Joyce Frieden

With the first board certification exam in hospital medicine less than a year away, the long-awaited program has grown in scope following the decision by the American Board of Family Medicine to allow family physicians to join internists in pursuing the new credential.

Starting in May 2010, family physicians as well as internists can sign up with their respective boards to take the exam that will be one of the requirements for certification with a Focused Practice in Hospital Medicine. The first exam will take place on Oct. 25, 2010.

The ABFM hopes to make its self-evaluation and practice improvement modules available starting in January, said Robert Catoi, a spokesperson for the American Board of Family Medicine (ABFM).

The new credential will be offered through the maintenance of certification (MOC) framework, explained Dr. Jeffrey Wiese, president-elect of the Society for Hospital Medicine and chair of the ABIM internal medicine question-writing committee.

“The new certification process is really a separate pathway,” he said. For example, a family physician doing his required MOC could choose to go down the hospital medicine process rather than the standard MOC process. But the framework is going to be the same, he said.

Candidates will have to complete requirements in four areas: citizenship (including evidence of state licensure), self-evaluation, practice improvement, and secure exam. These requirements can be met in lieu of the standard MOC process, but newly trained family physicians seeking the new credential must first be certified in family medicine and have at least 3 years of practice focused on hospital medicine.

“One wrinkle for hospitalists is that they would be required to have Advanced Cardiac Life Support certification,” Dr. Wiese noted. “The other wrinkle is that candidates would have to demonstrate a minimum number of inpatient medicine contacts over a specified time period.”

The self-evaluation module in the hospital medicine pathway is “not going to differ appreciably [from those used in the existing MOC process], but the vision going forward is [to have] more hospital-focused sets, on things like patient safety and transition of care,” said Dr. Wiese, who is a professor of medicine at Tulane University in New Orleans.

The practice improvement module for hospitalist certification “will focus on the ability to interact well with a team,” Dr. Wiese said. “The candidate would sign up, would identify some practice area, collect data on the practice, design an intervention, and collect data again after a few months to show an improvement in practice delivery.” Other clinicians involved in the intervention, such as nurses, respiratory therapists, and social workers, would get e-mails seeking feedback on the hospitalist's improvement.

Dr. Eric Holmboe, the ABIM's senior vice president and chief medical officer, noted that the idea for certification with a Focused Practice in Hospital Medicine came from hospitalists themselves. “They came to the board over 5 years ago saying they believed their field had matured to the point that it needed to have a specific program, and their primary driver was quality and defining the discipline,” he said. “They were interested in the [physician's] role in patient safety and quality and transitions at the hospital.”

In addition, the hospitalists felt that taking MOC exams that emphasized outpatient care was not a good fit for their practice, Dr. Holmboe said.

“ABIM's decision to recognize hospital medicine acknowledges the value that hospital-based internists can bring to improving patient care in this practice setting…. The rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists,” the ABIM statement continued.

The new certification process is considered a pilot program by the American Board of Medical Specialties, Dr. Holmboe noted. The ABIM “will be doing pretty extensive research … to find out what value and impact this [pathway] has for hospitalists and patients, and look at the public's perception of this new pathway and how they understand it. We will also talk with credentialists to see what impact this has on credentialing at the hospital.”

Because the program is a pilot, it could be discontinued if too few people take advantage of it, but Dr. Holmboe said he doesn't think that will happen.

Although the ABFM is the only board so far to join ABIM in the pilot program, it's possible that the American Board of Pediatrics or other boards may join, Mr. Catoi said. Dr. Holmboe said that although pediatrics might be a possibility, “we haven't had any conversations along those lines yet” with the specialty.

With the first board certification exam in hospital medicine less than a year away, the long-awaited program has grown in scope following the decision by the American Board of Family Medicine to allow family physicians to join internists in pursuing the new credential.

Starting in May 2010, family physicians as well as internists can sign up with their respective boards to take the exam that will be one of the requirements for certification with a Focused Practice in Hospital Medicine. The first exam will take place on Oct. 25, 2010.

The ABFM hopes to make its self-evaluation and practice improvement modules available starting in January, said Robert Catoi, a spokesperson for the American Board of Family Medicine (ABFM).

The new credential will be offered through the maintenance of certification (MOC) framework, explained Dr. Jeffrey Wiese, president-elect of the Society for Hospital Medicine and chair of the ABIM internal medicine question-writing committee.

“The new certification process is really a separate pathway,” he said. For example, a family physician doing his required MOC could choose to go down the hospital medicine process rather than the standard MOC process. But the framework is going to be the same, he said.

Candidates will have to complete requirements in four areas: citizenship (including evidence of state licensure), self-evaluation, practice improvement, and secure exam. These requirements can be met in lieu of the standard MOC process, but newly trained family physicians seeking the new credential must first be certified in family medicine and have at least 3 years of practice focused on hospital medicine.

“One wrinkle for hospitalists is that they would be required to have Advanced Cardiac Life Support certification,” Dr. Wiese noted. “The other wrinkle is that candidates would have to demonstrate a minimum number of inpatient medicine contacts over a specified time period.”

The self-evaluation module in the hospital medicine pathway is “not going to differ appreciably [from those used in the existing MOC process], but the vision going forward is [to have] more hospital-focused sets, on things like patient safety and transition of care,” said Dr. Wiese, who is a professor of medicine at Tulane University in New Orleans.

The practice improvement module for hospitalist certification “will focus on the ability to interact well with a team,” Dr. Wiese said. “The candidate would sign up, would identify some practice area, collect data on the practice, design an intervention, and collect data again after a few months to show an improvement in practice delivery.” Other clinicians involved in the intervention, such as nurses, respiratory therapists, and social workers, would get e-mails seeking feedback on the hospitalist's improvement.

Dr. Eric Holmboe, the ABIM's senior vice president and chief medical officer, noted that the idea for certification with a Focused Practice in Hospital Medicine came from hospitalists themselves. “They came to the board over 5 years ago saying they believed their field had matured to the point that it needed to have a specific program, and their primary driver was quality and defining the discipline,” he said. “They were interested in the [physician's] role in patient safety and quality and transitions at the hospital.”

In addition, the hospitalists felt that taking MOC exams that emphasized outpatient care was not a good fit for their practice, Dr. Holmboe said.

“ABIM's decision to recognize hospital medicine acknowledges the value that hospital-based internists can bring to improving patient care in this practice setting…. The rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists,” the ABIM statement continued.

The new certification process is considered a pilot program by the American Board of Medical Specialties, Dr. Holmboe noted. The ABIM “will be doing pretty extensive research … to find out what value and impact this [pathway] has for hospitalists and patients, and look at the public's perception of this new pathway and how they understand it. We will also talk with credentialists to see what impact this has on credentialing at the hospital.”

Because the program is a pilot, it could be discontinued if too few people take advantage of it, but Dr. Holmboe said he doesn't think that will happen.

Although the ABFM is the only board so far to join ABIM in the pilot program, it's possible that the American Board of Pediatrics or other boards may join, Mr. Catoi said. Dr. Holmboe said that although pediatrics might be a possibility, “we haven't had any conversations along those lines yet” with the specialty.

With the first board certification exam in hospital medicine less than a year away, the long-awaited program has grown in scope following the decision by the American Board of Family Medicine to allow family physicians to join internists in pursuing the new credential.

Starting in May 2010, family physicians as well as internists can sign up with their respective boards to take the exam that will be one of the requirements for certification with a Focused Practice in Hospital Medicine. The first exam will take place on Oct. 25, 2010.

The ABFM hopes to make its self-evaluation and practice improvement modules available starting in January, said Robert Catoi, a spokesperson for the American Board of Family Medicine (ABFM).

The new credential will be offered through the maintenance of certification (MOC) framework, explained Dr. Jeffrey Wiese, president-elect of the Society for Hospital Medicine and chair of the ABIM internal medicine question-writing committee.

“The new certification process is really a separate pathway,” he said. For example, a family physician doing his required MOC could choose to go down the hospital medicine process rather than the standard MOC process. But the framework is going to be the same, he said.

Candidates will have to complete requirements in four areas: citizenship (including evidence of state licensure), self-evaluation, practice improvement, and secure exam. These requirements can be met in lieu of the standard MOC process, but newly trained family physicians seeking the new credential must first be certified in family medicine and have at least 3 years of practice focused on hospital medicine.

“One wrinkle for hospitalists is that they would be required to have Advanced Cardiac Life Support certification,” Dr. Wiese noted. “The other wrinkle is that candidates would have to demonstrate a minimum number of inpatient medicine contacts over a specified time period.”

The self-evaluation module in the hospital medicine pathway is “not going to differ appreciably [from those used in the existing MOC process], but the vision going forward is [to have] more hospital-focused sets, on things like patient safety and transition of care,” said Dr. Wiese, who is a professor of medicine at Tulane University in New Orleans.

The practice improvement module for hospitalist certification “will focus on the ability to interact well with a team,” Dr. Wiese said. “The candidate would sign up, would identify some practice area, collect data on the practice, design an intervention, and collect data again after a few months to show an improvement in practice delivery.” Other clinicians involved in the intervention, such as nurses, respiratory therapists, and social workers, would get e-mails seeking feedback on the hospitalist's improvement.

Dr. Eric Holmboe, the ABIM's senior vice president and chief medical officer, noted that the idea for certification with a Focused Practice in Hospital Medicine came from hospitalists themselves. “They came to the board over 5 years ago saying they believed their field had matured to the point that it needed to have a specific program, and their primary driver was quality and defining the discipline,” he said. “They were interested in the [physician's] role in patient safety and quality and transitions at the hospital.”

In addition, the hospitalists felt that taking MOC exams that emphasized outpatient care was not a good fit for their practice, Dr. Holmboe said.

“ABIM's decision to recognize hospital medicine acknowledges the value that hospital-based internists can bring to improving patient care in this practice setting…. The rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists,” the ABIM statement continued.

The new certification process is considered a pilot program by the American Board of Medical Specialties, Dr. Holmboe noted. The ABIM “will be doing pretty extensive research … to find out what value and impact this [pathway] has for hospitalists and patients, and look at the public's perception of this new pathway and how they understand it. We will also talk with credentialists to see what impact this has on credentialing at the hospital.”

Because the program is a pilot, it could be discontinued if too few people take advantage of it, but Dr. Holmboe said he doesn't think that will happen.

Although the ABFM is the only board so far to join ABIM in the pilot program, it's possible that the American Board of Pediatrics or other boards may join, Mr. Catoi said. Dr. Holmboe said that although pediatrics might be a possibility, “we haven't had any conversations along those lines yet” with the specialty.

WASHINGTON — Should physicians whose behavior is seen as disruptive be allowed to find out who is complaining about them? That depends on who you ask, David J. Hyman said at the annual meeting of the American Health Lawyers Association.

Mr. Hyman, a health care lawyer in Tulsa, Okla., reviewed recently issued guidance to health care facilities on dealing with disruptive physicians. The guidance was issued by two different organizations: the American Medical Association and the Joint Commission.

The AMA's model bylaws on dealing with disruptive physicians say that “the accusation or complaint—and this is key to their approach—has to be written and signed; there are no secret allegations under the AMA code, no Star Chamber here,” he said. “This is counter to many practices going on at hospitals, and implicitly counter to the Joint Commission's approach,” which allows for anonymous complaints.

Many facilities allow for anonymous complaints and for withholding the details of what happened and when from the physician. That's because the physician could surmise from a fuller description who was involved, and the fear is that the doctor will take some sort of retributive action against the complainant, according to Mr. Hyman. “The AMA code addresses this by saying, 'Doc, you cannot take any retaliation against anybody who complains or is listed [on the complaint]. If you do, the heavy weight of sanction can be dropped on you for that alone.'”

Based on their guidelines, the Joint Commission appears to favor anonymous reporting. “If you can report anonymously, then you feel free to do it. On the other hand, [the person reporting] may just not like the doctor, and [think], 'I'm gonna get him.' ”

Allowing for anonymous complaints and withholding of details can be upsetting for the accused physician, Mr. Hyman pointed out. “The doctor's in a very frustrating position, saying, 'I didn't know I was doing it. I don't think I'm a bad guy, but you've got to tell me what it was I did.' ” Staff members handling the complaint then refuse to tell the physician the circumstances of the complaint even when the physician promises not to retaliate, leaving him unable to figure out what he did wrong.

Dr. Tobie Bresloff, chief quality officer at the Oklahoma Heart Institute, in Tulsa, noted that complainants should not be told what was done as a result of their complaint, even though that policy brings some grumbling.

“You need to say to that person, 'We have acted on it. We have a way to deal with these things; we will take care of it.' But they do not get [a report] if you talk to the doctor … or if the doctor gets a 20-day suspension. That is not their right to know. Just assure them it will be taken care of.”

The Joint Commission's “Sentinel Event Alert” on disruptive physicians can be found online at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htmwww.ama-assn.org/ama1/pub/upload/mm/21/medicalstaffcodeofconduct.pdf

WASHINGTON — Should physicians whose behavior is seen as disruptive be allowed to find out who is complaining about them? That depends on who you ask, David J. Hyman said at the annual meeting of the American Health Lawyers Association.

Mr. Hyman, a health care lawyer in Tulsa, Okla., reviewed recently issued guidance to health care facilities on dealing with disruptive physicians. The guidance was issued by two different organizations: the American Medical Association and the Joint Commission.

The AMA's model bylaws on dealing with disruptive physicians say that “the accusation or complaint—and this is key to their approach—has to be written and signed; there are no secret allegations under the AMA code, no Star Chamber here,” he said. “This is counter to many practices going on at hospitals, and implicitly counter to the Joint Commission's approach,” which allows for anonymous complaints.

Many facilities allow for anonymous complaints and for withholding the details of what happened and when from the physician. That's because the physician could surmise from a fuller description who was involved, and the fear is that the doctor will take some sort of retributive action against the complainant, according to Mr. Hyman. “The AMA code addresses this by saying, 'Doc, you cannot take any retaliation against anybody who complains or is listed [on the complaint]. If you do, the heavy weight of sanction can be dropped on you for that alone.'”

Based on their guidelines, the Joint Commission appears to favor anonymous reporting. “If you can report anonymously, then you feel free to do it. On the other hand, [the person reporting] may just not like the doctor, and [think], 'I'm gonna get him.' ”

Allowing for anonymous complaints and withholding of details can be upsetting for the accused physician, Mr. Hyman pointed out. “The doctor's in a very frustrating position, saying, 'I didn't know I was doing it. I don't think I'm a bad guy, but you've got to tell me what it was I did.' ” Staff members handling the complaint then refuse to tell the physician the circumstances of the complaint even when the physician promises not to retaliate, leaving him unable to figure out what he did wrong.

Dr. Tobie Bresloff, chief quality officer at the Oklahoma Heart Institute, in Tulsa, noted that complainants should not be told what was done as a result of their complaint, even though that policy brings some grumbling.

“You need to say to that person, 'We have acted on it. We have a way to deal with these things; we will take care of it.' But they do not get [a report] if you talk to the doctor … or if the doctor gets a 20-day suspension. That is not their right to know. Just assure them it will be taken care of.”

The Joint Commission's “Sentinel Event Alert” on disruptive physicians can be found online at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htmwww.ama-assn.org/ama1/pub/upload/mm/21/medicalstaffcodeofconduct.pdf

WASHINGTON — Should physicians whose behavior is seen as disruptive be allowed to find out who is complaining about them? That depends on who you ask, David J. Hyman said at the annual meeting of the American Health Lawyers Association.

Mr. Hyman, a health care lawyer in Tulsa, Okla., reviewed recently issued guidance to health care facilities on dealing with disruptive physicians. The guidance was issued by two different organizations: the American Medical Association and the Joint Commission.

The AMA's model bylaws on dealing with disruptive physicians say that “the accusation or complaint—and this is key to their approach—has to be written and signed; there are no secret allegations under the AMA code, no Star Chamber here,” he said. “This is counter to many practices going on at hospitals, and implicitly counter to the Joint Commission's approach,” which allows for anonymous complaints.

Many facilities allow for anonymous complaints and for withholding the details of what happened and when from the physician. That's because the physician could surmise from a fuller description who was involved, and the fear is that the doctor will take some sort of retributive action against the complainant, according to Mr. Hyman. “The AMA code addresses this by saying, 'Doc, you cannot take any retaliation against anybody who complains or is listed [on the complaint]. If you do, the heavy weight of sanction can be dropped on you for that alone.'”

Based on their guidelines, the Joint Commission appears to favor anonymous reporting. “If you can report anonymously, then you feel free to do it. On the other hand, [the person reporting] may just not like the doctor, and [think], 'I'm gonna get him.' ”

Allowing for anonymous complaints and withholding of details can be upsetting for the accused physician, Mr. Hyman pointed out. “The doctor's in a very frustrating position, saying, 'I didn't know I was doing it. I don't think I'm a bad guy, but you've got to tell me what it was I did.' ” Staff members handling the complaint then refuse to tell the physician the circumstances of the complaint even when the physician promises not to retaliate, leaving him unable to figure out what he did wrong.

Dr. Tobie Bresloff, chief quality officer at the Oklahoma Heart Institute, in Tulsa, noted that complainants should not be told what was done as a result of their complaint, even though that policy brings some grumbling.

“You need to say to that person, 'We have acted on it. We have a way to deal with these things; we will take care of it.' But they do not get [a report] if you talk to the doctor … or if the doctor gets a 20-day suspension. That is not their right to know. Just assure them it will be taken care of.”

The Joint Commission's “Sentinel Event Alert” on disruptive physicians can be found online at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htmwww.ama-assn.org/ama1/pub/upload/mm/21/medicalstaffcodeofconduct.pdf

WASHINGTON — Despite recessionary impacts on their reimbursement, physicians continue to see Medicaid patients, according to several state Medicaid directors.

“Knock on wood, we've not seen an impact,” Charles Duarte of the Nevada Department of Health and Human Services, said at a briefing sponsored by the Kaiser Family Foundation. “We still maintain contracts with about 93% of licensed physicians in the state, and about 65% of those indicate they are still seeing new [Medicaid] recipients,” according to a survey the department performed earlier in 2009.

New York state also cut Medicaid provider rates—not in ambulatory care, but in nursing home, home care, inpatient care, and pharmacy, said state Medicaid director Deborah Bachrach. “We monitor very carefully. We have not seen an impact on access, and we are working very hard with our physician community to enroll more physicians into Medicaid.”

Many states are struggling to provide services to Medicaid patients during this economic downturn, according to a 50-state Medicaid survey released by the foundation. On average, although states projected growth in Medicaid spending of 5.8% in fiscal year 2009, spending actually increased 7.9%, according to the survey. At the same time, enrollment growth, projected to grow by 3.6% for the year, was actually 5.4%.

What has allowed states to increase their Medicaid spending has been the American Recovery and Reinvestment Act, said Vernon K. Smith, Ph.D., principal at consulting firm Health Management Associates and one of the coauthors of the report.

In fiscal 2009, “states received Recovery Act funding for 9 months totaling $29 billion, of which 90% came through Medicaid” in the form of more matching dollars for the program, Dr. Smith said. “Without the federal stimulus funding, the Medicaid story in 2009 would have been dramatically different. Without any doubt we would have seen widespread cuts to eligibility and … cuts to payment rates would have been more severe.”

The Recovery Act also prevented cuts in another way: In order for the states to get the money, they were required not to make any cuts to Medicaid eligibility.

Although Medicaid spending increased overall in the last fiscal year, the portion of spending that came from states themselves—as opposed to the federal government—dropped by 6.3%, which was “simply unprecedented,” Dr. Smith noted. In addition, Medicaid spending for FY 2010 is projected to grow at a slower percentage rate than Medicaid enrollment, which also is highly unusual.

States are expecting the situation to worsen once Recovery Act funding goes away, at the end of 2012, according to Dr. Smith. At that point, more drastic cuts in benefits and payments will likely be considered, along with cuts in eligibility.

One wild card in the Medicaid scenario is health reform. Many states expressed concern that eligibility expansions, mandated minimum provider rates, and new administrative costs that might be included in a reform plan could add to state fiscal woes, the report's authors noted.

Despite the challenges, some states have expanded eligibility for certain categories of beneficiaries, and most have increased or are planning to increase their participation in electronic prescribing and electronic health records initiatives, according to the report.

The report—“The Crunch Continues: Medicaid Spending, Coverage and Policy in the Midst of a Recession”—is available online at www.kff.org

WASHINGTON — Despite recessionary impacts on their reimbursement, physicians continue to see Medicaid patients, according to several state Medicaid directors.

“Knock on wood, we've not seen an impact,” Charles Duarte of the Nevada Department of Health and Human Services, said at a briefing sponsored by the Kaiser Family Foundation. “We still maintain contracts with about 93% of licensed physicians in the state, and about 65% of those indicate they are still seeing new [Medicaid] recipients,” according to a survey the department performed earlier in 2009.

New York state also cut Medicaid provider rates—not in ambulatory care, but in nursing home, home care, inpatient care, and pharmacy, said state Medicaid director Deborah Bachrach. “We monitor very carefully. We have not seen an impact on access, and we are working very hard with our physician community to enroll more physicians into Medicaid.”

Many states are struggling to provide services to Medicaid patients during this economic downturn, according to a 50-state Medicaid survey released by the foundation. On average, although states projected growth in Medicaid spending of 5.8% in fiscal year 2009, spending actually increased 7.9%, according to the survey. At the same time, enrollment growth, projected to grow by 3.6% for the year, was actually 5.4%.

What has allowed states to increase their Medicaid spending has been the American Recovery and Reinvestment Act, said Vernon K. Smith, Ph.D., principal at consulting firm Health Management Associates and one of the coauthors of the report.

In fiscal 2009, “states received Recovery Act funding for 9 months totaling $29 billion, of which 90% came through Medicaid” in the form of more matching dollars for the program, Dr. Smith said. “Without the federal stimulus funding, the Medicaid story in 2009 would have been dramatically different. Without any doubt we would have seen widespread cuts to eligibility and … cuts to payment rates would have been more severe.”

The Recovery Act also prevented cuts in another way: In order for the states to get the money, they were required not to make any cuts to Medicaid eligibility.

Although Medicaid spending increased overall in the last fiscal year, the portion of spending that came from states themselves—as opposed to the federal government—dropped by 6.3%, which was “simply unprecedented,” Dr. Smith noted. In addition, Medicaid spending for FY 2010 is projected to grow at a slower percentage rate than Medicaid enrollment, which also is highly unusual.

States are expecting the situation to worsen once Recovery Act funding goes away, at the end of 2012, according to Dr. Smith. At that point, more drastic cuts in benefits and payments will likely be considered, along with cuts in eligibility.

One wild card in the Medicaid scenario is health reform. Many states expressed concern that eligibility expansions, mandated minimum provider rates, and new administrative costs that might be included in a reform plan could add to state fiscal woes, the report's authors noted.

Despite the challenges, some states have expanded eligibility for certain categories of beneficiaries, and most have increased or are planning to increase their participation in electronic prescribing and electronic health records initiatives, according to the report.

The report—“The Crunch Continues: Medicaid Spending, Coverage and Policy in the Midst of a Recession”—is available online at www.kff.org

WASHINGTON — Despite recessionary impacts on their reimbursement, physicians continue to see Medicaid patients, according to several state Medicaid directors.

“Knock on wood, we've not seen an impact,” Charles Duarte of the Nevada Department of Health and Human Services, said at a briefing sponsored by the Kaiser Family Foundation. “We still maintain contracts with about 93% of licensed physicians in the state, and about 65% of those indicate they are still seeing new [Medicaid] recipients,” according to a survey the department performed earlier in 2009.

New York state also cut Medicaid provider rates—not in ambulatory care, but in nursing home, home care, inpatient care, and pharmacy, said state Medicaid director Deborah Bachrach. “We monitor very carefully. We have not seen an impact on access, and we are working very hard with our physician community to enroll more physicians into Medicaid.”

Many states are struggling to provide services to Medicaid patients during this economic downturn, according to a 50-state Medicaid survey released by the foundation. On average, although states projected growth in Medicaid spending of 5.8% in fiscal year 2009, spending actually increased 7.9%, according to the survey. At the same time, enrollment growth, projected to grow by 3.6% for the year, was actually 5.4%.

What has allowed states to increase their Medicaid spending has been the American Recovery and Reinvestment Act, said Vernon K. Smith, Ph.D., principal at consulting firm Health Management Associates and one of the coauthors of the report.

In fiscal 2009, “states received Recovery Act funding for 9 months totaling $29 billion, of which 90% came through Medicaid” in the form of more matching dollars for the program, Dr. Smith said. “Without the federal stimulus funding, the Medicaid story in 2009 would have been dramatically different. Without any doubt we would have seen widespread cuts to eligibility and … cuts to payment rates would have been more severe.”

The Recovery Act also prevented cuts in another way: In order for the states to get the money, they were required not to make any cuts to Medicaid eligibility.

Although Medicaid spending increased overall in the last fiscal year, the portion of spending that came from states themselves—as opposed to the federal government—dropped by 6.3%, which was “simply unprecedented,” Dr. Smith noted. In addition, Medicaid spending for FY 2010 is projected to grow at a slower percentage rate than Medicaid enrollment, which also is highly unusual.

States are expecting the situation to worsen once Recovery Act funding goes away, at the end of 2012, according to Dr. Smith. At that point, more drastic cuts in benefits and payments will likely be considered, along with cuts in eligibility.

One wild card in the Medicaid scenario is health reform. Many states expressed concern that eligibility expansions, mandated minimum provider rates, and new administrative costs that might be included in a reform plan could add to state fiscal woes, the report's authors noted.

Despite the challenges, some states have expanded eligibility for certain categories of beneficiaries, and most have increased or are planning to increase their participation in electronic prescribing and electronic health records initiatives, according to the report.

The report—“The Crunch Continues: Medicaid Spending, Coverage and Policy in the Midst of a Recession”—is available online at www.kff.org

A new payment rule from the Centers for Medicare and Medicaid Services will increase the number and duration of payments to hospitals for cardiac and pulmonary rehabilitation services.

The expanded cardiac benefit is “very exciting,” said Dr. Alfred Bove, president of the American College of Cardiology. “A lot of us have been advocating rehabilitation for a long time, and lots of patients say, 'I can't afford it.' This would be a tremendous program for a lot of people after a major heart event.”

Previously, Medicare patients who experienced a heart attack or heart failure usually were covered for 8 weeks of cardiac rehabilitation with a maximum of three 1-hour sessions per week, Dr. Bove said. Under the new benefit, patients can receive up to 72 sessions of intensive cardiac rehabilitation over an 18-week period.

Being able to spread the sessions out will be quite valuable, Dr. Bove said. “So much of recovering is giving people confidence in what they can handle. So many people have a heart attack and go home and stare out the window because they have no idea what they can do that is safe. Improvement of depression and other symptoms [also] is better if you can get them into a rehab program.”

In addition, Medicare's approval of the expanded sessions will put pressure on private insurers to create the same kind of benefit, Dr. Bove noted.

Other outpatient payment changes included in the rule are:

▸ Physician supervision requirements. Nonphysician providers—physician assistants, nurse practitioners, certified nurse specialists, and certified nurse-midwives—may directly supervise all hospital outpatient therapeutic services that they are personally able to perform within their state scope of practice and hospital-granted privileges. Previous Medicare policy allowed only for physicians to provide direct supervision of these services.

▸ Kidney disease education. The CMS will establish payment to rural providers under the Medicare Physician Fee Schedule for kidney disease education services furnished on or after Jan. 1, 2010, for beneficiaries diagnosed with stage IV chronic kidney disease.

▸ Validation of quality reporting. To make sure that hospitals are accurately reporting measures using chart-abstracted data, the CMS will take a sample of actual patient records, determine how the measures should have been reported according to the Hospital Outpatient Department Quality Reporting Program, and compare results with the measures reported by the hospital. Although the CMS will begin validating hospital-submitted data for purposes of the 2011 payment update, the validation results will not affect a hospital's outpatient payments until 2012, according to the new rule.

The CMS also is planning to implement the third of four phases of its revised payment system for ambulatory surgery centers (ASCs). In general, the revised ASC payment rate for any given service is a percentage of the payment rate for the same service under the Outpatient Prospective Payment System. However, for new ASC services that are usually performed in physicians' offices, the ASC payment is capped at the amount the physician is paid under the Medicare fee schedule for practice expenses when providing the same service in the office.

The final rule is scheduled to be published in the Nov. 20 issue of the Federal Register. The CMS will accept comments on the final rule through Dec. 29, and will respond to them in the 2011 final outpatient rule.

Information on the outpatient payment rule is available online at www.cms.hhs.gov/HospitalOutpatientPPS

A new payment rule from the Centers for Medicare and Medicaid Services will increase the number and duration of payments to hospitals for cardiac and pulmonary rehabilitation services.

The expanded cardiac benefit is “very exciting,” said Dr. Alfred Bove, president of the American College of Cardiology. “A lot of us have been advocating rehabilitation for a long time, and lots of patients say, 'I can't afford it.' This would be a tremendous program for a lot of people after a major heart event.”

Previously, Medicare patients who experienced a heart attack or heart failure usually were covered for 8 weeks of cardiac rehabilitation with a maximum of three 1-hour sessions per week, Dr. Bove said. Under the new benefit, patients can receive up to 72 sessions of intensive cardiac rehabilitation over an 18-week period.

Being able to spread the sessions out will be quite valuable, Dr. Bove said. “So much of recovering is giving people confidence in what they can handle. So many people have a heart attack and go home and stare out the window because they have no idea what they can do that is safe. Improvement of depression and other symptoms [also] is better if you can get them into a rehab program.”

In addition, Medicare's approval of the expanded sessions will put pressure on private insurers to create the same kind of benefit, Dr. Bove noted.

Other outpatient payment changes included in the rule are:

▸ Physician supervision requirements. Nonphysician providers—physician assistants, nurse practitioners, certified nurse specialists, and certified nurse-midwives—may directly supervise all hospital outpatient therapeutic services that they are personally able to perform within their state scope of practice and hospital-granted privileges. Previous Medicare policy allowed only for physicians to provide direct supervision of these services.

▸ Kidney disease education. The CMS will establish payment to rural providers under the Medicare Physician Fee Schedule for kidney disease education services furnished on or after Jan. 1, 2010, for beneficiaries diagnosed with stage IV chronic kidney disease.

▸ Validation of quality reporting. To make sure that hospitals are accurately reporting measures using chart-abstracted data, the CMS will take a sample of actual patient records, determine how the measures should have been reported according to the Hospital Outpatient Department Quality Reporting Program, and compare results with the measures reported by the hospital. Although the CMS will begin validating hospital-submitted data for purposes of the 2011 payment update, the validation results will not affect a hospital's outpatient payments until 2012, according to the new rule.

The CMS also is planning to implement the third of four phases of its revised payment system for ambulatory surgery centers (ASCs). In general, the revised ASC payment rate for any given service is a percentage of the payment rate for the same service under the Outpatient Prospective Payment System. However, for new ASC services that are usually performed in physicians' offices, the ASC payment is capped at the amount the physician is paid under the Medicare fee schedule for practice expenses when providing the same service in the office.

The final rule is scheduled to be published in the Nov. 20 issue of the Federal Register. The CMS will accept comments on the final rule through Dec. 29, and will respond to them in the 2011 final outpatient rule.

Information on the outpatient payment rule is available online at www.cms.hhs.gov/HospitalOutpatientPPS

A new payment rule from the Centers for Medicare and Medicaid Services will increase the number and duration of payments to hospitals for cardiac and pulmonary rehabilitation services.

The expanded cardiac benefit is “very exciting,” said Dr. Alfred Bove, president of the American College of Cardiology. “A lot of us have been advocating rehabilitation for a long time, and lots of patients say, 'I can't afford it.' This would be a tremendous program for a lot of people after a major heart event.”

Previously, Medicare patients who experienced a heart attack or heart failure usually were covered for 8 weeks of cardiac rehabilitation with a maximum of three 1-hour sessions per week, Dr. Bove said. Under the new benefit, patients can receive up to 72 sessions of intensive cardiac rehabilitation over an 18-week period.

Being able to spread the sessions out will be quite valuable, Dr. Bove said. “So much of recovering is giving people confidence in what they can handle. So many people have a heart attack and go home and stare out the window because they have no idea what they can do that is safe. Improvement of depression and other symptoms [also] is better if you can get them into a rehab program.”

In addition, Medicare's approval of the expanded sessions will put pressure on private insurers to create the same kind of benefit, Dr. Bove noted.

Other outpatient payment changes included in the rule are:

▸ Physician supervision requirements. Nonphysician providers—physician assistants, nurse practitioners, certified nurse specialists, and certified nurse-midwives—may directly supervise all hospital outpatient therapeutic services that they are personally able to perform within their state scope of practice and hospital-granted privileges. Previous Medicare policy allowed only for physicians to provide direct supervision of these services.

▸ Kidney disease education. The CMS will establish payment to rural providers under the Medicare Physician Fee Schedule for kidney disease education services furnished on or after Jan. 1, 2010, for beneficiaries diagnosed with stage IV chronic kidney disease.

▸ Validation of quality reporting. To make sure that hospitals are accurately reporting measures using chart-abstracted data, the CMS will take a sample of actual patient records, determine how the measures should have been reported according to the Hospital Outpatient Department Quality Reporting Program, and compare results with the measures reported by the hospital. Although the CMS will begin validating hospital-submitted data for purposes of the 2011 payment update, the validation results will not affect a hospital's outpatient payments until 2012, according to the new rule.

The CMS also is planning to implement the third of four phases of its revised payment system for ambulatory surgery centers (ASCs). In general, the revised ASC payment rate for any given service is a percentage of the payment rate for the same service under the Outpatient Prospective Payment System. However, for new ASC services that are usually performed in physicians' offices, the ASC payment is capped at the amount the physician is paid under the Medicare fee schedule for practice expenses when providing the same service in the office.

The final rule is scheduled to be published in the Nov. 20 issue of the Federal Register. The CMS will accept comments on the final rule through Dec. 29, and will respond to them in the 2011 final outpatient rule.

Information on the outpatient payment rule is available online at www.cms.hhs.gov/HospitalOutpatientPPS

With the first board certification exam in hospital medicine less than a year away, the long-awaited program has grown in scope following the decision by the American Board of Family Medicine to allow family physicians to join internists in pursuing the new credential.

Starting in May 2010, internists and family physicians can sign up with their respective boards to take the exam that will be one of the requirements for certification with a Focused Practice in Hospital Medicine. The first exam will be on Oct. 25, 2010.

Internists seeking hospitalist certification already can start working on the required self-evaluation and practice improvement modules developed by the American Board of Internal Medicine (ABIM). The American Board of Family Medicine hopes to make its modules available starting in January, said Robert Catoi, a spokesperson for the ABFM.

The new credential will be offered through the maintenance of certification (MOC) framework, explained Dr. Jeffrey Wiese, president-elect of the Society for Hospital Medicine and chair of the ABIM internal medicine question-writing committee. The new certification process is “really a separate pathway,” he said. For example, “an internist [doing his required MOC] would choose to go down the hospital medicine process rather than the standard MOC process. But the framework is going to be the same.”

Candidates will have to complete requirements in four areas: citizenship (including evidence of state licensure), self-evaluation, practice improvement, and secure exam. These requirements can be met in lieu of the standard MOC process, but newly trained internists seeking the new credential must first be certified in internal medicine and have at least 3 years of practice focused on hospital medicine.

“One wrinkle for hospitalists is that they would be required to have Advanced Cardiac Life Support certification,” Dr. Wiese noted. A minimum number of inpatient medicine contacts also would be required.

The self-evaluation module in the hospital medicine pathway is “not going to differ appreciably [from those used in the existing MOC process], but the vision going forward is [to have] more hospital-focused sets, on things like patient safety and transition of care,” said Dr. Wiese, who is a professor of medicine at Tulane University in New Orleans.

The practice improvement module “will focus on the ability to interact well with a team,” he said. “The candidate would sign up, would identify some practice area, collect data on the practice, design an intervention, and collect data again after a few months to show an improvement in practice delivery.”

The secure exam will differ from the standard internal medicine exam “in that it has much greater hospital medicine–focused content, but also questions on quality, patient safety, and transitions,” he continued. “Individuals that pass this exam can hold themselves out to patients and say, 'I have competence understanding systems of care, transitions of care, and quality.' Our part is to design an exam that reflects all those virtues.”

Dr. Eric Holmboe, the ABIM's senior vice president and chief medical officer, noted that the idea for certification with a Focused Practice in Hospital Medicine came from hospitalists themselves. “They came to the board over 5 years ago saying they believed their field had matured to the point that it needed to have a specific program, and their primary driver was quality and defining the discipline,” he said. “They were interested in the [physician's] role in patient safety and quality and transitions at the hospital.”

In addition, the hospitalists felt that taking MOC exams that emphasized outpatient care was not a good fit for their practice, Dr. Holmboe said.

Dr. Holmboe noted that in addition to hospital medicine certification, an option for certification in ambulatory care (originally called comprehensive care/internal medicine) was under consideration in recent years. “There was a lot of concern about moving that forward, mostly because of the beleaguered state of primary care,” he said. “That's been put on hold—not that it [won't] necessarily come back, but we are not pursuing this MOC pathway right now.”

In a statement on its Web site, the ABIM noted that “the rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists.”

The ABIM did not go the subspecialty route with hospital medicine because “subspecialty practice involves applying internal medicine as well as specialized knowledge and procedures to a subset of internal medicine patients,” the statement explains. “In contrast, hospital medicine is the practice of internal medicine for patients during hospitalization.

The new certification process is considered a pilot program by the American Board of Medical Specialties, Dr. Holmboe noted. The ABIM “will be doing pretty extensive research … to find out what value and impact this [pathway] has for hospitalists and patients.”

Although the ABFM is the only board so far to join ABIM in the pilot program, it's possible that the American Board of Pediatrics or other boards may join, Mr. Catoi said. Dr. Holmboe said that although pediatrics might be a possibility, “we haven't had any conversations along those lines yet” with the specialty. He added that Focused Practice in Hospital Medicine “is not something that would be offered to [a specialty such as] ob.gyn.; it's about general practice in the hospital on a broad range of patients who are hospitalized for a variety of conditions.”

With the first board certification exam in hospital medicine less than a year away, the long-awaited program has grown in scope following the decision by the American Board of Family Medicine to allow family physicians to join internists in pursuing the new credential.

Starting in May 2010, internists and family physicians can sign up with their respective boards to take the exam that will be one of the requirements for certification with a Focused Practice in Hospital Medicine. The first exam will be on Oct. 25, 2010.

Internists seeking hospitalist certification already can start working on the required self-evaluation and practice improvement modules developed by the American Board of Internal Medicine (ABIM). The American Board of Family Medicine hopes to make its modules available starting in January, said Robert Catoi, a spokesperson for the ABFM.

The new credential will be offered through the maintenance of certification (MOC) framework, explained Dr. Jeffrey Wiese, president-elect of the Society for Hospital Medicine and chair of the ABIM internal medicine question-writing committee. The new certification process is “really a separate pathway,” he said. For example, “an internist [doing his required MOC] would choose to go down the hospital medicine process rather than the standard MOC process. But the framework is going to be the same.”

Candidates will have to complete requirements in four areas: citizenship (including evidence of state licensure), self-evaluation, practice improvement, and secure exam. These requirements can be met in lieu of the standard MOC process, but newly trained internists seeking the new credential must first be certified in internal medicine and have at least 3 years of practice focused on hospital medicine.

“One wrinkle for hospitalists is that they would be required to have Advanced Cardiac Life Support certification,” Dr. Wiese noted. A minimum number of inpatient medicine contacts also would be required.

The self-evaluation module in the hospital medicine pathway is “not going to differ appreciably [from those used in the existing MOC process], but the vision going forward is [to have] more hospital-focused sets, on things like patient safety and transition of care,” said Dr. Wiese, who is a professor of medicine at Tulane University in New Orleans.

The practice improvement module “will focus on the ability to interact well with a team,” he said. “The candidate would sign up, would identify some practice area, collect data on the practice, design an intervention, and collect data again after a few months to show an improvement in practice delivery.”

The secure exam will differ from the standard internal medicine exam “in that it has much greater hospital medicine–focused content, but also questions on quality, patient safety, and transitions,” he continued. “Individuals that pass this exam can hold themselves out to patients and say, 'I have competence understanding systems of care, transitions of care, and quality.' Our part is to design an exam that reflects all those virtues.”

Dr. Eric Holmboe, the ABIM's senior vice president and chief medical officer, noted that the idea for certification with a Focused Practice in Hospital Medicine came from hospitalists themselves. “They came to the board over 5 years ago saying they believed their field had matured to the point that it needed to have a specific program, and their primary driver was quality and defining the discipline,” he said. “They were interested in the [physician's] role in patient safety and quality and transitions at the hospital.”

In addition, the hospitalists felt that taking MOC exams that emphasized outpatient care was not a good fit for their practice, Dr. Holmboe said.

Dr. Holmboe noted that in addition to hospital medicine certification, an option for certification in ambulatory care (originally called comprehensive care/internal medicine) was under consideration in recent years. “There was a lot of concern about moving that forward, mostly because of the beleaguered state of primary care,” he said. “That's been put on hold—not that it [won't] necessarily come back, but we are not pursuing this MOC pathway right now.”

In a statement on its Web site, the ABIM noted that “the rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists.”

The ABIM did not go the subspecialty route with hospital medicine because “subspecialty practice involves applying internal medicine as well as specialized knowledge and procedures to a subset of internal medicine patients,” the statement explains. “In contrast, hospital medicine is the practice of internal medicine for patients during hospitalization.

The new certification process is considered a pilot program by the American Board of Medical Specialties, Dr. Holmboe noted. The ABIM “will be doing pretty extensive research … to find out what value and impact this [pathway] has for hospitalists and patients.”

Although the ABFM is the only board so far to join ABIM in the pilot program, it's possible that the American Board of Pediatrics or other boards may join, Mr. Catoi said. Dr. Holmboe said that although pediatrics might be a possibility, “we haven't had any conversations along those lines yet” with the specialty. He added that Focused Practice in Hospital Medicine “is not something that would be offered to [a specialty such as] ob.gyn.; it's about general practice in the hospital on a broad range of patients who are hospitalized for a variety of conditions.”

With the first board certification exam in hospital medicine less than a year away, the long-awaited program has grown in scope following the decision by the American Board of Family Medicine to allow family physicians to join internists in pursuing the new credential.

Starting in May 2010, internists and family physicians can sign up with their respective boards to take the exam that will be one of the requirements for certification with a Focused Practice in Hospital Medicine. The first exam will be on Oct. 25, 2010.

Internists seeking hospitalist certification already can start working on the required self-evaluation and practice improvement modules developed by the American Board of Internal Medicine (ABIM). The American Board of Family Medicine hopes to make its modules available starting in January, said Robert Catoi, a spokesperson for the ABFM.

The new credential will be offered through the maintenance of certification (MOC) framework, explained Dr. Jeffrey Wiese, president-elect of the Society for Hospital Medicine and chair of the ABIM internal medicine question-writing committee. The new certification process is “really a separate pathway,” he said. For example, “an internist [doing his required MOC] would choose to go down the hospital medicine process rather than the standard MOC process. But the framework is going to be the same.”

Candidates will have to complete requirements in four areas: citizenship (including evidence of state licensure), self-evaluation, practice improvement, and secure exam. These requirements can be met in lieu of the standard MOC process, but newly trained internists seeking the new credential must first be certified in internal medicine and have at least 3 years of practice focused on hospital medicine.

“One wrinkle for hospitalists is that they would be required to have Advanced Cardiac Life Support certification,” Dr. Wiese noted. A minimum number of inpatient medicine contacts also would be required.

The self-evaluation module in the hospital medicine pathway is “not going to differ appreciably [from those used in the existing MOC process], but the vision going forward is [to have] more hospital-focused sets, on things like patient safety and transition of care,” said Dr. Wiese, who is a professor of medicine at Tulane University in New Orleans.

The practice improvement module “will focus on the ability to interact well with a team,” he said. “The candidate would sign up, would identify some practice area, collect data on the practice, design an intervention, and collect data again after a few months to show an improvement in practice delivery.”

The secure exam will differ from the standard internal medicine exam “in that it has much greater hospital medicine–focused content, but also questions on quality, patient safety, and transitions,” he continued. “Individuals that pass this exam can hold themselves out to patients and say, 'I have competence understanding systems of care, transitions of care, and quality.' Our part is to design an exam that reflects all those virtues.”

Dr. Eric Holmboe, the ABIM's senior vice president and chief medical officer, noted that the idea for certification with a Focused Practice in Hospital Medicine came from hospitalists themselves. “They came to the board over 5 years ago saying they believed their field had matured to the point that it needed to have a specific program, and their primary driver was quality and defining the discipline,” he said. “They were interested in the [physician's] role in patient safety and quality and transitions at the hospital.”

In addition, the hospitalists felt that taking MOC exams that emphasized outpatient care was not a good fit for their practice, Dr. Holmboe said.

Dr. Holmboe noted that in addition to hospital medicine certification, an option for certification in ambulatory care (originally called comprehensive care/internal medicine) was under consideration in recent years. “There was a lot of concern about moving that forward, mostly because of the beleaguered state of primary care,” he said. “That's been put on hold—not that it [won't] necessarily come back, but we are not pursuing this MOC pathway right now.”

In a statement on its Web site, the ABIM noted that “the rapid growth and development of this field is evidenced by the fact that there are currently about 20,000 hospitalists in the United States; approximately 85% are internists.”

The ABIM did not go the subspecialty route with hospital medicine because “subspecialty practice involves applying internal medicine as well as specialized knowledge and procedures to a subset of internal medicine patients,” the statement explains. “In contrast, hospital medicine is the practice of internal medicine for patients during hospitalization.

The new certification process is considered a pilot program by the American Board of Medical Specialties, Dr. Holmboe noted. The ABIM “will be doing pretty extensive research … to find out what value and impact this [pathway] has for hospitalists and patients.”

Although the ABFM is the only board so far to join ABIM in the pilot program, it's possible that the American Board of Pediatrics or other boards may join, Mr. Catoi said. Dr. Holmboe said that although pediatrics might be a possibility, “we haven't had any conversations along those lines yet” with the specialty. He added that Focused Practice in Hospital Medicine “is not something that would be offered to [a specialty such as] ob.gyn.; it's about general practice in the hospital on a broad range of patients who are hospitalized for a variety of conditions.”

Can't get enough Policy & Practice? Check out our new podcast each Monday. egmnblog.wordpress.com

Americans Uneducated on Diabetes

Americans earn a “failing grade” on diabetes awareness, according to an online survey sponsored by the American Diabetes Association. Participants who answered a series of questions scored just 51% overall. Although more than three-fourths of respondents knew that not all diabetes patients need daily insulin injections, only 12% knew that the recommended diet for people with diabetes does not restrict starchy foods any more than does the diet recommended for all adults. “Many Americans have a very limited understanding of the basic facts about diabetes, as well as the serious consequences for health that accompany the disease,” Sue McLaughlin, the ADA's president for health care and education, said in a statement. “Unfortunately, numerous myths about diabetes exist, making it difficult for people to believe the science-based facts.” The survey of more than 2,000 adults was conducted by Harris Interactive.

Society Seeks More Stem Cell Study

The Endocrine Society would like to see an increase in federal funding for stem cell research, according to a new position statement from the group. The society wants the support to include what it calls promising yet neglected areas of stem cell research, such as cells generated through somatic cell nuclear transfer. “No research in recent history has offered as much hope as stem cell research in treating such a large number of debilitating diseases such as diabetes, Parkinson's disease, and Alzheimer's disease,” said Endocrine Society President Robert Vigersky. “For the full potential of stem cell research to be reached, the amount of federal funding and the scope of that funding need to be expanded.”

Bill Would Boost Bone-Health Efforts

Proposed federal legislation aims to create a national strategy against osteoporosis and other bone diseases. The Bone Health Promotion and Research Act (H.R. 3856) would expand research at the National Institutes of Health, fund states' surveillance of bone conditions, and increase education activities at the Centers for Disease Control and Prevention. The chief sponsors of the bill are Rep. Shelley Berkley (D-Nev.), who was diagnosed with osteoporosis more than a decade ago, and Rep. Michael C. Burgess (R-Tex.), a physician who has treated patients with the condition. “Osteoporosis and related bone diseases pose a public health issue of enormous proportions, affecting millions of Americans and costing billions of dollars,” Rep. Burgess said in a statement.

Kidney Data Beating Schedule

Incidence and prevalence data for end-stage kidney disease in the United States will be available online from the U.S. Renal Data System a year earlier than usual, the National Institute of Diabetes and Digestive and Kidney Diseases announced. The data, available online at

www.usrds.org/qtr/qrt_report_table_new.html

HHS Eyeing Imaging Pay

Some time during the current fiscal year, the Department of Health and Human Services' Office of Inspector General will start reviewing Medicare's Part B payments to physicians for imaging services. The focus will include “the physician professional cost component, malpractice costs, and practice expense,” according to the OIG. For each service, staff will determine whether the payment “reflects the actual expenses incurred and whether the utilization rate reflects current industry practices.” The agency also will investigate diagnostic x-rays performed in emergency departments. Imaging there has increased, said the OIG, and in 2007 had cost Medicare about $207 million in physician payments. The report on imaging in emergency departments is due within the year, but the overall imaging report is not expected until FY2011, said the OIG.

Practice Revenues Decline

Medical practice revenues fell in 2008, possibly because of declining patient volumes and payments from people in financial hardship, according to the Medical Group Management Association. Medical practices responded by trimming overhead costs more than 1%, but that wasn't enough to offset shrinking revenues, the MGMA found in its yearly practice-cost survey. Multispecialty group practices saw a 1.9% decline in total medical revenue in 2008, with substantial drops in both the number of procedures and the number of patients. Bad debt in multispecialty group practices from fee-for-service charges increased 13% from 2006 to 2008.

Can't get enough Policy & Practice? Check out our new podcast each Monday. egmnblog.wordpress.com

Americans Uneducated on Diabetes

Americans earn a “failing grade” on diabetes awareness, according to an online survey sponsored by the American Diabetes Association. Participants who answered a series of questions scored just 51% overall. Although more than three-fourths of respondents knew that not all diabetes patients need daily insulin injections, only 12% knew that the recommended diet for people with diabetes does not restrict starchy foods any more than does the diet recommended for all adults. “Many Americans have a very limited understanding of the basic facts about diabetes, as well as the serious consequences for health that accompany the disease,” Sue McLaughlin, the ADA's president for health care and education, said in a statement. “Unfortunately, numerous myths about diabetes exist, making it difficult for people to believe the science-based facts.” The survey of more than 2,000 adults was conducted by Harris Interactive.

Society Seeks More Stem Cell Study

The Endocrine Society would like to see an increase in federal funding for stem cell research, according to a new position statement from the group. The society wants the support to include what it calls promising yet neglected areas of stem cell research, such as cells generated through somatic cell nuclear transfer. “No research in recent history has offered as much hope as stem cell research in treating such a large number of debilitating diseases such as diabetes, Parkinson's disease, and Alzheimer's disease,” said Endocrine Society President Robert Vigersky. “For the full potential of stem cell research to be reached, the amount of federal funding and the scope of that funding need to be expanded.”

Bill Would Boost Bone-Health Efforts

Proposed federal legislation aims to create a national strategy against osteoporosis and other bone diseases. The Bone Health Promotion and Research Act (H.R. 3856) would expand research at the National Institutes of Health, fund states' surveillance of bone conditions, and increase education activities at the Centers for Disease Control and Prevention. The chief sponsors of the bill are Rep. Shelley Berkley (D-Nev.), who was diagnosed with osteoporosis more than a decade ago, and Rep. Michael C. Burgess (R-Tex.), a physician who has treated patients with the condition. “Osteoporosis and related bone diseases pose a public health issue of enormous proportions, affecting millions of Americans and costing billions of dollars,” Rep. Burgess said in a statement.

Kidney Data Beating Schedule

Incidence and prevalence data for end-stage kidney disease in the United States will be available online from the U.S. Renal Data System a year earlier than usual, the National Institute of Diabetes and Digestive and Kidney Diseases announced. The data, available online at

www.usrds.org/qtr/qrt_report_table_new.html

HHS Eyeing Imaging Pay

Some time during the current fiscal year, the Department of Health and Human Services' Office of Inspector General will start reviewing Medicare's Part B payments to physicians for imaging services. The focus will include “the physician professional cost component, malpractice costs, and practice expense,” according to the OIG. For each service, staff will determine whether the payment “reflects the actual expenses incurred and whether the utilization rate reflects current industry practices.” The agency also will investigate diagnostic x-rays performed in emergency departments. Imaging there has increased, said the OIG, and in 2007 had cost Medicare about $207 million in physician payments. The report on imaging in emergency departments is due within the year, but the overall imaging report is not expected until FY2011, said the OIG.

Practice Revenues Decline

Medical practice revenues fell in 2008, possibly because of declining patient volumes and payments from people in financial hardship, according to the Medical Group Management Association. Medical practices responded by trimming overhead costs more than 1%, but that wasn't enough to offset shrinking revenues, the MGMA found in its yearly practice-cost survey. Multispecialty group practices saw a 1.9% decline in total medical revenue in 2008, with substantial drops in both the number of procedures and the number of patients. Bad debt in multispecialty group practices from fee-for-service charges increased 13% from 2006 to 2008.

Can't get enough Policy & Practice? Check out our new podcast each Monday. egmnblog.wordpress.com

Americans Uneducated on Diabetes

Americans earn a “failing grade” on diabetes awareness, according to an online survey sponsored by the American Diabetes Association. Participants who answered a series of questions scored just 51% overall. Although more than three-fourths of respondents knew that not all diabetes patients need daily insulin injections, only 12% knew that the recommended diet for people with diabetes does not restrict starchy foods any more than does the diet recommended for all adults. “Many Americans have a very limited understanding of the basic facts about diabetes, as well as the serious consequences for health that accompany the disease,” Sue McLaughlin, the ADA's president for health care and education, said in a statement. “Unfortunately, numerous myths about diabetes exist, making it difficult for people to believe the science-based facts.” The survey of more than 2,000 adults was conducted by Harris Interactive.

Society Seeks More Stem Cell Study

The Endocrine Society would like to see an increase in federal funding for stem cell research, according to a new position statement from the group. The society wants the support to include what it calls promising yet neglected areas of stem cell research, such as cells generated through somatic cell nuclear transfer. “No research in recent history has offered as much hope as stem cell research in treating such a large number of debilitating diseases such as diabetes, Parkinson's disease, and Alzheimer's disease,” said Endocrine Society President Robert Vigersky. “For the full potential of stem cell research to be reached, the amount of federal funding and the scope of that funding need to be expanded.”

Bill Would Boost Bone-Health Efforts

Proposed federal legislation aims to create a national strategy against osteoporosis and other bone diseases. The Bone Health Promotion and Research Act (H.R. 3856) would expand research at the National Institutes of Health, fund states' surveillance of bone conditions, and increase education activities at the Centers for Disease Control and Prevention. The chief sponsors of the bill are Rep. Shelley Berkley (D-Nev.), who was diagnosed with osteoporosis more than a decade ago, and Rep. Michael C. Burgess (R-Tex.), a physician who has treated patients with the condition. “Osteoporosis and related bone diseases pose a public health issue of enormous proportions, affecting millions of Americans and costing billions of dollars,” Rep. Burgess said in a statement.

Kidney Data Beating Schedule

Incidence and prevalence data for end-stage kidney disease in the United States will be available online from the U.S. Renal Data System a year earlier than usual, the National Institute of Diabetes and Digestive and Kidney Diseases announced. The data, available online at

www.usrds.org/qtr/qrt_report_table_new.html

HHS Eyeing Imaging Pay

Some time during the current fiscal year, the Department of Health and Human Services' Office of Inspector General will start reviewing Medicare's Part B payments to physicians for imaging services. The focus will include “the physician professional cost component, malpractice costs, and practice expense,” according to the OIG. For each service, staff will determine whether the payment “reflects the actual expenses incurred and whether the utilization rate reflects current industry practices.” The agency also will investigate diagnostic x-rays performed in emergency departments. Imaging there has increased, said the OIG, and in 2007 had cost Medicare about $207 million in physician payments. The report on imaging in emergency departments is due within the year, but the overall imaging report is not expected until FY2011, said the OIG.

Practice Revenues Decline

Medical practice revenues fell in 2008, possibly because of declining patient volumes and payments from people in financial hardship, according to the Medical Group Management Association. Medical practices responded by trimming overhead costs more than 1%, but that wasn't enough to offset shrinking revenues, the MGMA found in its yearly practice-cost survey. Multispecialty group practices saw a 1.9% decline in total medical revenue in 2008, with substantial drops in both the number of procedures and the number of patients. Bad debt in multispecialty group practices from fee-for-service charges increased 13% from 2006 to 2008.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital and colleagues wrote. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market. Payment listings were found on each company's website and included a wide range of direct and indirect expenditures (N. Engl. J. Med. 2009;361:1466–74).

The authors compared the payments with conflict-of-interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and there were 282 payments that exceeded $100,000. Approximately one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments.

The researchers also surveyed 91 physicians who did not disclose payments; 36 physicians responded to the survey. Reasons for nondisclosure included the payment being unrelated to the presentation topic (39%) and misunderstanding the disclosure requirements (14%). In addition, 11% of respondents reported that the payment had been disclosed but was inaccurately printed in the program.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

As for their own disclosures, the authors noted that co-authors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study. No other conflicts of interest were reported.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital and colleagues wrote. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market. Payment listings were found on each company's website and included a wide range of direct and indirect expenditures (N. Engl. J. Med. 2009;361:1466–74).

The authors compared the payments with conflict-of-interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and there were 282 payments that exceeded $100,000. Approximately one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments.

The researchers also surveyed 91 physicians who did not disclose payments; 36 physicians responded to the survey. Reasons for nondisclosure included the payment being unrelated to the presentation topic (39%) and misunderstanding the disclosure requirements (14%). In addition, 11% of respondents reported that the payment had been disclosed but was inaccurately printed in the program.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

As for their own disclosures, the authors noted that co-authors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study. No other conflicts of interest were reported.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future,” Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital and colleagues wrote. “Legislation requiring all drug and device manufacturers to publicly disclose payments to physicians is currently pending in the U.S. Congress and has been met with widespread support.”

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market. Payment listings were found on each company's website and included a wide range of direct and indirect expenditures (N. Engl. J. Med. 2009;361:1466–74).

The authors compared the payments with conflict-of-interest disclosures made by physicians who either presented at or served as board or committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS).

A total of 1,347 payments were made to 1,162 physicians during 2007. Overall, 166 physicians received payments from multiple companies, and there were 282 payments that exceeded $100,000. Approximately one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting.

In 70% of the 299 cases that could be evaluated for topic relatedness, the payment was directly related to the topic of the presentation at the meeting.

The overall disclosure rate for the payments was 71%, including 79% for directly related payments, 50% for indirectly related payments, and 49% for unrelated payments.

The researchers also surveyed 91 physicians who did not disclose payments; 36 physicians responded to the survey. Reasons for nondisclosure included the payment being unrelated to the presentation topic (39%) and misunderstanding the disclosure requirements (14%). In addition, 11% of respondents reported that the payment had been disclosed but was inaccurately printed in the program.

The authors cited the high rate of nondisclosure as the most notable finding of their study, saying that the disclosures didn't occur “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” They also noted that the 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

As for their own disclosures, the authors noted that co-authors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study. No other conflicts of interest were reported.

WASHINGTON — A combination of metformin and the oral contraceptive Ortho Tri-Cyclen improves lipid profiles more than does an oral contraceptive alone in patients with polycystic ovary syndrome, according to preliminary data from a small pilot study presented at the annual meeting of the Androgen Excess and PCOS Society.

In this randomized, double-blind, placebo-controlled study, Dr. Pauline Essah of Virginia Commonwealth University, Richmond, and colleagues assigned 17 women with PCOS to an OC plus 500 mg of metformin three times daily or an OC plus a placebo three times daily.

After 3 months, there was no difference between the two groups in weight, BMI, fasting insulin, or fasting glucose measurements. However, the OC-metformin group experienced a trend toward higher HDL cholesterol (55.6 vs. 47.6 mg/dL) and lower triglyceride levels (86.8 vs. 152.7 mg/dL) compared with the group that took OCs alone. The combination group also demonstrated a significant increase in acute insulin response to glucose.

Also, patients in the OC-metformin group “went from 4.7% to 9.4% in flow-mediated dilatation,” a significant improvement, while patients in the OC-alone group did not experience a significant change, Dr. Essah said. “The combination seems to be more beneficial than OC monotherapy because it enhances beta-cell function and endothelial function, and improvements in these factors may attenuate the cardiovascular risks from OCs.” The study was funded by the National Institutes of Health. Dr. Essah said she had no financial conflicts of interest to report.

WASHINGTON — A combination of metformin and the oral contraceptive Ortho Tri-Cyclen improves lipid profiles more than does an oral contraceptive alone in patients with polycystic ovary syndrome, according to preliminary data from a small pilot study presented at the annual meeting of the Androgen Excess and PCOS Society.

In this randomized, double-blind, placebo-controlled study, Dr. Pauline Essah of Virginia Commonwealth University, Richmond, and colleagues assigned 17 women with PCOS to an OC plus 500 mg of metformin three times daily or an OC plus a placebo three times daily.

After 3 months, there was no difference between the two groups in weight, BMI, fasting insulin, or fasting glucose measurements. However, the OC-metformin group experienced a trend toward higher HDL cholesterol (55.6 vs. 47.6 mg/dL) and lower triglyceride levels (86.8 vs. 152.7 mg/dL) compared with the group that took OCs alone. The combination group also demonstrated a significant increase in acute insulin response to glucose.

Also, patients in the OC-metformin group “went from 4.7% to 9.4% in flow-mediated dilatation,” a significant improvement, while patients in the OC-alone group did not experience a significant change, Dr. Essah said. “The combination seems to be more beneficial than OC monotherapy because it enhances beta-cell function and endothelial function, and improvements in these factors may attenuate the cardiovascular risks from OCs.” The study was funded by the National Institutes of Health. Dr. Essah said she had no financial conflicts of interest to report.

WASHINGTON — A combination of metformin and the oral contraceptive Ortho Tri-Cyclen improves lipid profiles more than does an oral contraceptive alone in patients with polycystic ovary syndrome, according to preliminary data from a small pilot study presented at the annual meeting of the Androgen Excess and PCOS Society.

In this randomized, double-blind, placebo-controlled study, Dr. Pauline Essah of Virginia Commonwealth University, Richmond, and colleagues assigned 17 women with PCOS to an OC plus 500 mg of metformin three times daily or an OC plus a placebo three times daily.

After 3 months, there was no difference between the two groups in weight, BMI, fasting insulin, or fasting glucose measurements. However, the OC-metformin group experienced a trend toward higher HDL cholesterol (55.6 vs. 47.6 mg/dL) and lower triglyceride levels (86.8 vs. 152.7 mg/dL) compared with the group that took OCs alone. The combination group also demonstrated a significant increase in acute insulin response to glucose.

Also, patients in the OC-metformin group “went from 4.7% to 9.4% in flow-mediated dilatation,” a significant improvement, while patients in the OC-alone group did not experience a significant change, Dr. Essah said. “The combination seems to be more beneficial than OC monotherapy because it enhances beta-cell function and endothelial function, and improvements in these factors may attenuate the cardiovascular risks from OCs.” The study was funded by the National Institutes of Health. Dr. Essah said she had no financial conflicts of interest to report.

WASHINGTON — Electronic health records systems should be precertified to comply with Recovery Act requirements even before the government issues its final certification rules, a federal advisory panel recommends.

Because the final rules may not go into effect until next year, “the suggestion is to establish something called preliminary certification based on the assumption that vendors would be willing to take a reasonable risk that what has been proposed in the regulatory process is probably pretty close to what is going to come out the other side,” Paul Egerman, cochair of the certification/adoption workgroup of the Health and Human Services Department's Health Information Technology (HIT) Policy Committee, said at a meeting of the committee.

That way, vendors could start certifying based on the proposed criteria, “and when the regulatory process is completed, hopefully there's only a very small adjustment that we can tack on” before the software becomes HHS-certified, he added.

Whether and when HHS will adopt its committee's recommendation is uncertain at this point, according to Dr. David Blumenthal, the committee's chair and national HIT coordinator at HHS.

“We'll have to do this in a deliberate way that includes public comment and takes the necessary steps within the department and in the federal government generally,” he said during a conference call. “I think the rule-making process we have to go through will make it very difficult to react in that time frame.”

Despite Dr. Blumenthal's cautious response, the Certification Commission for Health Information Technology (CCHIT)—currently the only federally approved certification body for EHR—is moving ahead. During a Sept. 3 conference call, CCHIT officials announced that they were going to publish criteria at the end of September for EHR vendors to meet in order to “precertify” one or more components of their EHR systems. The organization planned to begin accepting precertification applications on Oct. 7. Once certification requirements, slated for spring publication, are final, CCHIT will revise its criteria accordingly and perform any additional testing needed to make sure the precertified systems conform to the final regulations.

Under the Recovery Act, formally known as the American Recovery and Reinvestment Act, $19 billion has been set aside to encourage HIT adoption, including electronic health records. The money includes up to $44,000 in financial incentives for each physician who purchases a certified EHR system and makes “meaningful use” of it by 2011; physicians who adopt EHRs later will also get an incentive, but the amount will diminish gradually over several years and disappear completely after 2014. Providers who have not adopted EHRs by 2015 will see reductions in their Medicare reimbursement.

Right now, only CCHIT can certify an EHR; certification/adoption workgroup members emphasized the need for more than one certifying organization and recommended that any certifying groups be distinct from those that set the certification criteria.

To help physicians and hospitals get ready to implement EHRs, the Obama administration is making $598 million in Recovery Act funds available now to establish 70 HIT “extension centers” that will provide hospitals and clinicians with hands-on technical assistance in the selection, acquisition, implementation, and meaningful use of certified EHRs. The extension center grants will be awarded on a rolling basis, with the first being issued in fiscal year 2010, which began on Oct. 1.

Another $564 million is also being made available in fiscal 2010 to states and state-designated groups to implement health information exchange.

HHS also will provide assistance to health care providers through the HIT Research Center, which will disseminate relevant information on effective practices and help the extension centers collaborate with one another and share best practices on EHR use.

In other business at the meeting, the committee also refined its proposed definition of certification. The new definition reads, “HHS certification means that a system is able to support the achievement of privacy and interoperability, and that the system is able to support the achievement of the meaningful use results that the government expects.”

The workgroup on the definition of meaningful use outlined its plans, which included a meeting to address gaps in meaningful use criteria. Specifically, the group planned to meet in October to hear from specialist physicians about how to make the criteria relevant to them.

They also wanted to address the needs of smaller practices and hospitals, and of safety net providers.

Committee member Gayle Harrell of Stuart, Fla., a former member of the Florida state legislature and the wife of a retired ob.gyn., said she was happy to hear that the workgroup was focusing on specialists.

“I'm delighted that you're going to be meeting with the specialties and understanding the impact of meaningful use criteria on them,” she said.

The committee also discussed barriers to widespread EHR adoption. Committee member Judith Faulkner of Epic Systems Corp. in Verona, Wis., said cost was not the biggest issue for many of the providers with whom she had spoken. “It doesn't matter what the incentive money is,” she said.

Ms. Harrell agreed, noting, “The real barrier is legal concerns. Our customers are not jumping on [EHRs] because lawyers and their other advisers are much more [concerned] about legal issues, and I don't think the money matters as much.”

WASHINGTON — Electronic health records systems should be precertified to comply with Recovery Act requirements even before the government issues its final certification rules, a federal advisory panel recommends.

Because the final rules may not go into effect until next year, “the suggestion is to establish something called preliminary certification based on the assumption that vendors would be willing to take a reasonable risk that what has been proposed in the regulatory process is probably pretty close to what is going to come out the other side,” Paul Egerman, cochair of the certification/adoption workgroup of the Health and Human Services Department's Health Information Technology (HIT) Policy Committee, said at a meeting of the committee.

That way, vendors could start certifying based on the proposed criteria, “and when the regulatory process is completed, hopefully there's only a very small adjustment that we can tack on” before the software becomes HHS-certified, he added.

Whether and when HHS will adopt its committee's recommendation is uncertain at this point, according to Dr. David Blumenthal, the committee's chair and national HIT coordinator at HHS.

“We'll have to do this in a deliberate way that includes public comment and takes the necessary steps within the department and in the federal government generally,” he said during a conference call. “I think the rule-making process we have to go through will make it very difficult to react in that time frame.”

Despite Dr. Blumenthal's cautious response, the Certification Commission for Health Information Technology (CCHIT)—currently the only federally approved certification body for EHR—is moving ahead. During a Sept. 3 conference call, CCHIT officials announced that they were going to publish criteria at the end of September for EHR vendors to meet in order to “precertify” one or more components of their EHR systems. The organization planned to begin accepting precertification applications on Oct. 7. Once certification requirements, slated for spring publication, are final, CCHIT will revise its criteria accordingly and perform any additional testing needed to make sure the precertified systems conform to the final regulations.

Under the Recovery Act, formally known as the American Recovery and Reinvestment Act, $19 billion has been set aside to encourage HIT adoption, including electronic health records. The money includes up to $44,000 in financial incentives for each physician who purchases a certified EHR system and makes “meaningful use” of it by 2011; physicians who adopt EHRs later will also get an incentive, but the amount will diminish gradually over several years and disappear completely after 2014. Providers who have not adopted EHRs by 2015 will see reductions in their Medicare reimbursement.

Right now, only CCHIT can certify an EHR; certification/adoption workgroup members emphasized the need for more than one certifying organization and recommended that any certifying groups be distinct from those that set the certification criteria.

To help physicians and hospitals get ready to implement EHRs, the Obama administration is making $598 million in Recovery Act funds available now to establish 70 HIT “extension centers” that will provide hospitals and clinicians with hands-on technical assistance in the selection, acquisition, implementation, and meaningful use of certified EHRs. The extension center grants will be awarded on a rolling basis, with the first being issued in fiscal year 2010, which began on Oct. 1.

Another $564 million is also being made available in fiscal 2010 to states and state-designated groups to implement health information exchange.

HHS also will provide assistance to health care providers through the HIT Research Center, which will disseminate relevant information on effective practices and help the extension centers collaborate with one another and share best practices on EHR use.

In other business at the meeting, the committee also refined its proposed definition of certification. The new definition reads, “HHS certification means that a system is able to support the achievement of privacy and interoperability, and that the system is able to support the achievement of the meaningful use results that the government expects.”

The workgroup on the definition of meaningful use outlined its plans, which included a meeting to address gaps in meaningful use criteria. Specifically, the group planned to meet in October to hear from specialist physicians about how to make the criteria relevant to them.

They also wanted to address the needs of smaller practices and hospitals, and of safety net providers.

Committee member Gayle Harrell of Stuart, Fla., a former member of the Florida state legislature and the wife of a retired ob.gyn., said she was happy to hear that the workgroup was focusing on specialists.

“I'm delighted that you're going to be meeting with the specialties and understanding the impact of meaningful use criteria on them,” she said.

The committee also discussed barriers to widespread EHR adoption. Committee member Judith Faulkner of Epic Systems Corp. in Verona, Wis., said cost was not the biggest issue for many of the providers with whom she had spoken. “It doesn't matter what the incentive money is,” she said.

Ms. Harrell agreed, noting, “The real barrier is legal concerns. Our customers are not jumping on [EHRs] because lawyers and their other advisers are much more [concerned] about legal issues, and I don't think the money matters as much.”

WASHINGTON — Electronic health records systems should be precertified to comply with Recovery Act requirements even before the government issues its final certification rules, a federal advisory panel recommends.

Because the final rules may not go into effect until next year, “the suggestion is to establish something called preliminary certification based on the assumption that vendors would be willing to take a reasonable risk that what has been proposed in the regulatory process is probably pretty close to what is going to come out the other side,” Paul Egerman, cochair of the certification/adoption workgroup of the Health and Human Services Department's Health Information Technology (HIT) Policy Committee, said at a meeting of the committee.

That way, vendors could start certifying based on the proposed criteria, “and when the regulatory process is completed, hopefully there's only a very small adjustment that we can tack on” before the software becomes HHS-certified, he added.

Whether and when HHS will adopt its committee's recommendation is uncertain at this point, according to Dr. David Blumenthal, the committee's chair and national HIT coordinator at HHS.

“We'll have to do this in a deliberate way that includes public comment and takes the necessary steps within the department and in the federal government generally,” he said during a conference call. “I think the rule-making process we have to go through will make it very difficult to react in that time frame.”

Despite Dr. Blumenthal's cautious response, the Certification Commission for Health Information Technology (CCHIT)—currently the only federally approved certification body for EHR—is moving ahead. During a Sept. 3 conference call, CCHIT officials announced that they were going to publish criteria at the end of September for EHR vendors to meet in order to “precertify” one or more components of their EHR systems. The organization planned to begin accepting precertification applications on Oct. 7. Once certification requirements, slated for spring publication, are final, CCHIT will revise its criteria accordingly and perform any additional testing needed to make sure the precertified systems conform to the final regulations.

Under the Recovery Act, formally known as the American Recovery and Reinvestment Act, $19 billion has been set aside to encourage HIT adoption, including electronic health records. The money includes up to $44,000 in financial incentives for each physician who purchases a certified EHR system and makes “meaningful use” of it by 2011; physicians who adopt EHRs later will also get an incentive, but the amount will diminish gradually over several years and disappear completely after 2014. Providers who have not adopted EHRs by 2015 will see reductions in their Medicare reimbursement.

Right now, only CCHIT can certify an EHR; certification/adoption workgroup members emphasized the need for more than one certifying organization and recommended that any certifying groups be distinct from those that set the certification criteria.

To help physicians and hospitals get ready to implement EHRs, the Obama administration is making $598 million in Recovery Act funds available now to establish 70 HIT “extension centers” that will provide hospitals and clinicians with hands-on technical assistance in the selection, acquisition, implementation, and meaningful use of certified EHRs. The extension center grants will be awarded on a rolling basis, with the first being issued in fiscal year 2010, which began on Oct. 1.

Another $564 million is also being made available in fiscal 2010 to states and state-designated groups to implement health information exchange.

HHS also will provide assistance to health care providers through the HIT Research Center, which will disseminate relevant information on effective practices and help the extension centers collaborate with one another and share best practices on EHR use.

In other business at the meeting, the committee also refined its proposed definition of certification. The new definition reads, “HHS certification means that a system is able to support the achievement of privacy and interoperability, and that the system is able to support the achievement of the meaningful use results that the government expects.”

The workgroup on the definition of meaningful use outlined its plans, which included a meeting to address gaps in meaningful use criteria. Specifically, the group planned to meet in October to hear from specialist physicians about how to make the criteria relevant to them.

They also wanted to address the needs of smaller practices and hospitals, and of safety net providers.

Committee member Gayle Harrell of Stuart, Fla., a former member of the Florida state legislature and the wife of a retired ob.gyn., said she was happy to hear that the workgroup was focusing on specialists.

“I'm delighted that you're going to be meeting with the specialties and understanding the impact of meaningful use criteria on them,” she said.

The committee also discussed barriers to widespread EHR adoption. Committee member Judith Faulkner of Epic Systems Corp. in Verona, Wis., said cost was not the biggest issue for many of the providers with whom she had spoken. “It doesn't matter what the incentive money is,” she said.

Ms. Harrell agreed, noting, “The real barrier is legal concerns. Our customers are not jumping on [EHRs] because lawyers and their other advisers are much more [concerned] about legal issues, and I don't think the money matters as much.”

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future” pending legislation, wrote Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital Boston, and colleagues.

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market (N. Engl. J. Med. 2009;361:1466–74). They compared payments with conflict-of-interest disclosures by physicians who presented or served as board/committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons.

In all, 1,347 payments were made to 1,162 physicians. Overall, 166 physicians received payments from multiple companies, and 282 payments exceeded $100,000. Nearly one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting. Payment was directly related to the presentation topic in 70% of cases.

The overall disclosure rate for the payments was 71%, including 79% for directly related, 50% for indirectly related, and 49% for unrelated payments. Thirty-six respondents who did not disclose payments cited unrelated topics among their reasons.

The authors cited the high nondisclosure rate as most notable “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” The 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

As for their own disclosures, coauthors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study. No other conflicts were reported.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future” pending legislation, wrote Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital Boston, and colleagues.

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market (N. Engl. J. Med. 2009;361:1466–74). They compared payments with conflict-of-interest disclosures by physicians who presented or served as board/committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons.

In all, 1,347 payments were made to 1,162 physicians. Overall, 166 physicians received payments from multiple companies, and 282 payments exceeded $100,000. Nearly one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting. Payment was directly related to the presentation topic in 70% of cases.

The overall disclosure rate for the payments was 71%, including 79% for directly related, 50% for indirectly related, and 49% for unrelated payments. Thirty-six respondents who did not disclose payments cited unrelated topics among their reasons.

The authors cited the high nondisclosure rate as most notable “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” The 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

As for their own disclosures, coauthors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study. No other conflicts were reported.

Despite explicit requirements, a number of speakers at medical meetings do not disclose financial conflicts of interest, a study has found.

“Currently, disclosures by physicians are largely self-reported, but there is reason to suspect that this may change in the near future” pending legislation, wrote Dr. Kanu Okike of Brigham and Women's Hospital and Massachusetts General Hospital Boston, and colleagues.

The authors analyzed payments made to physicians in 2007 by five makers of total hip and knee prostheses that together account for nearly 95% of the market (N. Engl. J. Med. 2009;361:1466–74). They compared payments with conflict-of-interest disclosures by physicians who presented or served as board/committee members at the 2008 annual meeting of the American Academy of Orthopaedic Surgeons.

In all, 1,347 payments were made to 1,162 physicians. Overall, 166 physicians received payments from multiple companies, and 282 payments exceeded $100,000. Nearly one-fourth of the payments (344) were made to presenters or board/committee members at the AAOS meeting. Payment was directly related to the presentation topic in 70% of cases.

The overall disclosure rate for the payments was 71%, including 79% for directly related, 50% for indirectly related, and 49% for unrelated payments. Thirty-six respondents who did not disclose payments cited unrelated topics among their reasons.

The authors cited the high nondisclosure rate as most notable “despite instructions directing each participant to make a disclosure 'if he or she has received something of value from a commercial company or institution, which relates directly or indirectly to the subject of their presentation.'” The 43 nondisclosed payments relating directly to the presentations totaled $4.3 million.

As for their own disclosures, coauthors Dr. Mininder Kocher, Dr. Charles Mehlman, and Dr. Mohit Bhandari have received grants from or consulted for a number of medical device firms, including several of those mentioned in the study. No other conflicts were reported.