Mary Ellen Schneider

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save nearly $3.2 billion over 5 years.

The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from Medicare in fiscal year 2009 and about $183 billion over the next 5 years.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save nearly $3.2 billion over 5 years.

The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from Medicare in fiscal year 2009 and about $183 billion over the next 5 years.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save nearly $3.2 billion over 5 years.

The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from Medicare in fiscal year 2009 and about $183 billion over the next 5 years.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

Labor Dept. Proposes FMLA Changes

Just in time for the 15th anniversary of the Family and Medical Leave Act (FMLA), the Bush administration issued a notice of proposed rulemaking that contains changes to the definition of a “serious health condition” and would allow employers to directly contact physicians to clarify FMLA claims. The law currently defines a serious health condition as requiring more than 3 consecutive calendar days of incapacity plus two visits to a health care provider. Under the proposal, the two visits would need to occur within 30 days of the period of incapacity. The proposed rule would also allow employers to directly contact health care providers to clarify a medical certification, provided that they met the requirements of HIPAA medical privacy regulations. The proposal also implements provisions of the National Defense Authorization Act of 2008, which provides for up to 26 weeks of leave to care for a service member recovering from a serious illness or injury and up to 12 weeks of leave in certain circumstances when a family member is on active military duty.

ACOG Opposes Home Births

With direct-entry midwives seeking licensing to attend home births in various states around the country, the American College of Obstetricians and Gynecologists has reaffirmed its longstanding opposition to home births. The safest location for labor, delivery, and the immediate postpartum period is in a hospital or birthing center, according to the ACOG statement. Further, the college supports the provision of care only by midwives who have been certified by either the American College of Nurse-Midwives or the American Midwifery Certification Board. Decisions on where to give birth should not be influenced by trends or what is fashionable, ACOG warned. “Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly, she puts herself and her baby's health and life at unnecessary risk,” ACOG said in the statement.

Family Planning Budget at $300M

The Bush administration is seeking $300 million in Title X family planning funding for fiscal year 2009, the same level approved by Congress for fiscal year 2008. The budget request, which is now in the hands of Congress, fails to keep up with rising medical costs and the growing demand for services, reproductive rights advocates said. With 17 million women in need of publicly funded family planning services, the Title X budget should be increased by at least $100 million in FY 2009, according to the Planned Parenthood Federation of America. “Had Title X funding kept pace with medical inflation since FY 1980, last year it would have been funded at more than $725 million,” Mary Jane Gallagher, president and CEO of the National Family Planning and Reproductive Health Association, said in a statement.

Ensuring Mifepristone Safety

Following reports of tainted leukemia drugs being produced by the China-based company Shanghai Pharmaceutical Group, the Food and Drug Administration is being asked to account for the safety of another one of the company's products—mifepristone. Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, and the Planned Parenthood Federation of America are both calling on the FDA to share its plans for ensuring the safety of mifepristone. In a letter to the FDA, Rep. Waxman requested a briefing from the agency on the status of all inspections performed by the FDA at facilities owned by the Shanghai Pharmaceutical Group that manufacture drugs intended for export to the United States. Mifepristone is not manufactured at the same facility as the tainted drugs, and the mifepristone facility passed inspection by the FDA in May 2007, according to an FDA spokesman. The agency is considering whether follow-up inspections are necessary, the spokesman said.

Top 10 Ailments Cost $500B in 2005

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

Labor Dept. Proposes FMLA Changes

Just in time for the 15th anniversary of the Family and Medical Leave Act (FMLA), the Bush administration issued a notice of proposed rulemaking that contains changes to the definition of a “serious health condition” and would allow employers to directly contact physicians to clarify FMLA claims. The law currently defines a serious health condition as requiring more than 3 consecutive calendar days of incapacity plus two visits to a health care provider. Under the proposal, the two visits would need to occur within 30 days of the period of incapacity. The proposed rule would also allow employers to directly contact health care providers to clarify a medical certification, provided that they met the requirements of HIPAA medical privacy regulations. The proposal also implements provisions of the National Defense Authorization Act of 2008, which provides for up to 26 weeks of leave to care for a service member recovering from a serious illness or injury and up to 12 weeks of leave in certain circumstances when a family member is on active military duty.

ACOG Opposes Home Births

With direct-entry midwives seeking licensing to attend home births in various states around the country, the American College of Obstetricians and Gynecologists has reaffirmed its longstanding opposition to home births. The safest location for labor, delivery, and the immediate postpartum period is in a hospital or birthing center, according to the ACOG statement. Further, the college supports the provision of care only by midwives who have been certified by either the American College of Nurse-Midwives or the American Midwifery Certification Board. Decisions on where to give birth should not be influenced by trends or what is fashionable, ACOG warned. “Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly, she puts herself and her baby's health and life at unnecessary risk,” ACOG said in the statement.

Family Planning Budget at $300M

The Bush administration is seeking $300 million in Title X family planning funding for fiscal year 2009, the same level approved by Congress for fiscal year 2008. The budget request, which is now in the hands of Congress, fails to keep up with rising medical costs and the growing demand for services, reproductive rights advocates said. With 17 million women in need of publicly funded family planning services, the Title X budget should be increased by at least $100 million in FY 2009, according to the Planned Parenthood Federation of America. “Had Title X funding kept pace with medical inflation since FY 1980, last year it would have been funded at more than $725 million,” Mary Jane Gallagher, president and CEO of the National Family Planning and Reproductive Health Association, said in a statement.

Ensuring Mifepristone Safety

Following reports of tainted leukemia drugs being produced by the China-based company Shanghai Pharmaceutical Group, the Food and Drug Administration is being asked to account for the safety of another one of the company's products—mifepristone. Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, and the Planned Parenthood Federation of America are both calling on the FDA to share its plans for ensuring the safety of mifepristone. In a letter to the FDA, Rep. Waxman requested a briefing from the agency on the status of all inspections performed by the FDA at facilities owned by the Shanghai Pharmaceutical Group that manufacture drugs intended for export to the United States. Mifepristone is not manufactured at the same facility as the tainted drugs, and the mifepristone facility passed inspection by the FDA in May 2007, according to an FDA spokesman. The agency is considering whether follow-up inspections are necessary, the spokesman said.

Top 10 Ailments Cost $500B in 2005

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

Labor Dept. Proposes FMLA Changes

Just in time for the 15th anniversary of the Family and Medical Leave Act (FMLA), the Bush administration issued a notice of proposed rulemaking that contains changes to the definition of a “serious health condition” and would allow employers to directly contact physicians to clarify FMLA claims. The law currently defines a serious health condition as requiring more than 3 consecutive calendar days of incapacity plus two visits to a health care provider. Under the proposal, the two visits would need to occur within 30 days of the period of incapacity. The proposed rule would also allow employers to directly contact health care providers to clarify a medical certification, provided that they met the requirements of HIPAA medical privacy regulations. The proposal also implements provisions of the National Defense Authorization Act of 2008, which provides for up to 26 weeks of leave to care for a service member recovering from a serious illness or injury and up to 12 weeks of leave in certain circumstances when a family member is on active military duty.

ACOG Opposes Home Births

With direct-entry midwives seeking licensing to attend home births in various states around the country, the American College of Obstetricians and Gynecologists has reaffirmed its longstanding opposition to home births. The safest location for labor, delivery, and the immediate postpartum period is in a hospital or birthing center, according to the ACOG statement. Further, the college supports the provision of care only by midwives who have been certified by either the American College of Nurse-Midwives or the American Midwifery Certification Board. Decisions on where to give birth should not be influenced by trends or what is fashionable, ACOG warned. “Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly, she puts herself and her baby's health and life at unnecessary risk,” ACOG said in the statement.

Family Planning Budget at $300M

The Bush administration is seeking $300 million in Title X family planning funding for fiscal year 2009, the same level approved by Congress for fiscal year 2008. The budget request, which is now in the hands of Congress, fails to keep up with rising medical costs and the growing demand for services, reproductive rights advocates said. With 17 million women in need of publicly funded family planning services, the Title X budget should be increased by at least $100 million in FY 2009, according to the Planned Parenthood Federation of America. “Had Title X funding kept pace with medical inflation since FY 1980, last year it would have been funded at more than $725 million,” Mary Jane Gallagher, president and CEO of the National Family Planning and Reproductive Health Association, said in a statement.

Ensuring Mifepristone Safety

Following reports of tainted leukemia drugs being produced by the China-based company Shanghai Pharmaceutical Group, the Food and Drug Administration is being asked to account for the safety of another one of the company's products—mifepristone. Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, and the Planned Parenthood Federation of America are both calling on the FDA to share its plans for ensuring the safety of mifepristone. In a letter to the FDA, Rep. Waxman requested a briefing from the agency on the status of all inspections performed by the FDA at facilities owned by the Shanghai Pharmaceutical Group that manufacture drugs intended for export to the United States. Mifepristone is not manufactured at the same facility as the tainted drugs, and the mifepristone facility passed inspection by the FDA in May 2007, according to an FDA spokesman. The agency is considering whether follow-up inspections are necessary, the spokesman said.

Top 10 Ailments Cost $500B in 2005

The nation's 10 most expensive medical conditions cost about $500 billion to treat in 2005, according to the Agency for Healthcare Research and Quality. Heart disease topped the list at $76 billion, with trauma second at $72 billion and cancer third at $70 billion. Mental illness, including depression, cost $56 billion, and asthma and chronic obstructive pulmonary disease cost $54 billion. Hypertension cost $42 billion to treat, type 2 diabetes cost $34 billion, and osteoarthritis/joint diseases also cost $34 billion. Back problems and normal childbirth rounded out the list at $32 billion each. The agency counted money spent on office visits, clinic and emergency department use, hospital stays, home health care, and prescription medicines.

No single standardized assessment of medical student neurology clerkships provides a complete picture of the student's knowledge, skills, and professionalism, according to an evaluation conducted at the Harvard Medical School, Boston.

Rather, it is a composite approach which relies on results from three different assessments that ultimately offers medical students the most “transparent and fair” evaluation possible, and can most accurately take into account the different strengths of each individual student, according to the evaluation.

The research for this study was supported in part by the Academy at Harvard Medical School and also by the Birmingham Foundation.

The authors reported no conflicts of interest in relation to this study.

The study was prompted because “There's always the concern that the student who brings the better doughnuts gets the better grade,” said Dr. Jeremy Schmahmann, who is the the lead author of the study and also the neurology clerkship director at Massachusetts General Hospital.

However, by using a composite of three separate evaluations, students can have confidence in the final grade for the rotation—regardless of whether they bring doughnuts. And that final grade often can go on to influence their final choice of medical specialty, he said.

Researchers from Massachusetts General Hospital and the Harvard Medical School compared the results of the Subjective Evaluation Form (SEF), the Bedside Examination Exercise (BEE), and also the National Board of Medical Examiners Shelf examination (Shelf) in grading those medical students who were, at that time, participating in Harvard Medical School's 1-month-long neurology clerkship.

The researchers compared the final grades of 71 students who were assessed with the Subjective Evaluation Form alone and 409 students using the Bedside Examination Exercise alone from 1991 to 2002.

They also performed a prospective study of 132 students who were assessed using all three tests—the BEE, SEF, and the Shelf—between 2003 and 2006.

Among the 132 students who were tested on all three of the instruments, the researchers found that there was a normal distribution of scores across the class for each test.

However, the researchers found poor agreement on knowledge between the three tests.

For example, the comparison showed that the faculty members and residents who worked with students in the wards typically tended to overrate student knowledge, compared with the results of the Shelf examination.

“None of the test instruments, no matter how fairly administered we thought they were, was sufficiently reliable or valid to serve as the final grade for the rotation,” the researchers wrote.

As a result, the researchers developed a composite score that is based on weighted versions of the three assessments. The makeup of the composite exam is 70% of the Subjective Evaluation Form, 15% of the Bedside Examination Exercise, and 15% of the National Board of Medical Examiners Shelf examination.

In applying the composite process, students would be required to pass all three tests to graduate from the rotation.

The composite score had a normative distribution among all of the 132 students who were tested on it (Neurology 2008;70:706–12).

The study demonstrates what clerkship directors already know very well, and that is that no single instrument is capable of measuring everything, said Dr. Ralph Jozefowicz.

Dr. Jozefowicz is the neurology clerkship director at the University of Rochester (N.Y.) and also the chair of the education committee for the American Academy of Neurology.

“Each of these tools examines different things,” said Dr. Jozefowicz, who reviewed the article before publication.

The study drives home the point that using only the traditional clerkship evaluation—the Subjective Evaluation Form—is insufficient, he said.

If the evaluation is fair and comprehensive, taking into account all of the aspects of what makes a good clinician, it will ensure that students will strive to excel in all areas, he said.

“Testing drives the curriculum. People study what you test them on,” Dr. Jozefowicz said.

But there is at least one significant barrier to having more neurology programs around the country adopt the combined approach.

Programs must pay to use the Shelf exam.

Additionally, the Bedside Examination Exercise carries a monetary cost as well as considerable faculty time investment, said Jozefowicz.

No single standardized assessment of medical student neurology clerkships provides a complete picture of the student's knowledge, skills, and professionalism, according to an evaluation conducted at the Harvard Medical School, Boston.

Rather, it is a composite approach which relies on results from three different assessments that ultimately offers medical students the most “transparent and fair” evaluation possible, and can most accurately take into account the different strengths of each individual student, according to the evaluation.

The research for this study was supported in part by the Academy at Harvard Medical School and also by the Birmingham Foundation.

The authors reported no conflicts of interest in relation to this study.

The study was prompted because “There's always the concern that the student who brings the better doughnuts gets the better grade,” said Dr. Jeremy Schmahmann, who is the the lead author of the study and also the neurology clerkship director at Massachusetts General Hospital.

However, by using a composite of three separate evaluations, students can have confidence in the final grade for the rotation—regardless of whether they bring doughnuts. And that final grade often can go on to influence their final choice of medical specialty, he said.

Researchers from Massachusetts General Hospital and the Harvard Medical School compared the results of the Subjective Evaluation Form (SEF), the Bedside Examination Exercise (BEE), and also the National Board of Medical Examiners Shelf examination (Shelf) in grading those medical students who were, at that time, participating in Harvard Medical School's 1-month-long neurology clerkship.

The researchers compared the final grades of 71 students who were assessed with the Subjective Evaluation Form alone and 409 students using the Bedside Examination Exercise alone from 1991 to 2002.

They also performed a prospective study of 132 students who were assessed using all three tests—the BEE, SEF, and the Shelf—between 2003 and 2006.

Among the 132 students who were tested on all three of the instruments, the researchers found that there was a normal distribution of scores across the class for each test.

However, the researchers found poor agreement on knowledge between the three tests.

For example, the comparison showed that the faculty members and residents who worked with students in the wards typically tended to overrate student knowledge, compared with the results of the Shelf examination.

“None of the test instruments, no matter how fairly administered we thought they were, was sufficiently reliable or valid to serve as the final grade for the rotation,” the researchers wrote.

As a result, the researchers developed a composite score that is based on weighted versions of the three assessments. The makeup of the composite exam is 70% of the Subjective Evaluation Form, 15% of the Bedside Examination Exercise, and 15% of the National Board of Medical Examiners Shelf examination.

In applying the composite process, students would be required to pass all three tests to graduate from the rotation.

The composite score had a normative distribution among all of the 132 students who were tested on it (Neurology 2008;70:706–12).

The study demonstrates what clerkship directors already know very well, and that is that no single instrument is capable of measuring everything, said Dr. Ralph Jozefowicz.

Dr. Jozefowicz is the neurology clerkship director at the University of Rochester (N.Y.) and also the chair of the education committee for the American Academy of Neurology.

“Each of these tools examines different things,” said Dr. Jozefowicz, who reviewed the article before publication.

The study drives home the point that using only the traditional clerkship evaluation—the Subjective Evaluation Form—is insufficient, he said.

If the evaluation is fair and comprehensive, taking into account all of the aspects of what makes a good clinician, it will ensure that students will strive to excel in all areas, he said.

“Testing drives the curriculum. People study what you test them on,” Dr. Jozefowicz said.

But there is at least one significant barrier to having more neurology programs around the country adopt the combined approach.

Programs must pay to use the Shelf exam.

Additionally, the Bedside Examination Exercise carries a monetary cost as well as considerable faculty time investment, said Jozefowicz.

No single standardized assessment of medical student neurology clerkships provides a complete picture of the student's knowledge, skills, and professionalism, according to an evaluation conducted at the Harvard Medical School, Boston.

Rather, it is a composite approach which relies on results from three different assessments that ultimately offers medical students the most “transparent and fair” evaluation possible, and can most accurately take into account the different strengths of each individual student, according to the evaluation.

The research for this study was supported in part by the Academy at Harvard Medical School and also by the Birmingham Foundation.

The authors reported no conflicts of interest in relation to this study.

The study was prompted because “There's always the concern that the student who brings the better doughnuts gets the better grade,” said Dr. Jeremy Schmahmann, who is the the lead author of the study and also the neurology clerkship director at Massachusetts General Hospital.

However, by using a composite of three separate evaluations, students can have confidence in the final grade for the rotation—regardless of whether they bring doughnuts. And that final grade often can go on to influence their final choice of medical specialty, he said.

Researchers from Massachusetts General Hospital and the Harvard Medical School compared the results of the Subjective Evaluation Form (SEF), the Bedside Examination Exercise (BEE), and also the National Board of Medical Examiners Shelf examination (Shelf) in grading those medical students who were, at that time, participating in Harvard Medical School's 1-month-long neurology clerkship.

The researchers compared the final grades of 71 students who were assessed with the Subjective Evaluation Form alone and 409 students using the Bedside Examination Exercise alone from 1991 to 2002.

They also performed a prospective study of 132 students who were assessed using all three tests—the BEE, SEF, and the Shelf—between 2003 and 2006.

Among the 132 students who were tested on all three of the instruments, the researchers found that there was a normal distribution of scores across the class for each test.

However, the researchers found poor agreement on knowledge between the three tests.

For example, the comparison showed that the faculty members and residents who worked with students in the wards typically tended to overrate student knowledge, compared with the results of the Shelf examination.

“None of the test instruments, no matter how fairly administered we thought they were, was sufficiently reliable or valid to serve as the final grade for the rotation,” the researchers wrote.

As a result, the researchers developed a composite score that is based on weighted versions of the three assessments. The makeup of the composite exam is 70% of the Subjective Evaluation Form, 15% of the Bedside Examination Exercise, and 15% of the National Board of Medical Examiners Shelf examination.

In applying the composite process, students would be required to pass all three tests to graduate from the rotation.

The composite score had a normative distribution among all of the 132 students who were tested on it (Neurology 2008;70:706–12).

The study demonstrates what clerkship directors already know very well, and that is that no single instrument is capable of measuring everything, said Dr. Ralph Jozefowicz.

Dr. Jozefowicz is the neurology clerkship director at the University of Rochester (N.Y.) and also the chair of the education committee for the American Academy of Neurology.

“Each of these tools examines different things,” said Dr. Jozefowicz, who reviewed the article before publication.

The study drives home the point that using only the traditional clerkship evaluation—the Subjective Evaluation Form—is insufficient, he said.

If the evaluation is fair and comprehensive, taking into account all of the aspects of what makes a good clinician, it will ensure that students will strive to excel in all areas, he said.

“Testing drives the curriculum. People study what you test them on,” Dr. Jozefowicz said.

But there is at least one significant barrier to having more neurology programs around the country adopt the combined approach.

Programs must pay to use the Shelf exam.

Additionally, the Bedside Examination Exercise carries a monetary cost as well as considerable faculty time investment, said Jozefowicz.

Early Intervention in Autism Tested

Researchers at the University of Washington, Seattle, are investigating the benefits of early parental intervention with young siblings of children who have autism spectrum disorders, testing whether extra interaction between these babies and young toddlers and their parents can prevent or reduce the delays in social interaction associated with such disorders. The study will test such techniques as coos, lilting speech, eye contact and other interactions delivered by parents. The $11.3 million research project is expected to include 200 6-month-old babies from the Seattle area who have older siblings already diagnosed with autism or another autism spectrum disorder. Parents will receive developmental evaluations along with advice regarding appropriate services, and those families assigned to the intervention group will receive parent training, and, if appropriate, more intensive intervention for their infants.

NIH Invests in Epigenomics

Officials at the National Institutes of Health plan to spend more than $190 million over the next 5 years on epigenomics—a new field of biomedical research. While the field of epigenetics focuses on the processes that regulate how genes are turned on and off, epigenomics takes it a step farther by looking at the changes across many genes. The NIH is accepting grant applications for research on epigenome mapping centers, data analysis in epigenomics, technology development, and discovery of novel epigenetic marks in mammalian cells. The Epigenomics Program is a trans-NIH project that involves several NIH institutes including the National Institute of Neurological Disorders and Stroke. Information is available at

http://nihroadmap.nih.gov/epigenomics

FDA Would Expand Promotion

The Food and Drug Administration last month proposed draft guidance that would allow drug and medical device makers to distribute medical or scientific journal articles and reference publications that involve unapproved uses of FDA-approved drugs and medical devices. Drug and device makers had been allowed to disseminate such materials under guidelines set by the FDA, but that authority expired in September 2006. The FDA's new “Good Reprint Practices” draft guidance states that the article or reference should be published by an organization that has an editorial board and fully discloses conflicts of interest. In addition, articles should be peer reviewed, and manufacturers should not distribute special supplements or publications funded by product manufacturers, or articles not supported by credible medical evidence. Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, blasted the FDA for its proposal, which he said in a statement “is great news for the drug industry but terrible for the public health.”

Medicare EHR Demo

Small- and medium-size physician practices in a dozen health markets across the country will be eligible to receive Medicare incentive payments for using certified electronic health records under a new demonstration being launched by officials at the Department of Health and Human Services. Financial incentives will be awarded to up to 1,200 practices that use certified EHRs to meet certain quality measures. Physicians who participate in the demonstration would also be eligible to receive bonus payments based on the number of EHR functionalities physicians incorporate into their practices. Over the course of the 5-year project, individual physicians can earn up to $58,000; practices up to $290,000. The HHS will accept applications from officials in those communities where there is interest in participating in the demonstration project through mid-May of this year. HHS officials plan to launch the demonstration this year with four communities, with additional communities beginning the project in 2009. After the communities have been selected, the HHS will work with community officials to recruit physician practices.

Heart-Brain Link Overlooked

African Americans are not likely to be aware that good cardiac health is linked to good brain health, according to a survey conducted by the Alzheimer's Association and the American Heart Association. Sixty-one percent of survey respondents reported that they were concerned about developing heart disease and 40% said they were concerned about Alzheimer's, but only 6% knew there was a link between cardiovascular disease and dementia. African Americans are at greater risk for diabetes, high blood pressure, and vascular dementia than are other races. While half of those surveyed knew of their increased cardiovascular risk, only 8% were aware that they were also at increased risk for dementias including Alzheimer's disease. Fewer than 1 in 10 were aware that heart disease, hypertension, diabetes, and hypercholesterolemia were all linked to Alzheimer's. The survey was conducted online in January 2008 with a random sample of 1,210 African Americans and 1,004 adults of other races. The sampling error was plus or minus 3.5%.

Don't Blame Technology for Costs

Medical devices and in vitro diagnostics account for a relatively small 6% ($112 billion) of the nation's overall health expenditures and should not be blamed for rising health costs, officials from the device industry's lobby, AdvaMed, said at a briefing in February. The group released what it called one of the first-ever studies to examine device cost trends. The study—paid for by AdvaMed—was conducted by Roland Guy King, a former chief actuary for the Medicare and Medicaid programs. Devices and diagnostics accounted for a steady 6% of expenses from 1989 to 2004. Prices grew more slowly—1.2% annually—than did the medical consumer price index, which is about 5% a year, or the consumer price index, which is about 2.8% annually, according to the study. “The highly competitive medical device marketplace is working and delivering tremendous value both in patient care and in economic terms,” said Stephen J. Ubl, AdvaMed president and CEO.

Early Intervention in Autism Tested

Researchers at the University of Washington, Seattle, are investigating the benefits of early parental intervention with young siblings of children who have autism spectrum disorders, testing whether extra interaction between these babies and young toddlers and their parents can prevent or reduce the delays in social interaction associated with such disorders. The study will test such techniques as coos, lilting speech, eye contact and other interactions delivered by parents. The $11.3 million research project is expected to include 200 6-month-old babies from the Seattle area who have older siblings already diagnosed with autism or another autism spectrum disorder. Parents will receive developmental evaluations along with advice regarding appropriate services, and those families assigned to the intervention group will receive parent training, and, if appropriate, more intensive intervention for their infants.

NIH Invests in Epigenomics

Officials at the National Institutes of Health plan to spend more than $190 million over the next 5 years on epigenomics—a new field of biomedical research. While the field of epigenetics focuses on the processes that regulate how genes are turned on and off, epigenomics takes it a step farther by looking at the changes across many genes. The NIH is accepting grant applications for research on epigenome mapping centers, data analysis in epigenomics, technology development, and discovery of novel epigenetic marks in mammalian cells. The Epigenomics Program is a trans-NIH project that involves several NIH institutes including the National Institute of Neurological Disorders and Stroke. Information is available at

http://nihroadmap.nih.gov/epigenomics

FDA Would Expand Promotion

The Food and Drug Administration last month proposed draft guidance that would allow drug and medical device makers to distribute medical or scientific journal articles and reference publications that involve unapproved uses of FDA-approved drugs and medical devices. Drug and device makers had been allowed to disseminate such materials under guidelines set by the FDA, but that authority expired in September 2006. The FDA's new “Good Reprint Practices” draft guidance states that the article or reference should be published by an organization that has an editorial board and fully discloses conflicts of interest. In addition, articles should be peer reviewed, and manufacturers should not distribute special supplements or publications funded by product manufacturers, or articles not supported by credible medical evidence. Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, blasted the FDA for its proposal, which he said in a statement “is great news for the drug industry but terrible for the public health.”

Medicare EHR Demo

Small- and medium-size physician practices in a dozen health markets across the country will be eligible to receive Medicare incentive payments for using certified electronic health records under a new demonstration being launched by officials at the Department of Health and Human Services. Financial incentives will be awarded to up to 1,200 practices that use certified EHRs to meet certain quality measures. Physicians who participate in the demonstration would also be eligible to receive bonus payments based on the number of EHR functionalities physicians incorporate into their practices. Over the course of the 5-year project, individual physicians can earn up to $58,000; practices up to $290,000. The HHS will accept applications from officials in those communities where there is interest in participating in the demonstration project through mid-May of this year. HHS officials plan to launch the demonstration this year with four communities, with additional communities beginning the project in 2009. After the communities have been selected, the HHS will work with community officials to recruit physician practices.

Heart-Brain Link Overlooked

African Americans are not likely to be aware that good cardiac health is linked to good brain health, according to a survey conducted by the Alzheimer's Association and the American Heart Association. Sixty-one percent of survey respondents reported that they were concerned about developing heart disease and 40% said they were concerned about Alzheimer's, but only 6% knew there was a link between cardiovascular disease and dementia. African Americans are at greater risk for diabetes, high blood pressure, and vascular dementia than are other races. While half of those surveyed knew of their increased cardiovascular risk, only 8% were aware that they were also at increased risk for dementias including Alzheimer's disease. Fewer than 1 in 10 were aware that heart disease, hypertension, diabetes, and hypercholesterolemia were all linked to Alzheimer's. The survey was conducted online in January 2008 with a random sample of 1,210 African Americans and 1,004 adults of other races. The sampling error was plus or minus 3.5%.

Don't Blame Technology for Costs

Medical devices and in vitro diagnostics account for a relatively small 6% ($112 billion) of the nation's overall health expenditures and should not be blamed for rising health costs, officials from the device industry's lobby, AdvaMed, said at a briefing in February. The group released what it called one of the first-ever studies to examine device cost trends. The study—paid for by AdvaMed—was conducted by Roland Guy King, a former chief actuary for the Medicare and Medicaid programs. Devices and diagnostics accounted for a steady 6% of expenses from 1989 to 2004. Prices grew more slowly—1.2% annually—than did the medical consumer price index, which is about 5% a year, or the consumer price index, which is about 2.8% annually, according to the study. “The highly competitive medical device marketplace is working and delivering tremendous value both in patient care and in economic terms,” said Stephen J. Ubl, AdvaMed president and CEO.

Early Intervention in Autism Tested

Researchers at the University of Washington, Seattle, are investigating the benefits of early parental intervention with young siblings of children who have autism spectrum disorders, testing whether extra interaction between these babies and young toddlers and their parents can prevent or reduce the delays in social interaction associated with such disorders. The study will test such techniques as coos, lilting speech, eye contact and other interactions delivered by parents. The $11.3 million research project is expected to include 200 6-month-old babies from the Seattle area who have older siblings already diagnosed with autism or another autism spectrum disorder. Parents will receive developmental evaluations along with advice regarding appropriate services, and those families assigned to the intervention group will receive parent training, and, if appropriate, more intensive intervention for their infants.

NIH Invests in Epigenomics

Officials at the National Institutes of Health plan to spend more than $190 million over the next 5 years on epigenomics—a new field of biomedical research. While the field of epigenetics focuses on the processes that regulate how genes are turned on and off, epigenomics takes it a step farther by looking at the changes across many genes. The NIH is accepting grant applications for research on epigenome mapping centers, data analysis in epigenomics, technology development, and discovery of novel epigenetic marks in mammalian cells. The Epigenomics Program is a trans-NIH project that involves several NIH institutes including the National Institute of Neurological Disorders and Stroke. Information is available at

http://nihroadmap.nih.gov/epigenomics

FDA Would Expand Promotion

The Food and Drug Administration last month proposed draft guidance that would allow drug and medical device makers to distribute medical or scientific journal articles and reference publications that involve unapproved uses of FDA-approved drugs and medical devices. Drug and device makers had been allowed to disseminate such materials under guidelines set by the FDA, but that authority expired in September 2006. The FDA's new “Good Reprint Practices” draft guidance states that the article or reference should be published by an organization that has an editorial board and fully discloses conflicts of interest. In addition, articles should be peer reviewed, and manufacturers should not distribute special supplements or publications funded by product manufacturers, or articles not supported by credible medical evidence. Rep. Henry Waxman (D-Calif.), chairman of the House Committee on Oversight and Government Reform, blasted the FDA for its proposal, which he said in a statement “is great news for the drug industry but terrible for the public health.”

Medicare EHR Demo

Small- and medium-size physician practices in a dozen health markets across the country will be eligible to receive Medicare incentive payments for using certified electronic health records under a new demonstration being launched by officials at the Department of Health and Human Services. Financial incentives will be awarded to up to 1,200 practices that use certified EHRs to meet certain quality measures. Physicians who participate in the demonstration would also be eligible to receive bonus payments based on the number of EHR functionalities physicians incorporate into their practices. Over the course of the 5-year project, individual physicians can earn up to $58,000; practices up to $290,000. The HHS will accept applications from officials in those communities where there is interest in participating in the demonstration project through mid-May of this year. HHS officials plan to launch the demonstration this year with four communities, with additional communities beginning the project in 2009. After the communities have been selected, the HHS will work with community officials to recruit physician practices.

Heart-Brain Link Overlooked

African Americans are not likely to be aware that good cardiac health is linked to good brain health, according to a survey conducted by the Alzheimer's Association and the American Heart Association. Sixty-one percent of survey respondents reported that they were concerned about developing heart disease and 40% said they were concerned about Alzheimer's, but only 6% knew there was a link between cardiovascular disease and dementia. African Americans are at greater risk for diabetes, high blood pressure, and vascular dementia than are other races. While half of those surveyed knew of their increased cardiovascular risk, only 8% were aware that they were also at increased risk for dementias including Alzheimer's disease. Fewer than 1 in 10 were aware that heart disease, hypertension, diabetes, and hypercholesterolemia were all linked to Alzheimer's. The survey was conducted online in January 2008 with a random sample of 1,210 African Americans and 1,004 adults of other races. The sampling error was plus or minus 3.5%.

Don't Blame Technology for Costs

Medical devices and in vitro diagnostics account for a relatively small 6% ($112 billion) of the nation's overall health expenditures and should not be blamed for rising health costs, officials from the device industry's lobby, AdvaMed, said at a briefing in February. The group released what it called one of the first-ever studies to examine device cost trends. The study—paid for by AdvaMed—was conducted by Roland Guy King, a former chief actuary for the Medicare and Medicaid programs. Devices and diagnostics accounted for a steady 6% of expenses from 1989 to 2004. Prices grew more slowly—1.2% annually—than did the medical consumer price index, which is about 5% a year, or the consumer price index, which is about 2.8% annually, according to the study. “The highly competitive medical device marketplace is working and delivering tremendous value both in patient care and in economic terms,” said Stephen J. Ubl, AdvaMed president and CEO.

Following a 6-month initial investigation, New York Attorney General Andrew Cuomo announced plans to file suit against UnitedHealth Group and four of its subsidiaries for allegedly systematically underpaying consumers for their out-of-network medical expenses.

The attorney general claimed UnitedHealth Group used faulty data from its subsidiary, the billing information company Ingenix Inc., which resulted in the underestimation of “usual, customary, and reasonable” rates for out-of-network medical expenses and then provided unreasonably low reimbursement to consumers.

The attorney general's office has issued subpoenas to 16 other health insurance companies who use Ingenix. The subpoenas will seek documents that show how the companies calculate reasonable and customary rates, as well as copies of member complaints and appeals, and communications with Ingenix.

Five of the nation's largest health insurance companies rely on data from Ingenix, according to the attorney general.

UnitedHealth Group has denied that there are problems with the reference data used by Ingenix, which is “rigorously developed, geographically specific, comprehensive and organized using a transparent methodology,” according to a company statement.

Ingenix owns a database of billing information that many health insurers use to determine how much to reimburse consumers who go out of network for care. But the attorney general's preliminary investigation found the Ingenix data are provided by insurers with a vested interest in keeping the rates low and that there is no auditing of the data that come in, Linda Lacewell, head of the attorney general's Health Care Industry Task Force, said at a press conference to announce the industry-wide investigation.

The database also doesn't take into account whether a service was provided by a physician or a non-physician provider, a factor that would affect the price, Ms. Lacewell said.

“Our investigation has revealed that Ingenix is nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment,” she said.

About 70% of insured Americans pay higher premiums for the right to go out of their insurer's network for care. In exchange, the insurer typically promises to pay about 80% of the usual, customary, and reasonable rate. The consumer then is responsible for the bill's balance.

But the attorney general says UnitedHealth Group subscribers haven't been getting what they paid for when going out of network. For example, for a 15-minute office visit in which most physicians charged $200, United Health told subscribers that the typical cost was $77 and agreed to pay only $62, leaving consumers to pay the remainder of the $138 bill.

The situation also can create problems for the physician, Dr. Robert B. Goldberg, president of the Medical Society of the State of New York, said. When patients receive an underpayment from their insurer, it's usually the physician's bill they challenge, since it appears the doctor has overcharged.

The same charges were also made by the American Medical Association in an ongoing class action lawsuit it filed against UnitedHealth Group in 2000.

Following a 6-month initial investigation, New York Attorney General Andrew Cuomo announced plans to file suit against UnitedHealth Group and four of its subsidiaries for allegedly systematically underpaying consumers for their out-of-network medical expenses.

The attorney general claimed UnitedHealth Group used faulty data from its subsidiary, the billing information company Ingenix Inc., which resulted in the underestimation of “usual, customary, and reasonable” rates for out-of-network medical expenses and then provided unreasonably low reimbursement to consumers.

The attorney general's office has issued subpoenas to 16 other health insurance companies who use Ingenix. The subpoenas will seek documents that show how the companies calculate reasonable and customary rates, as well as copies of member complaints and appeals, and communications with Ingenix.

Five of the nation's largest health insurance companies rely on data from Ingenix, according to the attorney general.

UnitedHealth Group has denied that there are problems with the reference data used by Ingenix, which is “rigorously developed, geographically specific, comprehensive and organized using a transparent methodology,” according to a company statement.

Ingenix owns a database of billing information that many health insurers use to determine how much to reimburse consumers who go out of network for care. But the attorney general's preliminary investigation found the Ingenix data are provided by insurers with a vested interest in keeping the rates low and that there is no auditing of the data that come in, Linda Lacewell, head of the attorney general's Health Care Industry Task Force, said at a press conference to announce the industry-wide investigation.

The database also doesn't take into account whether a service was provided by a physician or a non-physician provider, a factor that would affect the price, Ms. Lacewell said.

“Our investigation has revealed that Ingenix is nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment,” she said.

About 70% of insured Americans pay higher premiums for the right to go out of their insurer's network for care. In exchange, the insurer typically promises to pay about 80% of the usual, customary, and reasonable rate. The consumer then is responsible for the bill's balance.

But the attorney general says UnitedHealth Group subscribers haven't been getting what they paid for when going out of network. For example, for a 15-minute office visit in which most physicians charged $200, United Health told subscribers that the typical cost was $77 and agreed to pay only $62, leaving consumers to pay the remainder of the $138 bill.

The situation also can create problems for the physician, Dr. Robert B. Goldberg, president of the Medical Society of the State of New York, said. When patients receive an underpayment from their insurer, it's usually the physician's bill they challenge, since it appears the doctor has overcharged.

The same charges were also made by the American Medical Association in an ongoing class action lawsuit it filed against UnitedHealth Group in 2000.

Following a 6-month initial investigation, New York Attorney General Andrew Cuomo announced plans to file suit against UnitedHealth Group and four of its subsidiaries for allegedly systematically underpaying consumers for their out-of-network medical expenses.

The attorney general claimed UnitedHealth Group used faulty data from its subsidiary, the billing information company Ingenix Inc., which resulted in the underestimation of “usual, customary, and reasonable” rates for out-of-network medical expenses and then provided unreasonably low reimbursement to consumers.

The attorney general's office has issued subpoenas to 16 other health insurance companies who use Ingenix. The subpoenas will seek documents that show how the companies calculate reasonable and customary rates, as well as copies of member complaints and appeals, and communications with Ingenix.

Five of the nation's largest health insurance companies rely on data from Ingenix, according to the attorney general.

UnitedHealth Group has denied that there are problems with the reference data used by Ingenix, which is “rigorously developed, geographically specific, comprehensive and organized using a transparent methodology,” according to a company statement.

Ingenix owns a database of billing information that many health insurers use to determine how much to reimburse consumers who go out of network for care. But the attorney general's preliminary investigation found the Ingenix data are provided by insurers with a vested interest in keeping the rates low and that there is no auditing of the data that come in, Linda Lacewell, head of the attorney general's Health Care Industry Task Force, said at a press conference to announce the industry-wide investigation.

The database also doesn't take into account whether a service was provided by a physician or a non-physician provider, a factor that would affect the price, Ms. Lacewell said.

“Our investigation has revealed that Ingenix is nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment,” she said.

About 70% of insured Americans pay higher premiums for the right to go out of their insurer's network for care. In exchange, the insurer typically promises to pay about 80% of the usual, customary, and reasonable rate. The consumer then is responsible for the bill's balance.

But the attorney general says UnitedHealth Group subscribers haven't been getting what they paid for when going out of network. For example, for a 15-minute office visit in which most physicians charged $200, United Health told subscribers that the typical cost was $77 and agreed to pay only $62, leaving consumers to pay the remainder of the $138 bill.

The situation also can create problems for the physician, Dr. Robert B. Goldberg, president of the Medical Society of the State of New York, said. When patients receive an underpayment from their insurer, it's usually the physician's bill they challenge, since it appears the doctor has overcharged.

The same charges were also made by the American Medical Association in an ongoing class action lawsuit it filed against UnitedHealth Group in 2000.

Merck Reaches Fraud Settlements

Pharmaceutical company Merck & Co. has agreed to pay more than $650 million to federal and state governments to resolve claims that the company provided kickbacks to physicians to purchase Merck products and failed to pay proper rebates to Medicaid. The company did not admit wrongdoing as part of the settlement. “Merck believes its pricing and sales and marketing policies and practices were consistent with all applicable regulations and contracts during the relevant time,” the company said in a statement. In a lawsuit filed in Philadelphia, a former Merck employee alleged that from 1997 to 2001 Merck sales representatives made illegal payments to physicians to purchase its drugs and disguised those payments as fees for training or funding for market research. In addition, the suit against Merck alleged that the company offered hospitals substantial discounts for purchasing Zocor (simvastatin) and Vioxx (rofecoxib) if they used those drugs primarily over other competing brands. Merck is alleged to have excluded those discounts when reporting price information to Medicaid, which is entitled to receive the “best price” under the law. In a separate lawsuit against Merck, a physician in New Orleans alleged a similar scheme in which the company would offer substantially lower prices on its Pepcid (famotidine) products once a hospital agreed to use the drug primarily over a competitor's product. Once again, Merck is alleged to have excluded those discounts in its reporting to Medicaid. Under the terms of the two settlements, Merck has agreed to pay more than $360 million to the federal government and more than $290 million to 49 states and the District of Columbia. The company also has also entered into a 5-year Corporate Integrity Agreement with the Health and Human Services Department Office of Inspector General.

M.D. Faces Plagiarism Charges

Dr. Lee S. Simon, a rheumatologist and associate clinical professor of medicine at Harvard Medical School, Boston, is under a cloud of suspicion after a computer program found significant similarities between an article he authored that was published in 2004 and an article by another author that was published a year earlier. An internal ad hoc committee at Harvard is conducting a preliminary review of the situation, according to a spokesman for the university. A computer program called eTBLAST, which was developed by researchers at the University of Texas Southwestern Medical Center at Dallas, identified duplications between Dr. Simon's article on the treatment of rheumatoid arthritis in Best Practice & Research Clinical Rheumatology in 2004 and a 2003 article published in the journal Expert Opinion on Drug Safety. Elsevier, which publishes Best Practice & Research Clinical Rheumatology and this publication, retracted Dr. Simon's article in January, saying that it “included the reproduction of several sections of text and much of the reference list” from the other paper. Dr. Simon had no comment on the accusation as of press time.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a new report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher-cost health problems, the report said. This could create high premiums and instability in the insurance pools that enroll those individuals, the report said. In addition, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, according to the report, “Do Individual Mandates Matter?”

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. The CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit will be $117 billion lower over the next 10 years than it had estimated last summer. The difference between the two projected costs results from the slowing of drug cost trends, lower estimates of plan spending, and higher expected rebates from drug manufacturers, the CMS said. Compared with original projections, the anticipated net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to a study by researchers at the Centers for Disease Control and Prevention and RTI International. The researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking, observing a decline in prevalence from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs, the researchers wrote. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Merck Reaches Fraud Settlements

Pharmaceutical company Merck & Co. has agreed to pay more than $650 million to federal and state governments to resolve claims that the company provided kickbacks to physicians to purchase Merck products and failed to pay proper rebates to Medicaid. The company did not admit wrongdoing as part of the settlement. “Merck believes its pricing and sales and marketing policies and practices were consistent with all applicable regulations and contracts during the relevant time,” the company said in a statement. In a lawsuit filed in Philadelphia, a former Merck employee alleged that from 1997 to 2001 Merck sales representatives made illegal payments to physicians to purchase its drugs and disguised those payments as fees for training or funding for market research. In addition, the suit against Merck alleged that the company offered hospitals substantial discounts for purchasing Zocor (simvastatin) and Vioxx (rofecoxib) if they used those drugs primarily over other competing brands. Merck is alleged to have excluded those discounts when reporting price information to Medicaid, which is entitled to receive the “best price” under the law. In a separate lawsuit against Merck, a physician in New Orleans alleged a similar scheme in which the company would offer substantially lower prices on its Pepcid (famotidine) products once a hospital agreed to use the drug primarily over a competitor's product. Once again, Merck is alleged to have excluded those discounts in its reporting to Medicaid. Under the terms of the two settlements, Merck has agreed to pay more than $360 million to the federal government and more than $290 million to 49 states and the District of Columbia. The company also has also entered into a 5-year Corporate Integrity Agreement with the Health and Human Services Department Office of Inspector General.

M.D. Faces Plagiarism Charges

Dr. Lee S. Simon, a rheumatologist and associate clinical professor of medicine at Harvard Medical School, Boston, is under a cloud of suspicion after a computer program found significant similarities between an article he authored that was published in 2004 and an article by another author that was published a year earlier. An internal ad hoc committee at Harvard is conducting a preliminary review of the situation, according to a spokesman for the university. A computer program called eTBLAST, which was developed by researchers at the University of Texas Southwestern Medical Center at Dallas, identified duplications between Dr. Simon's article on the treatment of rheumatoid arthritis in Best Practice & Research Clinical Rheumatology in 2004 and a 2003 article published in the journal Expert Opinion on Drug Safety. Elsevier, which publishes Best Practice & Research Clinical Rheumatology and this publication, retracted Dr. Simon's article in January, saying that it “included the reproduction of several sections of text and much of the reference list” from the other paper. Dr. Simon had no comment on the accusation as of press time.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a new report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher-cost health problems, the report said. This could create high premiums and instability in the insurance pools that enroll those individuals, the report said. In addition, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, according to the report, “Do Individual Mandates Matter?”

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. The CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit will be $117 billion lower over the next 10 years than it had estimated last summer. The difference between the two projected costs results from the slowing of drug cost trends, lower estimates of plan spending, and higher expected rebates from drug manufacturers, the CMS said. Compared with original projections, the anticipated net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to a study by researchers at the Centers for Disease Control and Prevention and RTI International. The researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking, observing a decline in prevalence from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs, the researchers wrote. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

Merck Reaches Fraud Settlements

Pharmaceutical company Merck & Co. has agreed to pay more than $650 million to federal and state governments to resolve claims that the company provided kickbacks to physicians to purchase Merck products and failed to pay proper rebates to Medicaid. The company did not admit wrongdoing as part of the settlement. “Merck believes its pricing and sales and marketing policies and practices were consistent with all applicable regulations and contracts during the relevant time,” the company said in a statement. In a lawsuit filed in Philadelphia, a former Merck employee alleged that from 1997 to 2001 Merck sales representatives made illegal payments to physicians to purchase its drugs and disguised those payments as fees for training or funding for market research. In addition, the suit against Merck alleged that the company offered hospitals substantial discounts for purchasing Zocor (simvastatin) and Vioxx (rofecoxib) if they used those drugs primarily over other competing brands. Merck is alleged to have excluded those discounts when reporting price information to Medicaid, which is entitled to receive the “best price” under the law. In a separate lawsuit against Merck, a physician in New Orleans alleged a similar scheme in which the company would offer substantially lower prices on its Pepcid (famotidine) products once a hospital agreed to use the drug primarily over a competitor's product. Once again, Merck is alleged to have excluded those discounts in its reporting to Medicaid. Under the terms of the two settlements, Merck has agreed to pay more than $360 million to the federal government and more than $290 million to 49 states and the District of Columbia. The company also has also entered into a 5-year Corporate Integrity Agreement with the Health and Human Services Department Office of Inspector General.

M.D. Faces Plagiarism Charges

Dr. Lee S. Simon, a rheumatologist and associate clinical professor of medicine at Harvard Medical School, Boston, is under a cloud of suspicion after a computer program found significant similarities between an article he authored that was published in 2004 and an article by another author that was published a year earlier. An internal ad hoc committee at Harvard is conducting a preliminary review of the situation, according to a spokesman for the university. A computer program called eTBLAST, which was developed by researchers at the University of Texas Southwestern Medical Center at Dallas, identified duplications between Dr. Simon's article on the treatment of rheumatoid arthritis in Best Practice & Research Clinical Rheumatology in 2004 and a 2003 article published in the journal Expert Opinion on Drug Safety. Elsevier, which publishes Best Practice & Research Clinical Rheumatology and this publication, retracted Dr. Simon's article in January, saying that it “included the reproduction of several sections of text and much of the reference list” from the other paper. Dr. Simon had no comment on the accusation as of press time.

Individual Mandates Necessary

Unless the United States adopts a single-payer health system, it will not be possible to achieve universal coverage without a mandate that requires individuals to purchase health insurance, a new report from the Urban Institute concluded. A system that encouraged but did not require people to get health insurance would tend to enroll disproportionate numbers of individuals with higher-cost health problems, the report said. This could create high premiums and instability in the insurance pools that enroll those individuals, the report said. In addition, the government would have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage, according to the report, “Do Individual Mandates Matter?”

Part D Costs Drop

The projected cost of providing Medicare beneficiaries with a prescription drug benefit through private health plans has dropped again, according to the Centers for Medicare and Medicaid Services. The CMS said in its fiscal year 2009 budget documents that the overall projected cost of the Part D drug benefit will be $117 billion lower over the next 10 years than it had estimated last summer. The difference between the two projected costs results from the slowing of drug cost trends, lower estimates of plan spending, and higher expected rebates from drug manufacturers, the CMS said. Compared with original projections, the anticipated net Medicare cost of the drug benefit will be $243.7 billion lower over the 10 years ending in 2013.

Programs Cut Smoking Rates

State tobacco control programs are effective at cutting adult smoking rates, according to a study by researchers at the Centers for Disease Control and Prevention and RTI International. The researchers were able to quantify the link between comprehensive tobacco control programs and a decrease in adult smoking, observing a decline in prevalence from more than 29% in 1985 to less than 19% in 2003. Among individual states, declines in adult smoking prevalence were directly related to increases in state per-person investments in tobacco control programs, the researchers wrote. Such programs use educational, clinical, regulatory, economic, and social strategies to establish smoke-free policies and social norms, to help tobacco users to quit, and to prevent people from starting to smoke. The study was published in the February issue of American Journal of Public Health.

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures. Mr. Leavitt was required to submit the proposal under a cost-saving measure included in the Medicare Modernization Act of 2003.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would also increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save more than $900 million in 2009 and nearly $3.2 billion over 5 years. The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records and to make personal health records available to Medicare beneficiaries.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years.

But the administration may encounter some trouble getting its proposals through Congress.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures. Mr. Leavitt was required to submit the proposal under a cost-saving measure included in the Medicare Modernization Act of 2003.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would also increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save more than $900 million in 2009 and nearly $3.2 billion over 5 years. The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records and to make personal health records available to Medicare beneficiaries.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years.

But the administration may encounter some trouble getting its proposals through Congress.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures. Mr. Leavitt was required to submit the proposal under a cost-saving measure included in the Medicare Modernization Act of 2003.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would also increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save more than $900 million in 2009 and nearly $3.2 billion over 5 years. The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records and to make personal health records available to Medicare beneficiaries.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years.

But the administration may encounter some trouble getting its proposals through Congress.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

In the final budget proposal of his presidency, President Bush is proposing substantial cuts to hospitals, skilled nursing facilities, and graduate medical education.

Leaders in the Democratic-controlled Congress instantly declared the proposal dead on arrival.

Under the plan, the Bush administration has put forth legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years, largely from hospital and other provider payments. The idea is to slow down the growth rate of the program from 7.2% to 5% over 5 years. But critics say the cuts would harm hospitals that care for low-income patients and train physicians.

The FY 2009 budget proposal calls for freezing payments to inpatient hospitals, long-term care hospitals, skilled nursing facilities, hospices, outpatient hospitals, and ambulance services from 2009 through 2011. Payments would then drop 0.65% annually under the proposal.

The proposal also outlines a payment freeze for inpatient rehabilitation facilities and ambulatory surgical centers in 2010 and 2011, followed by annual cuts. And home health agencies would also see a 0% update from 2009 through 2013 followed by annual payment cuts.

The proposal would reduce indirect medical education add-on payments from 5.5% to 2.2% over the next 3 years, and would eliminate the duplicate hospital indirect medical education payment for Medicare Advantage beneficiaries.

Hospitals would also face additional cuts under the plan. For example, the proposed budget would reduce hospital capital payments by 5% in 2009, and hospital disproportionate share payments would drop 30% over the next 2 years.

The FY 2009 budget plan also includes proposed legislative and administrative changes aimed at cutting nearly $18 billion from Medicaid over the next 5 years.

The administration's budget would reauthorize the State Children's Health Insurance Program (SCHIP) through 2013. The plan calls for a $19.7 billion increase to the program over 5 years, including $450 million in outreach grants to states and other organizations to help enroll uninsured children in the program.

One area that the administration's budget proposal does not address is the 10.6% physician pay cut scheduled to take place this July. The administration's budget “falls short” by not including a proposal to fix the Medicare physician payment formula, the American College of Cardiology said in a statement.

“Physicians are willing to do their part, but quality cannot be achieved under a zero-sum scenario,” according to the statement. “Continued deep payment cuts make it impossible for physicians to continue to invest in a health care infrastructure that facilitates data collection and quality improvement while ensuring that patients have access to high quality care.”

In total, the administration is requesting $711.2 billion for the Centers for Medicare and Medicaid Services to cover mandatory and discretionary outlays for the Medicare, Medicaid, and SCHIP programs. The request is a $32.7 billion increase over the FY 2008 funding level.

Federal research agencies are also facing funding cuts or freezes under the FY 2009 budget proposal.

The administration is proposing no increase for the National Institutes of Health, keeping the agency's budget at approximately $29.5 billion. Health advocates say the failure to expand NIH funding will hurt research efforts in several critical areas.

For example, the National Institute of Diabetes and Digestive and Kidney Diseases would receive an increase under the administration's proposal, but the $2.6 million bump amounts to a 0.15% increase over FY 2008. The American Diabetes Association is urging Congress to disregard the president's proposal and provide $112.5 million in additional funding, a 6.6% increase.

The administration's budget proposal also calls for $8.8 billion in funding for the Centers for Disease Control and Prevention, a $412 million drop from FY 2008. The Agency for Healthcare Research and Quality would also face a cut under the proposal. The president is calling for $326 million in funding for the agency, a $9 million decrease from FY 2008.

The Food and Drug Administration would receive a $130 million increase over FY 2008, bringing the total funding to 2.4 billion in FY 2009. The FDA budget proposal includes increases in the human drugs and devices programs at FDA.

Under the plan, the human drugs program would receive $984 million in FY 2009, an increase of $68 million. The increase includes estimated user fees coming into the agency. The increases are slated to fund improvements in drug safety and regulation of biologic therapies. The budget includes a funding commitment of $389.5 million for drug safety, an increase of $36 million in FY 2008. In addition, the budget includes a proposal to grant the FDA new authority to approve follow-on biologic proteins through a new regulatory pathway, and one seeking user fees to cover the costs of the new activity.

Under the administration's budget request, the medical devices program at FDA would receive $291 million, an increase of $7 million.

In the final budget proposal of his presidency, President Bush is proposing substantial cuts to hospitals, skilled nursing facilities, and graduate medical education.

Leaders in the Democratic-controlled Congress instantly declared the proposal dead on arrival.

Under the plan, the Bush administration has put forth legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years, largely from hospital and other provider payments. The idea is to slow down the growth rate of the program from 7.2% to 5% over 5 years. But critics say the cuts would harm hospitals that care for low-income patients and train physicians.

The FY 2009 budget proposal calls for freezing payments to inpatient hospitals, long-term care hospitals, skilled nursing facilities, hospices, outpatient hospitals, and ambulance services from 2009 through 2011. Payments would then drop 0.65% annually under the proposal.

The proposal also outlines a payment freeze for inpatient rehabilitation facilities and ambulatory surgical centers in 2010 and 2011, followed by annual cuts. And home health agencies would also see a 0% update from 2009 through 2013 followed by annual payment cuts.

The proposal would reduce indirect medical education add-on payments from 5.5% to 2.2% over the next 3 years, and would eliminate the duplicate hospital indirect medical education payment for Medicare Advantage beneficiaries.

Hospitals would also face additional cuts under the plan. For example, the proposed budget would reduce hospital capital payments by 5% in 2009, and hospital disproportionate share payments would drop 30% over the next 2 years.

The FY 2009 budget plan also includes proposed legislative and administrative changes aimed at cutting nearly $18 billion from Medicaid over the next 5 years.

The administration's budget would reauthorize the State Children's Health Insurance Program (SCHIP) through 2013. The plan calls for a $19.7 billion increase to the program over 5 years, including $450 million in outreach grants to states and other organizations to help enroll uninsured children in the program.

One area that the administration's budget proposal does not address is the 10.6% physician pay cut scheduled to take place this July. The administration's budget “falls short” by not including a proposal to fix the Medicare physician payment formula, the American College of Cardiology said in a statement.

“Physicians are willing to do their part, but quality cannot be achieved under a zero-sum scenario,” according to the statement. “Continued deep payment cuts make it impossible for physicians to continue to invest in a health care infrastructure that facilitates data collection and quality improvement while ensuring that patients have access to high quality care.”

In total, the administration is requesting $711.2 billion for the Centers for Medicare and Medicaid Services to cover mandatory and discretionary outlays for the Medicare, Medicaid, and SCHIP programs. The request is a $32.7 billion increase over the FY 2008 funding level.

Federal research agencies are also facing funding cuts or freezes under the FY 2009 budget proposal.

The administration is proposing no increase for the National Institutes of Health, keeping the agency's budget at approximately $29.5 billion. Health advocates say the failure to expand NIH funding will hurt research efforts in several critical areas.

For example, the National Institute of Diabetes and Digestive and Kidney Diseases would receive an increase under the administration's proposal, but the $2.6 million bump amounts to a 0.15% increase over FY 2008. The American Diabetes Association is urging Congress to disregard the president's proposal and provide $112.5 million in additional funding, a 6.6% increase.

The administration's budget proposal also calls for $8.8 billion in funding for the Centers for Disease Control and Prevention, a $412 million drop from FY 2008. The Agency for Healthcare Research and Quality would also face a cut under the proposal. The president is calling for $326 million in funding for the agency, a $9 million decrease from FY 2008.

The Food and Drug Administration would receive a $130 million increase over FY 2008, bringing the total funding to 2.4 billion in FY 2009. The FDA budget proposal includes increases in the human drugs and devices programs at FDA.

Under the plan, the human drugs program would receive $984 million in FY 2009, an increase of $68 million. The increase includes estimated user fees coming into the agency. The increases are slated to fund improvements in drug safety and regulation of biologic therapies. The budget includes a funding commitment of $389.5 million for drug safety, an increase of $36 million in FY 2008. In addition, the budget includes a proposal to grant the FDA new authority to approve follow-on biologic proteins through a new regulatory pathway, and one seeking user fees to cover the costs of the new activity.

Under the administration's budget request, the medical devices program at FDA would receive $291 million, an increase of $7 million.

In the final budget proposal of his presidency, President Bush is proposing substantial cuts to hospitals, skilled nursing facilities, and graduate medical education.

Leaders in the Democratic-controlled Congress instantly declared the proposal dead on arrival.

Under the plan, the Bush administration has put forth legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years, largely from hospital and other provider payments. The idea is to slow down the growth rate of the program from 7.2% to 5% over 5 years. But critics say the cuts would harm hospitals that care for low-income patients and train physicians.

The FY 2009 budget proposal calls for freezing payments to inpatient hospitals, long-term care hospitals, skilled nursing facilities, hospices, outpatient hospitals, and ambulance services from 2009 through 2011. Payments would then drop 0.65% annually under the proposal.

The proposal also outlines a payment freeze for inpatient rehabilitation facilities and ambulatory surgical centers in 2010 and 2011, followed by annual cuts. And home health agencies would also see a 0% update from 2009 through 2013 followed by annual payment cuts.

The proposal would reduce indirect medical education add-on payments from 5.5% to 2.2% over the next 3 years, and would eliminate the duplicate hospital indirect medical education payment for Medicare Advantage beneficiaries.

Hospitals would also face additional cuts under the plan. For example, the proposed budget would reduce hospital capital payments by 5% in 2009, and hospital disproportionate share payments would drop 30% over the next 2 years.

The FY 2009 budget plan also includes proposed legislative and administrative changes aimed at cutting nearly $18 billion from Medicaid over the next 5 years.

The administration's budget would reauthorize the State Children's Health Insurance Program (SCHIP) through 2013. The plan calls for a $19.7 billion increase to the program over 5 years, including $450 million in outreach grants to states and other organizations to help enroll uninsured children in the program.

One area that the administration's budget proposal does not address is the 10.6% physician pay cut scheduled to take place this July. The administration's budget “falls short” by not including a proposal to fix the Medicare physician payment formula, the American College of Cardiology said in a statement.

“Physicians are willing to do their part, but quality cannot be achieved under a zero-sum scenario,” according to the statement. “Continued deep payment cuts make it impossible for physicians to continue to invest in a health care infrastructure that facilitates data collection and quality improvement while ensuring that patients have access to high quality care.”

In total, the administration is requesting $711.2 billion for the Centers for Medicare and Medicaid Services to cover mandatory and discretionary outlays for the Medicare, Medicaid, and SCHIP programs. The request is a $32.7 billion increase over the FY 2008 funding level.

Federal research agencies are also facing funding cuts or freezes under the FY 2009 budget proposal.

The administration is proposing no increase for the National Institutes of Health, keeping the agency's budget at approximately $29.5 billion. Health advocates say the failure to expand NIH funding will hurt research efforts in several critical areas.

For example, the National Institute of Diabetes and Digestive and Kidney Diseases would receive an increase under the administration's proposal, but the $2.6 million bump amounts to a 0.15% increase over FY 2008. The American Diabetes Association is urging Congress to disregard the president's proposal and provide $112.5 million in additional funding, a 6.6% increase.

The administration's budget proposal also calls for $8.8 billion in funding for the Centers for Disease Control and Prevention, a $412 million drop from FY 2008. The Agency for Healthcare Research and Quality would also face a cut under the proposal. The president is calling for $326 million in funding for the agency, a $9 million decrease from FY 2008.

The Food and Drug Administration would receive a $130 million increase over FY 2008, bringing the total funding to 2.4 billion in FY 2009. The FDA budget proposal includes increases in the human drugs and devices programs at FDA.

Under the plan, the human drugs program would receive $984 million in FY 2009, an increase of $68 million. The increase includes estimated user fees coming into the agency. The increases are slated to fund improvements in drug safety and regulation of biologic therapies. The budget includes a funding commitment of $389.5 million for drug safety, an increase of $36 million in FY 2008. In addition, the budget includes a proposal to grant the FDA new authority to approve follow-on biologic proteins through a new regulatory pathway, and one seeking user fees to cover the costs of the new activity.

Under the administration's budget request, the medical devices program at FDA would receive $291 million, an increase of $7 million.

In a move that could have significant implications for physicians and hospitals, the insurer Aetna Inc. has said it will not pay its network hospitals for care necessitated by certain preventable errors.

The announcement follows a policy shift by the Centers for Medicare and Medicaid Services, which has finalized plans to stop paying for eight preventable events as of this October.

Aetna has incorporated language into its hospital contracts that calls for waiving all costs related to a number of serious reportable events. The language comes from the Leapfrog Group's “never events” policy, which includes a list of 28 events considered so harmful that they should never occur. The list, compiled by the National Quality Forum (NQF), comprises events ranging from surgery performed on the wrong body part or on the wrong patient, to stage III or IV pressure ulcers acquired after admission to a health care facility.

The policy instructs hospitals to report errors within 10 days to the Joint Commission, state reporting programs, or patient safety organizations.

Hospitals also are asked to take action to prevent future events and to apologize to the patient or family affected by the error. Aetna is the first health plan to endorse the Leapfrog policy. “The major goal here is to get hospitals to focus on having the systems in place to prevent these events from happening,” said Dr. Charles Cutler, Aetna's national medical director.

Adopting the Leapfrog Group's never events policy is not about saving money, Dr. Cutler said. In fact, many of the never events carry no additional cost. Instead, Aetna is seeking to send a consistent message to hospitals about quality, he said. “The intent here is not to be punitive.”

But the Aetna announcement has encountered some skepticism from the physician community.

The NQF list of never events is much broader than the eight preventable events selected under the Medicare policy, said Cynthia Brown, director of the division of advocacy and health policy at the American College of Surgeons (ACS). One reason that many of those events were not included on Medicare's list is that they are difficult to measure with the current coding system, she said.

Another problem with the Aetna approach is that it's hard to affix blame to a hospital or a particular physician. “If there's a problem with blood incompatibility, is it the surgeon's fault?” Ms. Brown asked. “It's hard to know how it's going to be operationalized,” she added.

When used properly, the NQF never events list protects patients and directs a patient environment enriched with safety and quality, said Dr. Frank Opelka, chair of the ACS Committee on Patient Safety and Quality Improvement. But he cautioned that if payers drift from the intentions of the NQF never events, the specifications could be lost and overreporting could create unintended consequences.

For example, because of hospital overcrowding and limited resources in a rural environment, a frail patient may be admitted despite the lack of health care resources. If the patient has a pressure ulcer that progresses from a stage II on admission to a stage III, this should not be considered an NQF never event, he said.

Dr. Opelka also questioned whether hospitals would continue to report these types of serious preventable errors if they aren't being paid for the care. “If the reports are generated from a hospital claims system and the payer no longer recognizes the events as payable, isn't the message to stop reporting rather than to prevent the never events?” asked Dr. Opelka, also vice chancellor for clinical affairs at Louisiana State University Health Sciences Center, New Orleans.

The policy is likely to affect all of Aetna's network hospitals over the next 3 years as the company renegotiates its contracts, Dr. Cutler said.

Since Medicare announced its policy shift last summer, other insurers have considered changes to their policies. Officials at Cigna, for example, are evaluating how to implement a similar policy within their hospital network. The insurer plans to have a national policy in place by October, said Cigna spokesman Mark Slitt.

In a move that could have significant implications for physicians and hospitals, the insurer Aetna Inc. has said it will not pay its network hospitals for care necessitated by certain preventable errors.

The announcement follows a policy shift by the Centers for Medicare and Medicaid Services, which has finalized plans to stop paying for eight preventable events as of this October.

Aetna has incorporated language into its hospital contracts that calls for waiving all costs related to a number of serious reportable events. The language comes from the Leapfrog Group's “never events” policy, which includes a list of 28 events considered so harmful that they should never occur. The list, compiled by the National Quality Forum (NQF), comprises events ranging from surgery performed on the wrong body part or on the wrong patient, to stage III or IV pressure ulcers acquired after admission to a health care facility.

The policy instructs hospitals to report errors within 10 days to the Joint Commission, state reporting programs, or patient safety organizations.

Hospitals also are asked to take action to prevent future events and to apologize to the patient or family affected by the error. Aetna is the first health plan to endorse the Leapfrog policy. “The major goal here is to get hospitals to focus on having the systems in place to prevent these events from happening,” said Dr. Charles Cutler, Aetna's national medical director.

Adopting the Leapfrog Group's never events policy is not about saving money, Dr. Cutler said. In fact, many of the never events carry no additional cost. Instead, Aetna is seeking to send a consistent message to hospitals about quality, he said. “The intent here is not to be punitive.”

But the Aetna announcement has encountered some skepticism from the physician community.

The NQF list of never events is much broader than the eight preventable events selected under the Medicare policy, said Cynthia Brown, director of the division of advocacy and health policy at the American College of Surgeons (ACS). One reason that many of those events were not included on Medicare's list is that they are difficult to measure with the current coding system, she said.

Another problem with the Aetna approach is that it's hard to affix blame to a hospital or a particular physician. “If there's a problem with blood incompatibility, is it the surgeon's fault?” Ms. Brown asked. “It's hard to know how it's going to be operationalized,” she added.

When used properly, the NQF never events list protects patients and directs a patient environment enriched with safety and quality, said Dr. Frank Opelka, chair of the ACS Committee on Patient Safety and Quality Improvement. But he cautioned that if payers drift from the intentions of the NQF never events, the specifications could be lost and overreporting could create unintended consequences.

For example, because of hospital overcrowding and limited resources in a rural environment, a frail patient may be admitted despite the lack of health care resources. If the patient has a pressure ulcer that progresses from a stage II on admission to a stage III, this should not be considered an NQF never event, he said.

Dr. Opelka also questioned whether hospitals would continue to report these types of serious preventable errors if they aren't being paid for the care. “If the reports are generated from a hospital claims system and the payer no longer recognizes the events as payable, isn't the message to stop reporting rather than to prevent the never events?” asked Dr. Opelka, also vice chancellor for clinical affairs at Louisiana State University Health Sciences Center, New Orleans.

The policy is likely to affect all of Aetna's network hospitals over the next 3 years as the company renegotiates its contracts, Dr. Cutler said.

Since Medicare announced its policy shift last summer, other insurers have considered changes to their policies. Officials at Cigna, for example, are evaluating how to implement a similar policy within their hospital network. The insurer plans to have a national policy in place by October, said Cigna spokesman Mark Slitt.

In a move that could have significant implications for physicians and hospitals, the insurer Aetna Inc. has said it will not pay its network hospitals for care necessitated by certain preventable errors.

The announcement follows a policy shift by the Centers for Medicare and Medicaid Services, which has finalized plans to stop paying for eight preventable events as of this October.

Aetna has incorporated language into its hospital contracts that calls for waiving all costs related to a number of serious reportable events. The language comes from the Leapfrog Group's “never events” policy, which includes a list of 28 events considered so harmful that they should never occur. The list, compiled by the National Quality Forum (NQF), comprises events ranging from surgery performed on the wrong body part or on the wrong patient, to stage III or IV pressure ulcers acquired after admission to a health care facility.

The policy instructs hospitals to report errors within 10 days to the Joint Commission, state reporting programs, or patient safety organizations.

Hospitals also are asked to take action to prevent future events and to apologize to the patient or family affected by the error. Aetna is the first health plan to endorse the Leapfrog policy. “The major goal here is to get hospitals to focus on having the systems in place to prevent these events from happening,” said Dr. Charles Cutler, Aetna's national medical director.

Adopting the Leapfrog Group's never events policy is not about saving money, Dr. Cutler said. In fact, many of the never events carry no additional cost. Instead, Aetna is seeking to send a consistent message to hospitals about quality, he said. “The intent here is not to be punitive.”

But the Aetna announcement has encountered some skepticism from the physician community.

The NQF list of never events is much broader than the eight preventable events selected under the Medicare policy, said Cynthia Brown, director of the division of advocacy and health policy at the American College of Surgeons (ACS). One reason that many of those events were not included on Medicare's list is that they are difficult to measure with the current coding system, she said.

Another problem with the Aetna approach is that it's hard to affix blame to a hospital or a particular physician. “If there's a problem with blood incompatibility, is it the surgeon's fault?” Ms. Brown asked. “It's hard to know how it's going to be operationalized,” she added.

When used properly, the NQF never events list protects patients and directs a patient environment enriched with safety and quality, said Dr. Frank Opelka, chair of the ACS Committee on Patient Safety and Quality Improvement. But he cautioned that if payers drift from the intentions of the NQF never events, the specifications could be lost and overreporting could create unintended consequences.

For example, because of hospital overcrowding and limited resources in a rural environment, a frail patient may be admitted despite the lack of health care resources. If the patient has a pressure ulcer that progresses from a stage II on admission to a stage III, this should not be considered an NQF never event, he said.

Dr. Opelka also questioned whether hospitals would continue to report these types of serious preventable errors if they aren't being paid for the care. “If the reports are generated from a hospital claims system and the payer no longer recognizes the events as payable, isn't the message to stop reporting rather than to prevent the never events?” asked Dr. Opelka, also vice chancellor for clinical affairs at Louisiana State University Health Sciences Center, New Orleans.

The policy is likely to affect all of Aetna's network hospitals over the next 3 years as the company renegotiates its contracts, Dr. Cutler said.

Since Medicare announced its policy shift last summer, other insurers have considered changes to their policies. Officials at Cigna, for example, are evaluating how to implement a similar policy within their hospital network. The insurer plans to have a national policy in place by October, said Cigna spokesman Mark Slitt.

Following a 6-month initial investigation, New York Attorney General Andrew Cuomo announced plans to file suit against UnitedHealth Group and four of its subsidiaries for allegedly systematically underpaying consumers for their out-of-network medical expenses.

The attorney general claimed that UnitedHealth Group used faulty data from one of its subsidiaries, the billing information company Ingenix Inc., which resulted in the underestimation of “usual, customary, and reasonable” rates for a range of out-of-network medical expenses and then provided unreasonably low reimbursement to consumers.

The investigation is ongoing and the attorney general's office has issued subpoenas to 16 other health insurance companies who use the Ingenix database. The subpoenas will seek documents that show how the companies calculate reasonable and customary rates, as well as copies of member complaints and appeals, and communications with Ingenix.

The investigation has national implications since five of the nation's largest health insurance companies rely on data from Ingenix, according to the attorney general.

UnitedHealth Group has denied that there are problems with the reference data used by Ingenix, which is “rigorously developed, geographically specific, comprehensive and organized using a transparent methodology,” according to a company statement. The insurer says it is in discussions with the attorney general's office and plans to cooperate fully.

Ingenix owns a database of billing information that many health insurers use to determine how much to reimburse consumers who go out of network for care. But the attorney general's preliminary investigation found that the Ingenix data are provided by insurers with a vested interest in keeping the rates low and that there is no auditing of the data that come in, Linda Lacewell, head of the attorney general's Health Care Industry Task Force, said at a press conference to announce the industry-wide investigation.

The database also doesn't take into account whether a service was provided by a physician or a non-physician provider, a factor that would affect the price, she said. “Our investigation has revealed Ingenix is nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment.”

About 70% of insured Americans pay higher premiums for the right to go out of their insurer's network for care. In exchange, the insurer typically promises to pay about 80% of the usual, customary, and reasonable rate. The consumer then is responsible for the balance of the bill.

But the attorney general says UnitedHealth Group subscribers haven't been getting what they paid for when going out of network. For example, for a 15-minute office visit in which most physicians charged $200, United told subscribers that the typical cost was $77 and agreed to pay only $62, leaving consumers to pay the remainder of the $138 bill.

“This is not news to us,” Dr. Nancy H. Nielsen, president-elect of the American Medical Association, said at the press conference.

In fact, the charges made by the attorney general are the same as those made by the AMA in an ongoing class action lawsuit it filed against UnitedHealth Group in 2000, which alleges that the insurer has been understating their calculation of usual, customary, and reasonable charges in payments to physicians and when reimbursing patients for out-of-network services.

While consumers are the ones responsible for paying the balance of these bills, it also can create a contentious situation for the physician, Dr. Robert B. Goldberg, president of the Medical Society of the State of New York, said at the press conference. When patients receive an underpayment from their insurers, it's usually the physician's bill that they challenge, he said, since the information from the insurer makes it appear that the doctor has overcharged for the service.

Following a 6-month initial investigation, New York Attorney General Andrew Cuomo announced plans to file suit against UnitedHealth Group and four of its subsidiaries for allegedly systematically underpaying consumers for their out-of-network medical expenses.

The attorney general claimed that UnitedHealth Group used faulty data from one of its subsidiaries, the billing information company Ingenix Inc., which resulted in the underestimation of “usual, customary, and reasonable” rates for a range of out-of-network medical expenses and then provided unreasonably low reimbursement to consumers.

The investigation is ongoing and the attorney general's office has issued subpoenas to 16 other health insurance companies who use the Ingenix database. The subpoenas will seek documents that show how the companies calculate reasonable and customary rates, as well as copies of member complaints and appeals, and communications with Ingenix.

The investigation has national implications since five of the nation's largest health insurance companies rely on data from Ingenix, according to the attorney general.

UnitedHealth Group has denied that there are problems with the reference data used by Ingenix, which is “rigorously developed, geographically specific, comprehensive and organized using a transparent methodology,” according to a company statement. The insurer says it is in discussions with the attorney general's office and plans to cooperate fully.

Ingenix owns a database of billing information that many health insurers use to determine how much to reimburse consumers who go out of network for care. But the attorney general's preliminary investigation found that the Ingenix data are provided by insurers with a vested interest in keeping the rates low and that there is no auditing of the data that come in, Linda Lacewell, head of the attorney general's Health Care Industry Task Force, said at a press conference to announce the industry-wide investigation.

The database also doesn't take into account whether a service was provided by a physician or a non-physician provider, a factor that would affect the price, she said. “Our investigation has revealed Ingenix is nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment.”

About 70% of insured Americans pay higher premiums for the right to go out of their insurer's network for care. In exchange, the insurer typically promises to pay about 80% of the usual, customary, and reasonable rate. The consumer then is responsible for the balance of the bill.

But the attorney general says UnitedHealth Group subscribers haven't been getting what they paid for when going out of network. For example, for a 15-minute office visit in which most physicians charged $200, United told subscribers that the typical cost was $77 and agreed to pay only $62, leaving consumers to pay the remainder of the $138 bill.

“This is not news to us,” Dr. Nancy H. Nielsen, president-elect of the American Medical Association, said at the press conference.

In fact, the charges made by the attorney general are the same as those made by the AMA in an ongoing class action lawsuit it filed against UnitedHealth Group in 2000, which alleges that the insurer has been understating their calculation of usual, customary, and reasonable charges in payments to physicians and when reimbursing patients for out-of-network services.

While consumers are the ones responsible for paying the balance of these bills, it also can create a contentious situation for the physician, Dr. Robert B. Goldberg, president of the Medical Society of the State of New York, said at the press conference. When patients receive an underpayment from their insurers, it's usually the physician's bill that they challenge, he said, since the information from the insurer makes it appear that the doctor has overcharged for the service.

Following a 6-month initial investigation, New York Attorney General Andrew Cuomo announced plans to file suit against UnitedHealth Group and four of its subsidiaries for allegedly systematically underpaying consumers for their out-of-network medical expenses.

The attorney general claimed that UnitedHealth Group used faulty data from one of its subsidiaries, the billing information company Ingenix Inc., which resulted in the underestimation of “usual, customary, and reasonable” rates for a range of out-of-network medical expenses and then provided unreasonably low reimbursement to consumers.

The investigation is ongoing and the attorney general's office has issued subpoenas to 16 other health insurance companies who use the Ingenix database. The subpoenas will seek documents that show how the companies calculate reasonable and customary rates, as well as copies of member complaints and appeals, and communications with Ingenix.

The investigation has national implications since five of the nation's largest health insurance companies rely on data from Ingenix, according to the attorney general.

UnitedHealth Group has denied that there are problems with the reference data used by Ingenix, which is “rigorously developed, geographically specific, comprehensive and organized using a transparent methodology,” according to a company statement. The insurer says it is in discussions with the attorney general's office and plans to cooperate fully.

Ingenix owns a database of billing information that many health insurers use to determine how much to reimburse consumers who go out of network for care. But the attorney general's preliminary investigation found that the Ingenix data are provided by insurers with a vested interest in keeping the rates low and that there is no auditing of the data that come in, Linda Lacewell, head of the attorney general's Health Care Industry Task Force, said at a press conference to announce the industry-wide investigation.

The database also doesn't take into account whether a service was provided by a physician or a non-physician provider, a factor that would affect the price, she said. “Our investigation has revealed Ingenix is nothing more than a conduit for rigged information that is defrauding consumers of their right to fair payment.”

About 70% of insured Americans pay higher premiums for the right to go out of their insurer's network for care. In exchange, the insurer typically promises to pay about 80% of the usual, customary, and reasonable rate. The consumer then is responsible for the balance of the bill.

But the attorney general says UnitedHealth Group subscribers haven't been getting what they paid for when going out of network. For example, for a 15-minute office visit in which most physicians charged $200, United told subscribers that the typical cost was $77 and agreed to pay only $62, leaving consumers to pay the remainder of the $138 bill.

“This is not news to us,” Dr. Nancy H. Nielsen, president-elect of the American Medical Association, said at the press conference.

In fact, the charges made by the attorney general are the same as those made by the AMA in an ongoing class action lawsuit it filed against UnitedHealth Group in 2000, which alleges that the insurer has been understating their calculation of usual, customary, and reasonable charges in payments to physicians and when reimbursing patients for out-of-network services.

While consumers are the ones responsible for paying the balance of these bills, it also can create a contentious situation for the physician, Dr. Robert B. Goldberg, president of the Medical Society of the State of New York, said at the press conference. When patients receive an underpayment from their insurers, it's usually the physician's bill that they challenge, he said, since the information from the insurer makes it appear that the doctor has overcharged for the service.