Mary Ellen Schneider

The number of Americans without health insurance reached 47 million last year, up from 44.8 million in 2005, according to new data released by the U.S. Census Bureau.

The percentage of individuals without health insurance also rose from 15.3% in 2005 to 15.8% in 2006.

This rise includes an increase in the number of uninsured children.

The percentage and number of children under the age of 18 years without health insurance increased from 8 million (10.9%) in 2005 to 8.7 million (11.7%) in 2006. Much of the increase in the uninsured rate for children can be attributed to a decline in private coverage, David Johnson, chief of the division of housing and household economic statistics at the Census Bureau, said during a news conference.

Overall, the percentage of individuals covered by any type of private insurance plan dropped from 68.5% in 2005 to 67.9% in 2006. And among children, the percentage with private coverage fell from 65.8% in 2005 to 64.6% in 2006, Mr. Johnson said.

At the same time, coverage by government insurance was also down from 27.3% in 2005 to 27% in 2006. The data are compiled from the 2007 Current Population Survey Annual Social and Economic Supplement.

The increase in the number of uninsured individuals between 2005 and 2006 is “pretty shocking,” said Karen Davis, Ph.D., president of The Commonwealth Fund, especially in a year when states have been under less financial pressure and when many have been trying to expand coverage.

The deterioration of dependent coverage among private plans is particularly disturbing and points to the importance of reauthorizing the State Children's Health Insurance Program (SCHIP) with adequate funding, she said.

The number and percentage of uninsured children had been falling consistently between 1998 and 2004, but that progress began to reverse in 2005, said Robert Greenstein, who is executive director of the Center on Budget and Policy Priorities.

These latest data from the Census Bureau show that the country is “losing significant ground” in the effort to insure children, he said, and he called on President Bush to rethink his position on funding for SCHIP.

The number of Americans without health insurance reached 47 million last year, up from 44.8 million in 2005, according to new data released by the U.S. Census Bureau.

The percentage of individuals without health insurance also rose from 15.3% in 2005 to 15.8% in 2006.

This rise includes an increase in the number of uninsured children.

The percentage and number of children under the age of 18 years without health insurance increased from 8 million (10.9%) in 2005 to 8.7 million (11.7%) in 2006. Much of the increase in the uninsured rate for children can be attributed to a decline in private coverage, David Johnson, chief of the division of housing and household economic statistics at the Census Bureau, said during a news conference.

Overall, the percentage of individuals covered by any type of private insurance plan dropped from 68.5% in 2005 to 67.9% in 2006. And among children, the percentage with private coverage fell from 65.8% in 2005 to 64.6% in 2006, Mr. Johnson said.

At the same time, coverage by government insurance was also down from 27.3% in 2005 to 27% in 2006. The data are compiled from the 2007 Current Population Survey Annual Social and Economic Supplement.

The increase in the number of uninsured individuals between 2005 and 2006 is “pretty shocking,” said Karen Davis, Ph.D., president of The Commonwealth Fund, especially in a year when states have been under less financial pressure and when many have been trying to expand coverage.

The deterioration of dependent coverage among private plans is particularly disturbing and points to the importance of reauthorizing the State Children's Health Insurance Program (SCHIP) with adequate funding, she said.

The number and percentage of uninsured children had been falling consistently between 1998 and 2004, but that progress began to reverse in 2005, said Robert Greenstein, who is executive director of the Center on Budget and Policy Priorities.

These latest data from the Census Bureau show that the country is “losing significant ground” in the effort to insure children, he said, and he called on President Bush to rethink his position on funding for SCHIP.

The number of Americans without health insurance reached 47 million last year, up from 44.8 million in 2005, according to new data released by the U.S. Census Bureau.

The percentage of individuals without health insurance also rose from 15.3% in 2005 to 15.8% in 2006.

This rise includes an increase in the number of uninsured children.

The percentage and number of children under the age of 18 years without health insurance increased from 8 million (10.9%) in 2005 to 8.7 million (11.7%) in 2006. Much of the increase in the uninsured rate for children can be attributed to a decline in private coverage, David Johnson, chief of the division of housing and household economic statistics at the Census Bureau, said during a news conference.

Overall, the percentage of individuals covered by any type of private insurance plan dropped from 68.5% in 2005 to 67.9% in 2006. And among children, the percentage with private coverage fell from 65.8% in 2005 to 64.6% in 2006, Mr. Johnson said.

At the same time, coverage by government insurance was also down from 27.3% in 2005 to 27% in 2006. The data are compiled from the 2007 Current Population Survey Annual Social and Economic Supplement.

The increase in the number of uninsured individuals between 2005 and 2006 is “pretty shocking,” said Karen Davis, Ph.D., president of The Commonwealth Fund, especially in a year when states have been under less financial pressure and when many have been trying to expand coverage.

The deterioration of dependent coverage among private plans is particularly disturbing and points to the importance of reauthorizing the State Children's Health Insurance Program (SCHIP) with adequate funding, she said.

The number and percentage of uninsured children had been falling consistently between 1998 and 2004, but that progress began to reverse in 2005, said Robert Greenstein, who is executive director of the Center on Budget and Policy Priorities.

These latest data from the Census Bureau show that the country is “losing significant ground” in the effort to insure children, he said, and he called on President Bush to rethink his position on funding for SCHIP.

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh.

That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention.

When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program–Operation Safety Net–has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. The meeting, sponsored by GlaxoSmithKline Inc. and the Robert Wood Johnson Foundation, aims to bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless.

The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is “growing very rapidly,” said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Interested in reaching out to the homeless population not being housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches.

With this entrée into the community, Dr. Withers began to offer his medical services. “I really had this vision of going and getting out under the bridges,” he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other primary care services. “There's a huge amount of hypertension on the streets,” he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care, Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi “Mimi” Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif.

“We're always sticking to the principle that every person should have a personal medical home,” she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dr. Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go out into the streets to identify homeless people in need of medical care and to walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther away from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. “We're trying to fill in the gaps,” she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. “We look at homelessness as a chronic disaster.”

For those involved, the time can be very rewarding. “It's very inspiring work,” Dr. Doohan said. “It reminds us of why we got into medicine in the first place.”

Once volunteers get involved in street medicine, they are usually hooked, said Dr. David M. Deci, a family physician at West Virginia University, Morgantown, and faculty adviser for MUSHROOM (Multidisciplinary Unsheltered Homeless Relief Outreach of Morgantown).

“In part, it really validates us as physicians,” Dr. Deci said. “You do what you can. You're not constrained by time.”

MUSHROOM, a student-run initiative, began in 2005. The medical students had heard about Dr. Wither's Operation Safety Net and wanted to do their part locally. After a few months of training and consultation with Dr. Withers, they started making rounds in Morgantown.

The students linked up with formerly homeless individuals in the community as well as the local mental health agency to help establish their credibility on the streets.

From the start, the program was designed purely by students, Dr. Deci said. It continues to be run and managed by students, who handle everything from inventory and volunteers to policy development. They make street rounds every other week.

“You're not there to change people, but to validate them as human beings worthy of quality care,” Dr. Deci said.

The role of all the volunteers in the program is to provide care, but also respect, he said.

Dr. Deci counseled patience for those physicians who want to reach out to unsheltered homeless individuals. These new patients may be skeptical of your involvement at first, but if you show up consistently they will eventually come around, he said.

Starting small is also important. Although Dr. Deci and his students would like to be making street rounds every night, they have settled on going out once every 2 weeks so they can provide a consistent presence.

The challenges of providing care on the street are numerous, from record keeping to obtaining malpractice coverage. But Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding. The work is a great service for the homeless people living on the street, he said, but it's an even greater service for the physicians, nurses, and others who volunteer their time.

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org

Dr. Jim Withers (left) brings medicine to the streets as part of Operation Safety Net, an outreach program he started in 1992. Mercy Hospital/Operation Safety Net

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh.

That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention.

When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program–Operation Safety Net–has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. The meeting, sponsored by GlaxoSmithKline Inc. and the Robert Wood Johnson Foundation, aims to bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless.

The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is “growing very rapidly,” said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Interested in reaching out to the homeless population not being housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches.

With this entrée into the community, Dr. Withers began to offer his medical services. “I really had this vision of going and getting out under the bridges,” he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other primary care services. “There's a huge amount of hypertension on the streets,” he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care, Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi “Mimi” Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif.

“We're always sticking to the principle that every person should have a personal medical home,” she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dr. Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go out into the streets to identify homeless people in need of medical care and to walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther away from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. “We're trying to fill in the gaps,” she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. “We look at homelessness as a chronic disaster.”

For those involved, the time can be very rewarding. “It's very inspiring work,” Dr. Doohan said. “It reminds us of why we got into medicine in the first place.”

Once volunteers get involved in street medicine, they are usually hooked, said Dr. David M. Deci, a family physician at West Virginia University, Morgantown, and faculty adviser for MUSHROOM (Multidisciplinary Unsheltered Homeless Relief Outreach of Morgantown).

“In part, it really validates us as physicians,” Dr. Deci said. “You do what you can. You're not constrained by time.”

MUSHROOM, a student-run initiative, began in 2005. The medical students had heard about Dr. Wither's Operation Safety Net and wanted to do their part locally. After a few months of training and consultation with Dr. Withers, they started making rounds in Morgantown.

The students linked up with formerly homeless individuals in the community as well as the local mental health agency to help establish their credibility on the streets.

From the start, the program was designed purely by students, Dr. Deci said. It continues to be run and managed by students, who handle everything from inventory and volunteers to policy development. They make street rounds every other week.

“You're not there to change people, but to validate them as human beings worthy of quality care,” Dr. Deci said.

The role of all the volunteers in the program is to provide care, but also respect, he said.

Dr. Deci counseled patience for those physicians who want to reach out to unsheltered homeless individuals. These new patients may be skeptical of your involvement at first, but if you show up consistently they will eventually come around, he said.

Starting small is also important. Although Dr. Deci and his students would like to be making street rounds every night, they have settled on going out once every 2 weeks so they can provide a consistent presence.

The challenges of providing care on the street are numerous, from record keeping to obtaining malpractice coverage. But Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding. The work is a great service for the homeless people living on the street, he said, but it's an even greater service for the physicians, nurses, and others who volunteer their time.

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org

Dr. Jim Withers (left) brings medicine to the streets as part of Operation Safety Net, an outreach program he started in 1992. Mercy Hospital/Operation Safety Net

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh.

That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention.

When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program–Operation Safety Net–has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. The meeting, sponsored by GlaxoSmithKline Inc. and the Robert Wood Johnson Foundation, aims to bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless.

The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is “growing very rapidly,” said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Interested in reaching out to the homeless population not being housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches.

With this entrée into the community, Dr. Withers began to offer his medical services. “I really had this vision of going and getting out under the bridges,” he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other primary care services. “There's a huge amount of hypertension on the streets,” he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care, Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi “Mimi” Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif.

“We're always sticking to the principle that every person should have a personal medical home,” she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dr. Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go out into the streets to identify homeless people in need of medical care and to walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther away from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. “We're trying to fill in the gaps,” she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. “We look at homelessness as a chronic disaster.”

For those involved, the time can be very rewarding. “It's very inspiring work,” Dr. Doohan said. “It reminds us of why we got into medicine in the first place.”

Once volunteers get involved in street medicine, they are usually hooked, said Dr. David M. Deci, a family physician at West Virginia University, Morgantown, and faculty adviser for MUSHROOM (Multidisciplinary Unsheltered Homeless Relief Outreach of Morgantown).

“In part, it really validates us as physicians,” Dr. Deci said. “You do what you can. You're not constrained by time.”

MUSHROOM, a student-run initiative, began in 2005. The medical students had heard about Dr. Wither's Operation Safety Net and wanted to do their part locally. After a few months of training and consultation with Dr. Withers, they started making rounds in Morgantown.

The students linked up with formerly homeless individuals in the community as well as the local mental health agency to help establish their credibility on the streets.

From the start, the program was designed purely by students, Dr. Deci said. It continues to be run and managed by students, who handle everything from inventory and volunteers to policy development. They make street rounds every other week.

“You're not there to change people, but to validate them as human beings worthy of quality care,” Dr. Deci said.

The role of all the volunteers in the program is to provide care, but also respect, he said.

Dr. Deci counseled patience for those physicians who want to reach out to unsheltered homeless individuals. These new patients may be skeptical of your involvement at first, but if you show up consistently they will eventually come around, he said.

Starting small is also important. Although Dr. Deci and his students would like to be making street rounds every night, they have settled on going out once every 2 weeks so they can provide a consistent presence.

The challenges of providing care on the street are numerous, from record keeping to obtaining malpractice coverage. But Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding. The work is a great service for the homeless people living on the street, he said, but it's an even greater service for the physicians, nurses, and others who volunteer their time.

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org

Dr. Jim Withers (left) brings medicine to the streets as part of Operation Safety Net, an outreach program he started in 1992. Mercy Hospital/Operation Safety Net

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh. That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention.

When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program—Operation Safety Net—has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. The meeting, sponsored by GlaxoSmithKline Inc. and the Robert Wood Johnson Foundation, aims to bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless.

The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is "growing very rapidly," said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Interested in reaching out to the homeless population not being housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches.

With this entrée into the community, Dr. Withers began to offer his medical services. "I really had this vision of going and getting out under the bridges," he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other services. "There's a huge amount of hypertension on the streets," he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care, Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi "Mimi" Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif.

"We're always sticking to the principle that every person should have a personal medical home," she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dr. Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go out into the streets to identify homeless people in need of medical care and walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther away from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. "We're trying to fill in the gaps," she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. "We look at homelessness as a chronic disaster."

For those involved, the time can be very rewarding. "It's very inspiring work," Dr. Doohan said. "It reminds us of why we got into medicine in the first place."

There are a number of challenges to providing care on the street, from record keeping to obtaining malpractice coverage, but Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding.

Dr. Jim Withers (left) brings medicine to the streets as part of Operation Safety Net, an outreach program for the homeless. Mercy Hospital/Operation Safety Net

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh. That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention.

When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program—Operation Safety Net—has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. The meeting, sponsored by GlaxoSmithKline Inc. and the Robert Wood Johnson Foundation, aims to bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless.

The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is "growing very rapidly," said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Interested in reaching out to the homeless population not being housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches.

With this entrée into the community, Dr. Withers began to offer his medical services. "I really had this vision of going and getting out under the bridges," he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other services. "There's a huge amount of hypertension on the streets," he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care, Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi "Mimi" Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif.

"We're always sticking to the principle that every person should have a personal medical home," she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dr. Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go out into the streets to identify homeless people in need of medical care and walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther away from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. "We're trying to fill in the gaps," she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. "We look at homelessness as a chronic disaster."

For those involved, the time can be very rewarding. "It's very inspiring work," Dr. Doohan said. "It reminds us of why we got into medicine in the first place."

There are a number of challenges to providing care on the street, from record keeping to obtaining malpractice coverage, but Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding.

Dr. Jim Withers (left) brings medicine to the streets as part of Operation Safety Net, an outreach program for the homeless. Mercy Hospital/Operation Safety Net

For more information about street medicine programs or the International Street Medicine Symposium, visit www.streetmedicine.org

Dr. Jim Withers is a familiar sight on the nighttime streets of Pittsburgh. That's because for the last 15 years he's been leaving the hospital behind to seek out unsheltered homeless people in need of medical attention.

When he started in 1992, dressed down and carrying a small backpack of medical supplies, he had to work hard to earn the trust of the homeless individuals he met. Today he's well known among his patients, and the reputation of his program—Operation Safety Net—has grown across the country and around the world.

In October, Dr. Withers will be among a group of physicians and nurses from the United States, Europe, and Asia who will gather in Houston for the third annual International Street Medicine Symposium. The meeting, sponsored by GlaxoSmithKline Inc. and the Robert Wood Johnson Foundation, aims to bring together health care providers who care for the hard-to-reach group known as the unsheltered homeless.

The meeting is a chance for street medicine providers to compare notes and swap ideas about fund-raising, outreach, and malpractice coverage.

The field is "growing very rapidly," said Dr. Withers, who, in addition to his role as director of Operation Safety Net, teaches internal medicine at Mercy Hospital in Pittsburgh.

Operation Safety Net has been the inspiration for programs in other cities. When it began in 1992, Dr. Withers was its sole physician. Interested in reaching out to the homeless population not being housed in shelters, he teamed up with a formerly homeless man who made frequent trips back to the street to distribute sleeping bags and sandwiches.

With this entrée into the community, Dr. Withers began to offer his medical services. "I really had this vision of going and getting out under the bridges," he said.

Months went by before he finally confessed his nighttime efforts to the CEO of his hospital. To his surprise, she embraced the idea immediately and sought to find ways that the hospital could aid his project. With that official backing, Dr. Withers quickly expanded his efforts with more volunteers and even a program administrator to keep things running at the office.

Out on the street, many medical needs can be met immediately, he said. For example, Dr. Withers and his team often treat wounds and burns, provide antibiotics, perform general skin care, and offer other services. "There's a huge amount of hypertension on the streets," he said.

But although there's a lot he can do for his homeless patients on the spot, the idea is not to be their only source of care, Dr. Withers said.

The goal is always to move people into more traditional health care settings, agreed Dr. Noemi "Mimi" Doohan, codirector of Doctors Without Walls in Santa Barbara, Calif.

"We're always sticking to the principle that every person should have a personal medical home," she said.

Dr. Doohan, a family physician who cofounded the Santa Barbara program with internist Dr. Dennis Baker, modeled her program on the work being done by Dr. Withers in Pittsburgh.

Doctors Without Walls began in 2005 and includes not only street medicine, but also care to the homeless in shelters, in the hospital, and at respite sites. So far, Dr. Doohan and her team of volunteers have focused on the Isla Vista neighborhood, considered something of a student ghetto with a stable, unsheltered, chronic homeless population.

The neighborhood already has an excellent not-for-profit clinic, so Dr. Doohan and her team don't try to duplicate those services. Instead, they go out into the streets to identify homeless people in need of medical care and walk them into the clinic where they can receive that care; if needed, they arrange for transfer to higher levels of care. This year, they plan to expand the program into areas farther away from the clinic and to provide care on the street.

One of the keys to their success has been working with the existing programs and agencies that provide services to the homeless, she said. Dr. Doohan and her team can provide more mobile and flexible care, but they try to ensure that their services build on what is already available. "We're trying to fill in the gaps," she said.

Since 2005, the program has survived on a shoestring budget and the work of its completely voluntary staff.

But one of the challenges the program has faced is a sense among local physicians that there aren't medical volunteer opportunities in their own hometown. Dr. Doohan is trying to get the message out that working with the homeless can be as rewarding as going to a distant disaster area. "We look at homelessness as a chronic disaster."

For those involved, the time can be very rewarding. "It's very inspiring work," Dr. Doohan said. "It reminds us of why we got into medicine in the first place."

There are a number of challenges to providing care on the street, from record keeping to obtaining malpractice coverage, but Dr. Withers said he has found that many of his volunteers like to do it simply because it's rewarding.

Dr. Jim Withers (left) brings medicine to the streets as part of Operation Safety Net, an outreach program for the homeless. Mercy Hospital/Operation Safety Net

Cost-containment strategies, such as tiered drug plans, reduce overall prescription drug utilization and increase the use of generics, according to an analysis of prescription drug use by Medicare-eligible retirees.

But even with decreased utilization, individuals enrolled in three-tiered drug plans, which charge higher copayments for certain medications, spent more money out of pocket than did individuals enrolled in single-tiered plans.

The study, conducted by researchers at Mathematica Policy Research Inc. and RTI International, included 352,760 Medicare beneficiaries with employer-sponsored drug coverage and dependent spouses aged 65 or older. The researchers analyzed five employer-sponsored drug plans: two with a single copayment tier, and three with a three-tiered structure.

The study is further confirmation that the retiree population is sensitive to price, Boyd H. Gilman, Ph.D., one of the study authors and a senior researcher at the Cambridge, Mass., office of Mathematica, said in an interview.

"They do respond to price, but we don't know what that means in terms of health outcomes," he said.

On average, individuals in single-tiered plans filled 46 prescriptions a year, compared with 38 prescriptions among those enrolled in three-tiered plans. But enrollees in singled-tiered plans used fewer generics, the researchers found.

Nearly 39% of the drugs purchased under single-tier plans were generics, compared with nearly 44% in three-tiered plans. Both findings were statistically significant.

The average annual expenditures by the drug plan per enrollee were higher in single-tiered plans, whereas enrollee out-of-pocket costs were higher among those enrolled in three-tiered drug plans, despite their lower drug utilization.

Drug plans spent about $1,943 per individual in single-tiered plans, versus $1,354 in three-tiered plans. Individuals enrolled in single-tier plans spent about $245 a year, compared with $469 spent by individuals enrolled in multitiered plans. These results were also statistically significant.

When they examined trends among individuals who filled prescriptions for chronic conditions, the researchers found that cost containment strategies had less of an effect on prescription drug use. Total expenditures and the number of prescriptions filled were still lower among beneficiaries enrolled in three-tiered plans, but to a lesser extent than when these individuals filled prescriptions for episodic care.

The findings were published online in the journal Health Services Research (Health Serv. Res. 2007 Sept. 11 [Epub doi:10.1111/j.1475-6773.2007.00774.x]). The study was funded by an internal grant from RTI International.

Cost-containment strategies, such as tiered drug plans, reduce overall prescription drug utilization and increase the use of generics, according to an analysis of prescription drug use by Medicare-eligible retirees.

But even with decreased utilization, individuals enrolled in three-tiered drug plans, which charge higher copayments for certain medications, spent more money out of pocket than did individuals enrolled in single-tiered plans.

The study, conducted by researchers at Mathematica Policy Research Inc. and RTI International, included 352,760 Medicare beneficiaries with employer-sponsored drug coverage and dependent spouses aged 65 or older. The researchers analyzed five employer-sponsored drug plans: two with a single copayment tier, and three with a three-tiered structure.

The study is further confirmation that the retiree population is sensitive to price, Boyd H. Gilman, Ph.D., one of the study authors and a senior researcher at the Cambridge, Mass., office of Mathematica, said in an interview.

"They do respond to price, but we don't know what that means in terms of health outcomes," he said.

On average, individuals in single-tiered plans filled 46 prescriptions a year, compared with 38 prescriptions among those enrolled in three-tiered plans. But enrollees in singled-tiered plans used fewer generics, the researchers found.

Nearly 39% of the drugs purchased under single-tier plans were generics, compared with nearly 44% in three-tiered plans. Both findings were statistically significant.

The average annual expenditures by the drug plan per enrollee were higher in single-tiered plans, whereas enrollee out-of-pocket costs were higher among those enrolled in three-tiered drug plans, despite their lower drug utilization.

Drug plans spent about $1,943 per individual in single-tiered plans, versus $1,354 in three-tiered plans. Individuals enrolled in single-tier plans spent about $245 a year, compared with $469 spent by individuals enrolled in multitiered plans. These results were also statistically significant.

When they examined trends among individuals who filled prescriptions for chronic conditions, the researchers found that cost containment strategies had less of an effect on prescription drug use. Total expenditures and the number of prescriptions filled were still lower among beneficiaries enrolled in three-tiered plans, but to a lesser extent than when these individuals filled prescriptions for episodic care.

The findings were published online in the journal Health Services Research (Health Serv. Res. 2007 Sept. 11 [Epub doi:10.1111/j.1475-6773.2007.00774.x]). The study was funded by an internal grant from RTI International.

Cost-containment strategies, such as tiered drug plans, reduce overall prescription drug utilization and increase the use of generics, according to an analysis of prescription drug use by Medicare-eligible retirees.

But even with decreased utilization, individuals enrolled in three-tiered drug plans, which charge higher copayments for certain medications, spent more money out of pocket than did individuals enrolled in single-tiered plans.

The study, conducted by researchers at Mathematica Policy Research Inc. and RTI International, included 352,760 Medicare beneficiaries with employer-sponsored drug coverage and dependent spouses aged 65 or older. The researchers analyzed five employer-sponsored drug plans: two with a single copayment tier, and three with a three-tiered structure.

The study is further confirmation that the retiree population is sensitive to price, Boyd H. Gilman, Ph.D., one of the study authors and a senior researcher at the Cambridge, Mass., office of Mathematica, said in an interview.

"They do respond to price, but we don't know what that means in terms of health outcomes," he said.

On average, individuals in single-tiered plans filled 46 prescriptions a year, compared with 38 prescriptions among those enrolled in three-tiered plans. But enrollees in singled-tiered plans used fewer generics, the researchers found.

Nearly 39% of the drugs purchased under single-tier plans were generics, compared with nearly 44% in three-tiered plans. Both findings were statistically significant.

The average annual expenditures by the drug plan per enrollee were higher in single-tiered plans, whereas enrollee out-of-pocket costs were higher among those enrolled in three-tiered drug plans, despite their lower drug utilization.

Drug plans spent about $1,943 per individual in single-tiered plans, versus $1,354 in three-tiered plans. Individuals enrolled in single-tier plans spent about $245 a year, compared with $469 spent by individuals enrolled in multitiered plans. These results were also statistically significant.

When they examined trends among individuals who filled prescriptions for chronic conditions, the researchers found that cost containment strategies had less of an effect on prescription drug use. Total expenditures and the number of prescriptions filled were still lower among beneficiaries enrolled in three-tiered plans, but to a lesser extent than when these individuals filled prescriptions for episodic care.

The findings were published online in the journal Health Services Research (Health Serv. Res. 2007 Sept. 11 [Epub doi:10.1111/j.1475-6773.2007.00774.x]). The study was funded by an internal grant from RTI International.

Medicare officials have launched a 2-year demonstration project aimed at preventing infusion fraud schemes in South Florida, where medical fraud has been on the rise.

Under the project, the Centers for Medicare and Medicaid Services is requiring infusion providers operating in several South Florida counties to reapply to be qualified Medicare infusion therapy providers. Those who fail to reapply within 30 days will have their Medicare billing privileges revoked.

Infusion therapy providers also will have their billing privileges revoked if they fail to report a change in ownership or have employees or owners who have committed a felony. Even those providers who reapply successfully may face increased scrutiny from CMS, including site visits.

"Prevention is the most important course here as we move to deal with those who are committing fraud against the program," Herb Kuhn, CMS acting deputy administrator, said during a press conference to announce the project.

The project is similar to other fraud prevention efforts recently launched by CMS. The agency is currently conducting demonstrations to root out fraudulent billing by durable medical equipment suppliers in South Florida and Southern California and among home health agencies in greater Los Angeles and Houston.

Although these projects focus on specific geographic areas, they provide a chance for CMS to test ideas that could be applicable across the country, Mr. Kuhn said, adding that he expects these projects to help the agency develop new tools to catch individuals if they try to relocate fraudulent schemes from one part of the country to another.

South Florida has already been the site of a string of prosecutions this year for fraud involving durable medical equipment and infusion therapy. Since March, the Department of Justice and the assistant U.S. attorneys from the Southern District of Florida have filed 47 indictments against individuals and entities that are alleged to have collectively billed Medicare more than $345 million in fraudulent charges.

The fraudulent billing comes in various forms. For example, in some cases the billing is done on behalf of fictional clinics or fictional patients. In other cases, patients may be infused with saline or another substance instead of the drug that is being billed to Medicare.

Medicare officials have launched a 2-year demonstration project aimed at preventing infusion fraud schemes in South Florida, where medical fraud has been on the rise.

Under the project, the Centers for Medicare and Medicaid Services is requiring infusion providers operating in several South Florida counties to reapply to be qualified Medicare infusion therapy providers. Those who fail to reapply within 30 days will have their Medicare billing privileges revoked.

Infusion therapy providers also will have their billing privileges revoked if they fail to report a change in ownership or have employees or owners who have committed a felony. Even those providers who reapply successfully may face increased scrutiny from CMS, including site visits.

"Prevention is the most important course here as we move to deal with those who are committing fraud against the program," Herb Kuhn, CMS acting deputy administrator, said during a press conference to announce the project.

The project is similar to other fraud prevention efforts recently launched by CMS. The agency is currently conducting demonstrations to root out fraudulent billing by durable medical equipment suppliers in South Florida and Southern California and among home health agencies in greater Los Angeles and Houston.

Although these projects focus on specific geographic areas, they provide a chance for CMS to test ideas that could be applicable across the country, Mr. Kuhn said, adding that he expects these projects to help the agency develop new tools to catch individuals if they try to relocate fraudulent schemes from one part of the country to another.

South Florida has already been the site of a string of prosecutions this year for fraud involving durable medical equipment and infusion therapy. Since March, the Department of Justice and the assistant U.S. attorneys from the Southern District of Florida have filed 47 indictments against individuals and entities that are alleged to have collectively billed Medicare more than $345 million in fraudulent charges.

The fraudulent billing comes in various forms. For example, in some cases the billing is done on behalf of fictional clinics or fictional patients. In other cases, patients may be infused with saline or another substance instead of the drug that is being billed to Medicare.

Medicare officials have launched a 2-year demonstration project aimed at preventing infusion fraud schemes in South Florida, where medical fraud has been on the rise.

Under the project, the Centers for Medicare and Medicaid Services is requiring infusion providers operating in several South Florida counties to reapply to be qualified Medicare infusion therapy providers. Those who fail to reapply within 30 days will have their Medicare billing privileges revoked.

Infusion therapy providers also will have their billing privileges revoked if they fail to report a change in ownership or have employees or owners who have committed a felony. Even those providers who reapply successfully may face increased scrutiny from CMS, including site visits.

"Prevention is the most important course here as we move to deal with those who are committing fraud against the program," Herb Kuhn, CMS acting deputy administrator, said during a press conference to announce the project.

The project is similar to other fraud prevention efforts recently launched by CMS. The agency is currently conducting demonstrations to root out fraudulent billing by durable medical equipment suppliers in South Florida and Southern California and among home health agencies in greater Los Angeles and Houston.

Although these projects focus on specific geographic areas, they provide a chance for CMS to test ideas that could be applicable across the country, Mr. Kuhn said, adding that he expects these projects to help the agency develop new tools to catch individuals if they try to relocate fraudulent schemes from one part of the country to another.

South Florida has already been the site of a string of prosecutions this year for fraud involving durable medical equipment and infusion therapy. Since March, the Department of Justice and the assistant U.S. attorneys from the Southern District of Florida have filed 47 indictments against individuals and entities that are alleged to have collectively billed Medicare more than $345 million in fraudulent charges.

The fraudulent billing comes in various forms. For example, in some cases the billing is done on behalf of fictional clinics or fictional patients. In other cases, patients may be infused with saline or another substance instead of the drug that is being billed to Medicare.

The full report is available online at www.ama-assn.org/go/disasterpreparedness

Public health systems need more federal funding to respond to both day-to-day emergencies and mass-casualty events, according to disaster preparedness recommendations released by a coalition of 18 health organizations.

The coalition, which was led by the American Medical Association and the American Public Health Association, issued a report with 53 recommendations aimed at leaders in medicine and government. Other coalition members include the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Surgeons. The project was funded under a cooperative agreement from the Centers for Disease Control and Prevention.

“The only thing we can probably predict with any certainty about terrorism attacks and other mass casualty events is this—we're not going to know the time, location, and magnitude in advance,” Dr. Ronald M. Davis, AMA president, said at a press conference. “But we have no excuse if our responses aren't known in advance.”

The report identifies nine critical areas needing immediate action, including:

▸ Increased federal funding should be allocated to expand emergency medical, trauma care, and disaster health preparedness systems across the country.

▸ Governmental entities and health systems must develop and evaluate processes to ensure a return to readiness for routine health care and future mass casualty events following a disaster.

▸ Funding for economic recovery after a disaster must emphasize the reestablishment of public health and health care systems.

▸ The Institute of Medicine should perform a comprehensive study of health system surge capacity.

▸ Emergency and disaster preparedness must be integrated with public health and health care systems nationwide to provide effective emergency and trauma care.

▸ Public health and health care officials must participate directly in disaster preparedness planning, mitigation, response, and recovery operations.

▸ Health disaster communications and health information exchange networks must be fully integrated and interoperable at every level of government and health systems.

▸ The government, health systems, and professional organizations should develop and distribute information on the management of adult and pediatric patients in day-to-day emergencies and catastrophic events.

▸ Public health and health care responders must be given adequate legal protections for providing care during a disaster.

The full report is available online at www.ama-assn.org/go/disasterpreparedness

Public health systems need more federal funding to respond to both day-to-day emergencies and mass-casualty events, according to disaster preparedness recommendations released by a coalition of 18 health organizations.

The coalition, which was led by the American Medical Association and the American Public Health Association, issued a report with 53 recommendations aimed at leaders in medicine and government. Other coalition members include the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Surgeons. The project was funded under a cooperative agreement from the Centers for Disease Control and Prevention.

“The only thing we can probably predict with any certainty about terrorism attacks and other mass casualty events is this—we're not going to know the time, location, and magnitude in advance,” Dr. Ronald M. Davis, AMA president, said at a press conference. “But we have no excuse if our responses aren't known in advance.”

The report identifies nine critical areas needing immediate action, including:

▸ Increased federal funding should be allocated to expand emergency medical, trauma care, and disaster health preparedness systems across the country.

▸ Governmental entities and health systems must develop and evaluate processes to ensure a return to readiness for routine health care and future mass casualty events following a disaster.

▸ Funding for economic recovery after a disaster must emphasize the reestablishment of public health and health care systems.

▸ The Institute of Medicine should perform a comprehensive study of health system surge capacity.

▸ Emergency and disaster preparedness must be integrated with public health and health care systems nationwide to provide effective emergency and trauma care.

▸ Public health and health care officials must participate directly in disaster preparedness planning, mitigation, response, and recovery operations.

▸ Health disaster communications and health information exchange networks must be fully integrated and interoperable at every level of government and health systems.

▸ The government, health systems, and professional organizations should develop and distribute information on the management of adult and pediatric patients in day-to-day emergencies and catastrophic events.

▸ Public health and health care responders must be given adequate legal protections for providing care during a disaster.

The full report is available online at www.ama-assn.org/go/disasterpreparedness

Public health systems need more federal funding to respond to both day-to-day emergencies and mass-casualty events, according to disaster preparedness recommendations released by a coalition of 18 health organizations.

The coalition, which was led by the American Medical Association and the American Public Health Association, issued a report with 53 recommendations aimed at leaders in medicine and government. Other coalition members include the American Academy of Pediatrics, the American College of Emergency Physicians, and the American College of Surgeons. The project was funded under a cooperative agreement from the Centers for Disease Control and Prevention.

“The only thing we can probably predict with any certainty about terrorism attacks and other mass casualty events is this—we're not going to know the time, location, and magnitude in advance,” Dr. Ronald M. Davis, AMA president, said at a press conference. “But we have no excuse if our responses aren't known in advance.”

The report identifies nine critical areas needing immediate action, including:

▸ Increased federal funding should be allocated to expand emergency medical, trauma care, and disaster health preparedness systems across the country.

▸ Governmental entities and health systems must develop and evaluate processes to ensure a return to readiness for routine health care and future mass casualty events following a disaster.

▸ Funding for economic recovery after a disaster must emphasize the reestablishment of public health and health care systems.

▸ The Institute of Medicine should perform a comprehensive study of health system surge capacity.

▸ Emergency and disaster preparedness must be integrated with public health and health care systems nationwide to provide effective emergency and trauma care.

▸ Public health and health care officials must participate directly in disaster preparedness planning, mitigation, response, and recovery operations.

▸ Health disaster communications and health information exchange networks must be fully integrated and interoperable at every level of government and health systems.

▸ The government, health systems, and professional organizations should develop and distribute information on the management of adult and pediatric patients in day-to-day emergencies and catastrophic events.

▸ Public health and health care responders must be given adequate legal protections for providing care during a disaster.

Women Lack Cholesterol Knowledge

Despite the best intentions to manage their cholesterol, fewer than a third of women know their cholesterol levels, according to a survey commissioned by the Society for Women's Health Research. The survey found that women are aware of the health risks of cholesterol. For example, 85% of women know that high cholesterol can lead to stroke. However, about 36% of women did not know that high cholesterol has no symptoms and nearly half of the women surveyed were not familiar with terms such as LDL and HDL cholesterol. “Clearly, strides have been made in educating women on the risks of high cholesterol, but the disconnect between awareness and action needs to be addressed,” Phyllis Greenberger, president and CEO of the Society for Women's Health Research, said in a statement. The telephone survey included 524 adult American women.

Including Women in Research

The participation of women in clinical trials is essential to understanding how medical conditions and therapies affect men and women differently, according to a committee opinion from the American College of Obstetricians and Gynecologists. In the opinion, the ACOG Committee on Ethics outlined a number of recommendations for including women, and in particular pregnant women, in research trials. For example, the committee recommended that researchers evaluate protocols for their potential impact on both the woman and the fetus and make that evaluation part of the informed consent process. The committee also advised that only the informed consent of the pregnant woman is necessary for research. However, informed consent must be obtained from the father when federal regulations require it for research that could benefit the fetus only. The ACOG statement is an update to a committee opinion on research involving women, which was published in 2004. The committee opinion was published in the September issue of Obstetrics & Gynecology.

Distributing HPV Vaccine

The 7,500 publicly funded family planning clinics around the country may be a natural fit for providing education about the human papillomavirus (HPV) vaccine and distributing it, according to an analysis by the Guttmacher Institute. These clinics reach a large number of reproductive-age women and in particular those at high risk. In 2002, one-third of women aged 15–24 years who obtained reproductive health services received that care at a family planning clinic. “Clinics are an especially important source of health information and services for low-income women and minority women, who are at particularly great risk of developing and dying from cervical cancer,” Rachel Benson Gold, the article author, said in a statement. However, these clinics will also face some challenges if they try to provide the HPV vaccine and related counseling, Ms. Gold wrote. Cost is one potential barrier. The three-shot regimen costs about $300 per individual, even with the discount provided to clinics. In addition, family planning clinics will have to decide what population to offer the vaccine to and how to ensure that women return for all three shots. The analysis, which appeared in the summer issue of the Guttmacher Policy Review, was supported by a grant from the Ford Foundation.

Infant Mortality Drops Slightly

The infant mortality rate was 6.79 per 1,000 births in 2004, a less than 1% drop from 2003, according to final 2004 data released by the Centers for Disease Control and Prevention. The small decrease in infant mortality was not statistically significant. With the exception of 2002, the infant mortality rate has decreased or remained steady from 1958 through 2004, according to CDC. In 2004, the 10 leading causes of infant death were congenital malformations, low birth weight, sudden infant death syndrome, maternal complications, unintentional injuries, cord and placental complications, respiratory diseases of the newborn, bacterial sepsis of the newborn, neonatal hemorrhage, and circulatory diseases. These 10 causes accounted for more than 68% of infant deaths in the United States in 2004.

Small Practices Fall to One in Three

Physicians are shying away from solo and two-physician practices, according to a new report from the Center for Studying Health System Change. Although these small practices are still the most common practice arrangements, between 1996–1997 and 2004–2005 researchers saw a shift from solo and two-person practices to midsized, single-specialty groups of 6–50 physicians. The percentage of physicians who practiced in solo and two-person practices fell from 41% in 1996–1997 to 33% in 2004–2005. During the same time period, the percentage of physicians practicing in midsized groups rose from 13% to 18%. The biggest declines in physicians choosing small practices have come from medical specialists and surgical specialists, whereas the proportion of primary care physicians in small practices has remained steady at about 36%. “Physicians appear to be organizing in larger, single-specialty practices that present enhanced opportunities to offer more profitable ancillary services rather than organizing in ways that support coordination of care,” Paul B. Ginsburg, Ph.D., president of the Center for Studying Health System Change, said in a statement. The report's findings are based on the group's nationally representative Community Tracking Study Physician Survey.

Women Lack Cholesterol Knowledge

Despite the best intentions to manage their cholesterol, fewer than a third of women know their cholesterol levels, according to a survey commissioned by the Society for Women's Health Research. The survey found that women are aware of the health risks of cholesterol. For example, 85% of women know that high cholesterol can lead to stroke. However, about 36% of women did not know that high cholesterol has no symptoms and nearly half of the women surveyed were not familiar with terms such as LDL and HDL cholesterol. “Clearly, strides have been made in educating women on the risks of high cholesterol, but the disconnect between awareness and action needs to be addressed,” Phyllis Greenberger, president and CEO of the Society for Women's Health Research, said in a statement. The telephone survey included 524 adult American women.

Including Women in Research

The participation of women in clinical trials is essential to understanding how medical conditions and therapies affect men and women differently, according to a committee opinion from the American College of Obstetricians and Gynecologists. In the opinion, the ACOG Committee on Ethics outlined a number of recommendations for including women, and in particular pregnant women, in research trials. For example, the committee recommended that researchers evaluate protocols for their potential impact on both the woman and the fetus and make that evaluation part of the informed consent process. The committee also advised that only the informed consent of the pregnant woman is necessary for research. However, informed consent must be obtained from the father when federal regulations require it for research that could benefit the fetus only. The ACOG statement is an update to a committee opinion on research involving women, which was published in 2004. The committee opinion was published in the September issue of Obstetrics & Gynecology.

Distributing HPV Vaccine

The 7,500 publicly funded family planning clinics around the country may be a natural fit for providing education about the human papillomavirus (HPV) vaccine and distributing it, according to an analysis by the Guttmacher Institute. These clinics reach a large number of reproductive-age women and in particular those at high risk. In 2002, one-third of women aged 15–24 years who obtained reproductive health services received that care at a family planning clinic. “Clinics are an especially important source of health information and services for low-income women and minority women, who are at particularly great risk of developing and dying from cervical cancer,” Rachel Benson Gold, the article author, said in a statement. However, these clinics will also face some challenges if they try to provide the HPV vaccine and related counseling, Ms. Gold wrote. Cost is one potential barrier. The three-shot regimen costs about $300 per individual, even with the discount provided to clinics. In addition, family planning clinics will have to decide what population to offer the vaccine to and how to ensure that women return for all three shots. The analysis, which appeared in the summer issue of the Guttmacher Policy Review, was supported by a grant from the Ford Foundation.

Infant Mortality Drops Slightly

The infant mortality rate was 6.79 per 1,000 births in 2004, a less than 1% drop from 2003, according to final 2004 data released by the Centers for Disease Control and Prevention. The small decrease in infant mortality was not statistically significant. With the exception of 2002, the infant mortality rate has decreased or remained steady from 1958 through 2004, according to CDC. In 2004, the 10 leading causes of infant death were congenital malformations, low birth weight, sudden infant death syndrome, maternal complications, unintentional injuries, cord and placental complications, respiratory diseases of the newborn, bacterial sepsis of the newborn, neonatal hemorrhage, and circulatory diseases. These 10 causes accounted for more than 68% of infant deaths in the United States in 2004.

Small Practices Fall to One in Three

Physicians are shying away from solo and two-physician practices, according to a new report from the Center for Studying Health System Change. Although these small practices are still the most common practice arrangements, between 1996–1997 and 2004–2005 researchers saw a shift from solo and two-person practices to midsized, single-specialty groups of 6–50 physicians. The percentage of physicians who practiced in solo and two-person practices fell from 41% in 1996–1997 to 33% in 2004–2005. During the same time period, the percentage of physicians practicing in midsized groups rose from 13% to 18%. The biggest declines in physicians choosing small practices have come from medical specialists and surgical specialists, whereas the proportion of primary care physicians in small practices has remained steady at about 36%. “Physicians appear to be organizing in larger, single-specialty practices that present enhanced opportunities to offer more profitable ancillary services rather than organizing in ways that support coordination of care,” Paul B. Ginsburg, Ph.D., president of the Center for Studying Health System Change, said in a statement. The report's findings are based on the group's nationally representative Community Tracking Study Physician Survey.

Women Lack Cholesterol Knowledge

Despite the best intentions to manage their cholesterol, fewer than a third of women know their cholesterol levels, according to a survey commissioned by the Society for Women's Health Research. The survey found that women are aware of the health risks of cholesterol. For example, 85% of women know that high cholesterol can lead to stroke. However, about 36% of women did not know that high cholesterol has no symptoms and nearly half of the women surveyed were not familiar with terms such as LDL and HDL cholesterol. “Clearly, strides have been made in educating women on the risks of high cholesterol, but the disconnect between awareness and action needs to be addressed,” Phyllis Greenberger, president and CEO of the Society for Women's Health Research, said in a statement. The telephone survey included 524 adult American women.

Including Women in Research

The participation of women in clinical trials is essential to understanding how medical conditions and therapies affect men and women differently, according to a committee opinion from the American College of Obstetricians and Gynecologists. In the opinion, the ACOG Committee on Ethics outlined a number of recommendations for including women, and in particular pregnant women, in research trials. For example, the committee recommended that researchers evaluate protocols for their potential impact on both the woman and the fetus and make that evaluation part of the informed consent process. The committee also advised that only the informed consent of the pregnant woman is necessary for research. However, informed consent must be obtained from the father when federal regulations require it for research that could benefit the fetus only. The ACOG statement is an update to a committee opinion on research involving women, which was published in 2004. The committee opinion was published in the September issue of Obstetrics & Gynecology.

Distributing HPV Vaccine

The 7,500 publicly funded family planning clinics around the country may be a natural fit for providing education about the human papillomavirus (HPV) vaccine and distributing it, according to an analysis by the Guttmacher Institute. These clinics reach a large number of reproductive-age women and in particular those at high risk. In 2002, one-third of women aged 15–24 years who obtained reproductive health services received that care at a family planning clinic. “Clinics are an especially important source of health information and services for low-income women and minority women, who are at particularly great risk of developing and dying from cervical cancer,” Rachel Benson Gold, the article author, said in a statement. However, these clinics will also face some challenges if they try to provide the HPV vaccine and related counseling, Ms. Gold wrote. Cost is one potential barrier. The three-shot regimen costs about $300 per individual, even with the discount provided to clinics. In addition, family planning clinics will have to decide what population to offer the vaccine to and how to ensure that women return for all three shots. The analysis, which appeared in the summer issue of the Guttmacher Policy Review, was supported by a grant from the Ford Foundation.

Infant Mortality Drops Slightly

The infant mortality rate was 6.79 per 1,000 births in 2004, a less than 1% drop from 2003, according to final 2004 data released by the Centers for Disease Control and Prevention. The small decrease in infant mortality was not statistically significant. With the exception of 2002, the infant mortality rate has decreased or remained steady from 1958 through 2004, according to CDC. In 2004, the 10 leading causes of infant death were congenital malformations, low birth weight, sudden infant death syndrome, maternal complications, unintentional injuries, cord and placental complications, respiratory diseases of the newborn, bacterial sepsis of the newborn, neonatal hemorrhage, and circulatory diseases. These 10 causes accounted for more than 68% of infant deaths in the United States in 2004.

Small Practices Fall to One in Three

Physicians are shying away from solo and two-physician practices, according to a new report from the Center for Studying Health System Change. Although these small practices are still the most common practice arrangements, between 1996–1997 and 2004–2005 researchers saw a shift from solo and two-person practices to midsized, single-specialty groups of 6–50 physicians. The percentage of physicians who practiced in solo and two-person practices fell from 41% in 1996–1997 to 33% in 2004–2005. During the same time period, the percentage of physicians practicing in midsized groups rose from 13% to 18%. The biggest declines in physicians choosing small practices have come from medical specialists and surgical specialists, whereas the proportion of primary care physicians in small practices has remained steady at about 36%. “Physicians appear to be organizing in larger, single-specialty practices that present enhanced opportunities to offer more profitable ancillary services rather than organizing in ways that support coordination of care,” Paul B. Ginsburg, Ph.D., president of the Center for Studying Health System Change, said in a statement. The report's findings are based on the group's nationally representative Community Tracking Study Physician Survey.

Medicare officials have launched a 2-year demonstration project aimed at preventing infusion fraud schemes in South Florida, where medical fraud has been on the rise.

Under the project, the Centers for Medicare and Medicaid Services is requiring infusion providers operating in several South Florida counties to reapply to be qualified Medicare infusion therapy providers.

Those who fail to reapply within 30 days will have their Medicare billing privileges revoked.

Infusion therapy providers also will have their billing privileges revoked if they fail to report a change in ownership or have employees or owners who have committed a felony. Even those providers who reapply successfully may face increased scrutiny from CMS, including site visits.

“Prevention is the most important course here as we move to deal with those who are committing fraud against the program,” Herb Kuhn, CMS acting deputy administrator, said during a press briefing to announce the demonstration project.

The infusion fraud project is similar to other fraud prevention efforts recently launched by CMS. The agency is currently conducting demonstrations to root out fraudulent billing by durable medical equipment suppliers in South Florida and Southern California and among home health agencies in greater Los Angeles and Houston.

Although these projects focus on specific geographic areas, they provide a chance for CMS to test ideas that could be applicable across the country, Mr. Kuhn said, adding that he expects these projects to help the agency develop new tools to catch individuals if they try to relocate fraudulent schemes from one part of the country to another.

South Florida has already been the site of a string of prosecutions this year for fraud involving durable medical equipment and infusion therapy. Since March, the Department of Justice and the assistant U.S. attorneys from the Southern District of Florida have filed 47 indictments against individuals and entities that are alleged to have collectively billed Medicare more than $345 million in fraudulent charges.

“Health care fraud here in South Florida is a substantial problem,” said R. Alexander Acosta, U.S. Attorney for the Southern District of Florida.

The fraudulent billing submitted to Medicare can come in a number of forms.

For example, in some cases the billing is done on behalf of fictional clinics or fictional patients.

In other cases, patients may be infused with saline or another substance instead of the drug that is being billed to Medicare.

ELSEVIER GLOBAL MEDICAL NEWS

Medicare officials have launched a 2-year demonstration project aimed at preventing infusion fraud schemes in South Florida, where medical fraud has been on the rise.

Under the project, the Centers for Medicare and Medicaid Services is requiring infusion providers operating in several South Florida counties to reapply to be qualified Medicare infusion therapy providers.

Those who fail to reapply within 30 days will have their Medicare billing privileges revoked.

Infusion therapy providers also will have their billing privileges revoked if they fail to report a change in ownership or have employees or owners who have committed a felony. Even those providers who reapply successfully may face increased scrutiny from CMS, including site visits.

“Prevention is the most important course here as we move to deal with those who are committing fraud against the program,” Herb Kuhn, CMS acting deputy administrator, said during a press briefing to announce the demonstration project.

The infusion fraud project is similar to other fraud prevention efforts recently launched by CMS. The agency is currently conducting demonstrations to root out fraudulent billing by durable medical equipment suppliers in South Florida and Southern California and among home health agencies in greater Los Angeles and Houston.

Although these projects focus on specific geographic areas, they provide a chance for CMS to test ideas that could be applicable across the country, Mr. Kuhn said, adding that he expects these projects to help the agency develop new tools to catch individuals if they try to relocate fraudulent schemes from one part of the country to another.

South Florida has already been the site of a string of prosecutions this year for fraud involving durable medical equipment and infusion therapy. Since March, the Department of Justice and the assistant U.S. attorneys from the Southern District of Florida have filed 47 indictments against individuals and entities that are alleged to have collectively billed Medicare more than $345 million in fraudulent charges.

“Health care fraud here in South Florida is a substantial problem,” said R. Alexander Acosta, U.S. Attorney for the Southern District of Florida.

The fraudulent billing submitted to Medicare can come in a number of forms.

For example, in some cases the billing is done on behalf of fictional clinics or fictional patients.

In other cases, patients may be infused with saline or another substance instead of the drug that is being billed to Medicare.

ELSEVIER GLOBAL MEDICAL NEWS

Medicare officials have launched a 2-year demonstration project aimed at preventing infusion fraud schemes in South Florida, where medical fraud has been on the rise.

Under the project, the Centers for Medicare and Medicaid Services is requiring infusion providers operating in several South Florida counties to reapply to be qualified Medicare infusion therapy providers.

Those who fail to reapply within 30 days will have their Medicare billing privileges revoked.

Infusion therapy providers also will have their billing privileges revoked if they fail to report a change in ownership or have employees or owners who have committed a felony. Even those providers who reapply successfully may face increased scrutiny from CMS, including site visits.

“Prevention is the most important course here as we move to deal with those who are committing fraud against the program,” Herb Kuhn, CMS acting deputy administrator, said during a press briefing to announce the demonstration project.

The infusion fraud project is similar to other fraud prevention efforts recently launched by CMS. The agency is currently conducting demonstrations to root out fraudulent billing by durable medical equipment suppliers in South Florida and Southern California and among home health agencies in greater Los Angeles and Houston.

Although these projects focus on specific geographic areas, they provide a chance for CMS to test ideas that could be applicable across the country, Mr. Kuhn said, adding that he expects these projects to help the agency develop new tools to catch individuals if they try to relocate fraudulent schemes from one part of the country to another.

South Florida has already been the site of a string of prosecutions this year for fraud involving durable medical equipment and infusion therapy. Since March, the Department of Justice and the assistant U.S. attorneys from the Southern District of Florida have filed 47 indictments against individuals and entities that are alleged to have collectively billed Medicare more than $345 million in fraudulent charges.

“Health care fraud here in South Florida is a substantial problem,” said R. Alexander Acosta, U.S. Attorney for the Southern District of Florida.

The fraudulent billing submitted to Medicare can come in a number of forms.

For example, in some cases the billing is done on behalf of fictional clinics or fictional patients.

In other cases, patients may be infused with saline or another substance instead of the drug that is being billed to Medicare.

ELSEVIER GLOBAL MEDICAL NEWS

This summer, Massachusetts residents were required to sign up for health insurance coverage or face financial penalties as the state began implementation of its landmark health reform initiative.

But some patients are now finding that obtaining insurance coverage doesn't guarantee access to a physician in a state where there are significant physician shortages in primary care and several specialties.

In a recent study of the state's physician workforce, the Massachusetts Medical Society found that there is a “critical” shortage of internists and a “severe” shortage of family physicians. Seven other specialties—anesthesiology, cardiology, gastroenterology, neurosurgery, psychiatry, urology, and vascular surgery—are also facing either critical or severe shortages, the study found.

The primary care shortages are of special concern since the state's requirement to have health insurance is based on the premise of access to care, said Brian Rosman, research director for Health Care for All, a Massachusetts-based advocacy group.

The group has already heard sporadic reports of access problems from individuals who recently enrolled in insurance programs, Mr. Rosman said. They have also heard complaints about long wait times for an appointment and closed practice panels.

“People are really frustrated, and frankly we're not able to help them,” he said.

The workforce study points to some reasons why patients are having access problems. About 70% of physicians said their practices were having difficulty filling physician vacancies; the same percentage said the pool of physician applicants is inadequate, according to a survey of 1,295 practicing physicians that was conducted as part of the workforce study.

The report also noted that internal medicine appointments are becoming harder to get.

This year 51% of internists are accepting new patients, down from 64% in 2006, according to a telephone survey of 600 physician offices across the state. In addition, the average wait time among internal medicine physicians who are accepting new patients is 52 days, compared with 33 days in 2006, the survey revealed.

This is the second year in a row that the Massachusetts Medical Society has documented significant shortages in primary care, and shortages in neurosurgery, anesthesiology, cardiology, and gastroenterology have been ongoing for the past 5 years or more.

But this year the shortages occur against the backdrop of a much-anticipated health reform effort in the state.

With the passage of a 2006 law, Massachusetts is requiring that all residents who can afford to do so obtain health insurance. Further, the state has expanded access to Medicaid, is offering subsidized health plans to some residents, and is requiring employers to pay a portion of their employees' premiums or face a penalty.

As of July 2007, adults in the state must carry health insurance that meets minimum standards. If the requirement is not met by the end of the year, individuals will lose their personal exemption when filing their 2007 state personal income taxes, amounting to a penalty of about $219. Penalties will increase significantly in 2008.

Before the implementation of the health reform legislation, Massachusetts had about 372,000 residents without health insurance, according to the Commonwealth Connector, the state agency that administers the law.

As of mid-July, the state estimated that more than 155,000 residents were newly insured.

Even before the final health reform legislation was passed, there were discussions among legislators and health policy experts about access issues, Mr. Rosman said. But the consensus at the time was that even with physician shortages, it would be better to provide insurance to more individuals. “There are no quick solutions,” he said. “There are no cheap solutions.”

Health Care for All has called for the creation of a state commission to examine primary care and to investigate potential strategies for improving physician recruitment—student loan forgiveness, for example.

While there have been localized areas of access problems, most individuals are able to get an appointment to see a physician, said Dr. Marylou Buyse, president and CEO of the Massachusetts Association of Health Plans and a primary care physician in West Roxbury.

Even if some practices have long wait times for an appointment, patients can seek out other physicians, she said. The health plans, for their part, are ready and willing to work with individuals to find available doctors. “None of us want to see people insured and not be able to get care,” Dr. Buyse said.

But even without an additional 100,000 or more individuals potentially seeking primary care treatment, physicians say the system is under stress because of other factors.

The lack of professional liability reform in the state, implementation of costly pay-for-performance programs, and administrative hassles like prior authorizations are all taking their toll on practicing physicians, according to the report from the Massachusetts Medical Society. Add to that high housing costs and generally low reimbursement rates and many physicians are concerned that the state could be facing an even deeper erosion of its primary care system.

The reports of a shortage are no surprise to Dr. Dennis Dimitri, vice chair of the department of family medicine and community health at the University of Massachusetts in Worcester. Some family physicians on the university's medical staff are so busy that they have closed their practices to new patients, he said. And recruiting new physicians has been difficult.

He has even heard of instances in which local community health centers, the traditional safety net providers, have had to temporarily close their practices to new patients because of understaffing, Dr. Dimitri said.

Much of the problem comes down to how payments are aligned on a national level. The health care system disproportionately rewards procedural medicine instead of preventive services, said Dr. Dimitri, who is also president-elect of the Massachusetts Academy of Family Physicians.

“That plays a huge role in medical student choices,” he said.

When medical students finish school facing a six-figure educational debt, they are less likely to choose a lower-earning primary care practice, Dr. Dimitri pointed out.

States such as Massachusetts have been trying to deal with the problem locally, he said, but a national approach will likely be necessary with the federal government taking a hard look at how it reimburses for physician services.

“This crisis is going to be upon us in the next 5 years in a way that no one has previously anticipated,” Dr. Dimitri remarked.

Payment is the bottom line, agreed Dr. Barry Izenstein, governor of the Massachusetts chapter of the American College of Physicians and an endocrinologist in Springfield.

Medical students will continue to be attracted to procedural specialties as long as the payers continue to pay for volume of services and procedures, he said.

While medical student debt reform is an important short-term solution, it will only provide a patch for the system.

In the long term, the entire payment system needs to be reformed.

Policy makers will need to consider new approaches, such as the patient-centered medical home, which has been endorsed by a number of primary care societies, he said.

ELSEVIER GLOBAL MEDICAL NEWS

This summer, Massachusetts residents were required to sign up for health insurance coverage or face financial penalties as the state began implementation of its landmark health reform initiative.

But some patients are now finding that obtaining insurance coverage doesn't guarantee access to a physician in a state where there are significant physician shortages in primary care and several specialties.

In a recent study of the state's physician workforce, the Massachusetts Medical Society found that there is a “critical” shortage of internists and a “severe” shortage of family physicians. Seven other specialties—anesthesiology, cardiology, gastroenterology, neurosurgery, psychiatry, urology, and vascular surgery—are also facing either critical or severe shortages, the study found.

The primary care shortages are of special concern since the state's requirement to have health insurance is based on the premise of access to care, said Brian Rosman, research director for Health Care for All, a Massachusetts-based advocacy group.

The group has already heard sporadic reports of access problems from individuals who recently enrolled in insurance programs, Mr. Rosman said. They have also heard complaints about long wait times for an appointment and closed practice panels.

“People are really frustrated, and frankly we're not able to help them,” he said.

The workforce study points to some reasons why patients are having access problems. About 70% of physicians said their practices were having difficulty filling physician vacancies; the same percentage said the pool of physician applicants is inadequate, according to a survey of 1,295 practicing physicians that was conducted as part of the workforce study.

The report also noted that internal medicine appointments are becoming harder to get.

This year 51% of internists are accepting new patients, down from 64% in 2006, according to a telephone survey of 600 physician offices across the state. In addition, the average wait time among internal medicine physicians who are accepting new patients is 52 days, compared with 33 days in 2006, the survey revealed.

This is the second year in a row that the Massachusetts Medical Society has documented significant shortages in primary care, and shortages in neurosurgery, anesthesiology, cardiology, and gastroenterology have been ongoing for the past 5 years or more.

But this year the shortages occur against the backdrop of a much-anticipated health reform effort in the state.

With the passage of a 2006 law, Massachusetts is requiring that all residents who can afford to do so obtain health insurance. Further, the state has expanded access to Medicaid, is offering subsidized health plans to some residents, and is requiring employers to pay a portion of their employees' premiums or face a penalty.

As of July 2007, adults in the state must carry health insurance that meets minimum standards. If the requirement is not met by the end of the year, individuals will lose their personal exemption when filing their 2007 state personal income taxes, amounting to a penalty of about $219. Penalties will increase significantly in 2008.

Before the implementation of the health reform legislation, Massachusetts had about 372,000 residents without health insurance, according to the Commonwealth Connector, the state agency that administers the law.

As of mid-July, the state estimated that more than 155,000 residents were newly insured.

Even before the final health reform legislation was passed, there were discussions among legislators and health policy experts about access issues, Mr. Rosman said. But the consensus at the time was that even with physician shortages, it would be better to provide insurance to more individuals. “There are no quick solutions,” he said. “There are no cheap solutions.”

Health Care for All has called for the creation of a state commission to examine primary care and to investigate potential strategies for improving physician recruitment—student loan forgiveness, for example.

While there have been localized areas of access problems, most individuals are able to get an appointment to see a physician, said Dr. Marylou Buyse, president and CEO of the Massachusetts Association of Health Plans and a primary care physician in West Roxbury.

Even if some practices have long wait times for an appointment, patients can seek out other physicians, she said. The health plans, for their part, are ready and willing to work with individuals to find available doctors. “None of us want to see people insured and not be able to get care,” Dr. Buyse said.

But even without an additional 100,000 or more individuals potentially seeking primary care treatment, physicians say the system is under stress because of other factors.

The lack of professional liability reform in the state, implementation of costly pay-for-performance programs, and administrative hassles like prior authorizations are all taking their toll on practicing physicians, according to the report from the Massachusetts Medical Society. Add to that high housing costs and generally low reimbursement rates and many physicians are concerned that the state could be facing an even deeper erosion of its primary care system.

The reports of a shortage are no surprise to Dr. Dennis Dimitri, vice chair of the department of family medicine and community health at the University of Massachusetts in Worcester. Some family physicians on the university's medical staff are so busy that they have closed their practices to new patients, he said. And recruiting new physicians has been difficult.

He has even heard of instances in which local community health centers, the traditional safety net providers, have had to temporarily close their practices to new patients because of understaffing, Dr. Dimitri said.

Much of the problem comes down to how payments are aligned on a national level. The health care system disproportionately rewards procedural medicine instead of preventive services, said Dr. Dimitri, who is also president-elect of the Massachusetts Academy of Family Physicians.

“That plays a huge role in medical student choices,” he said.

When medical students finish school facing a six-figure educational debt, they are less likely to choose a lower-earning primary care practice, Dr. Dimitri pointed out.

States such as Massachusetts have been trying to deal with the problem locally, he said, but a national approach will likely be necessary with the federal government taking a hard look at how it reimburses for physician services.

“This crisis is going to be upon us in the next 5 years in a way that no one has previously anticipated,” Dr. Dimitri remarked.

Payment is the bottom line, agreed Dr. Barry Izenstein, governor of the Massachusetts chapter of the American College of Physicians and an endocrinologist in Springfield.

Medical students will continue to be attracted to procedural specialties as long as the payers continue to pay for volume of services and procedures, he said.

While medical student debt reform is an important short-term solution, it will only provide a patch for the system.

In the long term, the entire payment system needs to be reformed.

Policy makers will need to consider new approaches, such as the patient-centered medical home, which has been endorsed by a number of primary care societies, he said.

ELSEVIER GLOBAL MEDICAL NEWS

This summer, Massachusetts residents were required to sign up for health insurance coverage or face financial penalties as the state began implementation of its landmark health reform initiative.

But some patients are now finding that obtaining insurance coverage doesn't guarantee access to a physician in a state where there are significant physician shortages in primary care and several specialties.

In a recent study of the state's physician workforce, the Massachusetts Medical Society found that there is a “critical” shortage of internists and a “severe” shortage of family physicians. Seven other specialties—anesthesiology, cardiology, gastroenterology, neurosurgery, psychiatry, urology, and vascular surgery—are also facing either critical or severe shortages, the study found.

The primary care shortages are of special concern since the state's requirement to have health insurance is based on the premise of access to care, said Brian Rosman, research director for Health Care for All, a Massachusetts-based advocacy group.

The group has already heard sporadic reports of access problems from individuals who recently enrolled in insurance programs, Mr. Rosman said. They have also heard complaints about long wait times for an appointment and closed practice panels.

“People are really frustrated, and frankly we're not able to help them,” he said.

The workforce study points to some reasons why patients are having access problems. About 70% of physicians said their practices were having difficulty filling physician vacancies; the same percentage said the pool of physician applicants is inadequate, according to a survey of 1,295 practicing physicians that was conducted as part of the workforce study.

The report also noted that internal medicine appointments are becoming harder to get.

This year 51% of internists are accepting new patients, down from 64% in 2006, according to a telephone survey of 600 physician offices across the state. In addition, the average wait time among internal medicine physicians who are accepting new patients is 52 days, compared with 33 days in 2006, the survey revealed.

This is the second year in a row that the Massachusetts Medical Society has documented significant shortages in primary care, and shortages in neurosurgery, anesthesiology, cardiology, and gastroenterology have been ongoing for the past 5 years or more.

But this year the shortages occur against the backdrop of a much-anticipated health reform effort in the state.

With the passage of a 2006 law, Massachusetts is requiring that all residents who can afford to do so obtain health insurance. Further, the state has expanded access to Medicaid, is offering subsidized health plans to some residents, and is requiring employers to pay a portion of their employees' premiums or face a penalty.

As of July 2007, adults in the state must carry health insurance that meets minimum standards. If the requirement is not met by the end of the year, individuals will lose their personal exemption when filing their 2007 state personal income taxes, amounting to a penalty of about $219. Penalties will increase significantly in 2008.

Before the implementation of the health reform legislation, Massachusetts had about 372,000 residents without health insurance, according to the Commonwealth Connector, the state agency that administers the law.

As of mid-July, the state estimated that more than 155,000 residents were newly insured.

Even before the final health reform legislation was passed, there were discussions among legislators and health policy experts about access issues, Mr. Rosman said. But the consensus at the time was that even with physician shortages, it would be better to provide insurance to more individuals. “There are no quick solutions,” he said. “There are no cheap solutions.”

Health Care for All has called for the creation of a state commission to examine primary care and to investigate potential strategies for improving physician recruitment—student loan forgiveness, for example.

While there have been localized areas of access problems, most individuals are able to get an appointment to see a physician, said Dr. Marylou Buyse, president and CEO of the Massachusetts Association of Health Plans and a primary care physician in West Roxbury.

Even if some practices have long wait times for an appointment, patients can seek out other physicians, she said. The health plans, for their part, are ready and willing to work with individuals to find available doctors. “None of us want to see people insured and not be able to get care,” Dr. Buyse said.

But even without an additional 100,000 or more individuals potentially seeking primary care treatment, physicians say the system is under stress because of other factors.

The lack of professional liability reform in the state, implementation of costly pay-for-performance programs, and administrative hassles like prior authorizations are all taking their toll on practicing physicians, according to the report from the Massachusetts Medical Society. Add to that high housing costs and generally low reimbursement rates and many physicians are concerned that the state could be facing an even deeper erosion of its primary care system.

The reports of a shortage are no surprise to Dr. Dennis Dimitri, vice chair of the department of family medicine and community health at the University of Massachusetts in Worcester. Some family physicians on the university's medical staff are so busy that they have closed their practices to new patients, he said. And recruiting new physicians has been difficult.

He has even heard of instances in which local community health centers, the traditional safety net providers, have had to temporarily close their practices to new patients because of understaffing, Dr. Dimitri said.

Much of the problem comes down to how payments are aligned on a national level. The health care system disproportionately rewards procedural medicine instead of preventive services, said Dr. Dimitri, who is also president-elect of the Massachusetts Academy of Family Physicians.

“That plays a huge role in medical student choices,” he said.

When medical students finish school facing a six-figure educational debt, they are less likely to choose a lower-earning primary care practice, Dr. Dimitri pointed out.

States such as Massachusetts have been trying to deal with the problem locally, he said, but a national approach will likely be necessary with the federal government taking a hard look at how it reimburses for physician services.

“This crisis is going to be upon us in the next 5 years in a way that no one has previously anticipated,” Dr. Dimitri remarked.

Payment is the bottom line, agreed Dr. Barry Izenstein, governor of the Massachusetts chapter of the American College of Physicians and an endocrinologist in Springfield.

Medical students will continue to be attracted to procedural specialties as long as the payers continue to pay for volume of services and procedures, he said.

While medical student debt reform is an important short-term solution, it will only provide a patch for the system.

In the long term, the entire payment system needs to be reformed.

Policy makers will need to consider new approaches, such as the patient-centered medical home, which has been endorsed by a number of primary care societies, he said.

ELSEVIER GLOBAL MEDICAL NEWS

The true impact isn't known yet, but an administrative change by the Centers for Medicare and Medicaid Services to rules governing the State Children's Health Insurance Program—made on a Friday night during Congress' August recess—may have the effect of dropping children who currently have coverage.

Sen. Jay Rockefeller (D-W.Va.), one of the original coauthors of SCHIP, sent a letter to President George W. Bush chiding the administration for making the change without congressional input.

“Not only do I question the wisdom and legality of this new policy, I also question the process,” wrote Sen. Rockefeller, noting that “a policy change of this magnitude should, at a minimum, be handled through the formal rule-making process, with proper public notice and comment, and not through unilateral subregulatory guidance.”

About 4 million children are eligible for Medicaid or SCHIP currently; some 6 million received benefits in 2006. An estimated 9 million children do not have health insurance.

SCHIP, now entering its 10th year, has been the subject of fierce battles this year, as lawmakers have struggled to come up with financing for the next 5 years that is palatable to both parties. Authorization for SCHIP expires Sept. 30. Before leaving for summer recess, the House and the Senate passed vastly different funding packages. (See box.)

President Bush said he would veto either bill, saying that he viewed both as a back-door way of expanding government-financed health care at the expense of the private insurance market.

So, the Aug. 17 letter from CMS Director for Medicaid and State Operations Dennis G. Smith to state health officials should not have come as a surprise. In the letter, states were told that if they were raising eligibility for children whose family incomes were equal to or above 250% of the federal poverty level, they would have to meet stringent new requirements. The goal: to ensure that these families aren't opting for SCHIP instead of private insurance.

“Existing regulations … provide that states must have 'reasonable procedures' to prevent substitution of public SCHIP coverage for private coverage,” wrote Mr. Smith.

Many states have had such procedures in place, but the CMS is now requiring that specific processes be implemented. For instance, children will have to be uninsured for at least 1 year before receiving SCHIP benefits. Currently, only Alaska requires a year-long exclusion, said Judy Solomon, a senior fellow with the Center on Budget and Policy Priorities, a Washington-based policy research organization. Most states impose a 1- to 6-month waiting period, but most also have generous exceptions to those rules.

Under the administrative change, states also will have to prove that they've enrolled at least 95% of children who are below 200% of the federal poverty level, and document that the number of low-income children who are eligible for and covered by private insurance has not dropped by more than 2% in the past 5 years.

States that have already increased their eligibility to 250% or more—18 states—will have to comply with the new requirements within a year or lose some of their federal matching funds.

The CMS said that the requirements should not harm children who currently receive benefits. “We would not expect any effect on current enrollees,” wrote Mr. Smith.

While it's not clear how many children might be dropped, “At the very least, you're going to have thousands of children unable to get coverage,” said Ms. Solomon, noting that the hurdles might be too high for new enrollees.

SCHIP was designed to give states flexibility to meet the needs of their own citizenry, noted Ms. Solomon. For instance, states with a higher cost of living and the ability to shoulder a higher fiscal burden—like New York, New Jersey, and Massachusetts—have increased income eligibility levels.

But the new CMS policy is severely diminishing that flexibility. “This turns back the clock,” said Ms. Solomon.

At presstime, the House and Senate were scheduled to meet in conference this month to determine the course of SCHIP over the next 5 years.

Senate and House SCHIP Bills Differ

In August, the Senate overwhelmingly passed S. 1893, which includes a $35-billion increase for SCHIP. The funds would come from an increase in the federal tobacco tax.

The approved House legislation (H.R. 3162), on the other hand, contains a number of provisions unrelated to SCHIP. For example, the bill would halt next year's planned 10% cut in the Medicare physician fee schedule, instead putting in a place a 0.5% increase for 2008 and another for 2009.

In terms of SCHIP funding, the House bill calls for a $50-billion increase in funding and would pay for it with both increases in the federal tobacco tax and cuts to subsidies given to Medicare Advantage plans.

The House bill also outlines a new physician payment structure under Medicare that would set a separate conversion factor for six service categories:

▸ Evaluation and management for primary care.

▸ Evaluation and management for other services.

▸ Imaging.

▸ Major procedures.

▸ Anesthesia services, and

▸ Minor procedures.

The proposed formula would also take prescription drugs out of the spending targets and would take into account Medicare coverage decisions when setting targets, according to Rich Trachtman, American College of Physicians legislative affairs director.

But the formula would still lead to deep payment cuts starting in 2010, so there is an understanding among legislators and leaders in medicine that the updates for 2010 and beyond would require additional action, Mr. Trachtman said.

But the American College of Cardiology expressed problems with the new structure for Medicare payments outlined in the House bill. The proposed payment structure would be based on a system of separate expenditure targets that ACC asserts would not take into account the appropriate growth in services, including many common cardiovascular services.

“While the ACC appreciates congressional efforts to stop Medicare physician payment cuts, it is critical that any new payment structure is fair to all physicians,” the ACC said in a statement.

The House bill also would codify protection for six drug classes under Medicare Part D. Starting in 2009, Medicare drug plans would be required to include all or substantially all Part D drugs in each of the following classes: anticonvulsants, antineoplastics, antiretrovirals, antidepressants, antipsychotics, and immunosuppressants.

The bill would also waive cost sharing for Medicare beneficiaries for certain preventive services including diabetes outpatient self-management training services, cardiovascular screening blood tests, diabetes screening tests, screening mammography, screening Pap smear and pelvic exam, and bone mass measurement.

The true impact isn't known yet, but an administrative change by the Centers for Medicare and Medicaid Services to rules governing the State Children's Health Insurance Program—made on a Friday night during Congress' August recess—may have the effect of dropping children who currently have coverage.

Sen. Jay Rockefeller (D-W.Va.), one of the original coauthors of SCHIP, sent a letter to President George W. Bush chiding the administration for making the change without congressional input.

“Not only do I question the wisdom and legality of this new policy, I also question the process,” wrote Sen. Rockefeller, noting that “a policy change of this magnitude should, at a minimum, be handled through the formal rule-making process, with proper public notice and comment, and not through unilateral subregulatory guidance.”

About 4 million children are eligible for Medicaid or SCHIP currently; some 6 million received benefits in 2006. An estimated 9 million children do not have health insurance.

SCHIP, now entering its 10th year, has been the subject of fierce battles this year, as lawmakers have struggled to come up with financing for the next 5 years that is palatable to both parties. Authorization for SCHIP expires Sept. 30. Before leaving for summer recess, the House and the Senate passed vastly different funding packages. (See box.)

President Bush said he would veto either bill, saying that he viewed both as a back-door way of expanding government-financed health care at the expense of the private insurance market.

So, the Aug. 17 letter from CMS Director for Medicaid and State Operations Dennis G. Smith to state health officials should not have come as a surprise. In the letter, states were told that if they were raising eligibility for children whose family incomes were equal to or above 250% of the federal poverty level, they would have to meet stringent new requirements. The goal: to ensure that these families aren't opting for SCHIP instead of private insurance.

“Existing regulations … provide that states must have 'reasonable procedures' to prevent substitution of public SCHIP coverage for private coverage,” wrote Mr. Smith.

Many states have had such procedures in place, but the CMS is now requiring that specific processes be implemented. For instance, children will have to be uninsured for at least 1 year before receiving SCHIP benefits. Currently, only Alaska requires a year-long exclusion, said Judy Solomon, a senior fellow with the Center on Budget and Policy Priorities, a Washington-based policy research organization. Most states impose a 1- to 6-month waiting period, but most also have generous exceptions to those rules.

Under the administrative change, states also will have to prove that they've enrolled at least 95% of children who are below 200% of the federal poverty level, and document that the number of low-income children who are eligible for and covered by private insurance has not dropped by more than 2% in the past 5 years.

States that have already increased their eligibility to 250% or more—18 states—will have to comply with the new requirements within a year or lose some of their federal matching funds.

The CMS said that the requirements should not harm children who currently receive benefits. “We would not expect any effect on current enrollees,” wrote Mr. Smith.

While it's not clear how many children might be dropped, “At the very least, you're going to have thousands of children unable to get coverage,” said Ms. Solomon, noting that the hurdles might be too high for new enrollees.

SCHIP was designed to give states flexibility to meet the needs of their own citizenry, noted Ms. Solomon. For instance, states with a higher cost of living and the ability to shoulder a higher fiscal burden—like New York, New Jersey, and Massachusetts—have increased income eligibility levels.

But the new CMS policy is severely diminishing that flexibility. “This turns back the clock,” said Ms. Solomon.

At presstime, the House and Senate were scheduled to meet in conference this month to determine the course of SCHIP over the next 5 years.

Senate and House SCHIP Bills Differ

In August, the Senate overwhelmingly passed S. 1893, which includes a $35-billion increase for SCHIP. The funds would come from an increase in the federal tobacco tax.

The approved House legislation (H.R. 3162), on the other hand, contains a number of provisions unrelated to SCHIP. For example, the bill would halt next year's planned 10% cut in the Medicare physician fee schedule, instead putting in a place a 0.5% increase for 2008 and another for 2009.

In terms of SCHIP funding, the House bill calls for a $50-billion increase in funding and would pay for it with both increases in the federal tobacco tax and cuts to subsidies given to Medicare Advantage plans.

The House bill also outlines a new physician payment structure under Medicare that would set a separate conversion factor for six service categories:

▸ Evaluation and management for primary care.

▸ Evaluation and management for other services.

▸ Imaging.

▸ Major procedures.

▸ Anesthesia services, and

▸ Minor procedures.

The proposed formula would also take prescription drugs out of the spending targets and would take into account Medicare coverage decisions when setting targets, according to Rich Trachtman, American College of Physicians legislative affairs director.

But the formula would still lead to deep payment cuts starting in 2010, so there is an understanding among legislators and leaders in medicine that the updates for 2010 and beyond would require additional action, Mr. Trachtman said.

But the American College of Cardiology expressed problems with the new structure for Medicare payments outlined in the House bill. The proposed payment structure would be based on a system of separate expenditure targets that ACC asserts would not take into account the appropriate growth in services, including many common cardiovascular services.

“While the ACC appreciates congressional efforts to stop Medicare physician payment cuts, it is critical that any new payment structure is fair to all physicians,” the ACC said in a statement.

The House bill also would codify protection for six drug classes under Medicare Part D. Starting in 2009, Medicare drug plans would be required to include all or substantially all Part D drugs in each of the following classes: anticonvulsants, antineoplastics, antiretrovirals, antidepressants, antipsychotics, and immunosuppressants.

The bill would also waive cost sharing for Medicare beneficiaries for certain preventive services including diabetes outpatient self-management training services, cardiovascular screening blood tests, diabetes screening tests, screening mammography, screening Pap smear and pelvic exam, and bone mass measurement.

The true impact isn't known yet, but an administrative change by the Centers for Medicare and Medicaid Services to rules governing the State Children's Health Insurance Program—made on a Friday night during Congress' August recess—may have the effect of dropping children who currently have coverage.

Sen. Jay Rockefeller (D-W.Va.), one of the original coauthors of SCHIP, sent a letter to President George W. Bush chiding the administration for making the change without congressional input.

“Not only do I question the wisdom and legality of this new policy, I also question the process,” wrote Sen. Rockefeller, noting that “a policy change of this magnitude should, at a minimum, be handled through the formal rule-making process, with proper public notice and comment, and not through unilateral subregulatory guidance.”

About 4 million children are eligible for Medicaid or SCHIP currently; some 6 million received benefits in 2006. An estimated 9 million children do not have health insurance.

SCHIP, now entering its 10th year, has been the subject of fierce battles this year, as lawmakers have struggled to come up with financing for the next 5 years that is palatable to both parties. Authorization for SCHIP expires Sept. 30. Before leaving for summer recess, the House and the Senate passed vastly different funding packages. (See box.)

President Bush said he would veto either bill, saying that he viewed both as a back-door way of expanding government-financed health care at the expense of the private insurance market.

So, the Aug. 17 letter from CMS Director for Medicaid and State Operations Dennis G. Smith to state health officials should not have come as a surprise. In the letter, states were told that if they were raising eligibility for children whose family incomes were equal to or above 250% of the federal poverty level, they would have to meet stringent new requirements. The goal: to ensure that these families aren't opting for SCHIP instead of private insurance.

“Existing regulations … provide that states must have 'reasonable procedures' to prevent substitution of public SCHIP coverage for private coverage,” wrote Mr. Smith.

Many states have had such procedures in place, but the CMS is now requiring that specific processes be implemented. For instance, children will have to be uninsured for at least 1 year before receiving SCHIP benefits. Currently, only Alaska requires a year-long exclusion, said Judy Solomon, a senior fellow with the Center on Budget and Policy Priorities, a Washington-based policy research organization. Most states impose a 1- to 6-month waiting period, but most also have generous exceptions to those rules.

Under the administrative change, states also will have to prove that they've enrolled at least 95% of children who are below 200% of the federal poverty level, and document that the number of low-income children who are eligible for and covered by private insurance has not dropped by more than 2% in the past 5 years.

States that have already increased their eligibility to 250% or more—18 states—will have to comply with the new requirements within a year or lose some of their federal matching funds.

The CMS said that the requirements should not harm children who currently receive benefits. “We would not expect any effect on current enrollees,” wrote Mr. Smith.

While it's not clear how many children might be dropped, “At the very least, you're going to have thousands of children unable to get coverage,” said Ms. Solomon, noting that the hurdles might be too high for new enrollees.

SCHIP was designed to give states flexibility to meet the needs of their own citizenry, noted Ms. Solomon. For instance, states with a higher cost of living and the ability to shoulder a higher fiscal burden—like New York, New Jersey, and Massachusetts—have increased income eligibility levels.

But the new CMS policy is severely diminishing that flexibility. “This turns back the clock,” said Ms. Solomon.

At presstime, the House and Senate were scheduled to meet in conference this month to determine the course of SCHIP over the next 5 years.

Senate and House SCHIP Bills Differ

In August, the Senate overwhelmingly passed S. 1893, which includes a $35-billion increase for SCHIP. The funds would come from an increase in the federal tobacco tax.

The approved House legislation (H.R. 3162), on the other hand, contains a number of provisions unrelated to SCHIP. For example, the bill would halt next year's planned 10% cut in the Medicare physician fee schedule, instead putting in a place a 0.5% increase for 2008 and another for 2009.

In terms of SCHIP funding, the House bill calls for a $50-billion increase in funding and would pay for it with both increases in the federal tobacco tax and cuts to subsidies given to Medicare Advantage plans.

The House bill also outlines a new physician payment structure under Medicare that would set a separate conversion factor for six service categories:

▸ Evaluation and management for primary care.

▸ Evaluation and management for other services.

▸ Imaging.

▸ Major procedures.

▸ Anesthesia services, and

▸ Minor procedures.

The proposed formula would also take prescription drugs out of the spending targets and would take into account Medicare coverage decisions when setting targets, according to Rich Trachtman, American College of Physicians legislative affairs director.

But the formula would still lead to deep payment cuts starting in 2010, so there is an understanding among legislators and leaders in medicine that the updates for 2010 and beyond would require additional action, Mr. Trachtman said.

But the American College of Cardiology expressed problems with the new structure for Medicare payments outlined in the House bill. The proposed payment structure would be based on a system of separate expenditure targets that ACC asserts would not take into account the appropriate growth in services, including many common cardiovascular services.

“While the ACC appreciates congressional efforts to stop Medicare physician payment cuts, it is critical that any new payment structure is fair to all physicians,” the ACC said in a statement.

The House bill also would codify protection for six drug classes under Medicare Part D. Starting in 2009, Medicare drug plans would be required to include all or substantially all Part D drugs in each of the following classes: anticonvulsants, antineoplastics, antiretrovirals, antidepressants, antipsychotics, and immunosuppressants.

The bill would also waive cost sharing for Medicare beneficiaries for certain preventive services including diabetes outpatient self-management training services, cardiovascular screening blood tests, diabetes screening tests, screening mammography, screening Pap smear and pelvic exam, and bone mass measurement.