Mary Ellen Schneider

T he adoption of health information technology varies significantly among physicians who are in different specialties, according to a study from the Center for Studying Health System Change.

Although only 12% of physicians overall have adopted comprehensive electronic medical records, physician uptake of specific health IT functions, such as obtaining guidelines or writing prescriptions, varies depending on specialty. For example, 74% of emergency physicians have health IT systems that can access patient notes, compared with just 36% of psychiatrists.

The findings are based on the Health System Change (HSC) 2004–2005 Community Tracking Study Physician Survey, a national telephone poll that included responses from 6,628 physicians. As part of the survey, the physicians were asked about practice-based availability of information technology across five clinical areas: obtaining information about treatment alternatives or recommended guidelines; retrieving patient notes or problem lists; writing prescriptions; exchanging clinical data and images with other physicians; and exchanging clinical data and images with hospitals.

Because the physicians were asked about the availability of these health IT functions and not whether they actually used the technology, they were considered to have an electronic medical record if they answered that they had access to all five of the above functions.

Primary care physicians were less likely than were specialists to access patient notes and exchange data with other physicians.

There were also variations across specialties and subspecialties. For example, within primary care, internists were more likely than family physicians or pediatricians to have access to patient notes.

Oncologists were more likely than other specialists to obtain guidelines, exchange information with other physicians, and exchange information with hospitals.

One factor in the variation could be that certain clinical activities are more relevant for certain specialties. “Surgeons may have less need for IT to write prescriptions because they typically prescribe a narrow range of on-formulary medications on a short-term basis, in contrast to medical specialists and primary care physicians, who treat chronically ill patients who are taking multiple medications,” said Catherine Corey, who is an HSC health research analyst and one of the study authors.

Findings from previous surveys have noted that most pediatricians who do not have EMRs report as their reason that they were not able to find one with functionality that was specific to pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

T he adoption of health information technology varies significantly among physicians who are in different specialties, according to a study from the Center for Studying Health System Change.

Although only 12% of physicians overall have adopted comprehensive electronic medical records, physician uptake of specific health IT functions, such as obtaining guidelines or writing prescriptions, varies depending on specialty. For example, 74% of emergency physicians have health IT systems that can access patient notes, compared with just 36% of psychiatrists.

The findings are based on the Health System Change (HSC) 2004–2005 Community Tracking Study Physician Survey, a national telephone poll that included responses from 6,628 physicians. As part of the survey, the physicians were asked about practice-based availability of information technology across five clinical areas: obtaining information about treatment alternatives or recommended guidelines; retrieving patient notes or problem lists; writing prescriptions; exchanging clinical data and images with other physicians; and exchanging clinical data and images with hospitals.

Because the physicians were asked about the availability of these health IT functions and not whether they actually used the technology, they were considered to have an electronic medical record if they answered that they had access to all five of the above functions.

Primary care physicians were less likely than were specialists to access patient notes and exchange data with other physicians.

There were also variations across specialties and subspecialties. For example, within primary care, internists were more likely than family physicians or pediatricians to have access to patient notes.

Oncologists were more likely than other specialists to obtain guidelines, exchange information with other physicians, and exchange information with hospitals.

One factor in the variation could be that certain clinical activities are more relevant for certain specialties. “Surgeons may have less need for IT to write prescriptions because they typically prescribe a narrow range of on-formulary medications on a short-term basis, in contrast to medical specialists and primary care physicians, who treat chronically ill patients who are taking multiple medications,” said Catherine Corey, who is an HSC health research analyst and one of the study authors.

Findings from previous surveys have noted that most pediatricians who do not have EMRs report as their reason that they were not able to find one with functionality that was specific to pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

T he adoption of health information technology varies significantly among physicians who are in different specialties, according to a study from the Center for Studying Health System Change.

Although only 12% of physicians overall have adopted comprehensive electronic medical records, physician uptake of specific health IT functions, such as obtaining guidelines or writing prescriptions, varies depending on specialty. For example, 74% of emergency physicians have health IT systems that can access patient notes, compared with just 36% of psychiatrists.

The findings are based on the Health System Change (HSC) 2004–2005 Community Tracking Study Physician Survey, a national telephone poll that included responses from 6,628 physicians. As part of the survey, the physicians were asked about practice-based availability of information technology across five clinical areas: obtaining information about treatment alternatives or recommended guidelines; retrieving patient notes or problem lists; writing prescriptions; exchanging clinical data and images with other physicians; and exchanging clinical data and images with hospitals.

Because the physicians were asked about the availability of these health IT functions and not whether they actually used the technology, they were considered to have an electronic medical record if they answered that they had access to all five of the above functions.

Primary care physicians were less likely than were specialists to access patient notes and exchange data with other physicians.

There were also variations across specialties and subspecialties. For example, within primary care, internists were more likely than family physicians or pediatricians to have access to patient notes.

Oncologists were more likely than other specialists to obtain guidelines, exchange information with other physicians, and exchange information with hospitals.

One factor in the variation could be that certain clinical activities are more relevant for certain specialties. “Surgeons may have less need for IT to write prescriptions because they typically prescribe a narrow range of on-formulary medications on a short-term basis, in contrast to medical specialists and primary care physicians, who treat chronically ill patients who are taking multiple medications,” said Catherine Corey, who is an HSC health research analyst and one of the study authors.

Findings from previous surveys have noted that most pediatricians who do not have EMRs report as their reason that they were not able to find one with functionality that was specific to pediatrics.

ELSEVIER GLOBAL MEDICAL NEWS

NEW YORK — Taking baseline measurements of fasting blood glucose, lipids, weight, and waist circumference and monitoring those measures are essential to the early identification of metabolic complications in patients taking atypical antipsychotics, Dr. Harold E. Carlson said.

But Dr. Carlson, head of endocrinology at Stony Brook University, New York, said it also makes sense to consider alternative drug choices in patients at high risk for metabolic complications.

“If you have a choice, pick a different drug to begin with,” Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Data are not reliable enough to create a firm ranking of the relative metabolic risks of the atypical antipsychotics, but the available information suggests that the two worst offenders are clozapine (Clozaril) and olanzapine (Zyprexa), followed by risperidone (Risperdal) and quetiapine (Seroquel), followed by aripiprazole (Abilify) and ziprasidone (Geodon), he said.

It is possible to stay on top of these potential problems through close monitoring, Dr. Carlson said. For diabetes, obtain fasting blood glucose in all patients at baseline, at 3 months, and every 6 months after that. Fasting blood sugar should be monitored more frequently—monthly or quarterly—in high-risk patients, he said.

Patients at risk for diabetes include patients taking olanzapine or clozapine.

When feasible, consider alternative drug choices for high-risk patients or those with treatment-emergent diabetes mellitus, he said. Keep in mind that the diabetes may remit when the antipsychotic is stopped or changed, he said.

For lipid monitoring, obtain a fasting lipid panel at baseline, at 3 months, and then every 6 months for all patients. Obtain a fasting lipid panel quarterly for high-risk patients. High-risk patients include those with a high body mass index (BMI) or rapid weight gain on the drug, family or personal history of hyperlipidemia or coronary heart disease, and individuals receiving clozapine or olanzapine.

If lipid problems emerge, consider switching to a lower-risk antipsychotic or keep the patient on the drug and treat the lipid problem. Dr. Carlson disclosed financial relationships with several pharmaceutical companies, including Eli Lilly & Co.; Janssen L.P.; Otsuka America Pharmaceutical Inc.; Bristol-Myers Squibb Co.; Cephalon Inc.; McNeil Pediatrics, a division of McNeil-PPC Inc.; and Shire U.S. Inc.

Consider alternative drugs for high-risk patients or those with treatment-emergent diabetes mellitus. DR. CARLSON

NEW YORK — Taking baseline measurements of fasting blood glucose, lipids, weight, and waist circumference and monitoring those measures are essential to the early identification of metabolic complications in patients taking atypical antipsychotics, Dr. Harold E. Carlson said.

But Dr. Carlson, head of endocrinology at Stony Brook University, New York, said it also makes sense to consider alternative drug choices in patients at high risk for metabolic complications.

“If you have a choice, pick a different drug to begin with,” Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Data are not reliable enough to create a firm ranking of the relative metabolic risks of the atypical antipsychotics, but the available information suggests that the two worst offenders are clozapine (Clozaril) and olanzapine (Zyprexa), followed by risperidone (Risperdal) and quetiapine (Seroquel), followed by aripiprazole (Abilify) and ziprasidone (Geodon), he said.

It is possible to stay on top of these potential problems through close monitoring, Dr. Carlson said. For diabetes, obtain fasting blood glucose in all patients at baseline, at 3 months, and every 6 months after that. Fasting blood sugar should be monitored more frequently—monthly or quarterly—in high-risk patients, he said.

Patients at risk for diabetes include patients taking olanzapine or clozapine.

When feasible, consider alternative drug choices for high-risk patients or those with treatment-emergent diabetes mellitus, he said. Keep in mind that the diabetes may remit when the antipsychotic is stopped or changed, he said.

For lipid monitoring, obtain a fasting lipid panel at baseline, at 3 months, and then every 6 months for all patients. Obtain a fasting lipid panel quarterly for high-risk patients. High-risk patients include those with a high body mass index (BMI) or rapid weight gain on the drug, family or personal history of hyperlipidemia or coronary heart disease, and individuals receiving clozapine or olanzapine.

If lipid problems emerge, consider switching to a lower-risk antipsychotic or keep the patient on the drug and treat the lipid problem. Dr. Carlson disclosed financial relationships with several pharmaceutical companies, including Eli Lilly & Co.; Janssen L.P.; Otsuka America Pharmaceutical Inc.; Bristol-Myers Squibb Co.; Cephalon Inc.; McNeil Pediatrics, a division of McNeil-PPC Inc.; and Shire U.S. Inc.

Consider alternative drugs for high-risk patients or those with treatment-emergent diabetes mellitus. DR. CARLSON

NEW YORK — Taking baseline measurements of fasting blood glucose, lipids, weight, and waist circumference and monitoring those measures are essential to the early identification of metabolic complications in patients taking atypical antipsychotics, Dr. Harold E. Carlson said.

But Dr. Carlson, head of endocrinology at Stony Brook University, New York, said it also makes sense to consider alternative drug choices in patients at high risk for metabolic complications.

“If you have a choice, pick a different drug to begin with,” Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Data are not reliable enough to create a firm ranking of the relative metabolic risks of the atypical antipsychotics, but the available information suggests that the two worst offenders are clozapine (Clozaril) and olanzapine (Zyprexa), followed by risperidone (Risperdal) and quetiapine (Seroquel), followed by aripiprazole (Abilify) and ziprasidone (Geodon), he said.

It is possible to stay on top of these potential problems through close monitoring, Dr. Carlson said. For diabetes, obtain fasting blood glucose in all patients at baseline, at 3 months, and every 6 months after that. Fasting blood sugar should be monitored more frequently—monthly or quarterly—in high-risk patients, he said.

Patients at risk for diabetes include patients taking olanzapine or clozapine.

When feasible, consider alternative drug choices for high-risk patients or those with treatment-emergent diabetes mellitus, he said. Keep in mind that the diabetes may remit when the antipsychotic is stopped or changed, he said.

For lipid monitoring, obtain a fasting lipid panel at baseline, at 3 months, and then every 6 months for all patients. Obtain a fasting lipid panel quarterly for high-risk patients. High-risk patients include those with a high body mass index (BMI) or rapid weight gain on the drug, family or personal history of hyperlipidemia or coronary heart disease, and individuals receiving clozapine or olanzapine.

If lipid problems emerge, consider switching to a lower-risk antipsychotic or keep the patient on the drug and treat the lipid problem. Dr. Carlson disclosed financial relationships with several pharmaceutical companies, including Eli Lilly & Co.; Janssen L.P.; Otsuka America Pharmaceutical Inc.; Bristol-Myers Squibb Co.; Cephalon Inc.; McNeil Pediatrics, a division of McNeil-PPC Inc.; and Shire U.S. Inc.

Consider alternative drugs for high-risk patients or those with treatment-emergent diabetes mellitus. DR. CARLSON

NEW YORK — When treating first-time, uncomplicated cases of anxiety in children and adolescents, it's usually best to start with a 6- to 12-week trial of psychosocial treatment, Dr. Moira Rynn said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

If the child does not respond to cognitive-behavioral therapy (CBT), consider adding a selective serotonin reuptake inhibitor (SSRI) at that point, said Dr. Rynn, deputy director of the division of child and adolescent psychiatry at Columbia University, New York.

The evidence base for medication treatment in children and adolescents has grown dramatically over the last decade, Dr. Rynn said, with randomized controlled trial data supporting the use of SSRIs for obsessive-compulsive disorder, generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder.

There is also strong evidence for the efficacy of psychosocial treatment. Multiple studies that show cognitive-behavior therapy works for children with anxiety.

For example, in a 1994 study of 47 children aged 9–13 years who had anxiety disorders, the benefit of a 16-session course of CBT was compared with being on a waiting list. More than 60% of the children who received CBT were found to be without a diagnosis at the posttest and were within normal limits on many measures at the 1-year follow-up point, compared with less than 10% among the group on the waiting list (J. Consult. Clin. Psychol. 1994;62:100–10). A follow-up study by the same group of researchers found similar results, with about 50% of children being without a diagnosis after CBT (J. Consult. Clin. Psychol. 1997;65:366–80).

Other studies have examined the benefits of adding a family component to CBT. For example, researchers at Griffith University in Nathan, Australia, randomly assigned 79 children aged 7–14 years with separation anxiety, overanxious disorder, or social phobia to receive CBT or CBT plus family management, or to be on a waiting list. Almost 70% of the children who were in the CBT groups did not meet diagnostic criteria for an anxiety disorder, compared with 26% of the children on the waiting list.

At the 12-month follow-up, CBT combined with family management performed better than CBT alone. About 70% of the children in the CBT-only group did not meet criteria for an anxiety disorder, compared with 96% in the CBT plus family management group (J. Consult. Clin. Psychol. 1996;64:333–42).

With strong evidence to support the use of both medication and CBT, providers have wondered whether a combined approach from the outset would have the greatest benefit for patients. Researchers are beginning to address that question, Dr. Rynn said. The Pediatric OCD Treatment Study (POTS) team, of which Dr. Rynn was a member, assessed the efficacy of sertraline (Zoloft), CBT, and combination therapy among 112 children aged 7–17 years. The project was a multisite, placebo-controlled, double-blind study.

During the first phase, patients were randomized to receive sertraline, CBT, combination therapy, or placebo for 12 weeks. The results of the intent-to-treat random regression analyses showed that all the active treatments were significantly more effective than placebo and that combination therapy outperformed either of the single active treatments.

The results with treatments using CBT alone and sertraline alone were not significantly different from one another (JAMA 2004;292:1969–76).

Another study compared the use of imipramine plus CBT with placebo plus CBT among adolescents who refused to attend school. Sixty-three students were randomly assigned to the two groups and 47 students completed the study. The mean attendance rate in the final week of the study was about 70% in the imipramine plus CBT group, compared with about 28% in the placebo plus CBT group. Depression and anxiety rating scales decreased in both groups but decreased significantly faster in the imipramine plus CBT group (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:111–2).

Researchers also have recently completed the Child/Adolescent Anxiety Multimodal Treatment Study, which examined the efficacy of sertraline with CBT alone, combination treatment, and placebo. The analysis of that data is almost complete, said Dr. Rynn, who participated in the research. Dr. Rynn disclosed that she received research support from AstraZeneca Pharmaceuticals LP, Forest Laboratories Inc., Neuropharm Group PLC, Pfizer Inc., and Wyeth.

NEW YORK — When treating first-time, uncomplicated cases of anxiety in children and adolescents, it's usually best to start with a 6- to 12-week trial of psychosocial treatment, Dr. Moira Rynn said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

If the child does not respond to cognitive-behavioral therapy (CBT), consider adding a selective serotonin reuptake inhibitor (SSRI) at that point, said Dr. Rynn, deputy director of the division of child and adolescent psychiatry at Columbia University, New York.

The evidence base for medication treatment in children and adolescents has grown dramatically over the last decade, Dr. Rynn said, with randomized controlled trial data supporting the use of SSRIs for obsessive-compulsive disorder, generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder.

There is also strong evidence for the efficacy of psychosocial treatment. Multiple studies that show cognitive-behavior therapy works for children with anxiety.

For example, in a 1994 study of 47 children aged 9–13 years who had anxiety disorders, the benefit of a 16-session course of CBT was compared with being on a waiting list. More than 60% of the children who received CBT were found to be without a diagnosis at the posttest and were within normal limits on many measures at the 1-year follow-up point, compared with less than 10% among the group on the waiting list (J. Consult. Clin. Psychol. 1994;62:100–10). A follow-up study by the same group of researchers found similar results, with about 50% of children being without a diagnosis after CBT (J. Consult. Clin. Psychol. 1997;65:366–80).

Other studies have examined the benefits of adding a family component to CBT. For example, researchers at Griffith University in Nathan, Australia, randomly assigned 79 children aged 7–14 years with separation anxiety, overanxious disorder, or social phobia to receive CBT or CBT plus family management, or to be on a waiting list. Almost 70% of the children who were in the CBT groups did not meet diagnostic criteria for an anxiety disorder, compared with 26% of the children on the waiting list.

At the 12-month follow-up, CBT combined with family management performed better than CBT alone. About 70% of the children in the CBT-only group did not meet criteria for an anxiety disorder, compared with 96% in the CBT plus family management group (J. Consult. Clin. Psychol. 1996;64:333–42).

With strong evidence to support the use of both medication and CBT, providers have wondered whether a combined approach from the outset would have the greatest benefit for patients. Researchers are beginning to address that question, Dr. Rynn said. The Pediatric OCD Treatment Study (POTS) team, of which Dr. Rynn was a member, assessed the efficacy of sertraline (Zoloft), CBT, and combination therapy among 112 children aged 7–17 years. The project was a multisite, placebo-controlled, double-blind study.

During the first phase, patients were randomized to receive sertraline, CBT, combination therapy, or placebo for 12 weeks. The results of the intent-to-treat random regression analyses showed that all the active treatments were significantly more effective than placebo and that combination therapy outperformed either of the single active treatments.

The results with treatments using CBT alone and sertraline alone were not significantly different from one another (JAMA 2004;292:1969–76).

Another study compared the use of imipramine plus CBT with placebo plus CBT among adolescents who refused to attend school. Sixty-three students were randomly assigned to the two groups and 47 students completed the study. The mean attendance rate in the final week of the study was about 70% in the imipramine plus CBT group, compared with about 28% in the placebo plus CBT group. Depression and anxiety rating scales decreased in both groups but decreased significantly faster in the imipramine plus CBT group (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:111–2).

Researchers also have recently completed the Child/Adolescent Anxiety Multimodal Treatment Study, which examined the efficacy of sertraline with CBT alone, combination treatment, and placebo. The analysis of that data is almost complete, said Dr. Rynn, who participated in the research. Dr. Rynn disclosed that she received research support from AstraZeneca Pharmaceuticals LP, Forest Laboratories Inc., Neuropharm Group PLC, Pfizer Inc., and Wyeth.

NEW YORK — When treating first-time, uncomplicated cases of anxiety in children and adolescents, it's usually best to start with a 6- to 12-week trial of psychosocial treatment, Dr. Moira Rynn said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

If the child does not respond to cognitive-behavioral therapy (CBT), consider adding a selective serotonin reuptake inhibitor (SSRI) at that point, said Dr. Rynn, deputy director of the division of child and adolescent psychiatry at Columbia University, New York.

The evidence base for medication treatment in children and adolescents has grown dramatically over the last decade, Dr. Rynn said, with randomized controlled trial data supporting the use of SSRIs for obsessive-compulsive disorder, generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder.

There is also strong evidence for the efficacy of psychosocial treatment. Multiple studies that show cognitive-behavior therapy works for children with anxiety.

For example, in a 1994 study of 47 children aged 9–13 years who had anxiety disorders, the benefit of a 16-session course of CBT was compared with being on a waiting list. More than 60% of the children who received CBT were found to be without a diagnosis at the posttest and were within normal limits on many measures at the 1-year follow-up point, compared with less than 10% among the group on the waiting list (J. Consult. Clin. Psychol. 1994;62:100–10). A follow-up study by the same group of researchers found similar results, with about 50% of children being without a diagnosis after CBT (J. Consult. Clin. Psychol. 1997;65:366–80).

Other studies have examined the benefits of adding a family component to CBT. For example, researchers at Griffith University in Nathan, Australia, randomly assigned 79 children aged 7–14 years with separation anxiety, overanxious disorder, or social phobia to receive CBT or CBT plus family management, or to be on a waiting list. Almost 70% of the children who were in the CBT groups did not meet diagnostic criteria for an anxiety disorder, compared with 26% of the children on the waiting list.

At the 12-month follow-up, CBT combined with family management performed better than CBT alone. About 70% of the children in the CBT-only group did not meet criteria for an anxiety disorder, compared with 96% in the CBT plus family management group (J. Consult. Clin. Psychol. 1996;64:333–42).

With strong evidence to support the use of both medication and CBT, providers have wondered whether a combined approach from the outset would have the greatest benefit for patients. Researchers are beginning to address that question, Dr. Rynn said. The Pediatric OCD Treatment Study (POTS) team, of which Dr. Rynn was a member, assessed the efficacy of sertraline (Zoloft), CBT, and combination therapy among 112 children aged 7–17 years. The project was a multisite, placebo-controlled, double-blind study.

During the first phase, patients were randomized to receive sertraline, CBT, combination therapy, or placebo for 12 weeks. The results of the intent-to-treat random regression analyses showed that all the active treatments were significantly more effective than placebo and that combination therapy outperformed either of the single active treatments.

The results with treatments using CBT alone and sertraline alone were not significantly different from one another (JAMA 2004;292:1969–76).

Another study compared the use of imipramine plus CBT with placebo plus CBT among adolescents who refused to attend school. Sixty-three students were randomly assigned to the two groups and 47 students completed the study. The mean attendance rate in the final week of the study was about 70% in the imipramine plus CBT group, compared with about 28% in the placebo plus CBT group. Depression and anxiety rating scales decreased in both groups but decreased significantly faster in the imipramine plus CBT group (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:111–2).

Researchers also have recently completed the Child/Adolescent Anxiety Multimodal Treatment Study, which examined the efficacy of sertraline with CBT alone, combination treatment, and placebo. The analysis of that data is almost complete, said Dr. Rynn, who participated in the research. Dr. Rynn disclosed that she received research support from AstraZeneca Pharmaceuticals LP, Forest Laboratories Inc., Neuropharm Group PLC, Pfizer Inc., and Wyeth.

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 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 their care. But the attorney general's preliminary investigation found that the Ingenix data are provided by insurers that have 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 held 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 at the press conference.

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, commented 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 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 their care. But the attorney general's preliminary investigation found that the Ingenix data are provided by insurers that have 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 held 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 at the press conference.

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, commented 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 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 their care. But the attorney general's preliminary investigation found that the Ingenix data are provided by insurers that have 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 held 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 at the press conference.

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, commented 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.

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.

“We cannot afford not to invest in diabetes research, treatment, and prevention–the consequences for our health care system and our society will be too severe,” Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. “The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis.”

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.

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.

“We cannot afford not to invest in diabetes research, treatment, and prevention–the consequences for our health care system and our society will be too severe,” Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. “The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis.”

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.

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.

“We cannot afford not to invest in diabetes research, treatment, and prevention–the consequences for our health care system and our society will be too severe,” Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. “The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis.”

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.

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

Over the next 3 years, more than 100 hospitals will collect quality data on mortality, appropriate care, efficiency, harm avoidance, and patient satisfaction with the aim of improving care and controlling costs.

The Quest: High Performing Hospitals project, which was launched by Premier Inc., a hospital performance improvement alliance, is also designed to test performance measures. "It's an opportunity to learn but also to guide the industry," said Stephanie Alexander, senior vice president and general manager of Premier's informatics division.

In the short term, the program is aimed at preparing hospitals for a world of value-based purchasing and pay for performance. Over the long term, it should help hospitals improve quality and safety while safely reducing costs.

Premier began recruiting hospitals for the program last summer and in January started collecting quality data. Over the course of the project, Premier will collect data on the following:

▸ Mortality, by using a risk-adjusted ratio to measure progress toward the goal of eliminating all avoidable deaths.

▸ Evidence-based care, via a measure of the percentage of patients receiving "perfect care" based on nationally recognized quality measures.

▸ Efficiency, through a measure of total inpatient cost per case-mix-adjusted discharge, including all of the costs associated with each episode of acute care.

▸ Patient experience, as measured using the Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction measures. The program will also study how patient satisfaction can relate to cost, quality, and safety.

▸ Harm avoidance, via measures of the prevention of health care-associated infections and adverse drug events. Premier is working with the Institute for Healthcare Improvement to develop automated measures of harm that can be reported without having to perform a manual chart review. The first year of the program will focus on mortality, evidence-based care, and efficiency. The hospitals will take on harm avoidance and patient satisfaction during the second year.

Premier will analyze the data from each hospital, disseminate best practices among the facilities, and provide financial incentives to the top-performing hospitals at the end of the 3-year project. The amount of the reward pool has yet to be determined. However, there are no penalties for hospitals who don't meet the goals.

There was no cost for hospitals to participate, Ms. Alexander said, but they needed to have a commitment at both the executive and board levels to meeting the quality goals. They also had to commit to data collection and sharing best practice knowledge, she said. Premier also encouraged hospitals not to make Quest a "special" project but to incorporate it into the everyday business of the facility. The project builds on the success of the Hospital Quality Incentive Demonstration project, a pay-for-performance initiative performed in collaboration with the Centers for Medicare and Medicaid Services that showed significant improvements in quality and reductions in the cost of care.

The Medicare demonstration showed that hospitals can improve both quality and cost and that there is no reason to think the lessons learned can't be applied beyond the conditions in the pilot project, said Dr. Stephen Schoenbaum, executive vice president for programs at the Commonwealth Fund and a member of the Quest advisory panel.

Over the next 3 years, more than 100 hospitals will collect quality data on mortality, appropriate care, efficiency, harm avoidance, and patient satisfaction with the aim of improving care and controlling costs.

The Quest: High Performing Hospitals project, which was launched by Premier Inc., a hospital performance improvement alliance, is also designed to test performance measures. "It's an opportunity to learn but also to guide the industry," said Stephanie Alexander, senior vice president and general manager of Premier's informatics division.

In the short term, the program is aimed at preparing hospitals for a world of value-based purchasing and pay for performance. Over the long term, it should help hospitals improve quality and safety while safely reducing costs.

Premier began recruiting hospitals for the program last summer and in January started collecting quality data. Over the course of the project, Premier will collect data on the following:

▸ Mortality, by using a risk-adjusted ratio to measure progress toward the goal of eliminating all avoidable deaths.

▸ Evidence-based care, via a measure of the percentage of patients receiving "perfect care" based on nationally recognized quality measures.

▸ Efficiency, through a measure of total inpatient cost per case-mix-adjusted discharge, including all of the costs associated with each episode of acute care.

▸ Patient experience, as measured using the Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction measures. The program will also study how patient satisfaction can relate to cost, quality, and safety.

▸ Harm avoidance, via measures of the prevention of health care-associated infections and adverse drug events. Premier is working with the Institute for Healthcare Improvement to develop automated measures of harm that can be reported without having to perform a manual chart review. The first year of the program will focus on mortality, evidence-based care, and efficiency. The hospitals will take on harm avoidance and patient satisfaction during the second year.

Premier will analyze the data from each hospital, disseminate best practices among the facilities, and provide financial incentives to the top-performing hospitals at the end of the 3-year project. The amount of the reward pool has yet to be determined. However, there are no penalties for hospitals who don't meet the goals.

There was no cost for hospitals to participate, Ms. Alexander said, but they needed to have a commitment at both the executive and board levels to meeting the quality goals. They also had to commit to data collection and sharing best practice knowledge, she said. Premier also encouraged hospitals not to make Quest a "special" project but to incorporate it into the everyday business of the facility. The project builds on the success of the Hospital Quality Incentive Demonstration project, a pay-for-performance initiative performed in collaboration with the Centers for Medicare and Medicaid Services that showed significant improvements in quality and reductions in the cost of care.

The Medicare demonstration showed that hospitals can improve both quality and cost and that there is no reason to think the lessons learned can't be applied beyond the conditions in the pilot project, said Dr. Stephen Schoenbaum, executive vice president for programs at the Commonwealth Fund and a member of the Quest advisory panel.

Over the next 3 years, more than 100 hospitals will collect quality data on mortality, appropriate care, efficiency, harm avoidance, and patient satisfaction with the aim of improving care and controlling costs.

The Quest: High Performing Hospitals project, which was launched by Premier Inc., a hospital performance improvement alliance, is also designed to test performance measures. "It's an opportunity to learn but also to guide the industry," said Stephanie Alexander, senior vice president and general manager of Premier's informatics division.

In the short term, the program is aimed at preparing hospitals for a world of value-based purchasing and pay for performance. Over the long term, it should help hospitals improve quality and safety while safely reducing costs.

Premier began recruiting hospitals for the program last summer and in January started collecting quality data. Over the course of the project, Premier will collect data on the following:

▸ Mortality, by using a risk-adjusted ratio to measure progress toward the goal of eliminating all avoidable deaths.

▸ Evidence-based care, via a measure of the percentage of patients receiving "perfect care" based on nationally recognized quality measures.

▸ Efficiency, through a measure of total inpatient cost per case-mix-adjusted discharge, including all of the costs associated with each episode of acute care.

▸ Patient experience, as measured using the Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction measures. The program will also study how patient satisfaction can relate to cost, quality, and safety.

▸ Harm avoidance, via measures of the prevention of health care-associated infections and adverse drug events. Premier is working with the Institute for Healthcare Improvement to develop automated measures of harm that can be reported without having to perform a manual chart review. The first year of the program will focus on mortality, evidence-based care, and efficiency. The hospitals will take on harm avoidance and patient satisfaction during the second year.

Premier will analyze the data from each hospital, disseminate best practices among the facilities, and provide financial incentives to the top-performing hospitals at the end of the 3-year project. The amount of the reward pool has yet to be determined. However, there are no penalties for hospitals who don't meet the goals.

There was no cost for hospitals to participate, Ms. Alexander said, but they needed to have a commitment at both the executive and board levels to meeting the quality goals. They also had to commit to data collection and sharing best practice knowledge, she said. Premier also encouraged hospitals not to make Quest a "special" project but to incorporate it into the everyday business of the facility. The project builds on the success of the Hospital Quality Incentive Demonstration project, a pay-for-performance initiative performed in collaboration with the Centers for Medicare and Medicaid Services that showed significant improvements in quality and reductions in the cost of care.

The Medicare demonstration showed that hospitals can improve both quality and cost and that there is no reason to think the lessons learned can't be applied beyond the conditions in the pilot project, said Dr. Stephen Schoenbaum, executive vice president for programs at the Commonwealth Fund and a member of the Quest advisory panel.

Doubt and low morale are rampant in many practices in light of the uncertainty surrounding Medicare physician payment rates this year.

While members of Congress averted a 10% cut in the Medicare physician fee schedule, replacing it instead with a 0.5% increase, that increase is mandated only until midyear. Congress must act again by July to keep an ever-deeper cut from going through.

The uncertainty is making it difficult for physicians to plan ahead even a year at a time, and is causing some to avoid taking on new Medicare patients.

Dr. Fred Ralston Jr., a general internist in Fayetteville, Tenn., and chair of the health and public policy committee of the American College of Physicians, rarely sees new patients in his established practice. However, given the recent lack of action to reform payments, he has decided to stop accepting new Medicare patients in his practice.

Although his eight-physician primary care group won't drop any current patients, he said that taking on new Medicare patients, with their complex problems, amounts to "charity." "The reimbursement for those with multiple problems is very limited compared to several less complex younger patients who could be seen in the same [amount of] time," Dr. Ralston said.

Other physicians made the decision not to take new Medicare patients years ago. Dr. Andrew Merritt, a family physician in Marcellus, N.Y., closed his practice to Medicare patients about 5 years ago because of the uncertainty of the payment situation.

As a result, Medicare now makes up less than 20% of his practice, and the current payment situation hasn't had a large impact on his bottom line. But if payments were to worsen significantly, he might be forced to consider other changes to his practice, such as limiting patients to presenting one problem at each appointment.

The fiscal situation makes rational long-term financial planning almost impossible, said Dr. Ralston. He estimates that in a practice in which almost two-thirds of the revenue goes to overhead, a 10% cut would mean about 30% off the bottom line.

For example, Dr. Ralston's practice purchased an electronic medical record system because they thought it would help them to provide better care to patients. But it was probably a foolish economic decision, he said, because they don't know whether they will have the revenue to pay for it.

"It continues the uncertainty of what the practice income will be," said Dr. Yul Ejnes, an internist in Cranston, R.I., and a member of the ACP Board of Regents. "We're all small businesses."

Practices can't do anything aggressive in terms of practice development and growth, he said. For example, it's difficult for a practice that needs to recruit new physicians to guarantee a competitive pay package when they can't estimate how much money will be coming in, he said.

It also affects the morale of physicians, especially those who care for the chronically ill elderly population, Dr. Ejnes said.

Dr. Robert Lebow, a solo internist and geriatrician in Southbridge, Mass., finds the Medicare payment situation to be demoralizing. Dr. Lebow, who still accepts new Medicare patients, said the flat payments are an added insult to the enormous paperwork burden and constant questioning of orders by payers. Dr. Lebow estimates that he spends an extra 1–2 hours a day completing paperwork for insurance companies.

And he is concerned about what this will mean to the future of primary care. Even as some payments for cognitive services have increased slightly in recent years, many physicians feel that it's too little, too late, he said.

Dr. Lebow, who is 63 years old, worries that there will be no one to replace him when he retires. "There are very few young people in primary care," he said.

Doubt and low morale are rampant in many practices in light of the uncertainty surrounding Medicare physician payment rates this year.

While members of Congress averted a 10% cut in the Medicare physician fee schedule, replacing it instead with a 0.5% increase, that increase is mandated only until midyear. Congress must act again by July to keep an ever-deeper cut from going through.

The uncertainty is making it difficult for physicians to plan ahead even a year at a time, and is causing some to avoid taking on new Medicare patients.

Dr. Fred Ralston Jr., a general internist in Fayetteville, Tenn., and chair of the health and public policy committee of the American College of Physicians, rarely sees new patients in his established practice. However, given the recent lack of action to reform payments, he has decided to stop accepting new Medicare patients in his practice.

Although his eight-physician primary care group won't drop any current patients, he said that taking on new Medicare patients, with their complex problems, amounts to "charity." "The reimbursement for those with multiple problems is very limited compared to several less complex younger patients who could be seen in the same [amount of] time," Dr. Ralston said.

Other physicians made the decision not to take new Medicare patients years ago. Dr. Andrew Merritt, a family physician in Marcellus, N.Y., closed his practice to Medicare patients about 5 years ago because of the uncertainty of the payment situation.

As a result, Medicare now makes up less than 20% of his practice, and the current payment situation hasn't had a large impact on his bottom line. But if payments were to worsen significantly, he might be forced to consider other changes to his practice, such as limiting patients to presenting one problem at each appointment.

The fiscal situation makes rational long-term financial planning almost impossible, said Dr. Ralston. He estimates that in a practice in which almost two-thirds of the revenue goes to overhead, a 10% cut would mean about 30% off the bottom line.

For example, Dr. Ralston's practice purchased an electronic medical record system because they thought it would help them to provide better care to patients. But it was probably a foolish economic decision, he said, because they don't know whether they will have the revenue to pay for it.

"It continues the uncertainty of what the practice income will be," said Dr. Yul Ejnes, an internist in Cranston, R.I., and a member of the ACP Board of Regents. "We're all small businesses."

Practices can't do anything aggressive in terms of practice development and growth, he said. For example, it's difficult for a practice that needs to recruit new physicians to guarantee a competitive pay package when they can't estimate how much money will be coming in, he said.

It also affects the morale of physicians, especially those who care for the chronically ill elderly population, Dr. Ejnes said.

Dr. Robert Lebow, a solo internist and geriatrician in Southbridge, Mass., finds the Medicare payment situation to be demoralizing. Dr. Lebow, who still accepts new Medicare patients, said the flat payments are an added insult to the enormous paperwork burden and constant questioning of orders by payers. Dr. Lebow estimates that he spends an extra 1–2 hours a day completing paperwork for insurance companies.

And he is concerned about what this will mean to the future of primary care. Even as some payments for cognitive services have increased slightly in recent years, many physicians feel that it's too little, too late, he said.

Dr. Lebow, who is 63 years old, worries that there will be no one to replace him when he retires. "There are very few young people in primary care," he said.

Doubt and low morale are rampant in many practices in light of the uncertainty surrounding Medicare physician payment rates this year.

While members of Congress averted a 10% cut in the Medicare physician fee schedule, replacing it instead with a 0.5% increase, that increase is mandated only until midyear. Congress must act again by July to keep an ever-deeper cut from going through.

The uncertainty is making it difficult for physicians to plan ahead even a year at a time, and is causing some to avoid taking on new Medicare patients.

Dr. Fred Ralston Jr., a general internist in Fayetteville, Tenn., and chair of the health and public policy committee of the American College of Physicians, rarely sees new patients in his established practice. However, given the recent lack of action to reform payments, he has decided to stop accepting new Medicare patients in his practice.

Although his eight-physician primary care group won't drop any current patients, he said that taking on new Medicare patients, with their complex problems, amounts to "charity." "The reimbursement for those with multiple problems is very limited compared to several less complex younger patients who could be seen in the same [amount of] time," Dr. Ralston said.

Other physicians made the decision not to take new Medicare patients years ago. Dr. Andrew Merritt, a family physician in Marcellus, N.Y., closed his practice to Medicare patients about 5 years ago because of the uncertainty of the payment situation.

As a result, Medicare now makes up less than 20% of his practice, and the current payment situation hasn't had a large impact on his bottom line. But if payments were to worsen significantly, he might be forced to consider other changes to his practice, such as limiting patients to presenting one problem at each appointment.

The fiscal situation makes rational long-term financial planning almost impossible, said Dr. Ralston. He estimates that in a practice in which almost two-thirds of the revenue goes to overhead, a 10% cut would mean about 30% off the bottom line.

For example, Dr. Ralston's practice purchased an electronic medical record system because they thought it would help them to provide better care to patients. But it was probably a foolish economic decision, he said, because they don't know whether they will have the revenue to pay for it.

"It continues the uncertainty of what the practice income will be," said Dr. Yul Ejnes, an internist in Cranston, R.I., and a member of the ACP Board of Regents. "We're all small businesses."

Practices can't do anything aggressive in terms of practice development and growth, he said. For example, it's difficult for a practice that needs to recruit new physicians to guarantee a competitive pay package when they can't estimate how much money will be coming in, he said.

It also affects the morale of physicians, especially those who care for the chronically ill elderly population, Dr. Ejnes said.

Dr. Robert Lebow, a solo internist and geriatrician in Southbridge, Mass., finds the Medicare payment situation to be demoralizing. Dr. Lebow, who still accepts new Medicare patients, said the flat payments are an added insult to the enormous paperwork burden and constant questioning of orders by payers. Dr. Lebow estimates that he spends an extra 1–2 hours a day completing paperwork for insurance companies.

And he is concerned about what this will mean to the future of primary care. Even as some payments for cognitive services have increased slightly in recent years, many physicians feel that it's too little, too late, he said.

Dr. Lebow, who is 63 years old, worries that there will be no one to replace him when he retires. "There are very few young people in primary care," he said.

In a move that could have significant implications for physicians and hospitals, the insurer Aetna 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 October 2008.

Aetna Inc. 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.

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."

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.

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 2008, said Cigna spokesman Mark Slitt.

The question is whether hospitals will continue to report these types of serious preventable errors. DR. OPELKA

In a move that could have significant implications for physicians and hospitals, the insurer Aetna 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 October 2008.

Aetna Inc. 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.

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."

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.

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 2008, said Cigna spokesman Mark Slitt.

The question is whether hospitals will continue to report these types of serious preventable errors. DR. OPELKA

In a move that could have significant implications for physicians and hospitals, the insurer Aetna 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 October 2008.

Aetna Inc. 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.

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."

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.

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 2008, said Cigna spokesman Mark Slitt.

The question is whether hospitals will continue to report these types of serious preventable errors. DR. OPELKA

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

Leaders in the Democratic-controlled Congress immediately 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.

"We cannot afford not to invest in diabetes research, treatment, and prevention—the consequences for our health care system and our society will be too severe," Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. "The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis."

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. The administration also is 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 planning substantial cuts to hospitals, skilled nursing facilities, and graduate medical education.

Leaders in the Democratic-controlled Congress immediately 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.

"We cannot afford not to invest in diabetes research, treatment, and prevention—the consequences for our health care system and our society will be too severe," Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. "The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis."

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. The administration also is 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 planning substantial cuts to hospitals, skilled nursing facilities, and graduate medical education.

Leaders in the Democratic-controlled Congress immediately 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.

"We cannot afford not to invest in diabetes research, treatment, and prevention—the consequences for our health care system and our society will be too severe," Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. "The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis."

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. The administration also is 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 Democrat-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.

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.

“We cannot afford not to invest in diabetes research, treatment, and prevention—the consequences for our health care system and our society will be too severe,” Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. “The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis.”

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 2009 budget 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. The administration also is 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 Democrat-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.

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.

“We cannot afford not to invest in diabetes research, treatment, and prevention—the consequences for our health care system and our society will be too severe,” Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. “The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis.”

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 2009 budget 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. The administration also is 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 Democrat-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.

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.

“We cannot afford not to invest in diabetes research, treatment, and prevention—the consequences for our health care system and our society will be too severe,” Dr. John B. Buse, president of medicine and science for the American Diabetes Association, said in a statement. “The American Diabetes Association calls on Congress to align their priorities and provide funds to remedy this growing health crisis.”

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 2009 budget 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. The administration also is 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.