ACS Surgery News

Businesses with fewer than 100 employees will have until 2016 to offer their workers health insurance or face penalties, according to a regulation released by the Internal Revenue Service.

The Affordable Care Act’s employer mandate had already been delayed until 2015 for all businesses with 50 or more employees. Businesses with fewer than 50 workers are exempt from providing health coverage under the ACA.

Under the new IRS regulation, released on Feb. 10, businesses with 50-99 workers have until 2016 before complying with the mandate, but they must report on their workers and coverage in 2015.

Larger businesses can phase in their health insurance offering starting in 2015. Under the rule, businesses with 100 or more workers must offer coverage to 70% of their full-time employees in 2015, and 95% of full-time workers in 2016.

[email protected]

On Twitter @maryellenny

Businesses with fewer than 100 employees will have until 2016 to offer their workers health insurance or face penalties, according to a regulation released by the Internal Revenue Service.

The Affordable Care Act’s employer mandate had already been delayed until 2015 for all businesses with 50 or more employees. Businesses with fewer than 50 workers are exempt from providing health coverage under the ACA.

Under the new IRS regulation, released on Feb. 10, businesses with 50-99 workers have until 2016 before complying with the mandate, but they must report on their workers and coverage in 2015.

Larger businesses can phase in their health insurance offering starting in 2015. Under the rule, businesses with 100 or more workers must offer coverage to 70% of their full-time employees in 2015, and 95% of full-time workers in 2016.

[email protected]

On Twitter @maryellenny

Businesses with fewer than 100 employees will have until 2016 to offer their workers health insurance or face penalties, according to a regulation released by the Internal Revenue Service.

The Affordable Care Act’s employer mandate had already been delayed until 2015 for all businesses with 50 or more employees. Businesses with fewer than 50 workers are exempt from providing health coverage under the ACA.

Under the new IRS regulation, released on Feb. 10, businesses with 50-99 workers have until 2016 before complying with the mandate, but they must report on their workers and coverage in 2015.

Larger businesses can phase in their health insurance offering starting in 2015. Under the rule, businesses with 100 or more workers must offer coverage to 70% of their full-time employees in 2015, and 95% of full-time workers in 2016.

[email protected]

On Twitter @maryellenny

The American Medical Association is urging Congress to work quickly to find a way to pay for a permanent repeal of Medicare’s Sustainable Growth Rate formula, before the current short-term patch expires on March 31.

During a press conference on Feb. 10, AMA President Ardis Dee Hoven put the organization’s full support behind the SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S. 2000), which eliminates the Sustainable Growth Rate (SGR) formula and provides 0.5% physician payment increases for 5 years. The bill, which was introduced simultaneously in the House and Senate on Feb. 6, consolidates Medicare’s quality incentive programs and phases in new payment models.

But the AMA remains opposed to another short-term SGR fix, including a proposal that would avert physician pay cuts under Medicare for another 9 months.

"This whole concept of continued patching is fiscally irresponsible," Dr. Hoven said. "It undermines continually the stability of the program."

Without some type of SGR fix, either short-term or long-term, Medicare physician payments are set to drop about 24% on April 1.

But approving a permanent SGR repeal in the next several weeks hinges on whether lawmakers can agree on how to pay for it. The Congressional Budget Office estimates that the cost could run as high as $150 billion over 10 years.

Dr. Hoven said the AMA would not make recommendations on how to offset the cost of the bill, but they would offer an opinion once lawmakers put a specific proposal on the table.

"Right now, the momentum is there," Dr. Hoven said. "These conversations have been ongoing for years. They simply need to get this done and get it done now."

[email protected]

On Twitter @maryellenny

The American Medical Association is urging Congress to work quickly to find a way to pay for a permanent repeal of Medicare’s Sustainable Growth Rate formula, before the current short-term patch expires on March 31.

During a press conference on Feb. 10, AMA President Ardis Dee Hoven put the organization’s full support behind the SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S. 2000), which eliminates the Sustainable Growth Rate (SGR) formula and provides 0.5% physician payment increases for 5 years. The bill, which was introduced simultaneously in the House and Senate on Feb. 6, consolidates Medicare’s quality incentive programs and phases in new payment models.

But the AMA remains opposed to another short-term SGR fix, including a proposal that would avert physician pay cuts under Medicare for another 9 months.

"This whole concept of continued patching is fiscally irresponsible," Dr. Hoven said. "It undermines continually the stability of the program."

Without some type of SGR fix, either short-term or long-term, Medicare physician payments are set to drop about 24% on April 1.

But approving a permanent SGR repeal in the next several weeks hinges on whether lawmakers can agree on how to pay for it. The Congressional Budget Office estimates that the cost could run as high as $150 billion over 10 years.

Dr. Hoven said the AMA would not make recommendations on how to offset the cost of the bill, but they would offer an opinion once lawmakers put a specific proposal on the table.

"Right now, the momentum is there," Dr. Hoven said. "These conversations have been ongoing for years. They simply need to get this done and get it done now."

[email protected]

On Twitter @maryellenny

The American Medical Association is urging Congress to work quickly to find a way to pay for a permanent repeal of Medicare’s Sustainable Growth Rate formula, before the current short-term patch expires on March 31.

During a press conference on Feb. 10, AMA President Ardis Dee Hoven put the organization’s full support behind the SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S. 2000), which eliminates the Sustainable Growth Rate (SGR) formula and provides 0.5% physician payment increases for 5 years. The bill, which was introduced simultaneously in the House and Senate on Feb. 6, consolidates Medicare’s quality incentive programs and phases in new payment models.

But the AMA remains opposed to another short-term SGR fix, including a proposal that would avert physician pay cuts under Medicare for another 9 months.

"This whole concept of continued patching is fiscally irresponsible," Dr. Hoven said. "It undermines continually the stability of the program."

Without some type of SGR fix, either short-term or long-term, Medicare physician payments are set to drop about 24% on April 1.

But approving a permanent SGR repeal in the next several weeks hinges on whether lawmakers can agree on how to pay for it. The Congressional Budget Office estimates that the cost could run as high as $150 billion over 10 years.

Dr. Hoven said the AMA would not make recommendations on how to offset the cost of the bill, but they would offer an opinion once lawmakers put a specific proposal on the table.

"Right now, the momentum is there," Dr. Hoven said. "These conversations have been ongoing for years. They simply need to get this done and get it done now."

[email protected]

On Twitter @maryellenny

NAPLES, FLA. – Posttraumatic stress disorder is disturbingly common among U.S. trauma surgeons, according to a national survey.

Among 453 members of the American Association for the Surgery of Trauma (AAST) and Eastern Association for the Surgery of Trauma (EAST), 40% had symptoms of PTSD and 15% met the diagnostic criteria for PTSD.

"It’s the elephant in the room," Dr. Bellal A. Joseph said at the annual scientific assembly of EAST.

Understanding the factors that predispose trauma surgeons to PTSD may benefit patients and the profession and may be useful to national trauma surgery associations to develop targeted interventions, said Dr. Joseph, a trauma and critical care surgeon at the University of Arizona Medical Center, Tucson.

"Active surveillance to promote wellness among trauma surgeons is warranted," he said.

Invited discussant Dr. Karen Lommel, a psychiatrist who recently converted to emergency medicine at the University of Kentucky, Lexington, described the findings as "quite remarkable."

"The issue of posttraumatic symptoms and PTSD affects all of us who work in trauma, whether we choose to acknowledge it or not," she said. "Pre-hospital workers, nurses, and mental health professionals have been extensively included in PTSD studies. Unfortunately, trauma surgeons – one of the most stoic of frontline providers – have been overlooked."

Dr. Joseph described receiving pushback when proposing the study to other trauma surgeons and was told flat-out by one respondent that its hypothesis is flawed.

A self-identified senior surgeon wrote: "I found that the assumptions of the questions did not fit the trauma program I work in nor the surgeons with whom I work. They actually take trauma call to relax. Stress is not a word in our vocabulary."

The two-part survey, sent to all members of EAST and the AAST (41% response rate), was not specifically identified as a PTSD survey, but included the validated PTSD CheckList-Civilian Version (PCL-C). A score of 35 or more on the 17-item PCL-C has previously shown a sensitivity of 85% for PTSD symptoms, while a score of 44 or more is 95% sensitive and 86% specific for a PTSD diagnosis, Dr. Joseph observed.

The survey respondents were mostly male (76%), white (80%), practiced in an urban hospital (89.6%), or Level 1 trauma center (71%). More than half (54.7%) had 11 years or more of clinical practice, 21% had military experience, and 14.3% had been deployed to war.

Three-fourths (66.4%) had an annual income of at least $300,000, but 90.5% spent no more than 4 hours per day of non–sleep relaxation and 26.5% took no more than 2 weeks vacation per year.

Only 6.2% said they suffered from depression and 3% from anxiety, but 66% reported using alcohol and 5.3% smoking.

Regarding the scope of their work, 85% had four or more 24-hour calls per month, 36% had at least three critical cases per call, and 24% had at least 10 operative trauma cases per month.

Surgeons who had more than five critical cases per call were seven times more likely to develop PTSD in multivariate analysis (odds ratio, 7; P = .001), Dr. Joseph said. No other factors were significantly associated with a PTSD diagnosis.

Independent predictors of PTSD symptoms in the multivariate analysis were male sex (OR, 2; P = .04); more than seven call duties/month (OR, 2.6; P = .001); more than 15 operative cases/month (OR, 3; P = .001); less than 4 hours of daily relaxation (OR, 7; P = .01)’ and less than 2 weeks of vacation/year (OR, 2: P = .02); he said.

Following the presentation, a surgeon from the Bronx, N.Y., said one of the sticking points for his CEO in the state’s move toward American College of Surgeons’ verification is the back-up call requirement for the trauma surgeons.

"We think of this back-up call requirement as patient-centric; when you’re busy, patients aren’t well taken care of," he said. "You’ve just flipped this argument for me, which is that there’s another human being involved: the trauma surgeon. I’m going to go back, show him your abstract, and say, ‘There is another human being at work here and maybe at that fifth critical ... that fifth Level 1 activation ... it’s time to call the back-up guy.’ "

One attendee rose to say she’d just lost a colleague to PTSD and asked who should best perform an intervention to avoid any potential harm to the surgeon’s career. Another attendee responded that what’s helped the military address PTSD in its health care workers is to try to remove the perceived stigma of PTSD.

Dr. Joseph agreed that the military has been instrumental in identifying this issue and could join with EAST and other professional organizations in developing an intervention for its members. PTSD screening, even among residents, also would not go amiss.

Additional analyses will focus on protective factors among respondents who did not develop PTSD as well as how surgeons in other countries, such as South America, address the aftermath of dealing with violence, accidents, and injury on a daily basis.

"I think lack of insight is what you hear across all the comments," Dr. Joseph said. "We all think we’re Superman. People that know me know I’m probably as tough as they come, but at the same time we have to look back and realize this really does affect us. We’re not invincible."

Dr. Joseph and his coauthors reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Posttraumatic stress disorder is disturbingly common among U.S. trauma surgeons, according to a national survey.

Among 453 members of the American Association for the Surgery of Trauma (AAST) and Eastern Association for the Surgery of Trauma (EAST), 40% had symptoms of PTSD and 15% met the diagnostic criteria for PTSD.

"It’s the elephant in the room," Dr. Bellal A. Joseph said at the annual scientific assembly of EAST.

Understanding the factors that predispose trauma surgeons to PTSD may benefit patients and the profession and may be useful to national trauma surgery associations to develop targeted interventions, said Dr. Joseph, a trauma and critical care surgeon at the University of Arizona Medical Center, Tucson.

"Active surveillance to promote wellness among trauma surgeons is warranted," he said.

Invited discussant Dr. Karen Lommel, a psychiatrist who recently converted to emergency medicine at the University of Kentucky, Lexington, described the findings as "quite remarkable."

"The issue of posttraumatic symptoms and PTSD affects all of us who work in trauma, whether we choose to acknowledge it or not," she said. "Pre-hospital workers, nurses, and mental health professionals have been extensively included in PTSD studies. Unfortunately, trauma surgeons – one of the most stoic of frontline providers – have been overlooked."

Dr. Joseph described receiving pushback when proposing the study to other trauma surgeons and was told flat-out by one respondent that its hypothesis is flawed.

A self-identified senior surgeon wrote: "I found that the assumptions of the questions did not fit the trauma program I work in nor the surgeons with whom I work. They actually take trauma call to relax. Stress is not a word in our vocabulary."

The two-part survey, sent to all members of EAST and the AAST (41% response rate), was not specifically identified as a PTSD survey, but included the validated PTSD CheckList-Civilian Version (PCL-C). A score of 35 or more on the 17-item PCL-C has previously shown a sensitivity of 85% for PTSD symptoms, while a score of 44 or more is 95% sensitive and 86% specific for a PTSD diagnosis, Dr. Joseph observed.

The survey respondents were mostly male (76%), white (80%), practiced in an urban hospital (89.6%), or Level 1 trauma center (71%). More than half (54.7%) had 11 years or more of clinical practice, 21% had military experience, and 14.3% had been deployed to war.

Three-fourths (66.4%) had an annual income of at least $300,000, but 90.5% spent no more than 4 hours per day of non–sleep relaxation and 26.5% took no more than 2 weeks vacation per year.

Only 6.2% said they suffered from depression and 3% from anxiety, but 66% reported using alcohol and 5.3% smoking.

Regarding the scope of their work, 85% had four or more 24-hour calls per month, 36% had at least three critical cases per call, and 24% had at least 10 operative trauma cases per month.

Surgeons who had more than five critical cases per call were seven times more likely to develop PTSD in multivariate analysis (odds ratio, 7; P = .001), Dr. Joseph said. No other factors were significantly associated with a PTSD diagnosis.

Independent predictors of PTSD symptoms in the multivariate analysis were male sex (OR, 2; P = .04); more than seven call duties/month (OR, 2.6; P = .001); more than 15 operative cases/month (OR, 3; P = .001); less than 4 hours of daily relaxation (OR, 7; P = .01)’ and less than 2 weeks of vacation/year (OR, 2: P = .02); he said.

Following the presentation, a surgeon from the Bronx, N.Y., said one of the sticking points for his CEO in the state’s move toward American College of Surgeons’ verification is the back-up call requirement for the trauma surgeons.

"We think of this back-up call requirement as patient-centric; when you’re busy, patients aren’t well taken care of," he said. "You’ve just flipped this argument for me, which is that there’s another human being involved: the trauma surgeon. I’m going to go back, show him your abstract, and say, ‘There is another human being at work here and maybe at that fifth critical ... that fifth Level 1 activation ... it’s time to call the back-up guy.’ "

One attendee rose to say she’d just lost a colleague to PTSD and asked who should best perform an intervention to avoid any potential harm to the surgeon’s career. Another attendee responded that what’s helped the military address PTSD in its health care workers is to try to remove the perceived stigma of PTSD.

Dr. Joseph agreed that the military has been instrumental in identifying this issue and could join with EAST and other professional organizations in developing an intervention for its members. PTSD screening, even among residents, also would not go amiss.

Additional analyses will focus on protective factors among respondents who did not develop PTSD as well as how surgeons in other countries, such as South America, address the aftermath of dealing with violence, accidents, and injury on a daily basis.

"I think lack of insight is what you hear across all the comments," Dr. Joseph said. "We all think we’re Superman. People that know me know I’m probably as tough as they come, but at the same time we have to look back and realize this really does affect us. We’re not invincible."

Dr. Joseph and his coauthors reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Posttraumatic stress disorder is disturbingly common among U.S. trauma surgeons, according to a national survey.

Among 453 members of the American Association for the Surgery of Trauma (AAST) and Eastern Association for the Surgery of Trauma (EAST), 40% had symptoms of PTSD and 15% met the diagnostic criteria for PTSD.

"It’s the elephant in the room," Dr. Bellal A. Joseph said at the annual scientific assembly of EAST.

Understanding the factors that predispose trauma surgeons to PTSD may benefit patients and the profession and may be useful to national trauma surgery associations to develop targeted interventions, said Dr. Joseph, a trauma and critical care surgeon at the University of Arizona Medical Center, Tucson.

"Active surveillance to promote wellness among trauma surgeons is warranted," he said.

Invited discussant Dr. Karen Lommel, a psychiatrist who recently converted to emergency medicine at the University of Kentucky, Lexington, described the findings as "quite remarkable."

"The issue of posttraumatic symptoms and PTSD affects all of us who work in trauma, whether we choose to acknowledge it or not," she said. "Pre-hospital workers, nurses, and mental health professionals have been extensively included in PTSD studies. Unfortunately, trauma surgeons – one of the most stoic of frontline providers – have been overlooked."

Dr. Joseph described receiving pushback when proposing the study to other trauma surgeons and was told flat-out by one respondent that its hypothesis is flawed.

A self-identified senior surgeon wrote: "I found that the assumptions of the questions did not fit the trauma program I work in nor the surgeons with whom I work. They actually take trauma call to relax. Stress is not a word in our vocabulary."

The two-part survey, sent to all members of EAST and the AAST (41% response rate), was not specifically identified as a PTSD survey, but included the validated PTSD CheckList-Civilian Version (PCL-C). A score of 35 or more on the 17-item PCL-C has previously shown a sensitivity of 85% for PTSD symptoms, while a score of 44 or more is 95% sensitive and 86% specific for a PTSD diagnosis, Dr. Joseph observed.

The survey respondents were mostly male (76%), white (80%), practiced in an urban hospital (89.6%), or Level 1 trauma center (71%). More than half (54.7%) had 11 years or more of clinical practice, 21% had military experience, and 14.3% had been deployed to war.

Three-fourths (66.4%) had an annual income of at least $300,000, but 90.5% spent no more than 4 hours per day of non–sleep relaxation and 26.5% took no more than 2 weeks vacation per year.

Only 6.2% said they suffered from depression and 3% from anxiety, but 66% reported using alcohol and 5.3% smoking.

Regarding the scope of their work, 85% had four or more 24-hour calls per month, 36% had at least three critical cases per call, and 24% had at least 10 operative trauma cases per month.

Surgeons who had more than five critical cases per call were seven times more likely to develop PTSD in multivariate analysis (odds ratio, 7; P = .001), Dr. Joseph said. No other factors were significantly associated with a PTSD diagnosis.

Independent predictors of PTSD symptoms in the multivariate analysis were male sex (OR, 2; P = .04); more than seven call duties/month (OR, 2.6; P = .001); more than 15 operative cases/month (OR, 3; P = .001); less than 4 hours of daily relaxation (OR, 7; P = .01)’ and less than 2 weeks of vacation/year (OR, 2: P = .02); he said.

Following the presentation, a surgeon from the Bronx, N.Y., said one of the sticking points for his CEO in the state’s move toward American College of Surgeons’ verification is the back-up call requirement for the trauma surgeons.

"We think of this back-up call requirement as patient-centric; when you’re busy, patients aren’t well taken care of," he said. "You’ve just flipped this argument for me, which is that there’s another human being involved: the trauma surgeon. I’m going to go back, show him your abstract, and say, ‘There is another human being at work here and maybe at that fifth critical ... that fifth Level 1 activation ... it’s time to call the back-up guy.’ "

One attendee rose to say she’d just lost a colleague to PTSD and asked who should best perform an intervention to avoid any potential harm to the surgeon’s career. Another attendee responded that what’s helped the military address PTSD in its health care workers is to try to remove the perceived stigma of PTSD.

Dr. Joseph agreed that the military has been instrumental in identifying this issue and could join with EAST and other professional organizations in developing an intervention for its members. PTSD screening, even among residents, also would not go amiss.

Additional analyses will focus on protective factors among respondents who did not develop PTSD as well as how surgeons in other countries, such as South America, address the aftermath of dealing with violence, accidents, and injury on a daily basis.

"I think lack of insight is what you hear across all the comments," Dr. Joseph said. "We all think we’re Superman. People that know me know I’m probably as tough as they come, but at the same time we have to look back and realize this really does affect us. We’re not invincible."

Dr. Joseph and his coauthors reported having no financial disclosures.

[email protected]

The emerging field of mHealth, which is the use of mobile applications to facilitate the delivery of medical care and to enhance patient engagement, continues to expand rapidly, largely out of sight of most primary care physicians. We suspect that it will remain out of sight until, it will seem, mobile health apps are everywhere.

The idea behind mHealth is, given that smartphones have become ubiquitous devices through which people do everything from shopping to making dinner reservations to mobile banking, they are a device that people are ready to use to improve their health. A core component of both the Patient-Centered Medical Home model and Accountable Care Organization is that the patient is at the "center" of care and is an important, if not the most important, member of the health care team.

Mobile apps fall into a number of categories, including those that allow patients to have more effective and efficient interactions with their physicians, track data for things like blood pressure and blood sugars for more effective self-management, and allow patients more direct access to their charts and medical information. We will outline a few of these types of functions below.

One new software platform seeks to improve what patients understand and remember from their physician encounter. It is a common, if not ubiquitous, experience that patients do not fully recall the details of their discussion with the physician during the office visit. It is been estimated that patients recall only about 20% of the information that is shared during an office visit; patients on average miss between 30% and 60% of the medication dosages that are prescribed. It is likely that this lack of understanding and recall interferes with adherence to both the advice and medications. One company has developed a platform with expertly developed educational modules about common diseases with full graphics. What is unique about the platform is that the conversation that the physician has with the patient, as well as annotations to the educational material and graphics, is included in a record of the patient’s visit that the patient can access through a secure portal at any time after the visit. Patients are free to review the material and share it with family members if they choose. By being able to understand their medical condition better, and the specific personalized information that their physician provides to them, patients should feel more engaged and more like they are a part of their health care team. If they are engaged in their own care, they will also be more likely to comply with the recommendation that the physician makes.

Another example of a patient engagement platform operates independently of the physician. If one assumes that information is good, then being aware of what you eat as well as receiving feedback on the number of calories consumed will naturally lead to less food eaten. This type of software has a calorie counter and a database of over 3 million foods. The user enters the type and amount of food eaten, and then the app tracks total calories, using an attractive interface. Most popular brands and restaurant choices are in the database. The mobile app makes it easy to record food that is eaten either through accessing the type of food through the mobile database, or by simply scanning the bar code from purchased foods. If one then enters the amount eaten, the app will calculate the calories consumed and add it to the personal calorie count. In addition, one can record the type and duration of exercise both to track exercise programs and to calculate the number of calories burned from the exercise. The app also has a social function and lets the user compare an exercise program and diet with that of friends or family members (with their permission, of course) to serve as mutual encouragement of each others’ goals.

Finally, electronic health record companies are developing mobile apps that integrate with the electronic health record. These apps have various functions such as allowing patients to access information in their medical record from their mobile device and providing secure two-way communication between physician and patient. Patients are able to view their lab results, request refills and referrals, access educational material, and ask questions. Some of these systems also allow providers to send reminders efficiently to patients, either individually or in bulk. Theoretically, a practice could query its database to find all patients over age 50 who have not had colorectal cancer screening in the last 10 years and then send secure HIPAA-compliant reminders to all patients in the practice who need that screening. The patients would then access the reminder through their mobile app and schedule follow-up. In addition to simply accessing information, that information is presented and collated in a thoughtful manner. For instance, instead of simply accessing a list of blood pressures, the blood pressures can be displayed in graph form over time for easier interpretation.

In summary, we stand on the precipice of a new age of medical information management where, if the dreams of mobile vendors come true, patients will be at the center of a stream of health care, disease management, and wellness information from which they, along with their doctor, with the help of real-time data, can fully participate in their health care and influence their health outcomes.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care.

The emerging field of mHealth, which is the use of mobile applications to facilitate the delivery of medical care and to enhance patient engagement, continues to expand rapidly, largely out of sight of most primary care physicians. We suspect that it will remain out of sight until, it will seem, mobile health apps are everywhere.

The idea behind mHealth is, given that smartphones have become ubiquitous devices through which people do everything from shopping to making dinner reservations to mobile banking, they are a device that people are ready to use to improve their health. A core component of both the Patient-Centered Medical Home model and Accountable Care Organization is that the patient is at the "center" of care and is an important, if not the most important, member of the health care team.

Mobile apps fall into a number of categories, including those that allow patients to have more effective and efficient interactions with their physicians, track data for things like blood pressure and blood sugars for more effective self-management, and allow patients more direct access to their charts and medical information. We will outline a few of these types of functions below.

One new software platform seeks to improve what patients understand and remember from their physician encounter. It is a common, if not ubiquitous, experience that patients do not fully recall the details of their discussion with the physician during the office visit. It is been estimated that patients recall only about 20% of the information that is shared during an office visit; patients on average miss between 30% and 60% of the medication dosages that are prescribed. It is likely that this lack of understanding and recall interferes with adherence to both the advice and medications. One company has developed a platform with expertly developed educational modules about common diseases with full graphics. What is unique about the platform is that the conversation that the physician has with the patient, as well as annotations to the educational material and graphics, is included in a record of the patient’s visit that the patient can access through a secure portal at any time after the visit. Patients are free to review the material and share it with family members if they choose. By being able to understand their medical condition better, and the specific personalized information that their physician provides to them, patients should feel more engaged and more like they are a part of their health care team. If they are engaged in their own care, they will also be more likely to comply with the recommendation that the physician makes.

Another example of a patient engagement platform operates independently of the physician. If one assumes that information is good, then being aware of what you eat as well as receiving feedback on the number of calories consumed will naturally lead to less food eaten. This type of software has a calorie counter and a database of over 3 million foods. The user enters the type and amount of food eaten, and then the app tracks total calories, using an attractive interface. Most popular brands and restaurant choices are in the database. The mobile app makes it easy to record food that is eaten either through accessing the type of food through the mobile database, or by simply scanning the bar code from purchased foods. If one then enters the amount eaten, the app will calculate the calories consumed and add it to the personal calorie count. In addition, one can record the type and duration of exercise both to track exercise programs and to calculate the number of calories burned from the exercise. The app also has a social function and lets the user compare an exercise program and diet with that of friends or family members (with their permission, of course) to serve as mutual encouragement of each others’ goals.

Finally, electronic health record companies are developing mobile apps that integrate with the electronic health record. These apps have various functions such as allowing patients to access information in their medical record from their mobile device and providing secure two-way communication between physician and patient. Patients are able to view their lab results, request refills and referrals, access educational material, and ask questions. Some of these systems also allow providers to send reminders efficiently to patients, either individually or in bulk. Theoretically, a practice could query its database to find all patients over age 50 who have not had colorectal cancer screening in the last 10 years and then send secure HIPAA-compliant reminders to all patients in the practice who need that screening. The patients would then access the reminder through their mobile app and schedule follow-up. In addition to simply accessing information, that information is presented and collated in a thoughtful manner. For instance, instead of simply accessing a list of blood pressures, the blood pressures can be displayed in graph form over time for easier interpretation.

In summary, we stand on the precipice of a new age of medical information management where, if the dreams of mobile vendors come true, patients will be at the center of a stream of health care, disease management, and wellness information from which they, along with their doctor, with the help of real-time data, can fully participate in their health care and influence their health outcomes.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care.

The emerging field of mHealth, which is the use of mobile applications to facilitate the delivery of medical care and to enhance patient engagement, continues to expand rapidly, largely out of sight of most primary care physicians. We suspect that it will remain out of sight until, it will seem, mobile health apps are everywhere.

The idea behind mHealth is, given that smartphones have become ubiquitous devices through which people do everything from shopping to making dinner reservations to mobile banking, they are a device that people are ready to use to improve their health. A core component of both the Patient-Centered Medical Home model and Accountable Care Organization is that the patient is at the "center" of care and is an important, if not the most important, member of the health care team.

Mobile apps fall into a number of categories, including those that allow patients to have more effective and efficient interactions with their physicians, track data for things like blood pressure and blood sugars for more effective self-management, and allow patients more direct access to their charts and medical information. We will outline a few of these types of functions below.

One new software platform seeks to improve what patients understand and remember from their physician encounter. It is a common, if not ubiquitous, experience that patients do not fully recall the details of their discussion with the physician during the office visit. It is been estimated that patients recall only about 20% of the information that is shared during an office visit; patients on average miss between 30% and 60% of the medication dosages that are prescribed. It is likely that this lack of understanding and recall interferes with adherence to both the advice and medications. One company has developed a platform with expertly developed educational modules about common diseases with full graphics. What is unique about the platform is that the conversation that the physician has with the patient, as well as annotations to the educational material and graphics, is included in a record of the patient’s visit that the patient can access through a secure portal at any time after the visit. Patients are free to review the material and share it with family members if they choose. By being able to understand their medical condition better, and the specific personalized information that their physician provides to them, patients should feel more engaged and more like they are a part of their health care team. If they are engaged in their own care, they will also be more likely to comply with the recommendation that the physician makes.

Another example of a patient engagement platform operates independently of the physician. If one assumes that information is good, then being aware of what you eat as well as receiving feedback on the number of calories consumed will naturally lead to less food eaten. This type of software has a calorie counter and a database of over 3 million foods. The user enters the type and amount of food eaten, and then the app tracks total calories, using an attractive interface. Most popular brands and restaurant choices are in the database. The mobile app makes it easy to record food that is eaten either through accessing the type of food through the mobile database, or by simply scanning the bar code from purchased foods. If one then enters the amount eaten, the app will calculate the calories consumed and add it to the personal calorie count. In addition, one can record the type and duration of exercise both to track exercise programs and to calculate the number of calories burned from the exercise. The app also has a social function and lets the user compare an exercise program and diet with that of friends or family members (with their permission, of course) to serve as mutual encouragement of each others’ goals.

Finally, electronic health record companies are developing mobile apps that integrate with the electronic health record. These apps have various functions such as allowing patients to access information in their medical record from their mobile device and providing secure two-way communication between physician and patient. Patients are able to view their lab results, request refills and referrals, access educational material, and ask questions. Some of these systems also allow providers to send reminders efficiently to patients, either individually or in bulk. Theoretically, a practice could query its database to find all patients over age 50 who have not had colorectal cancer screening in the last 10 years and then send secure HIPAA-compliant reminders to all patients in the practice who need that screening. The patients would then access the reminder through their mobile app and schedule follow-up. In addition to simply accessing information, that information is presented and collated in a thoughtful manner. For instance, instead of simply accessing a list of blood pressures, the blood pressures can be displayed in graph form over time for easier interpretation.

In summary, we stand on the precipice of a new age of medical information management where, if the dreams of mobile vendors come true, patients will be at the center of a stream of health care, disease management, and wellness information from which they, along with their doctor, with the help of real-time data, can fully participate in their health care and influence their health outcomes.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps. Dr. Notte is a family physician and clinical informaticist for Abington Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. An avid programmer, he has published software for handheld devices in partnership with national organizations, and he is always looking for new ways to bring evidence-based medicine to the point of care.

Doctors could see a 0.5% pay increase for 5 years and a transition to alternative delivery and payment models under consensus legislation to repeal the Medicare Sustainable Growth Rate formula.

The legislation, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015), is based on three separate proposals approved last year by the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee. It was introduced Feb. 6.

The bill does not address how to pay for the SGR replacement. One recent estimate by the Congressional Budget Office put that price tag at $120 billion to $150 billion.

Sen. Max Baucus (D-Mont.), chairman of the Finance committee, hailed the agreement. "This proposal would bring that cycle to an end and fix the broken system," he said in a statement. "Our bill makes Medicare’s physician payments more modern and efficient, and it will protect seniors’ access to their doctors."

American Medical Association President Ardis Dee Hoven commented that this consensus bill means that "Congress is closer than it has ever been to enacting fiscally-prudent legislation that would repeal Medicare’s fatally flawed sustainable growth rate formula."

Dr. Charles Cutler, chair of the American College of Physicians’ Board of Regents, said in a statement that the ACP was encouraged that the bill contained many of the elements it had backed, including:

• Replacing the SGR with a system focused on quality, value, and accountability.

• Consolidating the three existing quality programs into a streamlined and improved program that rewards physicians who meet performance thresholds and improve care for seniors.

• Implementing a process to improve payment accuracy.

• Creating incentives for physicians to move into advanced payment models.

Dr. Reid Blackwelder, president of the American Academy of Family Physicians said, "For more than a decade, the SGR has threatened our most vulnerable patients’ access to care by requiring drastic cuts in payment for medical services. By ending the annual, biannual, monthly, sometimes even bimonthly cycle of last-minute ‘fixes’ to prevent mandated SGR cuts, Congress will stabilize Medicare and bring peace of mind to their elderly and disabled constituents."

"Much work remains to create a system that can finally provide certainty to seniors and their doctors," Rep. Fred Upton (R-Mich.), chairman of the Energy and Commerce committee, said in a statement. "I look forward to building upon this progress and continuing the momentum until this is across the finish line."

The most recent cuts called for by the SGR were deferred as part of federal budget legislation enacted at the end of 2013. A short-term 0.5% increase in Medicare physician fees is slated to expire March 31.

[email protected]

On Twitter @aliciaault

Doctors could see a 0.5% pay increase for 5 years and a transition to alternative delivery and payment models under consensus legislation to repeal the Medicare Sustainable Growth Rate formula.

The legislation, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015), is based on three separate proposals approved last year by the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee. It was introduced Feb. 6.

The bill does not address how to pay for the SGR replacement. One recent estimate by the Congressional Budget Office put that price tag at $120 billion to $150 billion.

Sen. Max Baucus (D-Mont.), chairman of the Finance committee, hailed the agreement. "This proposal would bring that cycle to an end and fix the broken system," he said in a statement. "Our bill makes Medicare’s physician payments more modern and efficient, and it will protect seniors’ access to their doctors."

American Medical Association President Ardis Dee Hoven commented that this consensus bill means that "Congress is closer than it has ever been to enacting fiscally-prudent legislation that would repeal Medicare’s fatally flawed sustainable growth rate formula."

Dr. Charles Cutler, chair of the American College of Physicians’ Board of Regents, said in a statement that the ACP was encouraged that the bill contained many of the elements it had backed, including:

• Replacing the SGR with a system focused on quality, value, and accountability.

• Consolidating the three existing quality programs into a streamlined and improved program that rewards physicians who meet performance thresholds and improve care for seniors.

• Implementing a process to improve payment accuracy.

• Creating incentives for physicians to move into advanced payment models.

Dr. Reid Blackwelder, president of the American Academy of Family Physicians said, "For more than a decade, the SGR has threatened our most vulnerable patients’ access to care by requiring drastic cuts in payment for medical services. By ending the annual, biannual, monthly, sometimes even bimonthly cycle of last-minute ‘fixes’ to prevent mandated SGR cuts, Congress will stabilize Medicare and bring peace of mind to their elderly and disabled constituents."

"Much work remains to create a system that can finally provide certainty to seniors and their doctors," Rep. Fred Upton (R-Mich.), chairman of the Energy and Commerce committee, said in a statement. "I look forward to building upon this progress and continuing the momentum until this is across the finish line."

The most recent cuts called for by the SGR were deferred as part of federal budget legislation enacted at the end of 2013. A short-term 0.5% increase in Medicare physician fees is slated to expire March 31.

[email protected]

On Twitter @aliciaault

Doctors could see a 0.5% pay increase for 5 years and a transition to alternative delivery and payment models under consensus legislation to repeal the Medicare Sustainable Growth Rate formula.

The legislation, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015), is based on three separate proposals approved last year by the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee. It was introduced Feb. 6.

The bill does not address how to pay for the SGR replacement. One recent estimate by the Congressional Budget Office put that price tag at $120 billion to $150 billion.

Sen. Max Baucus (D-Mont.), chairman of the Finance committee, hailed the agreement. "This proposal would bring that cycle to an end and fix the broken system," he said in a statement. "Our bill makes Medicare’s physician payments more modern and efficient, and it will protect seniors’ access to their doctors."

American Medical Association President Ardis Dee Hoven commented that this consensus bill means that "Congress is closer than it has ever been to enacting fiscally-prudent legislation that would repeal Medicare’s fatally flawed sustainable growth rate formula."

Dr. Charles Cutler, chair of the American College of Physicians’ Board of Regents, said in a statement that the ACP was encouraged that the bill contained many of the elements it had backed, including:

• Replacing the SGR with a system focused on quality, value, and accountability.

• Consolidating the three existing quality programs into a streamlined and improved program that rewards physicians who meet performance thresholds and improve care for seniors.

• Implementing a process to improve payment accuracy.

• Creating incentives for physicians to move into advanced payment models.

Dr. Reid Blackwelder, president of the American Academy of Family Physicians said, "For more than a decade, the SGR has threatened our most vulnerable patients’ access to care by requiring drastic cuts in payment for medical services. By ending the annual, biannual, monthly, sometimes even bimonthly cycle of last-minute ‘fixes’ to prevent mandated SGR cuts, Congress will stabilize Medicare and bring peace of mind to their elderly and disabled constituents."

"Much work remains to create a system that can finally provide certainty to seniors and their doctors," Rep. Fred Upton (R-Mich.), chairman of the Energy and Commerce committee, said in a statement. "I look forward to building upon this progress and continuing the momentum until this is across the finish line."

The most recent cuts called for by the SGR were deferred as part of federal budget legislation enacted at the end of 2013. A short-term 0.5% increase in Medicare physician fees is slated to expire March 31.

[email protected]

On Twitter @aliciaault

WASHINGTON – Dr. Karen B. DeSalvo feels your pain.

As the government’s National Coordinator for Health Technology, Dr. DeSalvo says that she wants to redouble efforts to help all physicians adopt electronic health records (EHRs).

"We really want to help," Dr. DeSalvo said at a Feb. 5 forum on telemedicine sponsored by the journal Health Affairs. "We want to bring folks along," and ensure there is not a digital divide.

But her primary focus is interoperability.

Achieving interoperability "is going to be a complex and exciting endeavor," that will be not only about the basics of making it work, but also pulling all the stakeholders together to brainstorm creative solutions, Dr. DeSalvo said Feb. 6. at a health IT conference, sponsored by West Health Institute and the Office of the National Coordinator.

Dr. DeSalvo has experience in creating interoperable systems. After Hurricane Katrina, Dr. DeSalvo, then chief of general internal medicine and geriatrics at Tulane University and special assistant to its president for health policy, helped resurrect New Orleans’s health care system.

Paper records were lost or destroyed. Many patients were displaced and had patchy recollections of their medical histories. Health care professionals too were displaced; those that remained decided to "take this tipping point and move forward," she said. That meant building a new infrastructure – one that would be portable and easily accessible to providers and patients.

Health IT played a huge role in helping the city regain its medical bearings. "We skipped right to ... electronic health records and how we could use telehealth," Dr. DeSalvo said. Use of EHRs allowed physicians to quickly transition their practices into patient-centered medical homes and also meant that patients would be treated holistically, she said. Interoperability was key.

Although America "is not facing the urgency of a catastrophe like Katrina," she said, "it is at a slow boil," with costs continuing to rise and ongoing challenges with access to care and quality improvement.

[email protected]

On Twitter @aliciaault

WASHINGTON – Dr. Karen B. DeSalvo feels your pain.

As the government’s National Coordinator for Health Technology, Dr. DeSalvo says that she wants to redouble efforts to help all physicians adopt electronic health records (EHRs).

"We really want to help," Dr. DeSalvo said at a Feb. 5 forum on telemedicine sponsored by the journal Health Affairs. "We want to bring folks along," and ensure there is not a digital divide.

But her primary focus is interoperability.

Achieving interoperability "is going to be a complex and exciting endeavor," that will be not only about the basics of making it work, but also pulling all the stakeholders together to brainstorm creative solutions, Dr. DeSalvo said Feb. 6. at a health IT conference, sponsored by West Health Institute and the Office of the National Coordinator.

Dr. DeSalvo has experience in creating interoperable systems. After Hurricane Katrina, Dr. DeSalvo, then chief of general internal medicine and geriatrics at Tulane University and special assistant to its president for health policy, helped resurrect New Orleans’s health care system.

Paper records were lost or destroyed. Many patients were displaced and had patchy recollections of their medical histories. Health care professionals too were displaced; those that remained decided to "take this tipping point and move forward," she said. That meant building a new infrastructure – one that would be portable and easily accessible to providers and patients.

Health IT played a huge role in helping the city regain its medical bearings. "We skipped right to ... electronic health records and how we could use telehealth," Dr. DeSalvo said. Use of EHRs allowed physicians to quickly transition their practices into patient-centered medical homes and also meant that patients would be treated holistically, she said. Interoperability was key.

Although America "is not facing the urgency of a catastrophe like Katrina," she said, "it is at a slow boil," with costs continuing to rise and ongoing challenges with access to care and quality improvement.

[email protected]

On Twitter @aliciaault

WASHINGTON – Dr. Karen B. DeSalvo feels your pain.

As the government’s National Coordinator for Health Technology, Dr. DeSalvo says that she wants to redouble efforts to help all physicians adopt electronic health records (EHRs).

"We really want to help," Dr. DeSalvo said at a Feb. 5 forum on telemedicine sponsored by the journal Health Affairs. "We want to bring folks along," and ensure there is not a digital divide.

But her primary focus is interoperability.

Achieving interoperability "is going to be a complex and exciting endeavor," that will be not only about the basics of making it work, but also pulling all the stakeholders together to brainstorm creative solutions, Dr. DeSalvo said Feb. 6. at a health IT conference, sponsored by West Health Institute and the Office of the National Coordinator.

Dr. DeSalvo has experience in creating interoperable systems. After Hurricane Katrina, Dr. DeSalvo, then chief of general internal medicine and geriatrics at Tulane University and special assistant to its president for health policy, helped resurrect New Orleans’s health care system.

Paper records were lost or destroyed. Many patients were displaced and had patchy recollections of their medical histories. Health care professionals too were displaced; those that remained decided to "take this tipping point and move forward," she said. That meant building a new infrastructure – one that would be portable and easily accessible to providers and patients.

Health IT played a huge role in helping the city regain its medical bearings. "We skipped right to ... electronic health records and how we could use telehealth," Dr. DeSalvo said. Use of EHRs allowed physicians to quickly transition their practices into patient-centered medical homes and also meant that patients would be treated holistically, she said. Interoperability was key.

Although America "is not facing the urgency of a catastrophe like Katrina," she said, "it is at a slow boil," with costs continuing to rise and ongoing challenges with access to care and quality improvement.

[email protected]

On Twitter @aliciaault

Laparoscopic sleeve gastrectomy not only fails to improve gastroesophageal reflux disease in most patients who undergo the weight-loss procedure, it actually worsens GERD symptoms in many of them and induces GERD in 9%, according to a report published online Feb. 5 in JAMA Surgery.

In addition, patients with preexisting GERD who undergo laparoscopic sleeve gastrectomy (LSG) have high rates of surgical complications; revision surgery; failure to achieve weight loss; and failure to resolve weight-related comorbidities such as diabetes, obstructive sleep apnea, and hypertension. In contrast, patients who undergo gastric bypass show significant improvement in all of these outcomes, said Dr. Cecily E. DuPree and her associates in the department of surgery, Madigan Army Medical Center, Fort Lewis, Wash.

Based on the findings from their study of a national database including 4,832 patients who had laparoscopic sleeve gastrectomy (LSG) and 33,867 who had gastric bypass (GB), "we believe that all patients should be evaluated for the presence and severity of GERD and counseled regarding the relative efficacy of LSG vs. GB or other bariatric operations before surgery. Although there is no definitive evidence to support the listing of GERD as an absolute contraindication to LSG, the available data suggest that the presence of preexisting severe GERD or esophageal dysmotility may be considered a relative contraindication," they said.

Dr. DuPree and her colleagues noted that until now, the sleeve procedure’s effect on GERD was unknown. Small, single-center series "have raised significant concerns," but no large study has examined the issue. So she and her associates used data from a large, nationwide database (the Bariatric Outcomes Longitudinal Database) to track the resolution, persistence, or development of GERD in 4,832 patients who underwent laparoscopic sleeve gastrectomy in 2007-2010, comparing their outcomes with those of 33,867 patients who underwent gastric bypass during the same period and served as controls.

The overall prevalence of GERD was 49.7% in the entire study population, and that of severe GERD was 25.7%, confirming that this disorder is very common in candidates for bariatric surgery.

The prevalence of GERD was 44.5% among patients undergoing the sleeve procedure. "This highlights the concern that there is a large population at risk of adverse outcomes after LSG if the procedure is associated with anatomical or physiologic changes that increase the risk of postoperative GERD," the investigators noted.

Most LSG patients (84.1%) had persistent GERD symptoms after the procedure; only 15.9% reported resolution of symptoms. An additional 9.0% of LSG patients reported postoperative worsening of GERD symptoms. And 8.6% of patients who didn’t have GERD before undergoing sleeve gastrectomy developed the disorder afterward.

In contrast, most patients who underwent gastric bypass showed complete resolution (62.8%) or stabilization (17.6%) of GERD symptoms. Only 2.2% reported worsening GERD symptoms, and none developed de novo symptoms.

Among the LSG patients, the complication rate was significantly higher in those with preexisting GERD (15.1%) or preexisting severe GERD (16.3%) than in those without GERD (10.6%). "There was also a small but statistically significant increase in the need for revisional surgery between LSG patients with and without preoperative GERD symptoms (0.6% vs. 0.3%)," the investigators wrote (JAMA Surg. 2014 [doi:10.1001/jamasurg.2013.4323]).

In contrast, the presence of GERD had no effect on complications in the control group.

Similarly, the rate of failure to lose weight was higher in LSG patients with preoperative GERD and in LSG patients with severe preoperative GERD than in those without GERD. Again, the presence of GERD had no such effect on weight loss in the gastric bypass patients.

In addition, the percentage of patients who showed resolution of comorbidities was significantly decreased among patients with preoperative GERD who underwent LSG, compared with all other groups.

"These data raise significant concerns about the effect of LSG on the obesity-related comorbidity of GERD and suggest that most patients with preexisting GERD will have either no improvement or possibly worsening of their symptoms after LSG," Dr. DuPree and her associates said.

The exact reason why the sleeve procedure could contribute to the worsening of reflux or the de novo development of GERD is not known, but there are several anatomical or physiologic factors that may play a role. Laparoscopic sleeve gastrectomy may decrease lower esophageal sphincter resting tone, and it may disrupt the antropyloric pump mechanism or narrow the pylorus.

It is also possible that an excessively large or dilated gastric sleeve may retain the capacity for increased acid production, causing reflux, or that it may decrease esophageal acid clearance. And a hiatal hernia that is unrecognized at the time of surgery or that develops afterward could also produce reflux symptoms.

Modifying surgical technique so that sleeve size and volume are attended to, narrowing of the gastric body or pylorus is avoided, and hiatal hernias are assiduously identified and repaired may reduce the risk of post-LSG GERD, the investigators said.

Laparoscopic sleeve gastrectomy not only fails to improve gastroesophageal reflux disease in most patients who undergo the weight-loss procedure, it actually worsens GERD symptoms in many of them and induces GERD in 9%, according to a report published online Feb. 5 in JAMA Surgery.

In addition, patients with preexisting GERD who undergo laparoscopic sleeve gastrectomy (LSG) have high rates of surgical complications; revision surgery; failure to achieve weight loss; and failure to resolve weight-related comorbidities such as diabetes, obstructive sleep apnea, and hypertension. In contrast, patients who undergo gastric bypass show significant improvement in all of these outcomes, said Dr. Cecily E. DuPree and her associates in the department of surgery, Madigan Army Medical Center, Fort Lewis, Wash.

Based on the findings from their study of a national database including 4,832 patients who had laparoscopic sleeve gastrectomy (LSG) and 33,867 who had gastric bypass (GB), "we believe that all patients should be evaluated for the presence and severity of GERD and counseled regarding the relative efficacy of LSG vs. GB or other bariatric operations before surgery. Although there is no definitive evidence to support the listing of GERD as an absolute contraindication to LSG, the available data suggest that the presence of preexisting severe GERD or esophageal dysmotility may be considered a relative contraindication," they said.

Dr. DuPree and her colleagues noted that until now, the sleeve procedure’s effect on GERD was unknown. Small, single-center series "have raised significant concerns," but no large study has examined the issue. So she and her associates used data from a large, nationwide database (the Bariatric Outcomes Longitudinal Database) to track the resolution, persistence, or development of GERD in 4,832 patients who underwent laparoscopic sleeve gastrectomy in 2007-2010, comparing their outcomes with those of 33,867 patients who underwent gastric bypass during the same period and served as controls.

The overall prevalence of GERD was 49.7% in the entire study population, and that of severe GERD was 25.7%, confirming that this disorder is very common in candidates for bariatric surgery.

The prevalence of GERD was 44.5% among patients undergoing the sleeve procedure. "This highlights the concern that there is a large population at risk of adverse outcomes after LSG if the procedure is associated with anatomical or physiologic changes that increase the risk of postoperative GERD," the investigators noted.

Most LSG patients (84.1%) had persistent GERD symptoms after the procedure; only 15.9% reported resolution of symptoms. An additional 9.0% of LSG patients reported postoperative worsening of GERD symptoms. And 8.6% of patients who didn’t have GERD before undergoing sleeve gastrectomy developed the disorder afterward.

In contrast, most patients who underwent gastric bypass showed complete resolution (62.8%) or stabilization (17.6%) of GERD symptoms. Only 2.2% reported worsening GERD symptoms, and none developed de novo symptoms.

Among the LSG patients, the complication rate was significantly higher in those with preexisting GERD (15.1%) or preexisting severe GERD (16.3%) than in those without GERD (10.6%). "There was also a small but statistically significant increase in the need for revisional surgery between LSG patients with and without preoperative GERD symptoms (0.6% vs. 0.3%)," the investigators wrote (JAMA Surg. 2014 [doi:10.1001/jamasurg.2013.4323]).

In contrast, the presence of GERD had no effect on complications in the control group.

Similarly, the rate of failure to lose weight was higher in LSG patients with preoperative GERD and in LSG patients with severe preoperative GERD than in those without GERD. Again, the presence of GERD had no such effect on weight loss in the gastric bypass patients.

In addition, the percentage of patients who showed resolution of comorbidities was significantly decreased among patients with preoperative GERD who underwent LSG, compared with all other groups.

"These data raise significant concerns about the effect of LSG on the obesity-related comorbidity of GERD and suggest that most patients with preexisting GERD will have either no improvement or possibly worsening of their symptoms after LSG," Dr. DuPree and her associates said.

The exact reason why the sleeve procedure could contribute to the worsening of reflux or the de novo development of GERD is not known, but there are several anatomical or physiologic factors that may play a role. Laparoscopic sleeve gastrectomy may decrease lower esophageal sphincter resting tone, and it may disrupt the antropyloric pump mechanism or narrow the pylorus.

It is also possible that an excessively large or dilated gastric sleeve may retain the capacity for increased acid production, causing reflux, or that it may decrease esophageal acid clearance. And a hiatal hernia that is unrecognized at the time of surgery or that develops afterward could also produce reflux symptoms.

Modifying surgical technique so that sleeve size and volume are attended to, narrowing of the gastric body or pylorus is avoided, and hiatal hernias are assiduously identified and repaired may reduce the risk of post-LSG GERD, the investigators said.

Laparoscopic sleeve gastrectomy not only fails to improve gastroesophageal reflux disease in most patients who undergo the weight-loss procedure, it actually worsens GERD symptoms in many of them and induces GERD in 9%, according to a report published online Feb. 5 in JAMA Surgery.

In addition, patients with preexisting GERD who undergo laparoscopic sleeve gastrectomy (LSG) have high rates of surgical complications; revision surgery; failure to achieve weight loss; and failure to resolve weight-related comorbidities such as diabetes, obstructive sleep apnea, and hypertension. In contrast, patients who undergo gastric bypass show significant improvement in all of these outcomes, said Dr. Cecily E. DuPree and her associates in the department of surgery, Madigan Army Medical Center, Fort Lewis, Wash.

Based on the findings from their study of a national database including 4,832 patients who had laparoscopic sleeve gastrectomy (LSG) and 33,867 who had gastric bypass (GB), "we believe that all patients should be evaluated for the presence and severity of GERD and counseled regarding the relative efficacy of LSG vs. GB or other bariatric operations before surgery. Although there is no definitive evidence to support the listing of GERD as an absolute contraindication to LSG, the available data suggest that the presence of preexisting severe GERD or esophageal dysmotility may be considered a relative contraindication," they said.

Dr. DuPree and her colleagues noted that until now, the sleeve procedure’s effect on GERD was unknown. Small, single-center series "have raised significant concerns," but no large study has examined the issue. So she and her associates used data from a large, nationwide database (the Bariatric Outcomes Longitudinal Database) to track the resolution, persistence, or development of GERD in 4,832 patients who underwent laparoscopic sleeve gastrectomy in 2007-2010, comparing their outcomes with those of 33,867 patients who underwent gastric bypass during the same period and served as controls.

The overall prevalence of GERD was 49.7% in the entire study population, and that of severe GERD was 25.7%, confirming that this disorder is very common in candidates for bariatric surgery.

The prevalence of GERD was 44.5% among patients undergoing the sleeve procedure. "This highlights the concern that there is a large population at risk of adverse outcomes after LSG if the procedure is associated with anatomical or physiologic changes that increase the risk of postoperative GERD," the investigators noted.

Most LSG patients (84.1%) had persistent GERD symptoms after the procedure; only 15.9% reported resolution of symptoms. An additional 9.0% of LSG patients reported postoperative worsening of GERD symptoms. And 8.6% of patients who didn’t have GERD before undergoing sleeve gastrectomy developed the disorder afterward.

In contrast, most patients who underwent gastric bypass showed complete resolution (62.8%) or stabilization (17.6%) of GERD symptoms. Only 2.2% reported worsening GERD symptoms, and none developed de novo symptoms.

Among the LSG patients, the complication rate was significantly higher in those with preexisting GERD (15.1%) or preexisting severe GERD (16.3%) than in those without GERD (10.6%). "There was also a small but statistically significant increase in the need for revisional surgery between LSG patients with and without preoperative GERD symptoms (0.6% vs. 0.3%)," the investigators wrote (JAMA Surg. 2014 [doi:10.1001/jamasurg.2013.4323]).

In contrast, the presence of GERD had no effect on complications in the control group.

Similarly, the rate of failure to lose weight was higher in LSG patients with preoperative GERD and in LSG patients with severe preoperative GERD than in those without GERD. Again, the presence of GERD had no such effect on weight loss in the gastric bypass patients.

In addition, the percentage of patients who showed resolution of comorbidities was significantly decreased among patients with preoperative GERD who underwent LSG, compared with all other groups.

"These data raise significant concerns about the effect of LSG on the obesity-related comorbidity of GERD and suggest that most patients with preexisting GERD will have either no improvement or possibly worsening of their symptoms after LSG," Dr. DuPree and her associates said.

The exact reason why the sleeve procedure could contribute to the worsening of reflux or the de novo development of GERD is not known, but there are several anatomical or physiologic factors that may play a role. Laparoscopic sleeve gastrectomy may decrease lower esophageal sphincter resting tone, and it may disrupt the antropyloric pump mechanism or narrow the pylorus.

It is also possible that an excessively large or dilated gastric sleeve may retain the capacity for increased acid production, causing reflux, or that it may decrease esophageal acid clearance. And a hiatal hernia that is unrecognized at the time of surgery or that develops afterward could also produce reflux symptoms.

Modifying surgical technique so that sleeve size and volume are attended to, narrowing of the gastric body or pylorus is avoided, and hiatal hernias are assiduously identified and repaired may reduce the risk of post-LSG GERD, the investigators said.

CVS Pharmacy, the nation’s second largest pharmacy and 13th largest company in the world, threw down the gauntlet today to other pharmacy chains and vowed to stop selling tobacco products by Oct. 1, 2014.

As a retail pharmacy division of CVS Caremark, CVS Pharmacy is a drug store chain, a pharmacy benefit manager, and a leading retail health care provider. They have the "MinuteClinic" retail health clinics and can provide assistance with blood pressure and blood sugar management. In this sense, eliminating the sale of cigarettes is akin to removing cigarettes from the gift shops of hospitals and medical clinics. The major difference is that hospitals and clinics carried cigarettes as convenience items; for a company such as CVS Pharmacy, tobacco provided more than $1.5 billion in annual sales.

This is no small gamble. But it’s one that will hopefully pay off.

First of all, it’s the right thing to do in the interest of public health; 480,000 Americans still die of tobacco-related diseases annually. Second, the media attention and accolades received from President Obama, the American Medical Association, the Robert Wood Johnson Foundation, and the Campaign for Tobacco-Free Kids will, however short lived, bring recognition to the brand. CVS Pharmacy will now be identified as being concerned not only about patients who fill their prescriptions there, but also about the health and well-being of the communities in which the pharmacies operate. If another pharmacy chain follows suit, great, but CVS was first.

This attention will also garner attention to the other health care services that the retail chain provides, and it will increase the likelihood that hospitals, clinics, and ACOs will partner with the company.

Retail pharmacies will undoubtedly be a significant player in the delivery of health care, and medical organizations should be partnering with these companies. Unlike large medical institutions, which may be slow to action, a company like CVS could be more nimble and able to implement models of care in many of its more than 7,600 stores.

This could have a true population impact – arguably, more of an impact than training more physicians to provide care using traditional models. CVS’s announcement demonstrates that they are a willing and able partner in improving public health and engaging in health care delivery.

Dr. Ebbert is a professor of medicine at the Mayo Clinic, Rochester, Minn. He disclosed having financial relationships with Pfizer and GlaxoSmithKline, manufacturers of tobacco-dependence treatments.

CVS Pharmacy, the nation’s second largest pharmacy and 13th largest company in the world, threw down the gauntlet today to other pharmacy chains and vowed to stop selling tobacco products by Oct. 1, 2014.

As a retail pharmacy division of CVS Caremark, CVS Pharmacy is a drug store chain, a pharmacy benefit manager, and a leading retail health care provider. They have the "MinuteClinic" retail health clinics and can provide assistance with blood pressure and blood sugar management. In this sense, eliminating the sale of cigarettes is akin to removing cigarettes from the gift shops of hospitals and medical clinics. The major difference is that hospitals and clinics carried cigarettes as convenience items; for a company such as CVS Pharmacy, tobacco provided more than $1.5 billion in annual sales.

This is no small gamble. But it’s one that will hopefully pay off.

First of all, it’s the right thing to do in the interest of public health; 480,000 Americans still die of tobacco-related diseases annually. Second, the media attention and accolades received from President Obama, the American Medical Association, the Robert Wood Johnson Foundation, and the Campaign for Tobacco-Free Kids will, however short lived, bring recognition to the brand. CVS Pharmacy will now be identified as being concerned not only about patients who fill their prescriptions there, but also about the health and well-being of the communities in which the pharmacies operate. If another pharmacy chain follows suit, great, but CVS was first.

This attention will also garner attention to the other health care services that the retail chain provides, and it will increase the likelihood that hospitals, clinics, and ACOs will partner with the company.

Retail pharmacies will undoubtedly be a significant player in the delivery of health care, and medical organizations should be partnering with these companies. Unlike large medical institutions, which may be slow to action, a company like CVS could be more nimble and able to implement models of care in many of its more than 7,600 stores.

This could have a true population impact – arguably, more of an impact than training more physicians to provide care using traditional models. CVS’s announcement demonstrates that they are a willing and able partner in improving public health and engaging in health care delivery.

Dr. Ebbert is a professor of medicine at the Mayo Clinic, Rochester, Minn. He disclosed having financial relationships with Pfizer and GlaxoSmithKline, manufacturers of tobacco-dependence treatments.

CVS Pharmacy, the nation’s second largest pharmacy and 13th largest company in the world, threw down the gauntlet today to other pharmacy chains and vowed to stop selling tobacco products by Oct. 1, 2014.

As a retail pharmacy division of CVS Caremark, CVS Pharmacy is a drug store chain, a pharmacy benefit manager, and a leading retail health care provider. They have the "MinuteClinic" retail health clinics and can provide assistance with blood pressure and blood sugar management. In this sense, eliminating the sale of cigarettes is akin to removing cigarettes from the gift shops of hospitals and medical clinics. The major difference is that hospitals and clinics carried cigarettes as convenience items; for a company such as CVS Pharmacy, tobacco provided more than $1.5 billion in annual sales.

This is no small gamble. But it’s one that will hopefully pay off.

First of all, it’s the right thing to do in the interest of public health; 480,000 Americans still die of tobacco-related diseases annually. Second, the media attention and accolades received from President Obama, the American Medical Association, the Robert Wood Johnson Foundation, and the Campaign for Tobacco-Free Kids will, however short lived, bring recognition to the brand. CVS Pharmacy will now be identified as being concerned not only about patients who fill their prescriptions there, but also about the health and well-being of the communities in which the pharmacies operate. If another pharmacy chain follows suit, great, but CVS was first.

This attention will also garner attention to the other health care services that the retail chain provides, and it will increase the likelihood that hospitals, clinics, and ACOs will partner with the company.

Retail pharmacies will undoubtedly be a significant player in the delivery of health care, and medical organizations should be partnering with these companies. Unlike large medical institutions, which may be slow to action, a company like CVS could be more nimble and able to implement models of care in many of its more than 7,600 stores.

This could have a true population impact – arguably, more of an impact than training more physicians to provide care using traditional models. CVS’s announcement demonstrates that they are a willing and able partner in improving public health and engaging in health care delivery.

Dr. Ebbert is a professor of medicine at the Mayo Clinic, Rochester, Minn. He disclosed having financial relationships with Pfizer and GlaxoSmithKline, manufacturers of tobacco-dependence treatments.

CVS Pharmacy will stop selling cigarettes and other tobacco products by October of this year, the company announced Feb. 5.

CVS President and Chief Executive Officer Larry Merlo said in a statement that the sale of tobacco products is contrary to CVS’s responsibility to help patients manage chronic diseases such as high blood pressure, high cholesterol, and diabetes. "All of these conditions are made worse by smoking," he said. "Tobacco products have no place in a setting where health care is delivered."

In addition to pulling cigarettes from its shelves, CVS also plans to launch a national smoking cessation program in the spring for those trying to quit, Mr. Merlo added.

Dr. Troyen A. Brennan, CVS executive vice president and chief medical officer, and Dr. Steven A. Schroeder, of the Smoking Cessation Leadership Center at the University of California, San Francisco, further explained the decision in a JAMA commentary (JAMA 2014 Feb. 5 [doi:10.1001/jama.2014.686]). "This action may not lead many people to stop smoking; smokers will probably simply go elsewhere to buy cigarettes," they wrote. "But if other retailers follow this lead, tobacco products will become much more difficult to obtain."

Corund/Fotalia.com

U.S. Department of Health and Human Services secretary Kathleen Sebelius praised the effort in a statement, calling the move an "unprecedented step in the retail industry" that would contribute to positive health effects for the next generation.

"Nearly 500,000 Americans die early each year due to smoking, and smoking costs us $289 billion annually," she said, citing the recently released 50th Anniversary Surgeon General Report on smoking and health. "If we fail to reverse course, 5.6 million American children alive today will die prematurely due to smoking."

CVS’s decision also drew support from the American Medical Association. AMA president Dr. Ardis Dee Hoven said in a statement that she applauds the company’s decision to put public health first and recognize the importance of "supporting health and wellness instead of contributing to disease and death caused by tobacco use." Dr. Hoven also said she hoped the change would inspire other pharmacies to follow suit by ending cigarette sales in stores.

Dr. W. Michael Alberts, chief medical officer at Moffitt Cancer Center in Tampa, also voiced approval. "This is a major decision by CVS," he said in an interview. "It may even be a watershed moment akin to the decision to ban smoking on airplanes. Let’s hope such decisions become commonplace in corporate boardrooms."

[email protected]

CVS Pharmacy will stop selling cigarettes and other tobacco products by October of this year, the company announced Feb. 5.

CVS President and Chief Executive Officer Larry Merlo said in a statement that the sale of tobacco products is contrary to CVS’s responsibility to help patients manage chronic diseases such as high blood pressure, high cholesterol, and diabetes. "All of these conditions are made worse by smoking," he said. "Tobacco products have no place in a setting where health care is delivered."

In addition to pulling cigarettes from its shelves, CVS also plans to launch a national smoking cessation program in the spring for those trying to quit, Mr. Merlo added.

Dr. Troyen A. Brennan, CVS executive vice president and chief medical officer, and Dr. Steven A. Schroeder, of the Smoking Cessation Leadership Center at the University of California, San Francisco, further explained the decision in a JAMA commentary (JAMA 2014 Feb. 5 [doi:10.1001/jama.2014.686]). "This action may not lead many people to stop smoking; smokers will probably simply go elsewhere to buy cigarettes," they wrote. "But if other retailers follow this lead, tobacco products will become much more difficult to obtain."

Corund/Fotalia.com

U.S. Department of Health and Human Services secretary Kathleen Sebelius praised the effort in a statement, calling the move an "unprecedented step in the retail industry" that would contribute to positive health effects for the next generation.

"Nearly 500,000 Americans die early each year due to smoking, and smoking costs us $289 billion annually," she said, citing the recently released 50th Anniversary Surgeon General Report on smoking and health. "If we fail to reverse course, 5.6 million American children alive today will die prematurely due to smoking."

CVS’s decision also drew support from the American Medical Association. AMA president Dr. Ardis Dee Hoven said in a statement that she applauds the company’s decision to put public health first and recognize the importance of "supporting health and wellness instead of contributing to disease and death caused by tobacco use." Dr. Hoven also said she hoped the change would inspire other pharmacies to follow suit by ending cigarette sales in stores.

Dr. W. Michael Alberts, chief medical officer at Moffitt Cancer Center in Tampa, also voiced approval. "This is a major decision by CVS," he said in an interview. "It may even be a watershed moment akin to the decision to ban smoking on airplanes. Let’s hope such decisions become commonplace in corporate boardrooms."

[email protected]

CVS Pharmacy will stop selling cigarettes and other tobacco products by October of this year, the company announced Feb. 5.

CVS President and Chief Executive Officer Larry Merlo said in a statement that the sale of tobacco products is contrary to CVS’s responsibility to help patients manage chronic diseases such as high blood pressure, high cholesterol, and diabetes. "All of these conditions are made worse by smoking," he said. "Tobacco products have no place in a setting where health care is delivered."

In addition to pulling cigarettes from its shelves, CVS also plans to launch a national smoking cessation program in the spring for those trying to quit, Mr. Merlo added.

Dr. Troyen A. Brennan, CVS executive vice president and chief medical officer, and Dr. Steven A. Schroeder, of the Smoking Cessation Leadership Center at the University of California, San Francisco, further explained the decision in a JAMA commentary (JAMA 2014 Feb. 5 [doi:10.1001/jama.2014.686]). "This action may not lead many people to stop smoking; smokers will probably simply go elsewhere to buy cigarettes," they wrote. "But if other retailers follow this lead, tobacco products will become much more difficult to obtain."

Corund/Fotalia.com

U.S. Department of Health and Human Services secretary Kathleen Sebelius praised the effort in a statement, calling the move an "unprecedented step in the retail industry" that would contribute to positive health effects for the next generation.

"Nearly 500,000 Americans die early each year due to smoking, and smoking costs us $289 billion annually," she said, citing the recently released 50th Anniversary Surgeon General Report on smoking and health. "If we fail to reverse course, 5.6 million American children alive today will die prematurely due to smoking."

CVS’s decision also drew support from the American Medical Association. AMA president Dr. Ardis Dee Hoven said in a statement that she applauds the company’s decision to put public health first and recognize the importance of "supporting health and wellness instead of contributing to disease and death caused by tobacco use." Dr. Hoven also said she hoped the change would inspire other pharmacies to follow suit by ending cigarette sales in stores.

Dr. W. Michael Alberts, chief medical officer at Moffitt Cancer Center in Tampa, also voiced approval. "This is a major decision by CVS," he said in an interview. "It may even be a watershed moment akin to the decision to ban smoking on airplanes. Let’s hope such decisions become commonplace in corporate boardrooms."

[email protected]

The technical problems that plagued healthcare.gov throughout October and November could lead to 1 million fewer Americans signing up for health insurance in 2014, according to a report from the Congressional Budget Office.

The CBO previously estimated that 7 million individuals would enroll in health plans through the Affordable Care Act’s (ACA’s) insurance exchanges this year. But a report released Feb. 4 says it’s more likely that 6 million Americans will sign up during the open enrollment period that ends on March 31.

Mary Ellen Schneider/Frontline Medical News

Currently, more than 3 million people have enrolled in health plans through the state- and federally run exchanges, according to the Centers for Medicare & Medicaid Services. But CBO officials said that they expect many people to sign up toward the end of the open enrollment period, especially if they are purchasing a plan primarily to avoid a tax penalty for being uninsured.

"Thus, it is possible that the number of enrollees will reach the 7 million originally projected for 2014, just as it is possible that the number will fall short of the current estimate of 6 million," the report notes.

The CBO predicts that enrollment through the exchanges will reach 22 million by 2016 as people become more familiar with the new insurance options and federal subsidies.

Healthcare.gov’s technical problems likely also depressed enrollment through Medicaid and the Children’s Health Insurance Program (CHIP) this year. The CBO now estimates that 8 million individuals, not the 9 million initially projected, will enroll in Medicaid and CHIP in 2014.

Employment also could take a hit under the ACA, according to the CBO.

Between 2017 and 2024, there could be about a 1.5% to 2% drop in the total number of hours worked in the United States, mostly among low-wage earners as they choose to cut their hours and income to maintain eligibility for federal health insurance subsidies.

On the employer side, the CBO predicts that businesses could cut back on hiring to stay below the 50-worker threshold that requires them to either offer health insurance or pay a penalty. But the CBO also expects that over time, the penalty will have little effect on the hiring of workers because businesses will pass it on to their employees in the form of reduced wages.

Overall, the CBO estimates that the ACA will reduce aggregate compensation by about 1% over the 2017-2024 period, up from a 2010 estimate of 0.5%.

[email protected]

On Twitter @maryellenny

The technical problems that plagued healthcare.gov throughout October and November could lead to 1 million fewer Americans signing up for health insurance in 2014, according to a report from the Congressional Budget Office.

The CBO previously estimated that 7 million individuals would enroll in health plans through the Affordable Care Act’s (ACA’s) insurance exchanges this year. But a report released Feb. 4 says it’s more likely that 6 million Americans will sign up during the open enrollment period that ends on March 31.

Mary Ellen Schneider/Frontline Medical News

Currently, more than 3 million people have enrolled in health plans through the state- and federally run exchanges, according to the Centers for Medicare & Medicaid Services. But CBO officials said that they expect many people to sign up toward the end of the open enrollment period, especially if they are purchasing a plan primarily to avoid a tax penalty for being uninsured.

"Thus, it is possible that the number of enrollees will reach the 7 million originally projected for 2014, just as it is possible that the number will fall short of the current estimate of 6 million," the report notes.

The CBO predicts that enrollment through the exchanges will reach 22 million by 2016 as people become more familiar with the new insurance options and federal subsidies.

Healthcare.gov’s technical problems likely also depressed enrollment through Medicaid and the Children’s Health Insurance Program (CHIP) this year. The CBO now estimates that 8 million individuals, not the 9 million initially projected, will enroll in Medicaid and CHIP in 2014.

Employment also could take a hit under the ACA, according to the CBO.

Between 2017 and 2024, there could be about a 1.5% to 2% drop in the total number of hours worked in the United States, mostly among low-wage earners as they choose to cut their hours and income to maintain eligibility for federal health insurance subsidies.

On the employer side, the CBO predicts that businesses could cut back on hiring to stay below the 50-worker threshold that requires them to either offer health insurance or pay a penalty. But the CBO also expects that over time, the penalty will have little effect on the hiring of workers because businesses will pass it on to their employees in the form of reduced wages.

Overall, the CBO estimates that the ACA will reduce aggregate compensation by about 1% over the 2017-2024 period, up from a 2010 estimate of 0.5%.

[email protected]

On Twitter @maryellenny

The technical problems that plagued healthcare.gov throughout October and November could lead to 1 million fewer Americans signing up for health insurance in 2014, according to a report from the Congressional Budget Office.

The CBO previously estimated that 7 million individuals would enroll in health plans through the Affordable Care Act’s (ACA’s) insurance exchanges this year. But a report released Feb. 4 says it’s more likely that 6 million Americans will sign up during the open enrollment period that ends on March 31.

Mary Ellen Schneider/Frontline Medical News

Currently, more than 3 million people have enrolled in health plans through the state- and federally run exchanges, according to the Centers for Medicare & Medicaid Services. But CBO officials said that they expect many people to sign up toward the end of the open enrollment period, especially if they are purchasing a plan primarily to avoid a tax penalty for being uninsured.

"Thus, it is possible that the number of enrollees will reach the 7 million originally projected for 2014, just as it is possible that the number will fall short of the current estimate of 6 million," the report notes.

The CBO predicts that enrollment through the exchanges will reach 22 million by 2016 as people become more familiar with the new insurance options and federal subsidies.

Healthcare.gov’s technical problems likely also depressed enrollment through Medicaid and the Children’s Health Insurance Program (CHIP) this year. The CBO now estimates that 8 million individuals, not the 9 million initially projected, will enroll in Medicaid and CHIP in 2014.

Employment also could take a hit under the ACA, according to the CBO.

Between 2017 and 2024, there could be about a 1.5% to 2% drop in the total number of hours worked in the United States, mostly among low-wage earners as they choose to cut their hours and income to maintain eligibility for federal health insurance subsidies.

On the employer side, the CBO predicts that businesses could cut back on hiring to stay below the 50-worker threshold that requires them to either offer health insurance or pay a penalty. But the CBO also expects that over time, the penalty will have little effect on the hiring of workers because businesses will pass it on to their employees in the form of reduced wages.

Overall, the CBO estimates that the ACA will reduce aggregate compensation by about 1% over the 2017-2024 period, up from a 2010 estimate of 0.5%.

[email protected]

On Twitter @maryellenny