Mary Ellen Schneider

The Physician Payments Sunshine Act is a provision of the Affordable Care Act aimed at bringing transparency to the practice of pharmaceutical and device companies providing meals, gifts, and payments to physicians. It specifically requires that drug, device, and biologic manufacturers, as well as medical suppliers, report any "payment or other transfer of value" of $10 or greater to physicians and teaching hospitals. If payments and transfers of value to a single physician reach $100 in aggregate value for a year, the manufacturer must report all the payments.

The Centers for Medicare and Medicaid Services released a proposed rule on Dec. 14 outlining how the disclosures would work. Since CMS was a couple of months late in issuing that guidance, the proposal also gives manufacturers more time to prepare. Under the proposal, drug and device manufacturers will not need to begin collecting information this month, as required under Section 6002 of the law. Instead, they can hold off until CMS issues a final rule sometime in 2012. CMS predicted that the first reports required under the Physician Payments Sunshine Act will be publicly available by Sept. 30, 2013.

Allan Coukell, director of medical programs at The Pew Charitable Trusts in Washington, explains how the program might work and its likely impact on physicians and patient care.

Question: What information would be reported and where would the public see this information?

Mr. Coukell: The law requires drug and device companies to make public reports of transfers of value, which means gifts and payments, to physicians. The law creates a number of categories such as speakers bureaus, consulting, research, and so on. The act is comprehensive so any transfer of value must be reported. There are a couple of exceptions for drug samples as well as a provision that the reporting of payments for research can be delayed to protect commercial confidentiality. Companies do not have to report payments to physician employees. The law requires the HHS to create a public website that is searchable and sortable, and where the data can be downloaded.

Question: Do physicians need to do anything to prepare for the implementation of this provision?

Mr. Coukell: Physicians aren’t required to do anything. They don’t have to report anything. The law does ensure that they have the option to review the reports before they go public. There’s a 45-day window during which physicians can choose to take a look at what’s going to be reported. But it puts no onus on the physician to take any action.

Question: Do you think this type of public disclosure is likely to slow industry payments to physicians?

Mr. Coukell: No one knows for sure. In fact, we may never know because the Sunshine Act exists in the larger context of some evolving industry models. Generally, payments go down during recessions and as drugs come off patent, and while there are fewer heavily marketed blockbuster products. Also, we’ve had a trend in recent years of physicians being a bit less likely to see sales reps and a bit less likely to accept the lunches and gifts. Certainly there’s no reason to think that research would go down. That’s beneficial and will continue. It’s certainly possible that we’ll see some of the smaller gifts, payments, and meals trail off, possibly because there’s a cost to the company to track those items. However, there’s nothing in the law that changes the fundamental business model for the industry.

Question: What do you see as the likely effect of this regulation on prescribing and patient care in general?

Mr. Coukell: This is part of the larger context of a reevaluation by the medical profession of what constitutes an appropriate relationship between prescribers and the industry that markets products. Groups such as the Institute of Medicine and the Association of American Medical Colleges, leaders of the journals, a lot of high-profile academics, and professional societies are all saying we need to evaluate the extent of these relationships and their potential impact on care. Additionally, lot of medical schools and medical centers are instituting new industry-relations policies. I think the Sunshine Act brings some transparency to those relationships, but what will happen next is part of a larger overall shift. I do think there is something of a movement within the profession to have a little bit more of an arm’s length relationship with the marketing department. Research collaboration, on the other hand, is clearly beneficial and will continue.

Question: This provision of the health reform law has been touted as being good for patients. Is it good for physicians too?

Mr. Coukell: Transparency is good for everyone. When the Institute of Medicine did its report on conflict of interest in 2009, this was one of its major recommendations and it was part of restoring trust in the profession. I think having these relationships out in the open and having a healthy public dialogue is helpful. It’s also a chance for the drug and device companies to be able to provide context to the payments. Right now, there’s not much context. You may hear that a doctor gets a big payment, but is that going into his pocket or is it to cover the cost of tests or procedures for a clinical trial? Bringing some real substantive information to this is going to be beneficial to everybody.

Allan Coukell oversees the Pew Prescription Project, which conducts nonpartisan research related to federal oversight of drug safety. He previously practiced as a clinical pharmacist in oncology and bone marrow transplant at Victoria Hospital and London Regional Cancer Center in London, Ontario.

The Physician Payments Sunshine Act is a provision of the Affordable Care Act aimed at bringing transparency to the practice of pharmaceutical and device companies providing meals, gifts, and payments to physicians. It specifically requires that drug, device, and biologic manufacturers, as well as medical suppliers, report any "payment or other transfer of value" of $10 or greater to physicians and teaching hospitals. If payments and transfers of value to a single physician reach $100 in aggregate value for a year, the manufacturer must report all the payments.

The Centers for Medicare and Medicaid Services released a proposed rule on Dec. 14 outlining how the disclosures would work. Since CMS was a couple of months late in issuing that guidance, the proposal also gives manufacturers more time to prepare. Under the proposal, drug and device manufacturers will not need to begin collecting information this month, as required under Section 6002 of the law. Instead, they can hold off until CMS issues a final rule sometime in 2012. CMS predicted that the first reports required under the Physician Payments Sunshine Act will be publicly available by Sept. 30, 2013.

Allan Coukell, director of medical programs at The Pew Charitable Trusts in Washington, explains how the program might work and its likely impact on physicians and patient care.

Question: What information would be reported and where would the public see this information?

Mr. Coukell: The law requires drug and device companies to make public reports of transfers of value, which means gifts and payments, to physicians. The law creates a number of categories such as speakers bureaus, consulting, research, and so on. The act is comprehensive so any transfer of value must be reported. There are a couple of exceptions for drug samples as well as a provision that the reporting of payments for research can be delayed to protect commercial confidentiality. Companies do not have to report payments to physician employees. The law requires the HHS to create a public website that is searchable and sortable, and where the data can be downloaded.

Question: Do physicians need to do anything to prepare for the implementation of this provision?

Mr. Coukell: Physicians aren’t required to do anything. They don’t have to report anything. The law does ensure that they have the option to review the reports before they go public. There’s a 45-day window during which physicians can choose to take a look at what’s going to be reported. But it puts no onus on the physician to take any action.

Question: Do you think this type of public disclosure is likely to slow industry payments to physicians?

Mr. Coukell: No one knows for sure. In fact, we may never know because the Sunshine Act exists in the larger context of some evolving industry models. Generally, payments go down during recessions and as drugs come off patent, and while there are fewer heavily marketed blockbuster products. Also, we’ve had a trend in recent years of physicians being a bit less likely to see sales reps and a bit less likely to accept the lunches and gifts. Certainly there’s no reason to think that research would go down. That’s beneficial and will continue. It’s certainly possible that we’ll see some of the smaller gifts, payments, and meals trail off, possibly because there’s a cost to the company to track those items. However, there’s nothing in the law that changes the fundamental business model for the industry.

Question: What do you see as the likely effect of this regulation on prescribing and patient care in general?

Mr. Coukell: This is part of the larger context of a reevaluation by the medical profession of what constitutes an appropriate relationship between prescribers and the industry that markets products. Groups such as the Institute of Medicine and the Association of American Medical Colleges, leaders of the journals, a lot of high-profile academics, and professional societies are all saying we need to evaluate the extent of these relationships and their potential impact on care. Additionally, lot of medical schools and medical centers are instituting new industry-relations policies. I think the Sunshine Act brings some transparency to those relationships, but what will happen next is part of a larger overall shift. I do think there is something of a movement within the profession to have a little bit more of an arm’s length relationship with the marketing department. Research collaboration, on the other hand, is clearly beneficial and will continue.

Question: This provision of the health reform law has been touted as being good for patients. Is it good for physicians too?

Mr. Coukell: Transparency is good for everyone. When the Institute of Medicine did its report on conflict of interest in 2009, this was one of its major recommendations and it was part of restoring trust in the profession. I think having these relationships out in the open and having a healthy public dialogue is helpful. It’s also a chance for the drug and device companies to be able to provide context to the payments. Right now, there’s not much context. You may hear that a doctor gets a big payment, but is that going into his pocket or is it to cover the cost of tests or procedures for a clinical trial? Bringing some real substantive information to this is going to be beneficial to everybody.

Allan Coukell oversees the Pew Prescription Project, which conducts nonpartisan research related to federal oversight of drug safety. He previously practiced as a clinical pharmacist in oncology and bone marrow transplant at Victoria Hospital and London Regional Cancer Center in London, Ontario.

The Physician Payments Sunshine Act is a provision of the Affordable Care Act aimed at bringing transparency to the practice of pharmaceutical and device companies providing meals, gifts, and payments to physicians. It specifically requires that drug, device, and biologic manufacturers, as well as medical suppliers, report any "payment or other transfer of value" of $10 or greater to physicians and teaching hospitals. If payments and transfers of value to a single physician reach $100 in aggregate value for a year, the manufacturer must report all the payments.

The Centers for Medicare and Medicaid Services released a proposed rule on Dec. 14 outlining how the disclosures would work. Since CMS was a couple of months late in issuing that guidance, the proposal also gives manufacturers more time to prepare. Under the proposal, drug and device manufacturers will not need to begin collecting information this month, as required under Section 6002 of the law. Instead, they can hold off until CMS issues a final rule sometime in 2012. CMS predicted that the first reports required under the Physician Payments Sunshine Act will be publicly available by Sept. 30, 2013.

Allan Coukell, director of medical programs at The Pew Charitable Trusts in Washington, explains how the program might work and its likely impact on physicians and patient care.

Question: What information would be reported and where would the public see this information?

Mr. Coukell: The law requires drug and device companies to make public reports of transfers of value, which means gifts and payments, to physicians. The law creates a number of categories such as speakers bureaus, consulting, research, and so on. The act is comprehensive so any transfer of value must be reported. There are a couple of exceptions for drug samples as well as a provision that the reporting of payments for research can be delayed to protect commercial confidentiality. Companies do not have to report payments to physician employees. The law requires the HHS to create a public website that is searchable and sortable, and where the data can be downloaded.

Question: Do physicians need to do anything to prepare for the implementation of this provision?

Mr. Coukell: Physicians aren’t required to do anything. They don’t have to report anything. The law does ensure that they have the option to review the reports before they go public. There’s a 45-day window during which physicians can choose to take a look at what’s going to be reported. But it puts no onus on the physician to take any action.

Question: Do you think this type of public disclosure is likely to slow industry payments to physicians?

Mr. Coukell: No one knows for sure. In fact, we may never know because the Sunshine Act exists in the larger context of some evolving industry models. Generally, payments go down during recessions and as drugs come off patent, and while there are fewer heavily marketed blockbuster products. Also, we’ve had a trend in recent years of physicians being a bit less likely to see sales reps and a bit less likely to accept the lunches and gifts. Certainly there’s no reason to think that research would go down. That’s beneficial and will continue. It’s certainly possible that we’ll see some of the smaller gifts, payments, and meals trail off, possibly because there’s a cost to the company to track those items. However, there’s nothing in the law that changes the fundamental business model for the industry.

Question: What do you see as the likely effect of this regulation on prescribing and patient care in general?

Mr. Coukell: This is part of the larger context of a reevaluation by the medical profession of what constitutes an appropriate relationship between prescribers and the industry that markets products. Groups such as the Institute of Medicine and the Association of American Medical Colleges, leaders of the journals, a lot of high-profile academics, and professional societies are all saying we need to evaluate the extent of these relationships and their potential impact on care. Additionally, lot of medical schools and medical centers are instituting new industry-relations policies. I think the Sunshine Act brings some transparency to those relationships, but what will happen next is part of a larger overall shift. I do think there is something of a movement within the profession to have a little bit more of an arm’s length relationship with the marketing department. Research collaboration, on the other hand, is clearly beneficial and will continue.

Question: This provision of the health reform law has been touted as being good for patients. Is it good for physicians too?

Mr. Coukell: Transparency is good for everyone. When the Institute of Medicine did its report on conflict of interest in 2009, this was one of its major recommendations and it was part of restoring trust in the profession. I think having these relationships out in the open and having a healthy public dialogue is helpful. It’s also a chance for the drug and device companies to be able to provide context to the payments. Right now, there’s not much context. You may hear that a doctor gets a big payment, but is that going into his pocket or is it to cover the cost of tests or procedures for a clinical trial? Bringing some real substantive information to this is going to be beneficial to everybody.

Allan Coukell oversees the Pew Prescription Project, which conducts nonpartisan research related to federal oversight of drug safety. He previously practiced as a clinical pharmacist in oncology and bone marrow transplant at Victoria Hospital and London Regional Cancer Center in London, Ontario.

The U.S. House on Dec. 13 approved legislation that would avert a scheduled 27% cut to Medicare physician fees, but President Obama has already threatened to veto the bill, which includes several other provisions he opposes.

Physicians who treat Medicare patients will see their payments cut by 27.4% on Jan. 1 if lawmakers cannot agree on a plan to stop the cuts. The statutory cuts are called for under the Sustainable Growth Rate formula, which ties changes in Medicare physician payments to the gross domestic product. The House bill, which primarily sought to extend the payroll tax holiday, passed in a 234 to 193 vote. The legislation would replace the massive Medicare physician pay cut with a 1% pay raise for doctors in 2012 and 2013.

The "Middle Class Tax Relief & Job Creation Act" (H.R. 3630) would pay for the fee fix in part by making cuts to funding for the Affordable Care Act, including the Prevention and Public Health Fund. Additionally, the bill would raise Medicare premiums for high-income beneficiaries.

While averting the physician pay cut before the end of the year has been a priority for both Democrats and Republicans, other controversial elements of the legislation are likely to keep it stalled in Congress. For instance, the bill includes a provision to fast-track the permitting for the Keystone XL oil pipeline, which would run between Canada and the United States. It would also roll back certain environmental regulations.

President Obama issued a veto threat, taking Republican leaders in the House to task for playing politics with issues like the tax holiday and the physician fee fix. "Instead of working together to find a balanced approach that will actually pass both Houses of Congress, H.R. 3630 instead represents a choice to refight old political battles over health care and introduce ideological issues into what should be a simple debate about cutting taxes for the middle class," the president wrote in his veto message to Congress.

The U.S. House on Dec. 13 approved legislation that would avert a scheduled 27% cut to Medicare physician fees, but President Obama has already threatened to veto the bill, which includes several other provisions he opposes.

Physicians who treat Medicare patients will see their payments cut by 27.4% on Jan. 1 if lawmakers cannot agree on a plan to stop the cuts. The statutory cuts are called for under the Sustainable Growth Rate formula, which ties changes in Medicare physician payments to the gross domestic product. The House bill, which primarily sought to extend the payroll tax holiday, passed in a 234 to 193 vote. The legislation would replace the massive Medicare physician pay cut with a 1% pay raise for doctors in 2012 and 2013.

The "Middle Class Tax Relief & Job Creation Act" (H.R. 3630) would pay for the fee fix in part by making cuts to funding for the Affordable Care Act, including the Prevention and Public Health Fund. Additionally, the bill would raise Medicare premiums for high-income beneficiaries.

While averting the physician pay cut before the end of the year has been a priority for both Democrats and Republicans, other controversial elements of the legislation are likely to keep it stalled in Congress. For instance, the bill includes a provision to fast-track the permitting for the Keystone XL oil pipeline, which would run between Canada and the United States. It would also roll back certain environmental regulations.

President Obama issued a veto threat, taking Republican leaders in the House to task for playing politics with issues like the tax holiday and the physician fee fix. "Instead of working together to find a balanced approach that will actually pass both Houses of Congress, H.R. 3630 instead represents a choice to refight old political battles over health care and introduce ideological issues into what should be a simple debate about cutting taxes for the middle class," the president wrote in his veto message to Congress.

The U.S. House on Dec. 13 approved legislation that would avert a scheduled 27% cut to Medicare physician fees, but President Obama has already threatened to veto the bill, which includes several other provisions he opposes.

Physicians who treat Medicare patients will see their payments cut by 27.4% on Jan. 1 if lawmakers cannot agree on a plan to stop the cuts. The statutory cuts are called for under the Sustainable Growth Rate formula, which ties changes in Medicare physician payments to the gross domestic product. The House bill, which primarily sought to extend the payroll tax holiday, passed in a 234 to 193 vote. The legislation would replace the massive Medicare physician pay cut with a 1% pay raise for doctors in 2012 and 2013.

The "Middle Class Tax Relief & Job Creation Act" (H.R. 3630) would pay for the fee fix in part by making cuts to funding for the Affordable Care Act, including the Prevention and Public Health Fund. Additionally, the bill would raise Medicare premiums for high-income beneficiaries.

While averting the physician pay cut before the end of the year has been a priority for both Democrats and Republicans, other controversial elements of the legislation are likely to keep it stalled in Congress. For instance, the bill includes a provision to fast-track the permitting for the Keystone XL oil pipeline, which would run between Canada and the United States. It would also roll back certain environmental regulations.

President Obama issued a veto threat, taking Republican leaders in the House to task for playing politics with issues like the tax holiday and the physician fee fix. "Instead of working together to find a balanced approach that will actually pass both Houses of Congress, H.R. 3630 instead represents a choice to refight old political battles over health care and introduce ideological issues into what should be a simple debate about cutting taxes for the middle class," the president wrote in his veto message to Congress.

About one-third of adults who have been hospitalized don’t see a physician, nurse practitioner, or physician assistant within 30 days after discharge, according to an analysis conducted by the Center for Studying Health System Change.

The fact that recently discharged patients aren’t receiving care in the community has implications for federal efforts to reduce hospital readmissions, the researchers noted. The findings suggest that there are substantial gaps in coordination of post-discharge care.

"The implication is that reforms specific to one payer and focusing only on care processes within hospitals may fall short unless efforts to coordinate with community providers – and to encourage patients’ access to these providers – receive at least as much attention," Anna Sommers, Ph.D., a senior health researcher at the Center for Studying Health System Change and a coauthor of the study, said in a statement.

Even when patients do show up for post-discharge care, physicians often don’t have access to hospital discharge summaries or to information regarding changed medication regimens. And they may lack hospital test results that could shed light on potential unresolved medical issues, the researchers wrote.

The researchers from the Center for Studying Health System Change offered a range of possible policy changes that could help to improve care coordination, such as including post-acute care in new bundled payment experiments or rewarding primary care practices that focus on keeping high-risk patients out of the hospital.

The study was commissioned by the National Institute for Health Care Reform, a nonprofit, nonpartisan organization established by the International Union (United Auto Workers), Chrysler Group LLC, Ford Motor Co., and General Motors.

Patients were generally more likely to skip the post-discharge visit to the doctor if they were healthier, younger, and did not have serious chronic conditions. However, 46% of patients who did not follow up with a doctor had at least one chronic condition and 36% were in fair or poor physical health, the investigators found.

About 90% of patients reported at initial hospital admission that they had a usual source of care; however, more than 20% said it was very or somewhat difficult to contact their usual doctor by phone about a health problem. More than a third reported that their physicians’ office was very or somewhat difficult to contact after hours.

"These barriers may contribute to some patients not receiving care after discharge, although the prevalence of these barriers was similar for people who received or did not receive care after discharge," the investigators wrote.

Type of insurance did not affect whether patients saw a health care provider within 30 days of discharge. Among adults under age 65 years, about 66% of patients who were publicly insured saw a physician within 30 days after discharge, compared with 70% of privately insured patients. Trends were similar among those aged 65 years and older. About 65% of patients who were dually-eligible for Medicare and Medicaid saw a physician within 30 days, compared with 71% of Medicare beneficiaries with supplemental private (Medigap) insurance.

Overall, the 30-day readmission rates for adults aged 21 years and older was 8.2%. A third of adults (33%) were readmitted to the hospital within 1 year of discharge. The 30-day readmissions rate was significantly higher for patients who were sicker. For instance, adults in excellent or very good health had 30-day readmission rates of 5%, but the readmission rate was more than double that for people in fair or poor health. Readmission rates were also higher for people who had trouble bathing or dressing on their own and for those with two or more chronic conditions.

The researchers also found that more than a quarter (26%) of all 30-day readmissions were for conditions considered unrelated to the initial hospital visit. That number climbed to 37% for readmissions within 1 year. Unrelated readmissions were generally for comorbidities such as hypertension, heart failure, and stroke.

The researchers used data from the 2000-2008 Medical Expenditure Panel Survey (MEPS) to estimate the prevalence of hospital readmissions for all causes for adults aged 21 years and older, excluding obstetrical care. The researchers also analyzed the use of outpatient services within 30 days of discharge.

The study authors did not report any financial conflicts. The study was conducted by the Center for Studying Health System Change. It was commissioned by the National Institute for Health Care Reform, a nonpartisan organization established by the International Union (UAW), Chrysler Group LLC, Ford Motor Co., and General Motors.

About one-third of adults who have been hospitalized don’t see a physician, nurse practitioner, or physician assistant within 30 days after discharge, according to an analysis conducted by the Center for Studying Health System Change.

The fact that recently discharged patients aren’t receiving care in the community has implications for federal efforts to reduce hospital readmissions, the researchers noted. The findings suggest that there are substantial gaps in coordination of post-discharge care.

"The implication is that reforms specific to one payer and focusing only on care processes within hospitals may fall short unless efforts to coordinate with community providers – and to encourage patients’ access to these providers – receive at least as much attention," Anna Sommers, Ph.D., a senior health researcher at the Center for Studying Health System Change and a coauthor of the study, said in a statement.

Even when patients do show up for post-discharge care, physicians often don’t have access to hospital discharge summaries or to information regarding changed medication regimens. And they may lack hospital test results that could shed light on potential unresolved medical issues, the researchers wrote.

The researchers from the Center for Studying Health System Change offered a range of possible policy changes that could help to improve care coordination, such as including post-acute care in new bundled payment experiments or rewarding primary care practices that focus on keeping high-risk patients out of the hospital.

The study was commissioned by the National Institute for Health Care Reform, a nonprofit, nonpartisan organization established by the International Union (United Auto Workers), Chrysler Group LLC, Ford Motor Co., and General Motors.

Patients were generally more likely to skip the post-discharge visit to the doctor if they were healthier, younger, and did not have serious chronic conditions. However, 46% of patients who did not follow up with a doctor had at least one chronic condition and 36% were in fair or poor physical health, the investigators found.

About 90% of patients reported at initial hospital admission that they had a usual source of care; however, more than 20% said it was very or somewhat difficult to contact their usual doctor by phone about a health problem. More than a third reported that their physicians’ office was very or somewhat difficult to contact after hours.

"These barriers may contribute to some patients not receiving care after discharge, although the prevalence of these barriers was similar for people who received or did not receive care after discharge," the investigators wrote.

Type of insurance did not affect whether patients saw a health care provider within 30 days of discharge. Among adults under age 65 years, about 66% of patients who were publicly insured saw a physician within 30 days after discharge, compared with 70% of privately insured patients. Trends were similar among those aged 65 years and older. About 65% of patients who were dually-eligible for Medicare and Medicaid saw a physician within 30 days, compared with 71% of Medicare beneficiaries with supplemental private (Medigap) insurance.

Overall, the 30-day readmission rates for adults aged 21 years and older was 8.2%. A third of adults (33%) were readmitted to the hospital within 1 year of discharge. The 30-day readmissions rate was significantly higher for patients who were sicker. For instance, adults in excellent or very good health had 30-day readmission rates of 5%, but the readmission rate was more than double that for people in fair or poor health. Readmission rates were also higher for people who had trouble bathing or dressing on their own and for those with two or more chronic conditions.

The researchers also found that more than a quarter (26%) of all 30-day readmissions were for conditions considered unrelated to the initial hospital visit. That number climbed to 37% for readmissions within 1 year. Unrelated readmissions were generally for comorbidities such as hypertension, heart failure, and stroke.

The researchers used data from the 2000-2008 Medical Expenditure Panel Survey (MEPS) to estimate the prevalence of hospital readmissions for all causes for adults aged 21 years and older, excluding obstetrical care. The researchers also analyzed the use of outpatient services within 30 days of discharge.

The study authors did not report any financial conflicts. The study was conducted by the Center for Studying Health System Change. It was commissioned by the National Institute for Health Care Reform, a nonpartisan organization established by the International Union (UAW), Chrysler Group LLC, Ford Motor Co., and General Motors.

About one-third of adults who have been hospitalized don’t see a physician, nurse practitioner, or physician assistant within 30 days after discharge, according to an analysis conducted by the Center for Studying Health System Change.

The fact that recently discharged patients aren’t receiving care in the community has implications for federal efforts to reduce hospital readmissions, the researchers noted. The findings suggest that there are substantial gaps in coordination of post-discharge care.

"The implication is that reforms specific to one payer and focusing only on care processes within hospitals may fall short unless efforts to coordinate with community providers – and to encourage patients’ access to these providers – receive at least as much attention," Anna Sommers, Ph.D., a senior health researcher at the Center for Studying Health System Change and a coauthor of the study, said in a statement.

Even when patients do show up for post-discharge care, physicians often don’t have access to hospital discharge summaries or to information regarding changed medication regimens. And they may lack hospital test results that could shed light on potential unresolved medical issues, the researchers wrote.

The researchers from the Center for Studying Health System Change offered a range of possible policy changes that could help to improve care coordination, such as including post-acute care in new bundled payment experiments or rewarding primary care practices that focus on keeping high-risk patients out of the hospital.

The study was commissioned by the National Institute for Health Care Reform, a nonprofit, nonpartisan organization established by the International Union (United Auto Workers), Chrysler Group LLC, Ford Motor Co., and General Motors.

Patients were generally more likely to skip the post-discharge visit to the doctor if they were healthier, younger, and did not have serious chronic conditions. However, 46% of patients who did not follow up with a doctor had at least one chronic condition and 36% were in fair or poor physical health, the investigators found.

About 90% of patients reported at initial hospital admission that they had a usual source of care; however, more than 20% said it was very or somewhat difficult to contact their usual doctor by phone about a health problem. More than a third reported that their physicians’ office was very or somewhat difficult to contact after hours.

"These barriers may contribute to some patients not receiving care after discharge, although the prevalence of these barriers was similar for people who received or did not receive care after discharge," the investigators wrote.

Type of insurance did not affect whether patients saw a health care provider within 30 days of discharge. Among adults under age 65 years, about 66% of patients who were publicly insured saw a physician within 30 days after discharge, compared with 70% of privately insured patients. Trends were similar among those aged 65 years and older. About 65% of patients who were dually-eligible for Medicare and Medicaid saw a physician within 30 days, compared with 71% of Medicare beneficiaries with supplemental private (Medigap) insurance.

Overall, the 30-day readmission rates for adults aged 21 years and older was 8.2%. A third of adults (33%) were readmitted to the hospital within 1 year of discharge. The 30-day readmissions rate was significantly higher for patients who were sicker. For instance, adults in excellent or very good health had 30-day readmission rates of 5%, but the readmission rate was more than double that for people in fair or poor health. Readmission rates were also higher for people who had trouble bathing or dressing on their own and for those with two or more chronic conditions.

The researchers also found that more than a quarter (26%) of all 30-day readmissions were for conditions considered unrelated to the initial hospital visit. That number climbed to 37% for readmissions within 1 year. Unrelated readmissions were generally for comorbidities such as hypertension, heart failure, and stroke.

The researchers used data from the 2000-2008 Medical Expenditure Panel Survey (MEPS) to estimate the prevalence of hospital readmissions for all causes for adults aged 21 years and older, excluding obstetrical care. The researchers also analyzed the use of outpatient services within 30 days of discharge.

The study authors did not report any financial conflicts. The study was conducted by the Center for Studying Health System Change. It was commissioned by the National Institute for Health Care Reform, a nonpartisan organization established by the International Union (UAW), Chrysler Group LLC, Ford Motor Co., and General Motors.

Federal officials are requiring health plans to give consumers more information about how they are spending their premium dollars.

In a final rule released on Dec. 2, the Health and Human Services department made changes to its existing regulations governing health plans’ medical-loss ratio (MLR). Under the Affordable Care Act, health plans must spend at least 80% of their premium dollars on medical care and quality improvement activities. For large group plans, the threshold is 85%. If plans spend more than the allowed amount on other costs, such as overhead and marketing, they must provide rebates to consumers. The MLR requirements went into effect in January 2011 and the first rebate checks are scheduled to reach consumers in 2012.

The new rule requires that health plans notify their members of their MLR, even if they are not eligible for a rebate. Under the new notice provision, plans are also required to explain how their MLR has improved since the passage of the Affordable Care Act.

HHS is also instructing health plans to provide the rebates in ways that are not taxable, such as through lower premiums. And even though rebates go to the group policyholder, which is often an employer, health plans must provide information about the MLR and any associated rebates to all enrollees in the plan.

The final rule also makes technical changes in how the MLR is calculated. For example, health plans will be allowed to count some of the cost of ICD-10 conversion as quality improvement. The rule allows conversion costs of up to 0.3% of the earned premium to be considered a quality improvement activity during the 2012 and 2013 reporting years.

Federal officials are requiring health plans to give consumers more information about how they are spending their premium dollars.

In a final rule released on Dec. 2, the Health and Human Services department made changes to its existing regulations governing health plans’ medical-loss ratio (MLR). Under the Affordable Care Act, health plans must spend at least 80% of their premium dollars on medical care and quality improvement activities. For large group plans, the threshold is 85%. If plans spend more than the allowed amount on other costs, such as overhead and marketing, they must provide rebates to consumers. The MLR requirements went into effect in January 2011 and the first rebate checks are scheduled to reach consumers in 2012.

The new rule requires that health plans notify their members of their MLR, even if they are not eligible for a rebate. Under the new notice provision, plans are also required to explain how their MLR has improved since the passage of the Affordable Care Act.

HHS is also instructing health plans to provide the rebates in ways that are not taxable, such as through lower premiums. And even though rebates go to the group policyholder, which is often an employer, health plans must provide information about the MLR and any associated rebates to all enrollees in the plan.

The final rule also makes technical changes in how the MLR is calculated. For example, health plans will be allowed to count some of the cost of ICD-10 conversion as quality improvement. The rule allows conversion costs of up to 0.3% of the earned premium to be considered a quality improvement activity during the 2012 and 2013 reporting years.

Federal officials are requiring health plans to give consumers more information about how they are spending their premium dollars.

In a final rule released on Dec. 2, the Health and Human Services department made changes to its existing regulations governing health plans’ medical-loss ratio (MLR). Under the Affordable Care Act, health plans must spend at least 80% of their premium dollars on medical care and quality improvement activities. For large group plans, the threshold is 85%. If plans spend more than the allowed amount on other costs, such as overhead and marketing, they must provide rebates to consumers. The MLR requirements went into effect in January 2011 and the first rebate checks are scheduled to reach consumers in 2012.

The new rule requires that health plans notify their members of their MLR, even if they are not eligible for a rebate. Under the new notice provision, plans are also required to explain how their MLR has improved since the passage of the Affordable Care Act.

HHS is also instructing health plans to provide the rebates in ways that are not taxable, such as through lower premiums. And even though rebates go to the group policyholder, which is often an employer, health plans must provide information about the MLR and any associated rebates to all enrollees in the plan.

The final rule also makes technical changes in how the MLR is calculated. For example, health plans will be allowed to count some of the cost of ICD-10 conversion as quality improvement. The rule allows conversion costs of up to 0.3% of the earned premium to be considered a quality improvement activity during the 2012 and 2013 reporting years.

Physicians who support a single-payer health system are urging the federal government to reject the Institute of Medicine’s recommendations for designing the benefits package to be offered in the state-based health insurance exchanges.

Physicians for a National Health Plan (PNHP) is leading the effort to cast off recommendations issued by the Institute of Medicine (IOM) in October, charging the panel was unduly influenced by the insurance industry. The IOM panel called on the Department of Health and Human Services to base the essential benefits package on the benefits typically offered by small employers. It also urged the agency to consider cost when designing the package of required benefits.

In a Dec. 1 letter to HHS Secretary Kathleen Sebelius, more than 2,400 physicians, nurses, and health advocates criticized the IOM recommendations, saying that they would provide "skimpy" coverage.

"The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness," according to the PNHP letter. "Yet this strategy will not lower costs. Delaying care often creates even higher costs. Steadily rising copayments and deductibles over the past two decades have failed to stem skyrocketing medical inflation."

"The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness," according to the Physicians for a National Health Plan letter.

Dr. Steffie Woolhandler, a cofounder of PNHP and professor of public health at the City University of New York, said that the recommendations from the IOM panel are not what was envisioned by supporters of the Affordable Care Act. Instead, supporters had expected that the essential benefits package would be based on the more generous benefits offered by large employers.

The letter also attacked the IOM panel for including members who have "amassed personal wealth through their involvement with health insurers and other for-profit health care firms."

Dr. Woolhandler, who served as an IOM fellow in 1990-1991, cited the inclusion of Sam Ho, executive vice president of UnitedHealthcare, and Leonard Schaeffer, former chairman and CEO of WellPoint.

Allowing individuals with financial ties to the insurance industry to serve on the IOM panel is contrary to the IOM’s own recommendations, issued in 2009, on minimizing conflicts of interest on panels that issue clinical practice guidelines, Dr. Woolhandler added.

Although Mr. Ho and Mr. Schaeffer have knowledge about the insurance business, there are many qualified experts without conflicts who could have been selected for the panel, she said. "A lot of people know about health insurance benefits," she said.

The IOM stood by the panel and its recommendations. "The IOM report speaks for itself and details the solid rationale for each of its recommendations for achieving a balance between coverage and cost," said Christine Stencel, an IOM spokeswoman.

The 18-member panel was chaired by Dr. John R. Ball, former executive vice president of the American Society for Clinical Pathology. The panel also included Dr. Alan Nelson, a health policy expert and retired internist/endocrinologist; Christopher F. Koller, health insurance commissioner for Rhode Island; and several policy experts.

Physicians who support a single-payer health system are urging the federal government to reject the Institute of Medicine’s recommendations for designing the benefits package to be offered in the state-based health insurance exchanges.

Physicians for a National Health Plan (PNHP) is leading the effort to cast off recommendations issued by the Institute of Medicine (IOM) in October, charging the panel was unduly influenced by the insurance industry. The IOM panel called on the Department of Health and Human Services to base the essential benefits package on the benefits typically offered by small employers. It also urged the agency to consider cost when designing the package of required benefits.

In a Dec. 1 letter to HHS Secretary Kathleen Sebelius, more than 2,400 physicians, nurses, and health advocates criticized the IOM recommendations, saying that they would provide "skimpy" coverage.

"The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness," according to the PNHP letter. "Yet this strategy will not lower costs. Delaying care often creates even higher costs. Steadily rising copayments and deductibles over the past two decades have failed to stem skyrocketing medical inflation."

"The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness," according to the Physicians for a National Health Plan letter.

Dr. Steffie Woolhandler, a cofounder of PNHP and professor of public health at the City University of New York, said that the recommendations from the IOM panel are not what was envisioned by supporters of the Affordable Care Act. Instead, supporters had expected that the essential benefits package would be based on the more generous benefits offered by large employers.

The letter also attacked the IOM panel for including members who have "amassed personal wealth through their involvement with health insurers and other for-profit health care firms."

Dr. Woolhandler, who served as an IOM fellow in 1990-1991, cited the inclusion of Sam Ho, executive vice president of UnitedHealthcare, and Leonard Schaeffer, former chairman and CEO of WellPoint.

Allowing individuals with financial ties to the insurance industry to serve on the IOM panel is contrary to the IOM’s own recommendations, issued in 2009, on minimizing conflicts of interest on panels that issue clinical practice guidelines, Dr. Woolhandler added.

Although Mr. Ho and Mr. Schaeffer have knowledge about the insurance business, there are many qualified experts without conflicts who could have been selected for the panel, she said. "A lot of people know about health insurance benefits," she said.

The IOM stood by the panel and its recommendations. "The IOM report speaks for itself and details the solid rationale for each of its recommendations for achieving a balance between coverage and cost," said Christine Stencel, an IOM spokeswoman.

The 18-member panel was chaired by Dr. John R. Ball, former executive vice president of the American Society for Clinical Pathology. The panel also included Dr. Alan Nelson, a health policy expert and retired internist/endocrinologist; Christopher F. Koller, health insurance commissioner for Rhode Island; and several policy experts.

Physicians who support a single-payer health system are urging the federal government to reject the Institute of Medicine’s recommendations for designing the benefits package to be offered in the state-based health insurance exchanges.

Physicians for a National Health Plan (PNHP) is leading the effort to cast off recommendations issued by the Institute of Medicine (IOM) in October, charging the panel was unduly influenced by the insurance industry. The IOM panel called on the Department of Health and Human Services to base the essential benefits package on the benefits typically offered by small employers. It also urged the agency to consider cost when designing the package of required benefits.

In a Dec. 1 letter to HHS Secretary Kathleen Sebelius, more than 2,400 physicians, nurses, and health advocates criticized the IOM recommendations, saying that they would provide "skimpy" coverage.

"The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness," according to the PNHP letter. "Yet this strategy will not lower costs. Delaying care often creates even higher costs. Steadily rising copayments and deductibles over the past two decades have failed to stem skyrocketing medical inflation."

"The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness," according to the Physicians for a National Health Plan letter.

Dr. Steffie Woolhandler, a cofounder of PNHP and professor of public health at the City University of New York, said that the recommendations from the IOM panel are not what was envisioned by supporters of the Affordable Care Act. Instead, supporters had expected that the essential benefits package would be based on the more generous benefits offered by large employers.

The letter also attacked the IOM panel for including members who have "amassed personal wealth through their involvement with health insurers and other for-profit health care firms."

Dr. Woolhandler, who served as an IOM fellow in 1990-1991, cited the inclusion of Sam Ho, executive vice president of UnitedHealthcare, and Leonard Schaeffer, former chairman and CEO of WellPoint.

Allowing individuals with financial ties to the insurance industry to serve on the IOM panel is contrary to the IOM’s own recommendations, issued in 2009, on minimizing conflicts of interest on panels that issue clinical practice guidelines, Dr. Woolhandler added.

Although Mr. Ho and Mr. Schaeffer have knowledge about the insurance business, there are many qualified experts without conflicts who could have been selected for the panel, she said. "A lot of people know about health insurance benefits," she said.

The IOM stood by the panel and its recommendations. "The IOM report speaks for itself and details the solid rationale for each of its recommendations for achieving a balance between coverage and cost," said Christine Stencel, an IOM spokeswoman.

The 18-member panel was chaired by Dr. John R. Ball, former executive vice president of the American Society for Clinical Pathology. The panel also included Dr. Alan Nelson, a health policy expert and retired internist/endocrinologist; Christopher F. Koller, health insurance commissioner for Rhode Island; and several policy experts.

Dr. Lauren Doctoroff, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston, is part of a small but growing number of hospitalists who are seeing patients after they leave the hospital. Dr. Doctoroff, who is also an instructor of medicine at Harvard Medical School, Boston, is the medical director for the post-discharge clinic run jointly by Beth Israel and the hospital’s primary care practice, HealthCare Associates. The clinic, which opened its doors in September 2009, provides follow-up care to patients who have been recently discharged from the hospital or the emergency department.

In an interview with Hospitalist News, Dr. Doctoroff explained what led to the opening of the clinic and how working there has helped to make her a better hospitalist.

Hospitalist News: What drove the decision to open the post-discharge clinic at Beth Israel?

Dr. Doctoroff: The clinic was started as a joint venture between the hospitalist program and the general medicine department, which includes the faculty primary care practice, HealthCare Associates. There was a feeling from the hospitalist side that we could not get adequate and timely follow-up for our hospitalist patients at discharge. From the primary care perspective, I think they wanted to expose hospitalists to the outpatient work in the clinic and help us better organize the post-discharge planning that we do.

HN: Did you get push-back from primary care physicians in the community, and if so, how did you deal with that?

Dr. Doctoroff: Our clinic only sees patients who are affiliated with the primary care practice here. We do not have a stand-alone clinic where we see any patient that we discharge from the hospital. We have had some push-back from primary care doctors within the practice who feel that having us see a patient after a traumatic hospital admission is essentially another transition. And so they prefer to see their own patients after discharge. We developed processes to ensure that a primary care physician can know when their patient is scheduled in our clinic. But the effect of having us in the clinic has pushed the bar a little bit, so the primary care physicians seem to be scheduling their patients sooner, rather than having them come back to see them in a more haphazard way.

HN: Have you measured any outcomes since opening the clinic, such as the effect on readmissions?

Dr. Doctoroff: We were started essentially to help improve and create open access into this clinic. The main outcome that we started to look at was our impact on open access for patients after discharge. I have only preliminary data, but it shows that we really do see patients after discharge much more quickly than the primary care practice as a whole. Readmissions are what everyone is talking about these days, but our clinic wasn’t really established to reduce readmissions. It might be a secondary effect. But there are conflicting data about whether seeing a doctor actually reduces your risk of being readmitted. If you come to the doctor and you’re feeling poor, then you’re more likely to get readmitted than if you’d stayed home. But in those cases, being readmitted isn’t necessarily a bad outcome for the patient. It’s hard for me to think that seeing a doctor soon after discharge doesn’t help improve, if not readmissions, certainly quality of care.

HN: Do you enjoy the work in the discharge clinic, or does it detract from your inpatient responsibilities?

Dr. Doctoroff: I think that working in the discharge clinic has very much enriched my inpatient perspective. I think it really is invaluable to see the impact of discharge planning. You may think your discharge plan is good when you’re in the hospital, and then when you see the patient in the clinic, you think, "How was this ever considered to be a good plan?" For instance, why does a patient have four different appointments on different days with different specialists all in the 2 weeks after discharge? It’s really opened my eyes about what a good discharge plan and a good discharge summary are. I also feel more empathy for primary care physicians, as their job is definitely not an easy one.

HN: Do you think this clinic is a model for hospitalists in other parts of the country?

Dr. Doctoroff: The next stage of hospitalist medicine is going to include looking at our role as being a little broader than just being in the hospital. We as hospitalists are being held responsible for what happens to patients after discharge, whether it’s readmissions or other outcomes. I’m not sure that for every hospitalist group or every hospital, it will make sense to start a discharge clinic. I think there are models for discharge clinics in many different practice settings, both staffed by hospitalists and staffed by primary care doctors. But I do think that whether it’s a discharge clinic, whether it’s a post-discharge phone calling program, whether it’s just establishing better relationships with the primary care practices that you serve as a hospitalist, that this sort of connection is what’s going to be required to succeed as a hospitalist and in the new world of accountable care organizations and global payments.

This column, "Leaders," regularly appears in Hospitalist News, an Elsevier publication. Dr. Doctoroff had no disclosures to report.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

Dr. Lauren Doctoroff, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston, is part of a small but growing number of hospitalists who are seeing patients after they leave the hospital. Dr. Doctoroff, who is also an instructor of medicine at Harvard Medical School, Boston, is the medical director for the post-discharge clinic run jointly by Beth Israel and the hospital’s primary care practice, HealthCare Associates. The clinic, which opened its doors in September 2009, provides follow-up care to patients who have been recently discharged from the hospital or the emergency department.

In an interview with Hospitalist News, Dr. Doctoroff explained what led to the opening of the clinic and how working there has helped to make her a better hospitalist.

Hospitalist News: What drove the decision to open the post-discharge clinic at Beth Israel?

Dr. Doctoroff: The clinic was started as a joint venture between the hospitalist program and the general medicine department, which includes the faculty primary care practice, HealthCare Associates. There was a feeling from the hospitalist side that we could not get adequate and timely follow-up for our hospitalist patients at discharge. From the primary care perspective, I think they wanted to expose hospitalists to the outpatient work in the clinic and help us better organize the post-discharge planning that we do.

HN: Did you get push-back from primary care physicians in the community, and if so, how did you deal with that?

Dr. Doctoroff: Our clinic only sees patients who are affiliated with the primary care practice here. We do not have a stand-alone clinic where we see any patient that we discharge from the hospital. We have had some push-back from primary care doctors within the practice who feel that having us see a patient after a traumatic hospital admission is essentially another transition. And so they prefer to see their own patients after discharge. We developed processes to ensure that a primary care physician can know when their patient is scheduled in our clinic. But the effect of having us in the clinic has pushed the bar a little bit, so the primary care physicians seem to be scheduling their patients sooner, rather than having them come back to see them in a more haphazard way.

HN: Have you measured any outcomes since opening the clinic, such as the effect on readmissions?

Dr. Doctoroff: We were started essentially to help improve and create open access into this clinic. The main outcome that we started to look at was our impact on open access for patients after discharge. I have only preliminary data, but it shows that we really do see patients after discharge much more quickly than the primary care practice as a whole. Readmissions are what everyone is talking about these days, but our clinic wasn’t really established to reduce readmissions. It might be a secondary effect. But there are conflicting data about whether seeing a doctor actually reduces your risk of being readmitted. If you come to the doctor and you’re feeling poor, then you’re more likely to get readmitted than if you’d stayed home. But in those cases, being readmitted isn’t necessarily a bad outcome for the patient. It’s hard for me to think that seeing a doctor soon after discharge doesn’t help improve, if not readmissions, certainly quality of care.

HN: Do you enjoy the work in the discharge clinic, or does it detract from your inpatient responsibilities?

Dr. Doctoroff: I think that working in the discharge clinic has very much enriched my inpatient perspective. I think it really is invaluable to see the impact of discharge planning. You may think your discharge plan is good when you’re in the hospital, and then when you see the patient in the clinic, you think, "How was this ever considered to be a good plan?" For instance, why does a patient have four different appointments on different days with different specialists all in the 2 weeks after discharge? It’s really opened my eyes about what a good discharge plan and a good discharge summary are. I also feel more empathy for primary care physicians, as their job is definitely not an easy one.

HN: Do you think this clinic is a model for hospitalists in other parts of the country?

Dr. Doctoroff: The next stage of hospitalist medicine is going to include looking at our role as being a little broader than just being in the hospital. We as hospitalists are being held responsible for what happens to patients after discharge, whether it’s readmissions or other outcomes. I’m not sure that for every hospitalist group or every hospital, it will make sense to start a discharge clinic. I think there are models for discharge clinics in many different practice settings, both staffed by hospitalists and staffed by primary care doctors. But I do think that whether it’s a discharge clinic, whether it’s a post-discharge phone calling program, whether it’s just establishing better relationships with the primary care practices that you serve as a hospitalist, that this sort of connection is what’s going to be required to succeed as a hospitalist and in the new world of accountable care organizations and global payments.

This column, "Leaders," regularly appears in Hospitalist News, an Elsevier publication. Dr. Doctoroff had no disclosures to report.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

Dr. Lauren Doctoroff, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston, is part of a small but growing number of hospitalists who are seeing patients after they leave the hospital. Dr. Doctoroff, who is also an instructor of medicine at Harvard Medical School, Boston, is the medical director for the post-discharge clinic run jointly by Beth Israel and the hospital’s primary care practice, HealthCare Associates. The clinic, which opened its doors in September 2009, provides follow-up care to patients who have been recently discharged from the hospital or the emergency department.

In an interview with Hospitalist News, Dr. Doctoroff explained what led to the opening of the clinic and how working there has helped to make her a better hospitalist.

Hospitalist News: What drove the decision to open the post-discharge clinic at Beth Israel?

Dr. Doctoroff: The clinic was started as a joint venture between the hospitalist program and the general medicine department, which includes the faculty primary care practice, HealthCare Associates. There was a feeling from the hospitalist side that we could not get adequate and timely follow-up for our hospitalist patients at discharge. From the primary care perspective, I think they wanted to expose hospitalists to the outpatient work in the clinic and help us better organize the post-discharge planning that we do.

HN: Did you get push-back from primary care physicians in the community, and if so, how did you deal with that?

Dr. Doctoroff: Our clinic only sees patients who are affiliated with the primary care practice here. We do not have a stand-alone clinic where we see any patient that we discharge from the hospital. We have had some push-back from primary care doctors within the practice who feel that having us see a patient after a traumatic hospital admission is essentially another transition. And so they prefer to see their own patients after discharge. We developed processes to ensure that a primary care physician can know when their patient is scheduled in our clinic. But the effect of having us in the clinic has pushed the bar a little bit, so the primary care physicians seem to be scheduling their patients sooner, rather than having them come back to see them in a more haphazard way.

HN: Have you measured any outcomes since opening the clinic, such as the effect on readmissions?

Dr. Doctoroff: We were started essentially to help improve and create open access into this clinic. The main outcome that we started to look at was our impact on open access for patients after discharge. I have only preliminary data, but it shows that we really do see patients after discharge much more quickly than the primary care practice as a whole. Readmissions are what everyone is talking about these days, but our clinic wasn’t really established to reduce readmissions. It might be a secondary effect. But there are conflicting data about whether seeing a doctor actually reduces your risk of being readmitted. If you come to the doctor and you’re feeling poor, then you’re more likely to get readmitted than if you’d stayed home. But in those cases, being readmitted isn’t necessarily a bad outcome for the patient. It’s hard for me to think that seeing a doctor soon after discharge doesn’t help improve, if not readmissions, certainly quality of care.

HN: Do you enjoy the work in the discharge clinic, or does it detract from your inpatient responsibilities?

Dr. Doctoroff: I think that working in the discharge clinic has very much enriched my inpatient perspective. I think it really is invaluable to see the impact of discharge planning. You may think your discharge plan is good when you’re in the hospital, and then when you see the patient in the clinic, you think, "How was this ever considered to be a good plan?" For instance, why does a patient have four different appointments on different days with different specialists all in the 2 weeks after discharge? It’s really opened my eyes about what a good discharge plan and a good discharge summary are. I also feel more empathy for primary care physicians, as their job is definitely not an easy one.

HN: Do you think this clinic is a model for hospitalists in other parts of the country?

Dr. Doctoroff: The next stage of hospitalist medicine is going to include looking at our role as being a little broader than just being in the hospital. We as hospitalists are being held responsible for what happens to patients after discharge, whether it’s readmissions or other outcomes. I’m not sure that for every hospitalist group or every hospital, it will make sense to start a discharge clinic. I think there are models for discharge clinics in many different practice settings, both staffed by hospitalists and staffed by primary care doctors. But I do think that whether it’s a discharge clinic, whether it’s a post-discharge phone calling program, whether it’s just establishing better relationships with the primary care practices that you serve as a hospitalist, that this sort of connection is what’s going to be required to succeed as a hospitalist and in the new world of accountable care organizations and global payments.

This column, "Leaders," regularly appears in Hospitalist News, an Elsevier publication. Dr. Doctoroff had no disclosures to report.

Take us to your leader. Nominate a hospitalist whose work inspires you. E-mail suggestions to m.schneider@elsevier.com. Read previous columns at ehospitalistnews.com.

The U.S. Supreme Court has agreed to hear arguments on the constitutionality of the Affordable Care Act, with a decision likely to come in June.

On Nov. 14, the high court announced that it would consider arguments related to a well-publicized challenge to the health reform law originally filed in Florida. The Florida case, brought by a coalition of Republican attorneys general and governors from 26 states along with the National Federation of Independent Business, asserted that the individual mandate, which requires all Americans to have health insurance, violates the Constitution. The coalition of states also objected to the law's broad expansion of Medicaid. They argued that requiring states to invest billions of dollars in an enlarged Medicaid program violated state sovereignty.

The Supreme Court has agreed to hear arguments related to the constitutionality of both the individual mandate and the Medicaid expansion. The justices said that if the individual mandate is declared unconstitutional, they will then consider whether the law can stand without it or must be struck down completely.

Opponents of the Affordable Care Act cheered the court's decision to accept the case. Greg Abbott, the attorney general for Texas, which is part of the case being considered by the high court, said the court's decision means the law is just one step closer to being tossed out.

But White House officials think they can win. “We know the Affordable Care Act is constitutional and are confident the Supreme Court will agree,” White House communications director Dan Pfeiffer said in a statement.

Families USA, a consumer advocacy group that supports the ACA, said it is “surprised and troubled” that the court chose to review the expansion of Medicaid. It is “disingenuous for the states bringing this case to object to this expansion of Medicaid as 'coercive,' because the Affordable Care Act specifies that between 90% and 100% of the costs of this expansion will be paid for by the federal government,” Ron Pollack, executive director, said in a statement. “Striking down this Medicaid expansion would jeopardize health care for millions of low-income Americans at a time when they can least afford it.”

The first decision in the Florida case came in January when U.S. District Court Judge Roger Vinson ruled that the individual mandate was unconstitutional and voided the entire law. But he disagreed with the states' argument that the Medicaid expansion was unconstitutional.

Next, the 11th Circuit Court of Appeals in Atlanta took up the case, agreeing with Judge Vinson that the individual mandate violated the Commerce Clause of the U.S. Constitution. But on Aug. 12, the appeals court ruled that the individual mandate could be separated from the rest of the ACA, allowing that law to stand.

Both the federal government and the plaintiffs in the Florida suit petitioned the Supreme Court to take up the case. Court watchers had expected the justices to consider the ACA in its current term since there have been conflicting rulings from the appeals courts on the law.

A decision on the constitutionality of the individual mandate is expected from the court in June.

Source ©Dan Herrick/iStockphoto.com

The U.S. Supreme Court has agreed to hear arguments on the constitutionality of the Affordable Care Act, with a decision likely to come in June.

On Nov. 14, the high court announced that it would consider arguments related to a well-publicized challenge to the health reform law originally filed in Florida. The Florida case, brought by a coalition of Republican attorneys general and governors from 26 states along with the National Federation of Independent Business, asserted that the individual mandate, which requires all Americans to have health insurance, violates the Constitution. The coalition of states also objected to the law's broad expansion of Medicaid. They argued that requiring states to invest billions of dollars in an enlarged Medicaid program violated state sovereignty.

The Supreme Court has agreed to hear arguments related to the constitutionality of both the individual mandate and the Medicaid expansion. The justices said that if the individual mandate is declared unconstitutional, they will then consider whether the law can stand without it or must be struck down completely.

Opponents of the Affordable Care Act cheered the court's decision to accept the case. Greg Abbott, the attorney general for Texas, which is part of the case being considered by the high court, said the court's decision means the law is just one step closer to being tossed out.

But White House officials think they can win. “We know the Affordable Care Act is constitutional and are confident the Supreme Court will agree,” White House communications director Dan Pfeiffer said in a statement.

Families USA, a consumer advocacy group that supports the ACA, said it is “surprised and troubled” that the court chose to review the expansion of Medicaid. It is “disingenuous for the states bringing this case to object to this expansion of Medicaid as 'coercive,' because the Affordable Care Act specifies that between 90% and 100% of the costs of this expansion will be paid for by the federal government,” Ron Pollack, executive director, said in a statement. “Striking down this Medicaid expansion would jeopardize health care for millions of low-income Americans at a time when they can least afford it.”

The first decision in the Florida case came in January when U.S. District Court Judge Roger Vinson ruled that the individual mandate was unconstitutional and voided the entire law. But he disagreed with the states' argument that the Medicaid expansion was unconstitutional.

Next, the 11th Circuit Court of Appeals in Atlanta took up the case, agreeing with Judge Vinson that the individual mandate violated the Commerce Clause of the U.S. Constitution. But on Aug. 12, the appeals court ruled that the individual mandate could be separated from the rest of the ACA, allowing that law to stand.

Both the federal government and the plaintiffs in the Florida suit petitioned the Supreme Court to take up the case. Court watchers had expected the justices to consider the ACA in its current term since there have been conflicting rulings from the appeals courts on the law.

A decision on the constitutionality of the individual mandate is expected from the court in June.

Source ©Dan Herrick/iStockphoto.com

The U.S. Supreme Court has agreed to hear arguments on the constitutionality of the Affordable Care Act, with a decision likely to come in June.

On Nov. 14, the high court announced that it would consider arguments related to a well-publicized challenge to the health reform law originally filed in Florida. The Florida case, brought by a coalition of Republican attorneys general and governors from 26 states along with the National Federation of Independent Business, asserted that the individual mandate, which requires all Americans to have health insurance, violates the Constitution. The coalition of states also objected to the law's broad expansion of Medicaid. They argued that requiring states to invest billions of dollars in an enlarged Medicaid program violated state sovereignty.

The Supreme Court has agreed to hear arguments related to the constitutionality of both the individual mandate and the Medicaid expansion. The justices said that if the individual mandate is declared unconstitutional, they will then consider whether the law can stand without it or must be struck down completely.

Opponents of the Affordable Care Act cheered the court's decision to accept the case. Greg Abbott, the attorney general for Texas, which is part of the case being considered by the high court, said the court's decision means the law is just one step closer to being tossed out.

But White House officials think they can win. “We know the Affordable Care Act is constitutional and are confident the Supreme Court will agree,” White House communications director Dan Pfeiffer said in a statement.

Families USA, a consumer advocacy group that supports the ACA, said it is “surprised and troubled” that the court chose to review the expansion of Medicaid. It is “disingenuous for the states bringing this case to object to this expansion of Medicaid as 'coercive,' because the Affordable Care Act specifies that between 90% and 100% of the costs of this expansion will be paid for by the federal government,” Ron Pollack, executive director, said in a statement. “Striking down this Medicaid expansion would jeopardize health care for millions of low-income Americans at a time when they can least afford it.”

The first decision in the Florida case came in January when U.S. District Court Judge Roger Vinson ruled that the individual mandate was unconstitutional and voided the entire law. But he disagreed with the states' argument that the Medicaid expansion was unconstitutional.

Next, the 11th Circuit Court of Appeals in Atlanta took up the case, agreeing with Judge Vinson that the individual mandate violated the Commerce Clause of the U.S. Constitution. But on Aug. 12, the appeals court ruled that the individual mandate could be separated from the rest of the ACA, allowing that law to stand.

Both the federal government and the plaintiffs in the Florida suit petitioned the Supreme Court to take up the case. Court watchers had expected the justices to consider the ACA in its current term since there have been conflicting rulings from the appeals courts on the law.

A decision on the constitutionality of the individual mandate is expected from the court in June.

Source ©Dan Herrick/iStockphoto.com

Personhood Act Gets a No Vote

Voters in Mississippi rejected a ballot initiative that would have granted legal rights to embryos, starting at fertilization. Opponents of the measure had said that the state-constitution change not only would ban abortion in all but rare cases, but also would make forms of birth control and fertility treatment unavailable. Dr. Douglas Laube, the board chair of Physicians for Reproductive Choice and Health, said that the “personhood” amendment would have disallowed birth control options that prevent implantation of an embryo, such as emergency contraception and the use of intrauterine devices. The amendment's ban on destroying human embryos would have curtailed in vitro fertilization, he said. Dr. Jennifer Mason, a spokeswoman for Personhood USA, which is promoting similar constitutional amendments around the country, said that personhood amendments shouldn't make fertility services any less available. Nearly 60% of Mississippi voters rejected the ballot measure.

Court Blocks Ultrasound Mandate

A federal judge held up North Carolina's requirement that women seeking an abortion view an ultrasound image of their fetuses. Passed in July over Gov. Bev Perdue's veto, the law requires abortion providers to place the ultrasound images in the woman's line of sight and describe the images. The law includes other abortion restrictions, such as a 24-hour waiting period. In October, U.S. District Judge Catherine Eagles temporarily blocked enforcement of the ultrasound provision but let other provisions go into effect. Bebe Anderson, senior counsel at the Center for Reproductive Rights, a group challenging the law's constitutionality, said the ultrasound provision “forces doctors to go against their medical judgment to deliver an ideological message to their patients.”

Medicare Starts New Coverage

Medicare is now paying to screen beneficiaries for chlamydia, gonorrhea, syphilis, and hepatitis B. A decision memo in November also started coverage for behavioral counseling aimed at preventing sexually transmitted infections. Screening for chlamydia and gonorrhea is covered for the small Medicare populations made up of pregnant women aged 24 or younger, pregnant women who are at increased risk for sexually transmitted infections (STIs), and women at high risk of STIs. Syphilis screening will be covered for pregnant women and men and women at high risk for STIs. Hepatitis B screening will be available for pregnant women at the first prenatal visit and again at delivery for women with new or continuing risk factors. Medicare, which includes end-stage kidney-disease patients and disabled people, also will pay for up to two, 20- to 30-minute, face-to-face counseling sessions for all sexually active adolescents and adults at high risk for STIs.

Women Lack Fertility Knowledge

Many women don't understand how big a factor age is in becoming pregnant, according to a survey of more than 1,000 women aged 25-35 who are currently using birth control or not trying to conceive. The Fertility IQ 2011 survey found that only 31% of respondents agreed that increasing age is the single strongest risk factor for infertility. The survey, which measures knowledge of fertility, showed that women had the least knowledge about how long it takes to become pregnant and the likelihood that they will conceive at various ages. “While these data show that women have a general understanding about fertility issues, there is a clear need to educate further on the impact of age on fertility,” Barbara Collura, executive director of the national infertility association RESOLVE, said in a statement. The survey also found that nearly half of women rely on their ob.gyn.s for information on infertility, followed by online sources and family and friends. The survey was supported by EMD Serono, Inc.

Contraceptives Have Wide Appeal

A new analysis from the Guttmacher Institute shows that oral contraceptives appeal to teenagers for benefits beyond contraception, including menstrual pain, menstrual regulation, and acne. Among girls aged 15-19, 82% said they used oral contraceptives for such reasons, compared with 67% of this group who reported taking birth control pills for pregnancy prevention. One-third the 15- to 19-year-olds reported taking the pills solely for noncontraceptive reasons. The analysis involved data from the 2006-2008 National Survey of Family Growth, which is administered by the National Center for Health Statistics.

AMA: Little Insurance Competition

Four out of five metropolitan areas in the United States lack a competitive health insurance market, according to an analysis from the American Medical Association. In addition, in about half of all metropolitan markets, one health insurer controls 50% or more of the market. In half the states, competition is limited to two health insurers who together control about 70% of the market. According to the study, Alabama, Alaska, Delaware, Michigan, Hawaii, the District of Columbia, Nebraska, North Carolina, Indiana, and Maine have the least competitive health insurance markets in the country.

Personhood Act Gets a No Vote

Voters in Mississippi rejected a ballot initiative that would have granted legal rights to embryos, starting at fertilization. Opponents of the measure had said that the state-constitution change not only would ban abortion in all but rare cases, but also would make forms of birth control and fertility treatment unavailable. Dr. Douglas Laube, the board chair of Physicians for Reproductive Choice and Health, said that the “personhood” amendment would have disallowed birth control options that prevent implantation of an embryo, such as emergency contraception and the use of intrauterine devices. The amendment's ban on destroying human embryos would have curtailed in vitro fertilization, he said. Dr. Jennifer Mason, a spokeswoman for Personhood USA, which is promoting similar constitutional amendments around the country, said that personhood amendments shouldn't make fertility services any less available. Nearly 60% of Mississippi voters rejected the ballot measure.

Court Blocks Ultrasound Mandate

A federal judge held up North Carolina's requirement that women seeking an abortion view an ultrasound image of their fetuses. Passed in July over Gov. Bev Perdue's veto, the law requires abortion providers to place the ultrasound images in the woman's line of sight and describe the images. The law includes other abortion restrictions, such as a 24-hour waiting period. In October, U.S. District Judge Catherine Eagles temporarily blocked enforcement of the ultrasound provision but let other provisions go into effect. Bebe Anderson, senior counsel at the Center for Reproductive Rights, a group challenging the law's constitutionality, said the ultrasound provision “forces doctors to go against their medical judgment to deliver an ideological message to their patients.”

Medicare Starts New Coverage

Medicare is now paying to screen beneficiaries for chlamydia, gonorrhea, syphilis, and hepatitis B. A decision memo in November also started coverage for behavioral counseling aimed at preventing sexually transmitted infections. Screening for chlamydia and gonorrhea is covered for the small Medicare populations made up of pregnant women aged 24 or younger, pregnant women who are at increased risk for sexually transmitted infections (STIs), and women at high risk of STIs. Syphilis screening will be covered for pregnant women and men and women at high risk for STIs. Hepatitis B screening will be available for pregnant women at the first prenatal visit and again at delivery for women with new or continuing risk factors. Medicare, which includes end-stage kidney-disease patients and disabled people, also will pay for up to two, 20- to 30-minute, face-to-face counseling sessions for all sexually active adolescents and adults at high risk for STIs.

Women Lack Fertility Knowledge

Many women don't understand how big a factor age is in becoming pregnant, according to a survey of more than 1,000 women aged 25-35 who are currently using birth control or not trying to conceive. The Fertility IQ 2011 survey found that only 31% of respondents agreed that increasing age is the single strongest risk factor for infertility. The survey, which measures knowledge of fertility, showed that women had the least knowledge about how long it takes to become pregnant and the likelihood that they will conceive at various ages. “While these data show that women have a general understanding about fertility issues, there is a clear need to educate further on the impact of age on fertility,” Barbara Collura, executive director of the national infertility association RESOLVE, said in a statement. The survey also found that nearly half of women rely on their ob.gyn.s for information on infertility, followed by online sources and family and friends. The survey was supported by EMD Serono, Inc.

Contraceptives Have Wide Appeal

A new analysis from the Guttmacher Institute shows that oral contraceptives appeal to teenagers for benefits beyond contraception, including menstrual pain, menstrual regulation, and acne. Among girls aged 15-19, 82% said they used oral contraceptives for such reasons, compared with 67% of this group who reported taking birth control pills for pregnancy prevention. One-third the 15- to 19-year-olds reported taking the pills solely for noncontraceptive reasons. The analysis involved data from the 2006-2008 National Survey of Family Growth, which is administered by the National Center for Health Statistics.

AMA: Little Insurance Competition

Four out of five metropolitan areas in the United States lack a competitive health insurance market, according to an analysis from the American Medical Association. In addition, in about half of all metropolitan markets, one health insurer controls 50% or more of the market. In half the states, competition is limited to two health insurers who together control about 70% of the market. According to the study, Alabama, Alaska, Delaware, Michigan, Hawaii, the District of Columbia, Nebraska, North Carolina, Indiana, and Maine have the least competitive health insurance markets in the country.

Personhood Act Gets a No Vote

Voters in Mississippi rejected a ballot initiative that would have granted legal rights to embryos, starting at fertilization. Opponents of the measure had said that the state-constitution change not only would ban abortion in all but rare cases, but also would make forms of birth control and fertility treatment unavailable. Dr. Douglas Laube, the board chair of Physicians for Reproductive Choice and Health, said that the “personhood” amendment would have disallowed birth control options that prevent implantation of an embryo, such as emergency contraception and the use of intrauterine devices. The amendment's ban on destroying human embryos would have curtailed in vitro fertilization, he said. Dr. Jennifer Mason, a spokeswoman for Personhood USA, which is promoting similar constitutional amendments around the country, said that personhood amendments shouldn't make fertility services any less available. Nearly 60% of Mississippi voters rejected the ballot measure.

Court Blocks Ultrasound Mandate

A federal judge held up North Carolina's requirement that women seeking an abortion view an ultrasound image of their fetuses. Passed in July over Gov. Bev Perdue's veto, the law requires abortion providers to place the ultrasound images in the woman's line of sight and describe the images. The law includes other abortion restrictions, such as a 24-hour waiting period. In October, U.S. District Judge Catherine Eagles temporarily blocked enforcement of the ultrasound provision but let other provisions go into effect. Bebe Anderson, senior counsel at the Center for Reproductive Rights, a group challenging the law's constitutionality, said the ultrasound provision “forces doctors to go against their medical judgment to deliver an ideological message to their patients.”

Medicare Starts New Coverage

Medicare is now paying to screen beneficiaries for chlamydia, gonorrhea, syphilis, and hepatitis B. A decision memo in November also started coverage for behavioral counseling aimed at preventing sexually transmitted infections. Screening for chlamydia and gonorrhea is covered for the small Medicare populations made up of pregnant women aged 24 or younger, pregnant women who are at increased risk for sexually transmitted infections (STIs), and women at high risk of STIs. Syphilis screening will be covered for pregnant women and men and women at high risk for STIs. Hepatitis B screening will be available for pregnant women at the first prenatal visit and again at delivery for women with new or continuing risk factors. Medicare, which includes end-stage kidney-disease patients and disabled people, also will pay for up to two, 20- to 30-minute, face-to-face counseling sessions for all sexually active adolescents and adults at high risk for STIs.

Women Lack Fertility Knowledge

Many women don't understand how big a factor age is in becoming pregnant, according to a survey of more than 1,000 women aged 25-35 who are currently using birth control or not trying to conceive. The Fertility IQ 2011 survey found that only 31% of respondents agreed that increasing age is the single strongest risk factor for infertility. The survey, which measures knowledge of fertility, showed that women had the least knowledge about how long it takes to become pregnant and the likelihood that they will conceive at various ages. “While these data show that women have a general understanding about fertility issues, there is a clear need to educate further on the impact of age on fertility,” Barbara Collura, executive director of the national infertility association RESOLVE, said in a statement. The survey also found that nearly half of women rely on their ob.gyn.s for information on infertility, followed by online sources and family and friends. The survey was supported by EMD Serono, Inc.

Contraceptives Have Wide Appeal

A new analysis from the Guttmacher Institute shows that oral contraceptives appeal to teenagers for benefits beyond contraception, including menstrual pain, menstrual regulation, and acne. Among girls aged 15-19, 82% said they used oral contraceptives for such reasons, compared with 67% of this group who reported taking birth control pills for pregnancy prevention. One-third the 15- to 19-year-olds reported taking the pills solely for noncontraceptive reasons. The analysis involved data from the 2006-2008 National Survey of Family Growth, which is administered by the National Center for Health Statistics.

AMA: Little Insurance Competition

Four out of five metropolitan areas in the United States lack a competitive health insurance market, according to an analysis from the American Medical Association. In addition, in about half of all metropolitan markets, one health insurer controls 50% or more of the market. In half the states, competition is limited to two health insurers who together control about 70% of the market. According to the study, Alabama, Alaska, Delaware, Michigan, Hawaii, the District of Columbia, Nebraska, North Carolina, Indiana, and Maine have the least competitive health insurance markets in the country.

Starting Nov. 21, the National Committee on Quality Assurance will begin to accredit accountable care organizations.

The program offers three levels of accreditation based on the readiness of the ACO. As with the NCQA's recognition program for patient-centered medical homes, achieving accreditation at each level will be based on accruing a certain number of points by meeting standards and fulfilling some “must-pass” criteria.

NCQA officials said that they decided to establish the new program while ACOs are still in their infancy in order to provide payers and patients with some assurance about the model. The idea is to let everyone know that if a group of providers calls themselves an ACO, then they have adhered to a set of principles and are doing the right things for patients, Margaret E. O'Kane, NCQA president, said during a press briefing to announce the program.

Accreditation also offers a “roadmap” for groups that aspire to be ACOs, Ms. O'Kane said, by outlining the elements needed to qualify as an ACO. “If you can meet these standards, you can be an ACO.”

The NCQA is launching its accreditation program as many physicians and hospitals are still trying to figure out if they could operate as an ACO. On Oct. 20, the Centers for Medicare and Medicaid Services released its final rule spelling out how an ACO should be structured and how providers in the organization would be paid by Medicare. Ms. O'Kane said that NCQA officials tried to align their accreditation standards with the Medicare rules as much as possible.

NCQA will offer accreditation to providers in group practice arrangements, networks of individual practices, hospital-provider partnerships or joint ventures, hospitals and their employed or contracted providers, publicly governed entities that work with providers to arrange care, and partnerships with providers and health plans. ACOs will need to serve at least 5,000 patients to quality for the NCQA program.

ACOs that seek accreditation will be evaluated on 65 elements, including 4 “must-pass” items. The elements fall into the following seven broad categories:

▸ Program operations. ACOs must have the infrastructure necessary to coordinate providers.

▸ Access and availability. ACOs must have sufficient numbers and types of providers, as well as timely access to care. NCQA said that the range of providers should include primary care, specialty care, urgent/emergency/inpatient care, community- and home-based services, and long-term care.

▸ Primary care as the foundation. The NCQA accreditation program builds on the standards in its patient-centered medical home recognition program.

▸ Care management. This requirement includes providing population health programs.

▸ Care coordination and transitions. The ACO must have a coordinated system for timely information exchange across multiple providers.

▸ Patient rights and responsibilities. ACOs must have a process for patient complaints, and a way for patients to restrict access to their data.

▸ Performance reporting. ACOs must measure their performance and publicly report the results.

ACOs that seek NCQA accreditation will also be evaluated using 40 measures of clinical quality, patient experience, and efficiency and utilization.

The program is the product of 2 years of discussions by the NCQA's ACO Task Force, which includes patients, policy experts, representatives from integrated health systems, and physicians. NCQA also evaluated 2,200 public comments and pilot tested the standards among integrated delivery systems, multispecialty practice groups, and independent practice associations.

Starting Nov. 21, the National Committee on Quality Assurance will begin to accredit accountable care organizations.

The program offers three levels of accreditation based on the readiness of the ACO. As with the NCQA's recognition program for patient-centered medical homes, achieving accreditation at each level will be based on accruing a certain number of points by meeting standards and fulfilling some “must-pass” criteria.

NCQA officials said that they decided to establish the new program while ACOs are still in their infancy in order to provide payers and patients with some assurance about the model. The idea is to let everyone know that if a group of providers calls themselves an ACO, then they have adhered to a set of principles and are doing the right things for patients, Margaret E. O'Kane, NCQA president, said during a press briefing to announce the program.

Accreditation also offers a “roadmap” for groups that aspire to be ACOs, Ms. O'Kane said, by outlining the elements needed to qualify as an ACO. “If you can meet these standards, you can be an ACO.”

The NCQA is launching its accreditation program as many physicians and hospitals are still trying to figure out if they could operate as an ACO. On Oct. 20, the Centers for Medicare and Medicaid Services released its final rule spelling out how an ACO should be structured and how providers in the organization would be paid by Medicare. Ms. O'Kane said that NCQA officials tried to align their accreditation standards with the Medicare rules as much as possible.

NCQA will offer accreditation to providers in group practice arrangements, networks of individual practices, hospital-provider partnerships or joint ventures, hospitals and their employed or contracted providers, publicly governed entities that work with providers to arrange care, and partnerships with providers and health plans. ACOs will need to serve at least 5,000 patients to quality for the NCQA program.

ACOs that seek accreditation will be evaluated on 65 elements, including 4 “must-pass” items. The elements fall into the following seven broad categories:

▸ Program operations. ACOs must have the infrastructure necessary to coordinate providers.

▸ Access and availability. ACOs must have sufficient numbers and types of providers, as well as timely access to care. NCQA said that the range of providers should include primary care, specialty care, urgent/emergency/inpatient care, community- and home-based services, and long-term care.

▸ Primary care as the foundation. The NCQA accreditation program builds on the standards in its patient-centered medical home recognition program.

▸ Care management. This requirement includes providing population health programs.

▸ Care coordination and transitions. The ACO must have a coordinated system for timely information exchange across multiple providers.

▸ Patient rights and responsibilities. ACOs must have a process for patient complaints, and a way for patients to restrict access to their data.

▸ Performance reporting. ACOs must measure their performance and publicly report the results.

ACOs that seek NCQA accreditation will also be evaluated using 40 measures of clinical quality, patient experience, and efficiency and utilization.

The program is the product of 2 years of discussions by the NCQA's ACO Task Force, which includes patients, policy experts, representatives from integrated health systems, and physicians. NCQA also evaluated 2,200 public comments and pilot tested the standards among integrated delivery systems, multispecialty practice groups, and independent practice associations.

Starting Nov. 21, the National Committee on Quality Assurance will begin to accredit accountable care organizations.

The program offers three levels of accreditation based on the readiness of the ACO. As with the NCQA's recognition program for patient-centered medical homes, achieving accreditation at each level will be based on accruing a certain number of points by meeting standards and fulfilling some “must-pass” criteria.

NCQA officials said that they decided to establish the new program while ACOs are still in their infancy in order to provide payers and patients with some assurance about the model. The idea is to let everyone know that if a group of providers calls themselves an ACO, then they have adhered to a set of principles and are doing the right things for patients, Margaret E. O'Kane, NCQA president, said during a press briefing to announce the program.

Accreditation also offers a “roadmap” for groups that aspire to be ACOs, Ms. O'Kane said, by outlining the elements needed to qualify as an ACO. “If you can meet these standards, you can be an ACO.”

The NCQA is launching its accreditation program as many physicians and hospitals are still trying to figure out if they could operate as an ACO. On Oct. 20, the Centers for Medicare and Medicaid Services released its final rule spelling out how an ACO should be structured and how providers in the organization would be paid by Medicare. Ms. O'Kane said that NCQA officials tried to align their accreditation standards with the Medicare rules as much as possible.

NCQA will offer accreditation to providers in group practice arrangements, networks of individual practices, hospital-provider partnerships or joint ventures, hospitals and their employed or contracted providers, publicly governed entities that work with providers to arrange care, and partnerships with providers and health plans. ACOs will need to serve at least 5,000 patients to quality for the NCQA program.

ACOs that seek accreditation will be evaluated on 65 elements, including 4 “must-pass” items. The elements fall into the following seven broad categories:

▸ Program operations. ACOs must have the infrastructure necessary to coordinate providers.

▸ Access and availability. ACOs must have sufficient numbers and types of providers, as well as timely access to care. NCQA said that the range of providers should include primary care, specialty care, urgent/emergency/inpatient care, community- and home-based services, and long-term care.

▸ Primary care as the foundation. The NCQA accreditation program builds on the standards in its patient-centered medical home recognition program.

▸ Care management. This requirement includes providing population health programs.

▸ Care coordination and transitions. The ACO must have a coordinated system for timely information exchange across multiple providers.

▸ Patient rights and responsibilities. ACOs must have a process for patient complaints, and a way for patients to restrict access to their data.

▸ Performance reporting. ACOs must measure their performance and publicly report the results.

ACOs that seek NCQA accreditation will also be evaluated using 40 measures of clinical quality, patient experience, and efficiency and utilization.

The program is the product of 2 years of discussions by the NCQA's ACO Task Force, which includes patients, policy experts, representatives from integrated health systems, and physicians. NCQA also evaluated 2,200 public comments and pilot tested the standards among integrated delivery systems, multispecialty practice groups, and independent practice associations.

Legislation introduced in the U.S. House of Representatives would require that women be informed of their breast density when they receive their mammogram results, and that those with denser breasts be advised that they could benefit from additional screening.

The Breast Density and Mammography Reporting Act of 2011 (H.R. 3102), introduced in October by Rep. Rosa DeLauro (D-Conn.) and Rep. Steve Israel (D-N.Y.), is modeled after laws enacted in Connecticut in 2009 and in Texas earlier this year. Similar legislation was recently passed by the California legislature, but was vetoed by the governor.

Bills on breast density are also slated to be introduced in at least six other states next year, according to the consumer advocacy group Are You Dense.

The movement to pass these bills has grown largely from the outrage of women who have received years of normal mammogram results only to find out that they have an advanced-stage breast cancer that went undetected because of their dense breast tissue.

That was the experience of Are You Dense founder Nancy M. Cappello, Ph.D., who successfully lobbied lawmakers to enact the Connecticut legislation.

Although information on breast density is available on the mammography report sent to referring physicians, it's not mentioned in the “lay letter” received by women, Dr. Cappello said. That leaves most women in the dark about the fact that dense breasts can make mammograms more difficult to read, and that women with extremely dense breasts are at a higher risk for breast cancer, she said.

“It's a hoax in some respects, a cruel hoax,” she said.

Are You Dense and its supporters around the country have been working state by state to enact laws that require that women be notified of their breast density and their options for additional screening. They are also working at the federal level to change either the law or the regulations surrounding mammography.

Dr. Cappello said that trying to legislate the change wasn't her first choice, but without a national cancer organization or physician group stepping up to educate women, she doesn't have a better option for standardizing the communication on breast density.

In November, Dr. Cappello took her case to the Food and Drug Administration's National Mammography Quality Assurance Advisory Committee. The asked the committee, which provides nonbinding advice to the FDA, to recommend changing the federally mandated lay letter to include information on breast density. While the advisory committee members reached a consensus that breast tissue density should be reported in the mammography lay letter, several of the members said they were unsure what recommendation could be made to physicians and patients about what to do with the information. The committee also did not come to an agreement on the best say to further evaluate patients with dense breasts through other imaging modalities.

But given the uncertain timeframe for any action by the FDA, Are You Dense plans to continue its efforts to enact breast density legislation in the states and at the federal level.

So far, Dr. Cappello's legislative efforts have failed to gain support from major physician groups and patient advocacy organizations. Susan G. Komen for the Cure and the American Cancer Society both stayed on the sidelines during the recent legislative debate in California. The California chapter of the American College of Obstetricians and Gynecologists and the California Medical Association opposed the bill.

“It was a very difficult bill for us to oppose,” said Dr. Philip Diamond, a San Diego ob.gyn. and chair of ACOG District IX in California.

The problem was that the bill went beyond notifying women about their density and on to suggest that they speak with their physician about supplemental screening. The bill's language on supplemental screening goes beyond the existing evidence, Dr. Diamond said, and raised a host of concerns about what the cost of screening would mean for state-funded health programs.

“In the absence of a guideline nationally by either the cancer society or the radiology society or anyone, it's impossible to be able to figure out who needs supplement screening and who doesn't,” he said.

A big concern in California, Dr. Diamond said, is that such legislation would lead to the automatic ordering of supplemental ultrasounds and MRIs, regardless of the individual risk factors of the women involved.

That's exactly what has happened after the Connecticut law was enacted, according to New Haven ob.gyn. Howard Shaw, vice chair for the Connecticut section of ACOG.

Although the law has probably raised some awareness of the breast density issues for women, it has also sparked a reflexive ordering of supplemental testing for any women with dense breasts, he said, adding that the ordering is largely driven by liability concerns.

“There is a feeling by many that we're just going to order it because, if we don't order it and something happens, we're going to have a problem,” said Dr. Steven Fleischman, associate chief of ob.gyn. at Yale–New Haven Hospital and the legislative chair of ACOG District I.

Another problem with the Connecticut law is that there's a lack of data on how it's working, he said. Because there was no tracking component built into the law, there are many lingering questions about the number of supplemental tests, the additional costs, and whether more cancers are being detected earlier, he said.

“It's not just about cost; it's about 'Are we getting more cases, and are we getting them earlier,'” Dr. Fleischman said.

The digital mammogram (left) was negative, while the molecular breast imaging scan detected a ductal carcinoma in situ in this dense breast.

Source Courtesy Mayo Clinic

Legislation introduced in the U.S. House of Representatives would require that women be informed of their breast density when they receive their mammogram results, and that those with denser breasts be advised that they could benefit from additional screening.

The Breast Density and Mammography Reporting Act of 2011 (H.R. 3102), introduced in October by Rep. Rosa DeLauro (D-Conn.) and Rep. Steve Israel (D-N.Y.), is modeled after laws enacted in Connecticut in 2009 and in Texas earlier this year. Similar legislation was recently passed by the California legislature, but was vetoed by the governor.

Bills on breast density are also slated to be introduced in at least six other states next year, according to the consumer advocacy group Are You Dense.

The movement to pass these bills has grown largely from the outrage of women who have received years of normal mammogram results only to find out that they have an advanced-stage breast cancer that went undetected because of their dense breast tissue.

That was the experience of Are You Dense founder Nancy M. Cappello, Ph.D., who successfully lobbied lawmakers to enact the Connecticut legislation.

Although information on breast density is available on the mammography report sent to referring physicians, it's not mentioned in the “lay letter” received by women, Dr. Cappello said. That leaves most women in the dark about the fact that dense breasts can make mammograms more difficult to read, and that women with extremely dense breasts are at a higher risk for breast cancer, she said.

“It's a hoax in some respects, a cruel hoax,” she said.

Are You Dense and its supporters around the country have been working state by state to enact laws that require that women be notified of their breast density and their options for additional screening. They are also working at the federal level to change either the law or the regulations surrounding mammography.

Dr. Cappello said that trying to legislate the change wasn't her first choice, but without a national cancer organization or physician group stepping up to educate women, she doesn't have a better option for standardizing the communication on breast density.

In November, Dr. Cappello took her case to the Food and Drug Administration's National Mammography Quality Assurance Advisory Committee. The asked the committee, which provides nonbinding advice to the FDA, to recommend changing the federally mandated lay letter to include information on breast density. While the advisory committee members reached a consensus that breast tissue density should be reported in the mammography lay letter, several of the members said they were unsure what recommendation could be made to physicians and patients about what to do with the information. The committee also did not come to an agreement on the best say to further evaluate patients with dense breasts through other imaging modalities.

But given the uncertain timeframe for any action by the FDA, Are You Dense plans to continue its efforts to enact breast density legislation in the states and at the federal level.

So far, Dr. Cappello's legislative efforts have failed to gain support from major physician groups and patient advocacy organizations. Susan G. Komen for the Cure and the American Cancer Society both stayed on the sidelines during the recent legislative debate in California. The California chapter of the American College of Obstetricians and Gynecologists and the California Medical Association opposed the bill.

“It was a very difficult bill for us to oppose,” said Dr. Philip Diamond, a San Diego ob.gyn. and chair of ACOG District IX in California.

The problem was that the bill went beyond notifying women about their density and on to suggest that they speak with their physician about supplemental screening. The bill's language on supplemental screening goes beyond the existing evidence, Dr. Diamond said, and raised a host of concerns about what the cost of screening would mean for state-funded health programs.

“In the absence of a guideline nationally by either the cancer society or the radiology society or anyone, it's impossible to be able to figure out who needs supplement screening and who doesn't,” he said.

A big concern in California, Dr. Diamond said, is that such legislation would lead to the automatic ordering of supplemental ultrasounds and MRIs, regardless of the individual risk factors of the women involved.

That's exactly what has happened after the Connecticut law was enacted, according to New Haven ob.gyn. Howard Shaw, vice chair for the Connecticut section of ACOG.

Although the law has probably raised some awareness of the breast density issues for women, it has also sparked a reflexive ordering of supplemental testing for any women with dense breasts, he said, adding that the ordering is largely driven by liability concerns.

“There is a feeling by many that we're just going to order it because, if we don't order it and something happens, we're going to have a problem,” said Dr. Steven Fleischman, associate chief of ob.gyn. at Yale–New Haven Hospital and the legislative chair of ACOG District I.

Another problem with the Connecticut law is that there's a lack of data on how it's working, he said. Because there was no tracking component built into the law, there are many lingering questions about the number of supplemental tests, the additional costs, and whether more cancers are being detected earlier, he said.

“It's not just about cost; it's about 'Are we getting more cases, and are we getting them earlier,'” Dr. Fleischman said.

The digital mammogram (left) was negative, while the molecular breast imaging scan detected a ductal carcinoma in situ in this dense breast.

Source Courtesy Mayo Clinic

Legislation introduced in the U.S. House of Representatives would require that women be informed of their breast density when they receive their mammogram results, and that those with denser breasts be advised that they could benefit from additional screening.

The Breast Density and Mammography Reporting Act of 2011 (H.R. 3102), introduced in October by Rep. Rosa DeLauro (D-Conn.) and Rep. Steve Israel (D-N.Y.), is modeled after laws enacted in Connecticut in 2009 and in Texas earlier this year. Similar legislation was recently passed by the California legislature, but was vetoed by the governor.

Bills on breast density are also slated to be introduced in at least six other states next year, according to the consumer advocacy group Are You Dense.

The movement to pass these bills has grown largely from the outrage of women who have received years of normal mammogram results only to find out that they have an advanced-stage breast cancer that went undetected because of their dense breast tissue.

That was the experience of Are You Dense founder Nancy M. Cappello, Ph.D., who successfully lobbied lawmakers to enact the Connecticut legislation.

Although information on breast density is available on the mammography report sent to referring physicians, it's not mentioned in the “lay letter” received by women, Dr. Cappello said. That leaves most women in the dark about the fact that dense breasts can make mammograms more difficult to read, and that women with extremely dense breasts are at a higher risk for breast cancer, she said.

“It's a hoax in some respects, a cruel hoax,” she said.

Are You Dense and its supporters around the country have been working state by state to enact laws that require that women be notified of their breast density and their options for additional screening. They are also working at the federal level to change either the law or the regulations surrounding mammography.

Dr. Cappello said that trying to legislate the change wasn't her first choice, but without a national cancer organization or physician group stepping up to educate women, she doesn't have a better option for standardizing the communication on breast density.

In November, Dr. Cappello took her case to the Food and Drug Administration's National Mammography Quality Assurance Advisory Committee. The asked the committee, which provides nonbinding advice to the FDA, to recommend changing the federally mandated lay letter to include information on breast density. While the advisory committee members reached a consensus that breast tissue density should be reported in the mammography lay letter, several of the members said they were unsure what recommendation could be made to physicians and patients about what to do with the information. The committee also did not come to an agreement on the best say to further evaluate patients with dense breasts through other imaging modalities.

But given the uncertain timeframe for any action by the FDA, Are You Dense plans to continue its efforts to enact breast density legislation in the states and at the federal level.

So far, Dr. Cappello's legislative efforts have failed to gain support from major physician groups and patient advocacy organizations. Susan G. Komen for the Cure and the American Cancer Society both stayed on the sidelines during the recent legislative debate in California. The California chapter of the American College of Obstetricians and Gynecologists and the California Medical Association opposed the bill.

“It was a very difficult bill for us to oppose,” said Dr. Philip Diamond, a San Diego ob.gyn. and chair of ACOG District IX in California.

The problem was that the bill went beyond notifying women about their density and on to suggest that they speak with their physician about supplemental screening. The bill's language on supplemental screening goes beyond the existing evidence, Dr. Diamond said, and raised a host of concerns about what the cost of screening would mean for state-funded health programs.

“In the absence of a guideline nationally by either the cancer society or the radiology society or anyone, it's impossible to be able to figure out who needs supplement screening and who doesn't,” he said.

A big concern in California, Dr. Diamond said, is that such legislation would lead to the automatic ordering of supplemental ultrasounds and MRIs, regardless of the individual risk factors of the women involved.

That's exactly what has happened after the Connecticut law was enacted, according to New Haven ob.gyn. Howard Shaw, vice chair for the Connecticut section of ACOG.

Although the law has probably raised some awareness of the breast density issues for women, it has also sparked a reflexive ordering of supplemental testing for any women with dense breasts, he said, adding that the ordering is largely driven by liability concerns.

“There is a feeling by many that we're just going to order it because, if we don't order it and something happens, we're going to have a problem,” said Dr. Steven Fleischman, associate chief of ob.gyn. at Yale–New Haven Hospital and the legislative chair of ACOG District I.

Another problem with the Connecticut law is that there's a lack of data on how it's working, he said. Because there was no tracking component built into the law, there are many lingering questions about the number of supplemental tests, the additional costs, and whether more cancers are being detected earlier, he said.

“It's not just about cost; it's about 'Are we getting more cases, and are we getting them earlier,'” Dr. Fleischman said.

The digital mammogram (left) was negative, while the molecular breast imaging scan detected a ductal carcinoma in situ in this dense breast.

Source Courtesy Mayo Clinic