Mary Ellen Schneider

Epilepsy Hospitalizations Rise

Epilepsy-related hospitalizations rose 43% between 2000 and 2005, according to a report from the Agency for Healthcare Research and Quality. Epilepsy-related hospitalizations reached 136,000 in 2005, up from 95,000 in 2000. This rise follows a drop in epilepsy-related cases that took place between 1993 and 2000. Of hospital patients diagnosed with epilepsy, nearly two-thirds were under the age of 45. Convulsion-related hospitalizations also have been increasing, according to the Agency for Healthcare Research and Quality. Between 1993 and 2005, convulsion-related hospitalizations rose from 730,000 to 1.2 million, representing a hefty 69% increase over the 12-year period. Those patients who were hospitalized with a diagnosis that included convulsions were primarily middle-aged or elderly, according to the AHRQ. The agency's report is based on databases of inpatient hospital stays.

CDC Seeks Help From Neurologists

Officials at the Centers for Disease Control and Prevention are investigating cases of inflammatory neuropathy among pork processing plant workers in Minnesota and Indiana, and they are asking neurologists for help. In a letter to the American Academy of Neurology, CDC officials said that similar illnesses may be occurring at other pork processing plants and the government agency reached out to neurologists to provide any information about patients who might have developed similar symptoms. Last fall, clinicians at the Mayo Clinic in Rochester, Minn., reported an “unusual cluster” of 12 patients with inflammatory neuropathy, all of whom worked in an area of a pork processing plant where the heads of pigs were being processed. Additional patients were identified at a similar plant in Indiana. Most patients reported pain, numbness, and tingling in their extremities. The typical progression of the illness was development of “relatively symmetric mild to moderate weakness involving predominantly the distal lower limbs.” Ataxia also was reported. Neurologists should contact the CDC or their state health departments if they have made a diagnosis in the last year of peripheral neuropathy, myelopathy, or a mixed clinical presentation of peripheral/central or myelopathic involvement in individuals who were exposed to pig butchering or processing. Physicians with questions or information may contact the CDC at 770–488–7100. The CDC's letter to the American Academy of Neurology is available online at the Academy's Web site,

www.aan.com

NIH Sets New Research Goals

Officials at the National Institutes of Health have set research goals for the next decade aimed at speeding the development of new treatments for Down syndrome. The plan was developed with input from families of individuals with the disorder, Down syndrome advocacy organizations, and NIH scientists. The research blueprint calls for a host of changes, including greater access to laboratory animals with the characteristics of Down syndrome; increased research on the medical, cognitive, and behavioral conditions found in individuals with the disorder; and studies into whether aging has a greater impact on the mental processes in individuals who have the disorder. A number of NIH institutes are currently conducting research into Down syndrome. At the National Institute of Neurological Disorders and Stroke (NINDS), scientists are studying the potential role of the amyloid precursor protein gene in Down syndrome.

HHS Names Autism Panel

The Health and Human Services department has named a new committee in charge of coordinating efforts within the department to combat autism spectrum disorders. The panel, which was authorized under the Combating Autism Act of 2006, will facilitate the exchange of information on autism activities and research among federal agencies as well as coordinate autism-related programs and initiatives, according to a statement from the HHS. Dr. Thomas R. Insel, who is currently the director of the National Institute of Mental Health, is set to chair the panel. Dr. Insel said in a formal statement that the committee's very first task will be to develop a strategic plan for autism research to guide both public and private investments.

Blues Launch Campaign

The Blue Cross and Blue Shield Association last month unveiled a 5-point plan for building on the current employer-based health insurance system to improve quality, rein in costs, and provide universal coverage. The plan would create an independent institute in order to support research comparing the relative effectiveness of different medical treatments; change incentives so that providers are rewarded for delivering high-quality, coordinated care, especially for those with chronic illnesses; empower consumers and providers with personal health records and cost data on medical services; promote healthy lifestyles to prevent and manage chronic illness; and foster public-private solutions to cover the uninsured. The Blue Cross and Blue Shield Association said that it and its 39 member plans will promote the current initiative in a multifaceted campaign this year.

Low-Income Seniors Helped

The Centers for Medicare and Medicaid Services has proposed a new set of rules that would allow more low-income Medicare beneficiaries to remain in their current prescription drug plans without having to pay a premium. Each year, the CMS recalculates the amount of premium that will be paid by Medicare for low-income beneficiaries in each region, meaning that individual Part D plans might be fully covered by the subsidy in one year but not the next year. Until now, the Centers for Medicare and Medicaid Services has randomly reassigned some beneficiaries to another Part D plan if their current plan's premium would be higher than the subsidy amount. However, under the new rules, proposed last month and slated to be finalized in time for the 2009 plan year, would allow some prescription plan sponsors to offer a reduced premium to some individuals who are eligible for the low-income subsidy. The proposal would apply in regions where there otherwise would be fewer than five prescription drug plan sponsors with a “zero-premium” plan option for low-income beneficiaries.

Epilepsy Hospitalizations Rise

Epilepsy-related hospitalizations rose 43% between 2000 and 2005, according to a report from the Agency for Healthcare Research and Quality. Epilepsy-related hospitalizations reached 136,000 in 2005, up from 95,000 in 2000. This rise follows a drop in epilepsy-related cases that took place between 1993 and 2000. Of hospital patients diagnosed with epilepsy, nearly two-thirds were under the age of 45. Convulsion-related hospitalizations also have been increasing, according to the Agency for Healthcare Research and Quality. Between 1993 and 2005, convulsion-related hospitalizations rose from 730,000 to 1.2 million, representing a hefty 69% increase over the 12-year period. Those patients who were hospitalized with a diagnosis that included convulsions were primarily middle-aged or elderly, according to the AHRQ. The agency's report is based on databases of inpatient hospital stays.

CDC Seeks Help From Neurologists

Officials at the Centers for Disease Control and Prevention are investigating cases of inflammatory neuropathy among pork processing plant workers in Minnesota and Indiana, and they are asking neurologists for help. In a letter to the American Academy of Neurology, CDC officials said that similar illnesses may be occurring at other pork processing plants and the government agency reached out to neurologists to provide any information about patients who might have developed similar symptoms. Last fall, clinicians at the Mayo Clinic in Rochester, Minn., reported an “unusual cluster” of 12 patients with inflammatory neuropathy, all of whom worked in an area of a pork processing plant where the heads of pigs were being processed. Additional patients were identified at a similar plant in Indiana. Most patients reported pain, numbness, and tingling in their extremities. The typical progression of the illness was development of “relatively symmetric mild to moderate weakness involving predominantly the distal lower limbs.” Ataxia also was reported. Neurologists should contact the CDC or their state health departments if they have made a diagnosis in the last year of peripheral neuropathy, myelopathy, or a mixed clinical presentation of peripheral/central or myelopathic involvement in individuals who were exposed to pig butchering or processing. Physicians with questions or information may contact the CDC at 770–488–7100. The CDC's letter to the American Academy of Neurology is available online at the Academy's Web site,

www.aan.com

NIH Sets New Research Goals

Officials at the National Institutes of Health have set research goals for the next decade aimed at speeding the development of new treatments for Down syndrome. The plan was developed with input from families of individuals with the disorder, Down syndrome advocacy organizations, and NIH scientists. The research blueprint calls for a host of changes, including greater access to laboratory animals with the characteristics of Down syndrome; increased research on the medical, cognitive, and behavioral conditions found in individuals with the disorder; and studies into whether aging has a greater impact on the mental processes in individuals who have the disorder. A number of NIH institutes are currently conducting research into Down syndrome. At the National Institute of Neurological Disorders and Stroke (NINDS), scientists are studying the potential role of the amyloid precursor protein gene in Down syndrome.

HHS Names Autism Panel

The Health and Human Services department has named a new committee in charge of coordinating efforts within the department to combat autism spectrum disorders. The panel, which was authorized under the Combating Autism Act of 2006, will facilitate the exchange of information on autism activities and research among federal agencies as well as coordinate autism-related programs and initiatives, according to a statement from the HHS. Dr. Thomas R. Insel, who is currently the director of the National Institute of Mental Health, is set to chair the panel. Dr. Insel said in a formal statement that the committee's very first task will be to develop a strategic plan for autism research to guide both public and private investments.

Blues Launch Campaign

The Blue Cross and Blue Shield Association last month unveiled a 5-point plan for building on the current employer-based health insurance system to improve quality, rein in costs, and provide universal coverage. The plan would create an independent institute in order to support research comparing the relative effectiveness of different medical treatments; change incentives so that providers are rewarded for delivering high-quality, coordinated care, especially for those with chronic illnesses; empower consumers and providers with personal health records and cost data on medical services; promote healthy lifestyles to prevent and manage chronic illness; and foster public-private solutions to cover the uninsured. The Blue Cross and Blue Shield Association said that it and its 39 member plans will promote the current initiative in a multifaceted campaign this year.

Low-Income Seniors Helped

The Centers for Medicare and Medicaid Services has proposed a new set of rules that would allow more low-income Medicare beneficiaries to remain in their current prescription drug plans without having to pay a premium. Each year, the CMS recalculates the amount of premium that will be paid by Medicare for low-income beneficiaries in each region, meaning that individual Part D plans might be fully covered by the subsidy in one year but not the next year. Until now, the Centers for Medicare and Medicaid Services has randomly reassigned some beneficiaries to another Part D plan if their current plan's premium would be higher than the subsidy amount. However, under the new rules, proposed last month and slated to be finalized in time for the 2009 plan year, would allow some prescription plan sponsors to offer a reduced premium to some individuals who are eligible for the low-income subsidy. The proposal would apply in regions where there otherwise would be fewer than five prescription drug plan sponsors with a “zero-premium” plan option for low-income beneficiaries.

Epilepsy Hospitalizations Rise

Epilepsy-related hospitalizations rose 43% between 2000 and 2005, according to a report from the Agency for Healthcare Research and Quality. Epilepsy-related hospitalizations reached 136,000 in 2005, up from 95,000 in 2000. This rise follows a drop in epilepsy-related cases that took place between 1993 and 2000. Of hospital patients diagnosed with epilepsy, nearly two-thirds were under the age of 45. Convulsion-related hospitalizations also have been increasing, according to the Agency for Healthcare Research and Quality. Between 1993 and 2005, convulsion-related hospitalizations rose from 730,000 to 1.2 million, representing a hefty 69% increase over the 12-year period. Those patients who were hospitalized with a diagnosis that included convulsions were primarily middle-aged or elderly, according to the AHRQ. The agency's report is based on databases of inpatient hospital stays.

CDC Seeks Help From Neurologists

Officials at the Centers for Disease Control and Prevention are investigating cases of inflammatory neuropathy among pork processing plant workers in Minnesota and Indiana, and they are asking neurologists for help. In a letter to the American Academy of Neurology, CDC officials said that similar illnesses may be occurring at other pork processing plants and the government agency reached out to neurologists to provide any information about patients who might have developed similar symptoms. Last fall, clinicians at the Mayo Clinic in Rochester, Minn., reported an “unusual cluster” of 12 patients with inflammatory neuropathy, all of whom worked in an area of a pork processing plant where the heads of pigs were being processed. Additional patients were identified at a similar plant in Indiana. Most patients reported pain, numbness, and tingling in their extremities. The typical progression of the illness was development of “relatively symmetric mild to moderate weakness involving predominantly the distal lower limbs.” Ataxia also was reported. Neurologists should contact the CDC or their state health departments if they have made a diagnosis in the last year of peripheral neuropathy, myelopathy, or a mixed clinical presentation of peripheral/central or myelopathic involvement in individuals who were exposed to pig butchering or processing. Physicians with questions or information may contact the CDC at 770–488–7100. The CDC's letter to the American Academy of Neurology is available online at the Academy's Web site,

www.aan.com

NIH Sets New Research Goals

Officials at the National Institutes of Health have set research goals for the next decade aimed at speeding the development of new treatments for Down syndrome. The plan was developed with input from families of individuals with the disorder, Down syndrome advocacy organizations, and NIH scientists. The research blueprint calls for a host of changes, including greater access to laboratory animals with the characteristics of Down syndrome; increased research on the medical, cognitive, and behavioral conditions found in individuals with the disorder; and studies into whether aging has a greater impact on the mental processes in individuals who have the disorder. A number of NIH institutes are currently conducting research into Down syndrome. At the National Institute of Neurological Disorders and Stroke (NINDS), scientists are studying the potential role of the amyloid precursor protein gene in Down syndrome.

HHS Names Autism Panel

The Health and Human Services department has named a new committee in charge of coordinating efforts within the department to combat autism spectrum disorders. The panel, which was authorized under the Combating Autism Act of 2006, will facilitate the exchange of information on autism activities and research among federal agencies as well as coordinate autism-related programs and initiatives, according to a statement from the HHS. Dr. Thomas R. Insel, who is currently the director of the National Institute of Mental Health, is set to chair the panel. Dr. Insel said in a formal statement that the committee's very first task will be to develop a strategic plan for autism research to guide both public and private investments.

Blues Launch Campaign

The Blue Cross and Blue Shield Association last month unveiled a 5-point plan for building on the current employer-based health insurance system to improve quality, rein in costs, and provide universal coverage. The plan would create an independent institute in order to support research comparing the relative effectiveness of different medical treatments; change incentives so that providers are rewarded for delivering high-quality, coordinated care, especially for those with chronic illnesses; empower consumers and providers with personal health records and cost data on medical services; promote healthy lifestyles to prevent and manage chronic illness; and foster public-private solutions to cover the uninsured. The Blue Cross and Blue Shield Association said that it and its 39 member plans will promote the current initiative in a multifaceted campaign this year.

Low-Income Seniors Helped

The Centers for Medicare and Medicaid Services has proposed a new set of rules that would allow more low-income Medicare beneficiaries to remain in their current prescription drug plans without having to pay a premium. Each year, the CMS recalculates the amount of premium that will be paid by Medicare for low-income beneficiaries in each region, meaning that individual Part D plans might be fully covered by the subsidy in one year but not the next year. Until now, the Centers for Medicare and Medicaid Services has randomly reassigned some beneficiaries to another Part D plan if their current plan's premium would be higher than the subsidy amount. However, under the new rules, proposed last month and slated to be finalized in time for the 2009 plan year, would allow some prescription plan sponsors to offer a reduced premium to some individuals who are eligible for the low-income subsidy. The proposal would apply in regions where there otherwise would be fewer than five prescription drug plan sponsors with a “zero-premium” plan option for low-income beneficiaries.

Enbrel Sales Investigated

The New Jersey Attorney General's office is investigating Amgen for allegedly promoting Enbrel for off-label uses and for violating privacy laws to get access to potentially new patients. On Jan. 14, Attorney General Anne Milgram subpoenaed Amgen for all documents relating to the marketing, sale, and prescription of Enbrel between July 2002 and the present. The inquiry follows a lawsuit filed by two former sales representatives who alleged that the company encouraged them to search physicians' records for patients with mild psoriasis who might be potential candidates for Enbrel. The former employees also claimed to have directly contacted insurers to seek reimbursement for the drug. An Amgen spokeswoman said that the company will cooperate fully with the investigation and that the employees' claims “are completely without merit.” The company expects salespeople to follow the Code of Conduct. “Amgen does not instruct sales representatives to proactively review patient files or promote off-label for any reason,” said the spokeswoman.

NIH Research Centers Launched

The National Institutes of Health has funded three new centers to study translational research for lupus, posttraumatic osteoarthritis, and psoriasis. The lupus research efforts will be headquartered at the University of Texas Southwestern Medical Center in Dallas where researchers will use mouse models to identify the genetic background of developmental stages of the disease. The researchers received $5 million from the NIH to fund their work. Researchers at the University of Iowa, Iowa City, will work on new methods to delay the onset of osteoarthritis. Officials at the NIH awarded $7.5 million to fund that research. At the Center for Psoriasis Research Translation at Case Western Reserve University and the University Hospitals of Cleveland, researchers will conduct a preliminary efficacy study to test novel photodynamic therapy for psoriasis. The NIH awarded $6.37 million to fund the work on psoriasis.

Arthritis Prevalence On the Rise

The overall prevalence of arthritis is expected to rise by 40% by the year 2030, however, the prevalence of rheumatoid arthritis may be starting to fall, according to a recently published study (Arthritis Rheumatism. 2008;58:15-25). The analysis, which was conducted by the National Arthritis Data Workgroup, relies on a variety of surveys and databases to estimate the prevalence and number of affected individuals with rheumatic conditions. The work group is a consortium of experts in epidemiology that was formed to help provide a single source of national data on the impact of rheumatologic diseases. The researchers estimate that about 1.2 million adults in the United States (roughly 0.6%), have rheumatoid arthritis, based on 2005 data. But these figures are down from the 2.1 million adults who were estimated to have the condition in 1998. While the decline in rheumatoid arthritis identified in this study is consistent with other recent findings, the researchers could not point to a clear explanation. However, the researchers identified the aging population as the factor driving up overall arthritis prevalence figures. “This increase suggests that overall arthritis will have a growing impact on the health care and public health systems in the future, one that needs to be anticipated in order to provide the early diagnosis and interventions that could help reduce that impact,” the researchers wrote.

Enbrel Sales Investigated

The New Jersey Attorney General's office is investigating Amgen for allegedly promoting Enbrel for off-label uses and for violating privacy laws to get access to potentially new patients. On Jan. 14, Attorney General Anne Milgram subpoenaed Amgen for all documents relating to the marketing, sale, and prescription of Enbrel between July 2002 and the present. The inquiry follows a lawsuit filed by two former sales representatives who alleged that the company encouraged them to search physicians' records for patients with mild psoriasis who might be potential candidates for Enbrel. The former employees also claimed to have directly contacted insurers to seek reimbursement for the drug. An Amgen spokeswoman said that the company will cooperate fully with the investigation and that the employees' claims “are completely without merit.” The company expects salespeople to follow the Code of Conduct. “Amgen does not instruct sales representatives to proactively review patient files or promote off-label for any reason,” said the spokeswoman.

NIH Research Centers Launched

The National Institutes of Health has funded three new centers to study translational research for lupus, posttraumatic osteoarthritis, and psoriasis. The lupus research efforts will be headquartered at the University of Texas Southwestern Medical Center in Dallas where researchers will use mouse models to identify the genetic background of developmental stages of the disease. The researchers received $5 million from the NIH to fund their work. Researchers at the University of Iowa, Iowa City, will work on new methods to delay the onset of osteoarthritis. Officials at the NIH awarded $7.5 million to fund that research. At the Center for Psoriasis Research Translation at Case Western Reserve University and the University Hospitals of Cleveland, researchers will conduct a preliminary efficacy study to test novel photodynamic therapy for psoriasis. The NIH awarded $6.37 million to fund the work on psoriasis.

Arthritis Prevalence On the Rise

The overall prevalence of arthritis is expected to rise by 40% by the year 2030, however, the prevalence of rheumatoid arthritis may be starting to fall, according to a recently published study (Arthritis Rheumatism. 2008;58:15-25). The analysis, which was conducted by the National Arthritis Data Workgroup, relies on a variety of surveys and databases to estimate the prevalence and number of affected individuals with rheumatic conditions. The work group is a consortium of experts in epidemiology that was formed to help provide a single source of national data on the impact of rheumatologic diseases. The researchers estimate that about 1.2 million adults in the United States (roughly 0.6%), have rheumatoid arthritis, based on 2005 data. But these figures are down from the 2.1 million adults who were estimated to have the condition in 1998. While the decline in rheumatoid arthritis identified in this study is consistent with other recent findings, the researchers could not point to a clear explanation. However, the researchers identified the aging population as the factor driving up overall arthritis prevalence figures. “This increase suggests that overall arthritis will have a growing impact on the health care and public health systems in the future, one that needs to be anticipated in order to provide the early diagnosis and interventions that could help reduce that impact,” the researchers wrote.

Enbrel Sales Investigated

The New Jersey Attorney General's office is investigating Amgen for allegedly promoting Enbrel for off-label uses and for violating privacy laws to get access to potentially new patients. On Jan. 14, Attorney General Anne Milgram subpoenaed Amgen for all documents relating to the marketing, sale, and prescription of Enbrel between July 2002 and the present. The inquiry follows a lawsuit filed by two former sales representatives who alleged that the company encouraged them to search physicians' records for patients with mild psoriasis who might be potential candidates for Enbrel. The former employees also claimed to have directly contacted insurers to seek reimbursement for the drug. An Amgen spokeswoman said that the company will cooperate fully with the investigation and that the employees' claims “are completely without merit.” The company expects salespeople to follow the Code of Conduct. “Amgen does not instruct sales representatives to proactively review patient files or promote off-label for any reason,” said the spokeswoman.

NIH Research Centers Launched

The National Institutes of Health has funded three new centers to study translational research for lupus, posttraumatic osteoarthritis, and psoriasis. The lupus research efforts will be headquartered at the University of Texas Southwestern Medical Center in Dallas where researchers will use mouse models to identify the genetic background of developmental stages of the disease. The researchers received $5 million from the NIH to fund their work. Researchers at the University of Iowa, Iowa City, will work on new methods to delay the onset of osteoarthritis. Officials at the NIH awarded $7.5 million to fund that research. At the Center for Psoriasis Research Translation at Case Western Reserve University and the University Hospitals of Cleveland, researchers will conduct a preliminary efficacy study to test novel photodynamic therapy for psoriasis. The NIH awarded $6.37 million to fund the work on psoriasis.

Arthritis Prevalence On the Rise

The overall prevalence of arthritis is expected to rise by 40% by the year 2030, however, the prevalence of rheumatoid arthritis may be starting to fall, according to a recently published study (Arthritis Rheumatism. 2008;58:15-25). The analysis, which was conducted by the National Arthritis Data Workgroup, relies on a variety of surveys and databases to estimate the prevalence and number of affected individuals with rheumatic conditions. The work group is a consortium of experts in epidemiology that was formed to help provide a single source of national data on the impact of rheumatologic diseases. The researchers estimate that about 1.2 million adults in the United States (roughly 0.6%), have rheumatoid arthritis, based on 2005 data. But these figures are down from the 2.1 million adults who were estimated to have the condition in 1998. While the decline in rheumatoid arthritis identified in this study is consistent with other recent findings, the researchers could not point to a clear explanation. However, the researchers identified the aging population as the factor driving up overall arthritis prevalence figures. “This increase suggests that overall arthritis will have a growing impact on the health care and public health systems in the future, one that needs to be anticipated in order to provide the early diagnosis and interventions that could help reduce that impact,” the researchers wrote.

Most Americans favor a continuation of the employer-based health insurance system and say that they believe health insurance costs should be shared among individuals, employers, and the government, according to the results of a survey conducted by the Commonwealth Fund.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal health coverage.

These findings indicate that on certain health reform issues Americans' views may be more closely aligned with the proposals put forth by Democratic candidates for president than those outlined by Republicans.

For example, the leading Democratic candidates would require employers to offer health coverage to employees or pay for part of their coverage, while most of the Republican candidates are proposing changes to the tax code that could potentially reduce the role of employers in the health insurance market, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) and former Sen. John Edwards (D-N.C.) would support an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children. Of all the Republican candidates, no one is proposing an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older as part of its biennial health insurance survey. The group released the results from four health reform queries before they announced the other findings, which are scheduled to be released in March.

The survey respondents expressed broad support for an employer-based system of health insurance coverage. About 81% of respondents said that employers should either provide health insurance or contribute to a fund in order to cover all Americans. Support for this idea among respondents was high regardless of political affiliation, race, gender, age, and income.

The support for an individual insurance mandate to ensure coverage for all was lower; 68% of the respondents said that they strongly or somewhat favor a requirement that all individuals obtain health insurance. About 25% said they strongly or somewhat opposed the idea. About 7% said they didn't know, or refused to answer.

When respondents were asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government. About 15% said it should be mostly government financed, 8% said it should be paid for mostly by employers, and 6% favored having individuals pick up the tab. Another 5% said they didn't know, or refused to answer.

The survey also indicated that candidates' views on health care reform will be important in determining votes. About 86% of respondents said health care reform is very or somewhat important in determining their vote.

Most Americans favor a continuation of the employer-based health insurance system and say that they believe health insurance costs should be shared among individuals, employers, and the government, according to the results of a survey conducted by the Commonwealth Fund.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal health coverage.

These findings indicate that on certain health reform issues Americans' views may be more closely aligned with the proposals put forth by Democratic candidates for president than those outlined by Republicans.

For example, the leading Democratic candidates would require employers to offer health coverage to employees or pay for part of their coverage, while most of the Republican candidates are proposing changes to the tax code that could potentially reduce the role of employers in the health insurance market, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) and former Sen. John Edwards (D-N.C.) would support an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children. Of all the Republican candidates, no one is proposing an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older as part of its biennial health insurance survey. The group released the results from four health reform queries before they announced the other findings, which are scheduled to be released in March.

The survey respondents expressed broad support for an employer-based system of health insurance coverage. About 81% of respondents said that employers should either provide health insurance or contribute to a fund in order to cover all Americans. Support for this idea among respondents was high regardless of political affiliation, race, gender, age, and income.

The support for an individual insurance mandate to ensure coverage for all was lower; 68% of the respondents said that they strongly or somewhat favor a requirement that all individuals obtain health insurance. About 25% said they strongly or somewhat opposed the idea. About 7% said they didn't know, or refused to answer.

When respondents were asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government. About 15% said it should be mostly government financed, 8% said it should be paid for mostly by employers, and 6% favored having individuals pick up the tab. Another 5% said they didn't know, or refused to answer.

The survey also indicated that candidates' views on health care reform will be important in determining votes. About 86% of respondents said health care reform is very or somewhat important in determining their vote.

Most Americans favor a continuation of the employer-based health insurance system and say that they believe health insurance costs should be shared among individuals, employers, and the government, according to the results of a survey conducted by the Commonwealth Fund.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal health coverage.

These findings indicate that on certain health reform issues Americans' views may be more closely aligned with the proposals put forth by Democratic candidates for president than those outlined by Republicans.

For example, the leading Democratic candidates would require employers to offer health coverage to employees or pay for part of their coverage, while most of the Republican candidates are proposing changes to the tax code that could potentially reduce the role of employers in the health insurance market, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) and former Sen. John Edwards (D-N.C.) would support an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children. Of all the Republican candidates, no one is proposing an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older as part of its biennial health insurance survey. The group released the results from four health reform queries before they announced the other findings, which are scheduled to be released in March.

The survey respondents expressed broad support for an employer-based system of health insurance coverage. About 81% of respondents said that employers should either provide health insurance or contribute to a fund in order to cover all Americans. Support for this idea among respondents was high regardless of political affiliation, race, gender, age, and income.

The support for an individual insurance mandate to ensure coverage for all was lower; 68% of the respondents said that they strongly or somewhat favor a requirement that all individuals obtain health insurance. About 25% said they strongly or somewhat opposed the idea. About 7% said they didn't know, or refused to answer.

When respondents were asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government. About 15% said it should be mostly government financed, 8% said it should be paid for mostly by employers, and 6% favored having individuals pick up the tab. Another 5% said they didn't know, or refused to answer.

The survey also indicated that candidates' views on health care reform will be important in determining votes. About 86% of respondents said health care reform is very or somewhat important in determining their vote.

Medicare may soon begin providing coverage for continuous positive airway pressure devices for beneficiaries who have been diagnosed with obstructive sleep apnea using unattended home monitoring.

The coverage proposal is an expansion of Medicare's current policy, which provides coverage for continuous positive airway pressure (CPAP) only when a diagnosis of obstructive sleep apnea (OSA) has been confirmed using polysomnography in a sleep laboratory.

“Our proposed policy to extend coverage for continuous positive airway pressure provides more options for Medicare beneficiaries and their treating physicians,” Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, said in a statement.

The CMS released the proposal in December, and officials at the agency plan to issue a final national coverage determination in March 2008. Medicare officials estimate that as many as 4 million Medicare beneficiaries suffer from OSA.

The CMS proposal would extend coverage in cases where the diagnosis was made as a result of a combination of a clinical evaluation and unattended home sleep monitoring using a type II, III, or IV device.

In addition, Medicare is proposing to cover CPAP when the diagnosis of OSA is made through a clinical evaluation or another type of diagnostic test, as long as the patient is participating in a research study that meets CMS standards for clinical trial policy.

The current proposal “as is” is likely to result in a “wasteful use of resources” and could hurt patients, said Dr. Robert Thomas of Beth Israel Deaconess Medical Center in Boston. Single channel sleep monitoring devices have many problems, including false-negative results, said Dr. Thomas, who holds patents for technology to estimate sleep quality from an ECG and for CO₂ use in mixed sleep apnea treatment.

However, Dr. Thomas said, the CMS final policy is likely to be more sensible. “I do believe that doing all studies in the lab is not cost, time, or effort efficient,” he said. “So there is much merit in a sensible, best-science driven portable recording policy.”

The CMS also plans to limit coverage for the CPAP devices to an initial 12-week period to gauge whether the patient will respond to the treatment. Medicare will continue to cover use of the CPAP in those patients who respond to the treatment.

In addition, the CMS is planning to eliminate the requirement for a minimum 2 hours of continuous recorded sleep during testing, because patients with severe OSA may not be able to meet the requirement.

Dr. Thomas praised this aspect of the proposal, because some patients with severe disease and badly fragmented sleep never reach the sleep threshold quickly enough to conduct an air pressure titration on the same night.

The CMS based its decision on advice from the Medicare Evidence Development and Coverage Advisory Committee, external technology assessments from the Agency for Healthcare Research and Quality, a review of individual clinical studies, and public comments.

Agency officials concluded that the evidence was sufficient to allow for coverage based on diagnosis with type II, III, and IV home sleep testing monitors in appropriately selected patients.

Medicare may soon begin providing coverage for continuous positive airway pressure devices for beneficiaries who have been diagnosed with obstructive sleep apnea using unattended home monitoring.

The coverage proposal is an expansion of Medicare's current policy, which provides coverage for continuous positive airway pressure (CPAP) only when a diagnosis of obstructive sleep apnea (OSA) has been confirmed using polysomnography in a sleep laboratory.

“Our proposed policy to extend coverage for continuous positive airway pressure provides more options for Medicare beneficiaries and their treating physicians,” Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, said in a statement.

The CMS released the proposal in December, and officials at the agency plan to issue a final national coverage determination in March 2008. Medicare officials estimate that as many as 4 million Medicare beneficiaries suffer from OSA.

The CMS proposal would extend coverage in cases where the diagnosis was made as a result of a combination of a clinical evaluation and unattended home sleep monitoring using a type II, III, or IV device.

In addition, Medicare is proposing to cover CPAP when the diagnosis of OSA is made through a clinical evaluation or another type of diagnostic test, as long as the patient is participating in a research study that meets CMS standards for clinical trial policy.

The current proposal “as is” is likely to result in a “wasteful use of resources” and could hurt patients, said Dr. Robert Thomas of Beth Israel Deaconess Medical Center in Boston. Single channel sleep monitoring devices have many problems, including false-negative results, said Dr. Thomas, who holds patents for technology to estimate sleep quality from an ECG and for CO₂ use in mixed sleep apnea treatment.

However, Dr. Thomas said, the CMS final policy is likely to be more sensible. “I do believe that doing all studies in the lab is not cost, time, or effort efficient,” he said. “So there is much merit in a sensible, best-science driven portable recording policy.”

The CMS also plans to limit coverage for the CPAP devices to an initial 12-week period to gauge whether the patient will respond to the treatment. Medicare will continue to cover use of the CPAP in those patients who respond to the treatment.

In addition, the CMS is planning to eliminate the requirement for a minimum 2 hours of continuous recorded sleep during testing, because patients with severe OSA may not be able to meet the requirement.

Dr. Thomas praised this aspect of the proposal, because some patients with severe disease and badly fragmented sleep never reach the sleep threshold quickly enough to conduct an air pressure titration on the same night.

The CMS based its decision on advice from the Medicare Evidence Development and Coverage Advisory Committee, external technology assessments from the Agency for Healthcare Research and Quality, a review of individual clinical studies, and public comments.

Agency officials concluded that the evidence was sufficient to allow for coverage based on diagnosis with type II, III, and IV home sleep testing monitors in appropriately selected patients.

Medicare may soon begin providing coverage for continuous positive airway pressure devices for beneficiaries who have been diagnosed with obstructive sleep apnea using unattended home monitoring.

The coverage proposal is an expansion of Medicare's current policy, which provides coverage for continuous positive airway pressure (CPAP) only when a diagnosis of obstructive sleep apnea (OSA) has been confirmed using polysomnography in a sleep laboratory.

“Our proposed policy to extend coverage for continuous positive airway pressure provides more options for Medicare beneficiaries and their treating physicians,” Kerry Weems, acting administrator for the Centers for Medicare and Medicaid Services, said in a statement.

The CMS released the proposal in December, and officials at the agency plan to issue a final national coverage determination in March 2008. Medicare officials estimate that as many as 4 million Medicare beneficiaries suffer from OSA.

The CMS proposal would extend coverage in cases where the diagnosis was made as a result of a combination of a clinical evaluation and unattended home sleep monitoring using a type II, III, or IV device.

In addition, Medicare is proposing to cover CPAP when the diagnosis of OSA is made through a clinical evaluation or another type of diagnostic test, as long as the patient is participating in a research study that meets CMS standards for clinical trial policy.

The current proposal “as is” is likely to result in a “wasteful use of resources” and could hurt patients, said Dr. Robert Thomas of Beth Israel Deaconess Medical Center in Boston. Single channel sleep monitoring devices have many problems, including false-negative results, said Dr. Thomas, who holds patents for technology to estimate sleep quality from an ECG and for CO₂ use in mixed sleep apnea treatment.

However, Dr. Thomas said, the CMS final policy is likely to be more sensible. “I do believe that doing all studies in the lab is not cost, time, or effort efficient,” he said. “So there is much merit in a sensible, best-science driven portable recording policy.”

The CMS also plans to limit coverage for the CPAP devices to an initial 12-week period to gauge whether the patient will respond to the treatment. Medicare will continue to cover use of the CPAP in those patients who respond to the treatment.

In addition, the CMS is planning to eliminate the requirement for a minimum 2 hours of continuous recorded sleep during testing, because patients with severe OSA may not be able to meet the requirement.

Dr. Thomas praised this aspect of the proposal, because some patients with severe disease and badly fragmented sleep never reach the sleep threshold quickly enough to conduct an air pressure titration on the same night.

The CMS based its decision on advice from the Medicare Evidence Development and Coverage Advisory Committee, external technology assessments from the Agency for Healthcare Research and Quality, a review of individual clinical studies, and public comments.

Agency officials concluded that the evidence was sufficient to allow for coverage based on diagnosis with type II, III, and IV home sleep testing monitors in appropriately selected patients.

Doubt and low morale are rampant in many primary care 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, 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.

He 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 primary care 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, 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.

He 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 primary care 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, 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.

He 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.

Most Americans favor a continuation of the employer-based health insurance system and say that they believe health insurance costs should be shared among individuals, employers, and the government, the results of a survey conducted by the Commonwealth Fund show.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal health coverage.

These findings indicate that on certain health reform issues Americans' views may be more closely aligned with the proposals put forth by Democratic candidates for president than those outlined by Republicans.

For example, the leading Democratic candidates would require employers to offer health coverage to employees or pay for part of their coverage, while most of the Republican candidates are proposing changes to the tax code that could potentially reduce the role of employers in the health insurance market, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) and former Sen. John Edwards (D-N.C.) would support an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children.

Of all the Republican candidates, no one is proposing an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older as part of its biennial health insurance survey. The group released the results from four health reform queries before they announced the other findings, which are scheduled to be released in March.

The survey respondents expressed broad support for an employer-based system of health insurance coverage. About 81% of respondents said that employers should either provide health insurance or contribute to a fund in order to cover all Americans. Support for this idea among respondents was high regardless of political affiliation, race, gender, age, and income.

The support for an individual insurance mandate to ensure coverage for all was lower; 68% of the respondents said that they strongly or somewhat favor a requirement that all individuals obtain health insurance. About 25% said they strongly or somewhat opposed the idea. About 7% said they didn't know, or refused to answer.

When respondents were asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government. About 15% said it should be mostly government financed, 8% said it should be paid for mostly by employers, and 6% favored having individuals pick up the tab.

An additional 5% said they didn't know, or refused to answer.

Most Americans favor a continuation of the employer-based health insurance system and say that they believe health insurance costs should be shared among individuals, employers, and the government, the results of a survey conducted by the Commonwealth Fund show.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal health coverage.

These findings indicate that on certain health reform issues Americans' views may be more closely aligned with the proposals put forth by Democratic candidates for president than those outlined by Republicans.

For example, the leading Democratic candidates would require employers to offer health coverage to employees or pay for part of their coverage, while most of the Republican candidates are proposing changes to the tax code that could potentially reduce the role of employers in the health insurance market, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) and former Sen. John Edwards (D-N.C.) would support an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children.

Of all the Republican candidates, no one is proposing an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older as part of its biennial health insurance survey. The group released the results from four health reform queries before they announced the other findings, which are scheduled to be released in March.

The survey respondents expressed broad support for an employer-based system of health insurance coverage. About 81% of respondents said that employers should either provide health insurance or contribute to a fund in order to cover all Americans. Support for this idea among respondents was high regardless of political affiliation, race, gender, age, and income.

The support for an individual insurance mandate to ensure coverage for all was lower; 68% of the respondents said that they strongly or somewhat favor a requirement that all individuals obtain health insurance. About 25% said they strongly or somewhat opposed the idea. About 7% said they didn't know, or refused to answer.

When respondents were asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government. About 15% said it should be mostly government financed, 8% said it should be paid for mostly by employers, and 6% favored having individuals pick up the tab.

An additional 5% said they didn't know, or refused to answer.

Most Americans favor a continuation of the employer-based health insurance system and say that they believe health insurance costs should be shared among individuals, employers, and the government, the results of a survey conducted by the Commonwealth Fund show.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal health coverage.

These findings indicate that on certain health reform issues Americans' views may be more closely aligned with the proposals put forth by Democratic candidates for president than those outlined by Republicans.

For example, the leading Democratic candidates would require employers to offer health coverage to employees or pay for part of their coverage, while most of the Republican candidates are proposing changes to the tax code that could potentially reduce the role of employers in the health insurance market, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) and former Sen. John Edwards (D-N.C.) would support an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children.

Of all the Republican candidates, no one is proposing an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older as part of its biennial health insurance survey. The group released the results from four health reform queries before they announced the other findings, which are scheduled to be released in March.

The survey respondents expressed broad support for an employer-based system of health insurance coverage. About 81% of respondents said that employers should either provide health insurance or contribute to a fund in order to cover all Americans. Support for this idea among respondents was high regardless of political affiliation, race, gender, age, and income.

The support for an individual insurance mandate to ensure coverage for all was lower; 68% of the respondents said that they strongly or somewhat favor a requirement that all individuals obtain health insurance. About 25% said they strongly or somewhat opposed the idea. About 7% said they didn't know, or refused to answer.

When respondents were asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government. About 15% said it should be mostly government financed, 8% said it should be paid for mostly by employers, and 6% favored having individuals pick up the tab.

An additional 5% said they didn't know, or refused to answer.

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage to every Maine resident by 2009.

The program has seen success in targeting subsidies to low-income individuals, but it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

“The implementation can be just as difficult as actually passing the law,” said Debra J. Lipson, the lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and target the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 people.

But the program has fallen short of those expectations and as of September 2006, had enrolled about 11,100 people in DirigoChoice. About 5,000 people were enrolled in the MaineCare expansion. An additional 18,100 people were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicates that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as is in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Other states considering similar programs may need to offer stronger incentives to encourage employers to offer coverage and help with employee costs, the researchers wrote.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start and has not been able to generate enough revenue, according to the Commonwealth Fund report.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. While the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as “politically unsustainable in its current form,” the report says.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured people has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted.

In many ways the Maine experience is a cautionary tale for other states, said Tarren Bragdon, CEO of the Maine Heritage Policy Center in Portland. The program missed the mark by not limiting benefits to only the uninsured, he said, and states with limited resources should consider a more targeted approach.

Mr. Bragdon also advised policy makers in other states not to try to fund coverage expansions with projected savings. Those savings generally are small and inadequate to fund these types of expansions, he said.

The full report is available at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage to every Maine resident by 2009.

The program has seen success in targeting subsidies to low-income individuals, but it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

“The implementation can be just as difficult as actually passing the law,” said Debra J. Lipson, the lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and target the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 people.

But the program has fallen short of those expectations and as of September 2006, had enrolled about 11,100 people in DirigoChoice. About 5,000 people were enrolled in the MaineCare expansion. An additional 18,100 people were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicates that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as is in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Other states considering similar programs may need to offer stronger incentives to encourage employers to offer coverage and help with employee costs, the researchers wrote.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start and has not been able to generate enough revenue, according to the Commonwealth Fund report.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. While the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as “politically unsustainable in its current form,” the report says.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured people has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted.

In many ways the Maine experience is a cautionary tale for other states, said Tarren Bragdon, CEO of the Maine Heritage Policy Center in Portland. The program missed the mark by not limiting benefits to only the uninsured, he said, and states with limited resources should consider a more targeted approach.

Mr. Bragdon also advised policy makers in other states not to try to fund coverage expansions with projected savings. Those savings generally are small and inadequate to fund these types of expansions, he said.

The full report is available at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage to every Maine resident by 2009.

The program has seen success in targeting subsidies to low-income individuals, but it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

“The implementation can be just as difficult as actually passing the law,” said Debra J. Lipson, the lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and target the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 people.

But the program has fallen short of those expectations and as of September 2006, had enrolled about 11,100 people in DirigoChoice. About 5,000 people were enrolled in the MaineCare expansion. An additional 18,100 people were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicates that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as is in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Other states considering similar programs may need to offer stronger incentives to encourage employers to offer coverage and help with employee costs, the researchers wrote.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start and has not been able to generate enough revenue, according to the Commonwealth Fund report.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. While the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as “politically unsustainable in its current form,” the report says.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured people has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted.

In many ways the Maine experience is a cautionary tale for other states, said Tarren Bragdon, CEO of the Maine Heritage Policy Center in Portland. The program missed the mark by not limiting benefits to only the uninsured, he said, and states with limited resources should consider a more targeted approach.

Mr. Bragdon also advised policy makers in other states not to try to fund coverage expansions with projected savings. Those savings generally are small and inadequate to fund these types of expansions, he said.

The full report is available at www.mathematica-mpr.com/health/dirigochoice.asp

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

Although 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, Dr. Ralston said. 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 and the other physicians in his 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 primary care practices in light of the uncertainty surrounding Medicare physician payment rates this year.

Although 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, Dr. Ralston said. 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 and the other physicians in his 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 primary care practices in light of the uncertainty surrounding Medicare physician payment rates this year.

Although 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, Dr. Ralston said. 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 and the other physicians in his 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.

As physicians struggle to decide whether and when to incorporate electronic health records into their practices, personal health records are gaining popularity.

Personal health records (PHRs) allow patients to store and access their medical information electronically. Various versions are available through physicians, health systems, insurers, and employers, and are offered on a stand-alone, subscription basis. But with so many models, no two records are likely to be the same and each may present different challenges for the physician-patient relationship.

“We're really in a kind of Wild West situation with the PHR,” said Dr. Peter Basch, an internist and medical director for eHealth at MedStar Health, a seven-hospital system in Washington and Baltimore.

Currently, two types of records are dominant—those that are linked to a physician's or health system's electronic health record, and free-standing records, Dr. Basch said.

With connected PHRs, patients can usually access subsets of their medical data and communicate with their physicians' offices on selected matters such as scheduling appointments. With a free-standing PHR, patients generally have greater control of the data that are entered and over who can access the data. The market is more mature now in terms of connected PHRs, especially those that are linked to large medical groups and large health systems, Dr. Basch said.

In an effort to tame some of the variability in the market, Health Level Seven Inc. (HL7), a national organization that sets health information technology standards, has released a proposed personal health record standard. In August, HL7 unveiled its Personal Health Record System Functional Model, and sought public comments.

The HL7 general model can be customized so that it can be used with each of the various PHR models available in the marketplace. A vote is expected later this year on whether the PHR functional model will become an approved standard.

Another possible way to accelerate the development of the personal health record market is through the Certification Commission for Healthcare Information Technology (CCHIT), a body that already certifies ambulatory and inpatient electronic health record systems.

The CCHIT is looking at the area of personal health records, according to its chairman, Dr. Mark Leavitt. However, any certification of PHR products would be at least a year away, since the CCHIT has not developed certification criteria in that area. Although the PHR industry is still in its early stages, it is not necessary to wait for the industry to fully mature before developing certification criteria. In fact, setting standards early can be helpful, Dr. Leavitt said.

The PHR marketplace may get a boost from the CCHIT long before a PHR certification process gets started, he added. Through its electronic health record certification process, the CCHIT is requiring that records have the capability to send patient summary information, which would be helpful in populating a patient's PHR.

Many factors are driving the growth of PHRs. Employer groups, frustrated with escalating health costs, represent one faction pushing for PHR development. While the evidence is not yet in, the theory is that PHRs would allow patients to be better consumers, potentially saving employers money, Dr. Basch said.

Health insurers also are getting into the act. For example, Aetna recently announced that starting in January 2008, federal enrollees in any of the company's medical plans will have access to a password-protected online PHR. The record would include claims information on physician office visits, labs, diagnoses, treatment, and prescriptions. Even Medicare is testing the PHR field. In June, Medicare launched a pilot program to allow certain beneficiaries to access a PHR through participating Medicare Advantage and Part D drug plans.

There also are some patients who care deeply about having PHRs because they are managing chronic conditions for themselves or family members, Dr. Basch said.

Even if most consumers are not clamoring for PHRs, when surveyed, they do favor the concept. In a November 2006 survey commissioned by the Markle Foundation, nearly two-thirds of the 1,003 adults polled said they would like to access their medical information electronically, and 72% of those under age 40 said they would like to access their health information online.

But consumers who were surveyed also had significant concerns about the privacy and security of their records. For example, 80% said they were very concerned about identity theft, and 77% said they were very concerned about their medical information being used for marketing purposes.

Concerns about security and privacy are shared by physicians. With a free-standing PHR, physicians could receive requests from patients to populate their data, but they might be reluctant to send such sensitive data in an unsecured way or in a way that could compromise the security of their own electronic systems, Dr. Basch said.

An even more complicated question for physicians is what to do with information they receive from a PHR that may be entered or edited by the patient. If patients are restricting PHR content from their physicians, it could limit the utility of the record, said Dr. Michael Barr, vice president for practice advocacy and improvement at the American College of Physicians.

While the ACP has been supportive of the development of PHRs, the different PHR models have different implications for the physician-patient relationship and for office workflow, he said.

As physicians struggle to decide whether and when to incorporate electronic health records into their practices, personal health records are gaining popularity.

Personal health records (PHRs) allow patients to store and access their medical information electronically. Various versions are available through physicians, health systems, insurers, and employers, and are offered on a stand-alone, subscription basis. But with so many models, no two records are likely to be the same and each may present different challenges for the physician-patient relationship.

“We're really in a kind of Wild West situation with the PHR,” said Dr. Peter Basch, an internist and medical director for eHealth at MedStar Health, a seven-hospital system in Washington and Baltimore.

Currently, two types of records are dominant—those that are linked to a physician's or health system's electronic health record, and free-standing records, Dr. Basch said.

With connected PHRs, patients can usually access subsets of their medical data and communicate with their physicians' offices on selected matters such as scheduling appointments. With a free-standing PHR, patients generally have greater control of the data that are entered and over who can access the data. The market is more mature now in terms of connected PHRs, especially those that are linked to large medical groups and large health systems, Dr. Basch said.

In an effort to tame some of the variability in the market, Health Level Seven Inc. (HL7), a national organization that sets health information technology standards, has released a proposed personal health record standard. In August, HL7 unveiled its Personal Health Record System Functional Model, and sought public comments.

The HL7 general model can be customized so that it can be used with each of the various PHR models available in the marketplace. A vote is expected later this year on whether the PHR functional model will become an approved standard.

Another possible way to accelerate the development of the personal health record market is through the Certification Commission for Healthcare Information Technology (CCHIT), a body that already certifies ambulatory and inpatient electronic health record systems.

The CCHIT is looking at the area of personal health records, according to its chairman, Dr. Mark Leavitt. However, any certification of PHR products would be at least a year away, since the CCHIT has not developed certification criteria in that area. Although the PHR industry is still in its early stages, it is not necessary to wait for the industry to fully mature before developing certification criteria. In fact, setting standards early can be helpful, Dr. Leavitt said.

The PHR marketplace may get a boost from the CCHIT long before a PHR certification process gets started, he added. Through its electronic health record certification process, the CCHIT is requiring that records have the capability to send patient summary information, which would be helpful in populating a patient's PHR.

Many factors are driving the growth of PHRs. Employer groups, frustrated with escalating health costs, represent one faction pushing for PHR development. While the evidence is not yet in, the theory is that PHRs would allow patients to be better consumers, potentially saving employers money, Dr. Basch said.

Health insurers also are getting into the act. For example, Aetna recently announced that starting in January 2008, federal enrollees in any of the company's medical plans will have access to a password-protected online PHR. The record would include claims information on physician office visits, labs, diagnoses, treatment, and prescriptions. Even Medicare is testing the PHR field. In June, Medicare launched a pilot program to allow certain beneficiaries to access a PHR through participating Medicare Advantage and Part D drug plans.

There also are some patients who care deeply about having PHRs because they are managing chronic conditions for themselves or family members, Dr. Basch said.

Even if most consumers are not clamoring for PHRs, when surveyed, they do favor the concept. In a November 2006 survey commissioned by the Markle Foundation, nearly two-thirds of the 1,003 adults polled said they would like to access their medical information electronically, and 72% of those under age 40 said they would like to access their health information online.

But consumers who were surveyed also had significant concerns about the privacy and security of their records. For example, 80% said they were very concerned about identity theft, and 77% said they were very concerned about their medical information being used for marketing purposes.

Concerns about security and privacy are shared by physicians. With a free-standing PHR, physicians could receive requests from patients to populate their data, but they might be reluctant to send such sensitive data in an unsecured way or in a way that could compromise the security of their own electronic systems, Dr. Basch said.

An even more complicated question for physicians is what to do with information they receive from a PHR that may be entered or edited by the patient. If patients are restricting PHR content from their physicians, it could limit the utility of the record, said Dr. Michael Barr, vice president for practice advocacy and improvement at the American College of Physicians.

While the ACP has been supportive of the development of PHRs, the different PHR models have different implications for the physician-patient relationship and for office workflow, he said.

As physicians struggle to decide whether and when to incorporate electronic health records into their practices, personal health records are gaining popularity.

Personal health records (PHRs) allow patients to store and access their medical information electronically. Various versions are available through physicians, health systems, insurers, and employers, and are offered on a stand-alone, subscription basis. But with so many models, no two records are likely to be the same and each may present different challenges for the physician-patient relationship.

“We're really in a kind of Wild West situation with the PHR,” said Dr. Peter Basch, an internist and medical director for eHealth at MedStar Health, a seven-hospital system in Washington and Baltimore.

Currently, two types of records are dominant—those that are linked to a physician's or health system's electronic health record, and free-standing records, Dr. Basch said.

With connected PHRs, patients can usually access subsets of their medical data and communicate with their physicians' offices on selected matters such as scheduling appointments. With a free-standing PHR, patients generally have greater control of the data that are entered and over who can access the data. The market is more mature now in terms of connected PHRs, especially those that are linked to large medical groups and large health systems, Dr. Basch said.

In an effort to tame some of the variability in the market, Health Level Seven Inc. (HL7), a national organization that sets health information technology standards, has released a proposed personal health record standard. In August, HL7 unveiled its Personal Health Record System Functional Model, and sought public comments.

The HL7 general model can be customized so that it can be used with each of the various PHR models available in the marketplace. A vote is expected later this year on whether the PHR functional model will become an approved standard.

Another possible way to accelerate the development of the personal health record market is through the Certification Commission for Healthcare Information Technology (CCHIT), a body that already certifies ambulatory and inpatient electronic health record systems.

The CCHIT is looking at the area of personal health records, according to its chairman, Dr. Mark Leavitt. However, any certification of PHR products would be at least a year away, since the CCHIT has not developed certification criteria in that area. Although the PHR industry is still in its early stages, it is not necessary to wait for the industry to fully mature before developing certification criteria. In fact, setting standards early can be helpful, Dr. Leavitt said.

The PHR marketplace may get a boost from the CCHIT long before a PHR certification process gets started, he added. Through its electronic health record certification process, the CCHIT is requiring that records have the capability to send patient summary information, which would be helpful in populating a patient's PHR.

Many factors are driving the growth of PHRs. Employer groups, frustrated with escalating health costs, represent one faction pushing for PHR development. While the evidence is not yet in, the theory is that PHRs would allow patients to be better consumers, potentially saving employers money, Dr. Basch said.

Health insurers also are getting into the act. For example, Aetna recently announced that starting in January 2008, federal enrollees in any of the company's medical plans will have access to a password-protected online PHR. The record would include claims information on physician office visits, labs, diagnoses, treatment, and prescriptions. Even Medicare is testing the PHR field. In June, Medicare launched a pilot program to allow certain beneficiaries to access a PHR through participating Medicare Advantage and Part D drug plans.

There also are some patients who care deeply about having PHRs because they are managing chronic conditions for themselves or family members, Dr. Basch said.

Even if most consumers are not clamoring for PHRs, when surveyed, they do favor the concept. In a November 2006 survey commissioned by the Markle Foundation, nearly two-thirds of the 1,003 adults polled said they would like to access their medical information electronically, and 72% of those under age 40 said they would like to access their health information online.

But consumers who were surveyed also had significant concerns about the privacy and security of their records. For example, 80% said they were very concerned about identity theft, and 77% said they were very concerned about their medical information being used for marketing purposes.

Concerns about security and privacy are shared by physicians. With a free-standing PHR, physicians could receive requests from patients to populate their data, but they might be reluctant to send such sensitive data in an unsecured way or in a way that could compromise the security of their own electronic systems, Dr. Basch said.

An even more complicated question for physicians is what to do with information they receive from a PHR that may be entered or edited by the patient. If patients are restricting PHR content from their physicians, it could limit the utility of the record, said Dr. Michael Barr, vice president for practice advocacy and improvement at the American College of Physicians.

While the ACP has been supportive of the development of PHRs, the different PHR models have different implications for the physician-patient relationship and for office workflow, he said.

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage to every Maine resident by 2009.

While the program has seen success in targeting subsidies to low-income individuals, it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

"The implementation can be just as difficult as actually passing the law," said Debra J. Lipson, lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and targeted the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 individuals.

But the program has fallen short of those expectations and of as of September 2006, had enrolled about 11,100 individuals in DirigoChoice. About 5,000 individuals were enrolled in the MaineCare expansion. An additional 18,100 individuals were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicates that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as is in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Other states considering similar programs may need to offer stronger incentives to encourage employers to offer coverage and help with employee costs, the researchers wrote.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start and has not been able to generate enough revenue, according to the Commonwealth Fund report.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. While the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as "politically unsustainable in its current form," according to the report.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured individuals has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted. States are likely to be more successful if they have lower health care costs, greater price competition among health plans, or strong regulation that holds down premiums, the researchers concluded.

The full report is available online at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage to every Maine resident by 2009.

While the program has seen success in targeting subsidies to low-income individuals, it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

"The implementation can be just as difficult as actually passing the law," said Debra J. Lipson, lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and targeted the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 individuals.

But the program has fallen short of those expectations and of as of September 2006, had enrolled about 11,100 individuals in DirigoChoice. About 5,000 individuals were enrolled in the MaineCare expansion. An additional 18,100 individuals were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicates that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as is in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Other states considering similar programs may need to offer stronger incentives to encourage employers to offer coverage and help with employee costs, the researchers wrote.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start and has not been able to generate enough revenue, according to the Commonwealth Fund report.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. While the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as "politically unsustainable in its current form," according to the report.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured individuals has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted. States are likely to be more successful if they have lower health care costs, greater price competition among health plans, or strong regulation that holds down premiums, the researchers concluded.

The full report is available online at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage to every Maine resident by 2009.

While the program has seen success in targeting subsidies to low-income individuals, it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

"The implementation can be just as difficult as actually passing the law," said Debra J. Lipson, lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington, D.C.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and targeted the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 individuals.

But the program has fallen short of those expectations and of as of September 2006, had enrolled about 11,100 individuals in DirigoChoice. About 5,000 individuals were enrolled in the MaineCare expansion. An additional 18,100 individuals were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicates that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as is in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Other states considering similar programs may need to offer stronger incentives to encourage employers to offer coverage and help with employee costs, the researchers wrote.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start and has not been able to generate enough revenue, according to the Commonwealth Fund report.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. While the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as "politically unsustainable in its current form," according to the report.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured individuals has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted. States are likely to be more successful if they have lower health care costs, greater price competition among health plans, or strong regulation that holds down premiums, the researchers concluded.

The full report is available online at www.mathematica-mpr.com/health/dirigochoice.asp