have considered mandatory vaccination of school-aged girls.

Coping With a Malpractice Lawsuit

Despite legal advice to keep quiet about a pending medical malpractice suit, ob.gyns. need to talk about their feelings with family members, according to a statement from ACOG. In a May opinion, the college's Committee on Professional Liability advises physicians to inform family members of the lawsuit and the potential for publicity, while keeping clinical aspects confidential. Common responses to medical liability litigation include feelings of shock, outrage, denial, anxiety, guilt, shame, and despair, the opinion stated. Coping with medical professional liability litigation is an ongoing, complex process in which physicians often must struggle to regain a sense of personal identity and professional mastery as well as control of their clinical practices.” State or local medical societies and medical liability insurers may offer support groups for physicians and their families, or physicians can turn to individual professional counseling, the committee advised.

NIH Committee Gets New Members

The director of the National Institutes of Health recently appointed three new members to the institutes' Advisory Committee on Research on Women's Health. The new members are Dr. Linda C. Giudice, Dr. Nancy H. Nielsen, and Debra Toney, Ph.D. Dr. Giudice is a gynecologist and reproductive endocrinologist and chair of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. She also recently chaired the NIH Reproductive Medicine Network and currently sits on the Institute of Medicine's health sciences policy board. Dr. Nielsen, an internist, will become president of the American Medical Association in June. She is also senior associate dean of the State University of New York at Buffalo School of Medicine and Biomedical Sciences. Dr. Toney, a registered nurse who runs a licensed home health care agency, will assume the presidency of the National Black Nurses Association in August. She has more than 28 years' experience in leadership roles in family practice management, ambulatory care, and home health care. The Advisory Committee on Research on Women's Health is charged with advising the NIH director on research activities and the inclusion of women in clinical trials.

Side Effects Underreported

One in six Americans who have taken a prescription drug experienced a side effect serious enough to send them to the doctor or hospital, but only 35% of consumers said they know they can report these side effects to the FDA, according to a Consumer Reports poll. Additionally, 81% of respondents said they had seen or heard an ad for prescription drugs within the last 30 days, almost all on television. Consumers Union, the nonprofit publisher of the magazine, gave the FDA a petition signed by nearly 56,000 consumers asking that a toll-free number and Web site be included in all television drug ads so people can easily report their serious side effects. “What better way for the FDA to let consumers know how to report serious problems with their medications?” asked Consumers Union's Liz Foley in a statement.

Direct-to-Consumer Genetic Testing

Patients should be fully informed about how to interpret direct-to-consumer genetic tests, which provide only the probability of developing a disease, according to a new policy statement from the American College of Medical Genetics. The organization outlined minimum requirements for the use of any genetic testing protocol, including that patients be informed about the scientific evidence on which the test is based, that a knowledgeable professional should be involved in ordering and interpreting the test, that the clinical testing laboratory is properly accredited, and that privacy concerns are addressed. “Consumers need to be cautious and always involve their health care provider, and in some cases a medical geneticist or genetic counselor, in their decisions about genetic testing, said Michael S. Watson, Ph.D., executive director of the college, in a statement. The policy statement is available at

www.acmg.net

Women Hit Hard by Uninsured Status

Women of child-bearing age are more likely to be uninsured than are Americans in general, with potentially serious consequences for their health, according to the American College of Obstetricians and Gynecologists. About 18% of Americans younger than 65 years are uninsured, compared with 20% of women 15–44 years. Uninsured women are less likely to receive clinical breast exams and tests for cervical cancer, and are more likely to be diagnosed for diseases at more advanced stages. And since women are the health care decision makers in many families, their lack of access to the health care system has even greater consequences, according to ACOG. The problem of uninsured Americans is not going away and will require the continued attention of the medical community and elected officials, Dr. Kenneth L. Noller, ACOG president, said in a statement.

Iowa to Insurers: Cover HPV Vaccine

Iowa Gov. Chet Culver (D) recently signed legislation requiring insurers to provide coverage for vaccinations against the human papillomavirus. The new law, which will take effect Jan. 1, 2009, will require insurers that provide coverage for any vaccination or immunization to also offer coverage for the HPV vaccine. The law has a different focus from many of the legislative efforts in other states, which have considered mandatory vaccination of school-aged girls.

Coping With a Malpractice Lawsuit

Despite legal advice to keep quiet about a pending medical malpractice suit, ob.gyns. need to talk about their feelings with family members, according to a statement from ACOG. In a May opinion, the college's Committee on Professional Liability advises physicians to inform family members of the lawsuit and the potential for publicity, while keeping clinical aspects confidential. Common responses to medical liability litigation include feelings of shock, outrage, denial, anxiety, guilt, shame, and despair, the opinion stated. Coping with medical professional liability litigation is an ongoing, complex process in which physicians often must struggle to regain a sense of personal identity and professional mastery as well as control of their clinical practices.” State or local medical societies and medical liability insurers may offer support groups for physicians and their families, or physicians can turn to individual professional counseling, the committee advised.

NIH Committee Gets New Members

The director of the National Institutes of Health recently appointed three new members to the institutes' Advisory Committee on Research on Women's Health. The new members are Dr. Linda C. Giudice, Dr. Nancy H. Nielsen, and Debra Toney, Ph.D. Dr. Giudice is a gynecologist and reproductive endocrinologist and chair of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. She also recently chaired the NIH Reproductive Medicine Network and currently sits on the Institute of Medicine's health sciences policy board. Dr. Nielsen, an internist, will become president of the American Medical Association in June. She is also senior associate dean of the State University of New York at Buffalo School of Medicine and Biomedical Sciences. Dr. Toney, a registered nurse who runs a licensed home health care agency, will assume the presidency of the National Black Nurses Association in August. She has more than 28 years' experience in leadership roles in family practice management, ambulatory care, and home health care. The Advisory Committee on Research on Women's Health is charged with advising the NIH director on research activities and the inclusion of women in clinical trials.

Side Effects Underreported

One in six Americans who have taken a prescription drug experienced a side effect serious enough to send them to the doctor or hospital, but only 35% of consumers said they know they can report these side effects to the FDA, according to a Consumer Reports poll. Additionally, 81% of respondents said they had seen or heard an ad for prescription drugs within the last 30 days, almost all on television. Consumers Union, the nonprofit publisher of the magazine, gave the FDA a petition signed by nearly 56,000 consumers asking that a toll-free number and Web site be included in all television drug ads so people can easily report their serious side effects. “What better way for the FDA to let consumers know how to report serious problems with their medications?” asked Consumers Union's Liz Foley in a statement.

PHILADELPHIA — The jury is still out on whether aromatase inhibitors could offer an alternative to clomiphene in the treatment of infertility associated with polycystic ovary syndrome, based on results in two small clinical trials.

Aromatase inhibitors are on the horizon, Dr. Andrea D. Coviello said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS. Although they have been approved for use in breast cancer, they are still experimental for ovulation induction. Instead of blocking the receptors centrally in the hypothalamus and the pituitary, aromatase inhibitors completely block estradiol production. Like clomiphene, aromatase inhibitor drugs are used during the follicular phase, she said.

The rationale for moving to aromatase inhibitors is that this class of drugs is thought to have fewer antiestrogenic side effects, including a lower risk of ovarian hyperstimulation syndrome and a lower risk of multiple gestation. But there are also significant concerns about fetal development problems in the babies conceived by women who were using aromatase inhibitors, explained Dr. Coviello, of the Endocrinology, Diabetes, and Nutrition Section, Boston University School of Medicine.

A definitive study that would help physicians assess how aromatase inhibitors stack up to clomiphene has yet to be done. The available data are derived from very small studies, she noted.

In a prospective, randomized trial of 74 patients, researchers did not find a significant difference in pregnancy rates between women who received clomiphene and those who received the aromatase inhibitor letrozole (Fertil. Steril. 2006;86:1447–51). However, the researchers found significantly lower estrogen levels in the letrozole group on the day of human chorionic gonadotropin administration, Dr. Coviello said.

Another study, published online, compared the efficacy of letrozole and clomiphene among women who had failed to ovulate when taking 100 mg/day of clomiphene citrate (Fertil. Steril. 2008 January [Epubdoi:10.1016/j.fertnstert.2007.08.044]). Sixty-four patients were randomized to receive either 7.5 mg/day of letrozole or 150 mg/day of clomiphene. The researchers found that letrozole had better ovulation and pregnancy rates compared with clomiphene. However, those results came as no surprise because the women in the study were clomiphene resistant, Dr. Coviello said. So although it showed that letrozole is not inferior in terms of ovulation, it failed to make the case that aromatase inhibitors outperform clomiphene.

Dr. Coviello stated she had no financial conflicts of interest to disclose. INTERNAL MEDICINE NEWS, FAMILY PRACTICE NEWS, and this newspaper are published by the International Medical News Group, a division of Elsevier.

PHILADELPHIA — The jury is still out on whether aromatase inhibitors could offer an alternative to clomiphene in the treatment of infertility associated with polycystic ovary syndrome, based on results in two small clinical trials.

Aromatase inhibitors are on the horizon, Dr. Andrea D. Coviello said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS. Although they have been approved for use in breast cancer, they are still experimental for ovulation induction. Instead of blocking the receptors centrally in the hypothalamus and the pituitary, aromatase inhibitors completely block estradiol production. Like clomiphene, aromatase inhibitor drugs are used during the follicular phase, she said.

The rationale for moving to aromatase inhibitors is that this class of drugs is thought to have fewer antiestrogenic side effects, including a lower risk of ovarian hyperstimulation syndrome and a lower risk of multiple gestation. But there are also significant concerns about fetal development problems in the babies conceived by women who were using aromatase inhibitors, explained Dr. Coviello, of the Endocrinology, Diabetes, and Nutrition Section, Boston University School of Medicine.

A definitive study that would help physicians assess how aromatase inhibitors stack up to clomiphene has yet to be done. The available data are derived from very small studies, she noted.

In a prospective, randomized trial of 74 patients, researchers did not find a significant difference in pregnancy rates between women who received clomiphene and those who received the aromatase inhibitor letrozole (Fertil. Steril. 2006;86:1447–51). However, the researchers found significantly lower estrogen levels in the letrozole group on the day of human chorionic gonadotropin administration, Dr. Coviello said.

Another study, published online, compared the efficacy of letrozole and clomiphene among women who had failed to ovulate when taking 100 mg/day of clomiphene citrate (Fertil. Steril. 2008 January [Epubdoi:10.1016/j.fertnstert.2007.08.044]). Sixty-four patients were randomized to receive either 7.5 mg/day of letrozole or 150 mg/day of clomiphene. The researchers found that letrozole had better ovulation and pregnancy rates compared with clomiphene. However, those results came as no surprise because the women in the study were clomiphene resistant, Dr. Coviello said. So although it showed that letrozole is not inferior in terms of ovulation, it failed to make the case that aromatase inhibitors outperform clomiphene.

Dr. Coviello stated she had no financial conflicts of interest to disclose. INTERNAL MEDICINE NEWS, FAMILY PRACTICE NEWS, and this newspaper are published by the International Medical News Group, a division of Elsevier.

PHILADELPHIA — The jury is still out on whether aromatase inhibitors could offer an alternative to clomiphene in the treatment of infertility associated with polycystic ovary syndrome, based on results in two small clinical trials.

Aromatase inhibitors are on the horizon, Dr. Andrea D. Coviello said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS, and FAMILY PRACTICE NEWS. Although they have been approved for use in breast cancer, they are still experimental for ovulation induction. Instead of blocking the receptors centrally in the hypothalamus and the pituitary, aromatase inhibitors completely block estradiol production. Like clomiphene, aromatase inhibitor drugs are used during the follicular phase, she said.

The rationale for moving to aromatase inhibitors is that this class of drugs is thought to have fewer antiestrogenic side effects, including a lower risk of ovarian hyperstimulation syndrome and a lower risk of multiple gestation. But there are also significant concerns about fetal development problems in the babies conceived by women who were using aromatase inhibitors, explained Dr. Coviello, of the Endocrinology, Diabetes, and Nutrition Section, Boston University School of Medicine.

A definitive study that would help physicians assess how aromatase inhibitors stack up to clomiphene has yet to be done. The available data are derived from very small studies, she noted.

In a prospective, randomized trial of 74 patients, researchers did not find a significant difference in pregnancy rates between women who received clomiphene and those who received the aromatase inhibitor letrozole (Fertil. Steril. 2006;86:1447–51). However, the researchers found significantly lower estrogen levels in the letrozole group on the day of human chorionic gonadotropin administration, Dr. Coviello said.

Another study, published online, compared the efficacy of letrozole and clomiphene among women who had failed to ovulate when taking 100 mg/day of clomiphene citrate (Fertil. Steril. 2008 January [Epubdoi:10.1016/j.fertnstert.2007.08.044]). Sixty-four patients were randomized to receive either 7.5 mg/day of letrozole or 150 mg/day of clomiphene. The researchers found that letrozole had better ovulation and pregnancy rates compared with clomiphene. However, those results came as no surprise because the women in the study were clomiphene resistant, Dr. Coviello said. So although it showed that letrozole is not inferior in terms of ovulation, it failed to make the case that aromatase inhibitors outperform clomiphene.

Dr. Coviello stated she had no financial conflicts of interest to disclose. INTERNAL MEDICINE NEWS, FAMILY PRACTICE NEWS, and this newspaper are published by the International Medical News Group, a division of Elsevier.

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. “We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

A $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

Sen. McCain proposes replacing tax exclusions on the value of health benefits with a tax credit. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. “We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

A $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

Sen. McCain proposes replacing tax exclusions on the value of health benefits with a tax credit. John McCain 2008/

While the Democrats continue to debate the need for individual mandates for health coverage, Sen. John McCain recently unveiled a starkly different plan for reforming the health care system.

At the heart of Sen. McCain's health proposal is a plan to eliminate the tax exclusion that allows employees to avoid paying income tax on the value of their health benefits. Sen. McCain, the presumptive Republican presidential nominee, is proposing to replace that tax break with a refundable tax credit of $2,500 for individuals and $5,000 for families.

For those who remain in their employer-sponsored plan, the tax credit would roughly offset the increased income tax burden. For those seeking to buy their own health coverage on the individual market, the tax credit would be used to pay their premiums, according to Sen. McCain's plan.

Sen. McCain also espouses creating a national market for health insurance by allowing Americans to buy coverage across state lines.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” Sen. McCain said during a recent Tampa speech to announce details of his health care proposal. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

For those with preexisting conditions, Sen. McCain is proposing a Guaranteed Access Plan. The GAP would reflect the best practices of the more than 30 states that have a “high-risk” pool for individuals who cannot obtain health insurance. Sen. McCain pledged to work with Congress, governors, and industry to ensure that the initiative was adequately funded and included disease management programs, individual case management, and health and wellness programs.

The tax changes would not occur in a vacuum, said Crystal Benton, a spokeswoman for the McCain campaign. The idea is to reform the marketplace and drive down costs overall.

Grace-Marie Turner, a McCain campaign adviser and president of the Galen Institute, which favors free-market approaches to health care, said that Sen. McCain recognizes that the first step to expanding coverage is to make health care more affordable. The cornerstones of that approach include giving consumers more coverage options, paying for wellness and prevention, and getting rid of waste in the system.

But critics say the McCain plan would essentially destroy the employer-based health insurance system in the United States. “We are pretty amazed at how extreme a plan Mr. McCain has staked out,” said Roger Hickey, codirector of the Campaign for America's Future, a progressive think tank.

The elimination of the employee health benefits tax exclusion would be an excuse for employers of all sizes to get out of providing health insurance, leaving many workers to purchase coverage in the individual market where coverage is expensive and difficult to obtain. “Our prediction is a race to the bottom,” he said.

A $5,000 tax credit wouldn't be enough to cover the cost of family coverage, which the Kaiser Family Foundation estimates costs on average nearly $12,000, he said.

It's hard to predict exactly what will happen with employer-based coverage under this proposal, said Sara R. Collins, Ph.D., assistant vice president for the Program on the Future of Health Insurance at the Commonwealth Fund. The question is whether individuals who currently have comprehensive coverage through their employer would end up underinsured after moving into the individual market.

In the areas of health information technology and medical research funding, Sen. McCain's proposal is actually similar to the plans put forth by the Democratic candidates Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), said Naomi Senkeeto, a health policy analyst at the American College of Physicians.

Sen. McCain proposes replacing tax exclusions on the value of health benefits with a tax credit. John McCain 2008/

PHILADELPHIA — When physicians are initiating therapy for type 2 diabetes, they should consider integrating incretins into their medication arsenal, said Dr. Elliot Sternthal, clinical director of diabetes services at Boston Medical Center.

The injectable incretinomimetic exenatide, the injectable amylinomimetic pramlintide, and the dipeptidyl peptidase-4 inhibitor sitagliptin provide additional options for physicians in diabetes-modifying therapy. These compounds would also be attractive if they were to gain an indication for use in prediabetes because of their potential to prevent the progression of islet cell dysfunction seen in type 2 diabetes, he said.

But be sure to correctly identify the metabolic “stage” of diabetes patients based on their hemoglobin A1c levels, fasting blood sugar, 2-hour postprandial blood sugar, and renal and hepatic status, Dr. Sternthal said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS and FAMILY PRACTICE NEWS.

For type 2 diabetes patients with mild hyperglycemia or an HbA1c between 6% and 7%, the options for initiating treatment include an a-glucosidase inhibitor, metformin, thiazolidinedione (TZD), and sitagliptin. Advanced therapy could include combinations of these drugs, such as metformin plus a TZD.

For patients with moderate hyperglycemia with an HbA1c of 7%-8%, initial therapy options include an a-glucosidase inhibitor, metformin, TZD, sitagliptin, meglitinide, low-dose sulfonylurea, TZD plus metformin, or sitagliptin plus metformin. The use of metformin with sita- gliptin may actually increase the release of incretins, Dr. Sternthal said.

For later stages of moderate hyperglycemia, consider sulfonylurea plus either metformin or TZD, for example.

For patients with moderately severe hyperglycemia, or an HbA1c of 8%-9%, combinations are likely to be the first-line approach. Physicians can consider the use of high-dose sulfonylurea or metformin alone. However, initial therapy is likely to involve two-drug combinations such as metformin plus TZD, TZD plus sita- gliptin, or sulfonylurea plus exenatide.

For advanced therapy, consider three-drug combinations such as sulfonylurea plus metformin plus TZD.

You have to pick and choose what's best for your patient, said Dr. Sternthal, who is on the speakers bureau for Amylin, AstraZeneca, Eli Lilly & Co., and Merck.

In cases of severe hyperglycemia, with an HbA1c of greater than 9%, there is no role for monotherapy, Dr. Sternthal said. Initial therapy may even begin with the use of three agents, he said. Possible initial courses include metformin plus TZD plus exenatide, metformin plus TZD plus sitagliptin, and sulfonylurea plus metformin plus TZD.

The number of incretins available to treat type 2 diabetes is set to expand in the near future, said Dr. Marie E. McDonnell, director of inpatient diabetes at Boston Medical Center.

Liraglutide, a once-weekly formulation of exenatide (Byetta), is currently under investigation; exenatide also is being investigated for use in combination insulin. A dipeptidyl peptidase-4 (DPP-4) inhibitor, vildagliptin, is on the way. And glucagon receptor antagonists are also being studied, Dr. McDonnell said at the meeting.

But there is still no alternative to insulin therapy, said Dr. McDonnell, who is on the speakers bureau for Sanofi Aventis.

“Do not lose sight of insulin-deficient patients—they need you,” she said.

FAMILY PRACTICE NEWS and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

PHILADELPHIA — When physicians are initiating therapy for type 2 diabetes, they should consider integrating incretins into their medication arsenal, said Dr. Elliot Sternthal, clinical director of diabetes services at Boston Medical Center.

The injectable incretinomimetic exenatide, the injectable amylinomimetic pramlintide, and the dipeptidyl peptidase-4 inhibitor sitagliptin provide additional options for physicians in diabetes-modifying therapy. These compounds would also be attractive if they were to gain an indication for use in prediabetes because of their potential to prevent the progression of islet cell dysfunction seen in type 2 diabetes, he said.

But be sure to correctly identify the metabolic “stage” of diabetes patients based on their hemoglobin A1c levels, fasting blood sugar, 2-hour postprandial blood sugar, and renal and hepatic status, Dr. Sternthal said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS and FAMILY PRACTICE NEWS.

For type 2 diabetes patients with mild hyperglycemia or an HbA1c between 6% and 7%, the options for initiating treatment include an a-glucosidase inhibitor, metformin, thiazolidinedione (TZD), and sitagliptin. Advanced therapy could include combinations of these drugs, such as metformin plus a TZD.

For patients with moderate hyperglycemia with an HbA1c of 7%-8%, initial therapy options include an a-glucosidase inhibitor, metformin, TZD, sitagliptin, meglitinide, low-dose sulfonylurea, TZD plus metformin, or sitagliptin plus metformin. The use of metformin with sita- gliptin may actually increase the release of incretins, Dr. Sternthal said.

For later stages of moderate hyperglycemia, consider sulfonylurea plus either metformin or TZD, for example.

For patients with moderately severe hyperglycemia, or an HbA1c of 8%-9%, combinations are likely to be the first-line approach. Physicians can consider the use of high-dose sulfonylurea or metformin alone. However, initial therapy is likely to involve two-drug combinations such as metformin plus TZD, TZD plus sita- gliptin, or sulfonylurea plus exenatide.

For advanced therapy, consider three-drug combinations such as sulfonylurea plus metformin plus TZD.

You have to pick and choose what's best for your patient, said Dr. Sternthal, who is on the speakers bureau for Amylin, AstraZeneca, Eli Lilly & Co., and Merck.

In cases of severe hyperglycemia, with an HbA1c of greater than 9%, there is no role for monotherapy, Dr. Sternthal said. Initial therapy may even begin with the use of three agents, he said. Possible initial courses include metformin plus TZD plus exenatide, metformin plus TZD plus sitagliptin, and sulfonylurea plus metformin plus TZD.

The number of incretins available to treat type 2 diabetes is set to expand in the near future, said Dr. Marie E. McDonnell, director of inpatient diabetes at Boston Medical Center.

Liraglutide, a once-weekly formulation of exenatide (Byetta), is currently under investigation; exenatide also is being investigated for use in combination insulin. A dipeptidyl peptidase-4 (DPP-4) inhibitor, vildagliptin, is on the way. And glucagon receptor antagonists are also being studied, Dr. McDonnell said at the meeting.

But there is still no alternative to insulin therapy, said Dr. McDonnell, who is on the speakers bureau for Sanofi Aventis.

“Do not lose sight of insulin-deficient patients—they need you,” she said.

FAMILY PRACTICE NEWS and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.

PHILADELPHIA — When physicians are initiating therapy for type 2 diabetes, they should consider integrating incretins into their medication arsenal, said Dr. Elliot Sternthal, clinical director of diabetes services at Boston Medical Center.

The injectable incretinomimetic exenatide, the injectable amylinomimetic pramlintide, and the dipeptidyl peptidase-4 inhibitor sitagliptin provide additional options for physicians in diabetes-modifying therapy. These compounds would also be attractive if they were to gain an indication for use in prediabetes because of their potential to prevent the progression of islet cell dysfunction seen in type 2 diabetes, he said.

But be sure to correctly identify the metabolic “stage” of diabetes patients based on their hemoglobin A1c levels, fasting blood sugar, 2-hour postprandial blood sugar, and renal and hepatic status, Dr. Sternthal said at Endocrinology in the News, sponsored by Boston University, INTERNAL MEDICINE NEWS and FAMILY PRACTICE NEWS.

For type 2 diabetes patients with mild hyperglycemia or an HbA1c between 6% and 7%, the options for initiating treatment include an a-glucosidase inhibitor, metformin, thiazolidinedione (TZD), and sitagliptin. Advanced therapy could include combinations of these drugs, such as metformin plus a TZD.

For patients with moderate hyperglycemia with an HbA1c of 7%-8%, initial therapy options include an a-glucosidase inhibitor, metformin, TZD, sitagliptin, meglitinide, low-dose sulfonylurea, TZD plus metformin, or sitagliptin plus metformin. The use of metformin with sita- gliptin may actually increase the release of incretins, Dr. Sternthal said.

For later stages of moderate hyperglycemia, consider sulfonylurea plus either metformin or TZD, for example.

For patients with moderately severe hyperglycemia, or an HbA1c of 8%-9%, combinations are likely to be the first-line approach. Physicians can consider the use of high-dose sulfonylurea or metformin alone. However, initial therapy is likely to involve two-drug combinations such as metformin plus TZD, TZD plus sita- gliptin, or sulfonylurea plus exenatide.

For advanced therapy, consider three-drug combinations such as sulfonylurea plus metformin plus TZD.

You have to pick and choose what's best for your patient, said Dr. Sternthal, who is on the speakers bureau for Amylin, AstraZeneca, Eli Lilly & Co., and Merck.

In cases of severe hyperglycemia, with an HbA1c of greater than 9%, there is no role for monotherapy, Dr. Sternthal said. Initial therapy may even begin with the use of three agents, he said. Possible initial courses include metformin plus TZD plus exenatide, metformin plus TZD plus sitagliptin, and sulfonylurea plus metformin plus TZD.

The number of incretins available to treat type 2 diabetes is set to expand in the near future, said Dr. Marie E. McDonnell, director of inpatient diabetes at Boston Medical Center.

Liraglutide, a once-weekly formulation of exenatide (Byetta), is currently under investigation; exenatide also is being investigated for use in combination insulin. A dipeptidyl peptidase-4 (DPP-4) inhibitor, vildagliptin, is on the way. And glucagon receptor antagonists are also being studied, Dr. McDonnell said at the meeting.

But there is still no alternative to insulin therapy, said Dr. McDonnell, who is on the speakers bureau for Sanofi Aventis.

“Do not lose sight of insulin-deficient patients—they need you,” she said.

FAMILY PRACTICE NEWS and INTERNAL MEDICINE NEWS are published by the International Medical News Group, a division of Elsevier.